17 Jul Putting a Grade on the USPSTF Draft Guidelines
Post written by Nancy Cappello, Ph.D.
I was an excellent student. I loved learning, meeting up with my playmates, and socializing with my teachers. Within a few days of kindergarten, I discovered my destiny - I was going to be a teacher. My schooling motto became: work hard and play hard. To my astonishment, my teacher did not appreciate the play hard part as evidenced by my first report card overflowing with U's on the conduct side. My defense to my parents was that I am merely helping out the teacher, assisting my pint-size school mates with their school work assignments.
My first grade teacher, Mrs. Curtiss, gave me an 'official' green grade book that I discovered in her storage closet as I was tidying up the classroom during recess. I coveted that book as I recreated school. I immediately added my three-year old brother, Mark, to the roster and began grading him on his numbers, letters and following directions. I used my red pen on many occasions to write a big F, especially in the 'Following Nancy's Rules Category.' I kept that grade book throughout my grade-school years, eventually adding my youngest brother Stephen to the roster.
My destiny arrived in 1974 when I graduated with a Bachelor of Science Degree in Special Education. I landed my first teaching job at the same elementary I attended when I was a youngster. It was remarkable to discover that the inspirational Mrs. Eleanor Curtiss was in her final year of teaching. Calling my heroine by her first name was uneasy. At her retirement party, after much practice, I muttered out her first name as I hugged my beloved mentor good-bye.
The US Preventive Services Task Force (USPSTF) guidelines on proposed breast cancer screening were released this past month, doling out letter grades in five separate reports. As expected, the task force lamented about the harms of screening, especially in ages 40 to 49, naming false positives, over-diagnosis and unnecessary treatment as the culprits. Conferring a C grade in this population for 'at least moderate certainty that the net benefit is small,' the draft guidelines were immediately dismissed by a long list of organizations, medical trade groups, and lawmakers, describing them as flawed and short sighted. Having a conversation about the harms of over-diagnosis and over-treatment of cancers has little value to a patient when it cannot be precisely determined, in the unlikely event of a diagnosis, which breast cancer will harm and which will not.
The USPSTF also tackled the topic of 'Women with Dense Breasts' in a 92 page report which received sparse coverage in the media and only a few comments from the medical community. The white elephant in the screening room, dense breast tissue, was at least acknowledged by the task force, conferring an I grade, citing' insufficient evidence to assess the balance of benefits and harms of adjunctive screening.' The report begins with this conclusive statement "Screening Mammography has lower sensitivity and specificity for women with increased breast density, who also have a higher risk of breast cancer."
Since my advanced stage breast cancer in 2004, my Mission has been to disclose the limitations of mammography in dense breasts and its independent risk factor to the women with the dense breasts. Even though the masking and risk of dense breast tissue have been reported in the scientific literature for more two decades, not one of my health care providers, over a dozen years, ever informed me of all the facts about the limited sensitivity of mammography and the missed positives and the interval cancers caused by dense breast tissue.
The purpose of density disclosure is to present the patient-consumer the risks, in addition to the benefits, of the screening test that is being purchased for the sole purpose of detecting cancer. The disclosure of dense breast tissue is independent of any of the challenges of screening, such as insurance coding, adjunctive screening tests and work flow issues.
The USPSTF guidelines conclude that 'adjunctive screening of women with dense breasts will lead to the identification of more breast cancers (mostly invasive) but may be associated with higher recall rates and additional biopsies.
So should we dismiss the first part of the report's conclusion leading to identification of invasive cancers, because we do not like the second part? As stated on the USPSTF website, Women deserve to be aware of what the science says so they can make the best choice for themselves, together with their doctor.
Are You Dense Inc. and Are You Dense Advocacy, Inc. support breast health education and dialogue with health care providers so women can make an informed decision about breast screening. We also advocate for screening mammography beginning at 40, for the average risk woman, with the disclosure of her breast tissue composition with associated discussions of the causal and masking risk of dense breast tissue.
Inflating over-diagnosis claims to trump the detection of an invasive cancer and bemoaning the disclosure of a woman's dense breast tissue and discussions with health care providers about adjunctive screening will likely increase mortality.
In keeping with my grading prowess as a child, a teacher and an adjunct lecturer at a University, I confer a D grade to the USPSTF draft guidelines for being DENSE about the sole purpose of screening.