Changes to breast cancer screening guidelines have been big news since the release of the Canadian Task Force on Preventive Health Care’s updated guidelines in December. Women aged 50 to 74 are now recommended to undergo screening mammography every two to three years, while women 40 to 49 are advised not to undergo screening and not to examine their breasts, regardless of breast tissue density.
But patients must wade through the recommendations with caution.
Adoption of the new breast cancer update is projected to result in over 400 Canadians losing their lives each year. Incredibly, these new guidelines were issued without the involvement of an expert in breast diagnosis or treatment. Instead, the panel involved family doctors, nurses, a chiropractor, an occupational therapist and a nephrologist (kidney specialist).
Why? The task force claimed that including an expert in breast cancer diagnosis would bias the guideline development. The task force implied that because radiologists earn a living by diagnosing breast cancer, they place financial gain above the welfare of patients.
As a physician who lost a loved one to breast cancer, and as a mother, friend and colleague to many women affected by breast cancer, I find this particularly galling – and many of my colleagues in Canada agree.
The task force demonstrated an ignorance of the extensive evidence supporting breast cancer screening.
A recent study from Sweden published in the journal Cancer showed that screening mammography resulted in 60 per cent fewer deaths from breast cancer over a 20-year period. Another study published just last month in Cancer shows that after 30 years, screening mammography and advances in treatment have averted nearly 615,000 deaths from breast cancer in the U.S. alone.
A Canadian study of over two million women screened for breast cancer over 20 years showed that women 50 to 70 had a 40 per cent reduction in breast cancer mortality, and women aged 40 to 49 had a 44 per cent lower rate of dying from breast cancer when they participated in screening mammography.
The task force issued its 2018 guidelines without including these important studies. It focused instead on a 30-year-old Canadian National Breast Screening study that was discounted in 2002 by the World Health Organization due to poor quality mammography and poor study design. A breast cancer expert on the panel would have avoided this error.
The task force focused on harms of screening. The members cited an estimate of overdiagnosis of 41 per cent of breast cancers. No credible expert in screening estimates overdiagnosis to be more than 10 per cent, a number that has been substantiated by the Swedish screening trials. The 41 per cent is based on the outdated and discredited Canadian National Breast Screening study. A breast cancer expert on the panel would have been able to point this out.
The task force also focused on the harms of false positives from screening mammography. They estimated the rate of false positives to be 30 per cent. Wrong again. Canadian database statistics available online for free demonstrate the annual abnormal recall rates for each province and territory for screening mammography. The numbers are consistent – less than 10 per cent. A breast cancer expert on the panel would have been able to point out the error of this calculation.
And the task force didn’t consider one of the most significant harms of screening – the harm of a missed diagnosis or false negative.
Women with dense breast tissue have a much higher chance of being detected late with breast cancer, often after it has spread to the lymph nodes, because the cancer may be masked by their dense tissue. The task force ignored this evidence and didn’t consider the added risk of dense breast tissue in their guidelines. A breast cancer expert on the panel would have been aware of this harm.
Over 44,000 Canadians have signed a petition asking for these flawed guidelines to be opposed.
What needs to happen now?
The federal Health Minister should reject the task force guidelines. A new task force should be convened that includes experts of breast cancer screening mammography. And the Canadian task force should update the breast cancer screening guidelines to include evidence from recent observational trials and actual Canadian data on screening mammography.
To do less than this would be to fail Canadian women and their families.
Dr. Jean Seely is the head of breast imaging at The Ottawa Hospital and professor of radiology at the University of Ottawa. She is president of the Canadian Society of Breast Imaging. She sits on the executive board of the Canadian Association of Radiologists Mammography Accreditation Program and Breast Imaging Working Group.