Canada Recommends Fewer Mammograms

Fran Lowry

November 28, 2011

November 28, 2011 — Canadian women will now have to wait as long as 3 years between breast-screening mammograms, according to a new set of breast cancer guidelines released by the Canadian Task Force on Preventive Health Care (CTFOPHC).

They have also been told not to do breast self-exams, and their doctors have been told not to perform breast examinations in the office.

The CTFOPHC reasons that regular screening for breast cancer with mammography, breast self-exam, and clinical examinations — all practices that have been widely recommended to reduce breast cancer mortality — causes women too much anxiety, results in too many false positives, and is too costly.

Currently, women in Canada have yearly mammograms, and primary care physicians do manual breast exams, usually during a woman's annual physical examination.

The restrictive new recommendations were published in the November 22 issue of CMAJ.

Thousands of Women Will Die, Says ACR

These breast cancer screening guidelines will cost the lives of Canadian women, according to the American College of Radiology (ACR).

They "ignore the results of landmark randomized controlled trials, which show that regular screening significantly reduces breast cancer deaths in these women. While implementation of the CTFOPH guidelines may save money each year on screening costs, the result will be thousands of unnecessary breast cancer deaths," the ACR says.

Barbara Monsees, MD, a diagnostic radiologist from St. Louis, Missouri, who chairs the ACR's Breast Imaging Commission, said in a statement that "panels without profound expertise in breast cancer screening should not be issuing guidelines. These recommendations are derived from flawed analyses and they defy common sense. Women and providers who are looking for guidance are getting bad advice from both task forces."

In 2009, the United States Preventative Services Task Force (USPSTF) issued similar guidelines, which created a furor among breast cancer prevention advocates.

Canadian Task Force Should Be Congratulated

In an editorial accompanying the release of the new guidelines, Peter C. Gøtzsche, MD, from the Nordic Cochrane Centre, Copenhagen, Denmark, lauds the CTFOPHC for its recommendations.

He writes that the Canadian recommendations on mammography screening "are even more conservative" than those introduced 2 years ago in the United States, "which created an uproar...from people interested in maintaining the status quo."

Dr. Gøtzsche maintains that screening with mammography does not reduce the occurrence of advanced cancers. He also states that "rigorous observational studies" in Europe have failed to find an effect of mammography screening, and that mammography screening produces patients with breast cancer from among healthy women and increases the number of mastectomies.

"The best method we have to reduce the risk of breast cancer is to stop the screening program. This could reduce the risk by one third in the screened age group, as the level of overdiagnosis in countries with organized screening programs is about 50%," he writes.

"If screening had been a drug, it would have been withdrawn from the market. Which country will be first to stop mammography screening?" he asks.

Dr. Gøtzsche is well known for his outspoken views against mammography, and the Nordic Cochrane Group, of which is a member, was recently accused of orchestrating "an active antiscreening campaign" by an international group of breast screening experts in a letter to the Lancet.

Women in Their 40s Get Breast Cancer

The Canadian guidelines are even more negative than the American guidelines, noted radiologist Stamatia Destounis, MD, from Elizabeth Wende Breast Care, LLC, in Rochester, New York.

"The USPSTF said that for women 40 to 49, it should be a decision made with your doctor; they didn't come out and say don't do it. The Canadians even say no to breast self-exam and clinical breast exam. I don't know. We have patients coming in who have found lumps in their breasts that are significant lumps. We have doctors finding lumps in their patients that are significant lumps. It's very hard to know what to do when you have these kind of recommendations," Dr. Destounis told Medscape Medical News.

She recently did a retrospective review of patients who came to her center over a 10-year period and found that almost 20% of the breast cancers that were diagnosed were in women 40 to 49 years of age. About half of these were diagnosed in women with no known risk factors for breast cancer.

"These task forces say going through screening is stressful for women. But what woman is going to say: 'No, this is too stressful. I am not happy having extra views. I'm not going to have an ultrasound?' Most of us would say: 'I have family, I have kids, I have responsibilities. I want to make sure I'm ok and I'm a productive member of society at any age.' We women tend to be the care providers whatever our age, and we have a lot of things to do. So what woman is going to say: 'No, I'm too stressed to have this needle biopsy; it is just too much for me to handle'?" Dr. Destounis asked.

"Instead, I am going to say: 'Do whatever you need to do to make sure I'm ok.' Yes, it is stressful to go through these tests, but it's our lot as women. Saying don't do screening because it is stressful just doesn't make any sense."

Dr. Monsees is the chair of the American College of Radiology Breast Imaging Commission. Dr. Gøtzsche and Dr. Destounis have disclosed no relevant financial relationships.

CMAJ. 2011;183:1991-2001, 1957-1958. Abstract, Editorial

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