However, cancer screening techniques, especially for breast and cervical cancer, have come under scrutiny as health care expenditures soar in developed countries. Are these screening tests for cancer really necessary? What does current scientific evidence tell us? The most common cancer screening methods used today are the prostate specific antigen (PSA) for prostate cancer ( which was addressed extensively in a recent HealthWorldNet article 'Prostate Cancer Screening needs a Massage' [3]), mammography for breast cancer, and the Pap test for cervical cancer. 

BREAST CANCER SCREENING

The mammogram has been in use for more than 35 years. Despite the fact that the technology is far from perfect, worldwide mammogram screening remains the gold standard for breast cancer screening. Current medical guidelines in the US recommend mammograms to be performed annually in women starting at age 40. In other countries, screening starts only at age 50, every 2 to 3 years.

After extensive research of the latest medical literature, the US Preventive Services Task Force (USPSTF)[4] in November 2009 issued new federal guidelines recommending that the starting age for mammograms be raised to 50 specifically:

• The USPSTF recommends against routine screening mammography in women aged 40 to 49 years.
• The USPSTF recommends biennial screening mammography for women between the ages of 50 and 74 years.
• The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
  

As expected, these recommendations created quite a furor, and to say the least, started a heated debate between the 'Screen Less' group, aka The Task Force,  and the 'Screen Same' crowd. And, most of the resistance to this change has come from the majority of organizations dedicated to improving the survival rate of breast cancer.

'Screen Less' is based on the following:

(1) Overusage

Like in the case of the PSA-prostate cancer issue, mammogram screening leads to over diagnosis and overtreatment of breast cancer. Experts say that many cases of breast mass detected by a mammogram are benign or not aggressive and just disappear with time or go into spontaneous remission. According to a 2008 study:  “…it appears that some breast cancers detected by repeated mammographic screening would not persist to be detectable by a single mammogram at the end of 6 years. This raises the possibility that the natural course of some screen-detected invasive breast cancers is to spontaneously regress”  [5]

Detection by mammograms, therefore, often leads to false alarms and unnecessary confirmatory tests, including invasive biopsy.

(2) Too many false positives

One of the shortcomings of mammograms is the high rate of false positives which lead to false alarms and the unnecessary burden of worry and fear and also, ultimately results in many unnecessary procedures including invasive biopsies.

(3) Screening at 40 is too early

The task force does not deny the benefits of breast cancer screening. However, based on the analysis of the current state of evidence, it doesn’t make much of a difference if screening starts 10 years later at age 50. They compared breast cancer mortality rates between the US and other developed countries (UK, most of Europe) that screen only starting at age 50 and found no significant differences. Their conclusion is that screening at age 40 is not necessary and considering the high rate of false positives, why should patients have to worry 10 years too early?

(4) Radiation exposure

Women undergoing mammograms are exposed to low levels of radiation that may present some health risks. A study by Dutch researchers[6] showed that in women who are at high risk for breast cancer, e.g. those who have BRCA1 or BRCA2 mutation or a strong family history of breast cancer, mammogram exposures actually increase their risk of developing the disease. This is especially true in young women exposed before the age of 20. Although mammograms are usually not recommended at such a young age, high-risk women are advised to have yearly mammograms starting at an early age. The American Cancer Society (ACS) recommends screening for high-risk patients starting at age 30. The authors concluded: “Screening is very important. However, for young, high-risk women, a careful approach is advised when considering mammography for screening."[7]

(5) Cost

Unnecessary mammograms are a burden on the health care system. In 2005, the average cost of a mammogram in the US was 125 US$[8]. In a survey, more than half (53%) of the women identified cost as a major barrier to getting a mammogram[9]. Most private insurance cover mammograms but women without coverage are most likely to give mammograms a pass.

Some advocacy groups believe money spent on unnecessary mammograms can be used better in providing quality health care for everybody, not only those who can afford it. The National Breast Cancer Coalition (NBCC) states: NBCC has long questioned the limitations of mammography screening. For years it has been clear that mammography is not the answer to the breast cancer epidemic. At best, mammography screening may offer only very small benefits to certain age groups of women. There are public health interventions that could save more lives and use fewer health care resources than mammography screening programs. One such intervention would be to ensure that all women diagnosed with breast cancer have access to quality health care. [10]

On the other hand, those who advocate 'Screen Same'  base their contentions on the following:

(1)  Breast cancer can hit before age 40.

There are many cases of women without family history of breast cancer that were diagnosed with the disease at a very young age. For these women, the screening test and early diagnosis may have saved their lives.

(2) Insurance coverage.  Although the recommendations are not legally binding, insurance companies may use the task force’s findings to deny coverage of mammograms before age 50. US Health Secretary Kathleen Sebelius was quick to reassure that this wouldn’t happen when she told MSNBC: The task force does "not set federal policy and they don't determine what services are covered by the federal government… "The task force has presented some new evidence for consideration but our policies remain unchanged. Indeed, I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action."[11]

(3) Save lives, not money.

The cost issue is of course currently a touchy topic in the US and has added ammunition to the arguments of those who are against a universal health care system, or the so-called “health care rationing”. Patients rather go for saving lives than saving money. Former head of the National Institutes for Health (NIH) Dr. Bernardine Healy told Fox News:

"This will increase the number of women dying of breast cancer. Women in their 40s have a very aggressive kind of breast cancer. They tend to progress fast. And to not screen women in that age group is astounding to me, and it goes against the bulk of individuals who are actually caring for patients. You may save some money… but you're not going to save lives.  [12]”

(4) Better be scared than be sorry. There are women who rather take unnecessary fear that false positives on mammograms may bring than miss the chance of an early diagnosis and early treatment. According to breast cancer survivor and US Representative Debbie Wasserman Schultz: "We have to make sure that we're not forgetting about the people. And that's what the task force forgot about this week, is that we're not thinking about big, amorphous blobs of -- of people. Making -- these recommendations say that we can trade one life to save the angst and anxiety in a -- a larger group of women, and that's totally inappropriate.'[10]

And the American Cancer Society’s (ACS) position is to ignore the USPSTF guidelines, based on the statement ACD Chief Medical Officer Dr. Otis W. Brawley: “The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider. When recommendations are based on judgments about the balance of risks and benefits, reasonable experts can look at the same data and reach different conclusions."[13]