Curbing costs have trumped saving lives. That’s the message sent by the Canadian Task Force on Preventive Health Care, whose guidelines, released November 21, recommend against routine mammography screening for most women age 40 to 49. In my 20 plus years of practice I have never seen anything so bewildering as these recommendations.
Specifically, the task force says the “harms and costs of false-positive results, over diagnosis and overtreatment” outweigh any “significant reductions in the relative risk of death from breast cancer.”
And so we have come to a crossroads.
With the soaring cost of healthcare, faceless ‘committees’ that may now be deciding who lives and who dies based on what gets ‘covered’—aka—paid. This is despite the fact an estimated 5,100 Canadian women will die of breast cancer this year.
The Task Force further recommends women 50 to 74 with an average risk of breast cancer should get a mammogram every two to three years. It points to evidence showing that 2,100 women need to be screened over 11 years to prevent one death, but one in three of them get false-positives.
The problem is that the way in which these results have been compiled is highly questionable. Dr. Nancy Wadden is chair of the Canadian Association of Radiologist’s Mammography Accreditation Program and medical director of the breast screening program for Newfoundland and Labrador. She says the task force looked at studies that were over 25 years old, involving equipment that is outdated and no longer available. “There’s been enormous change in breast imaging since that time, [and] in addition, radiologists’ interpretation skills have improved tremendously,” says Dr. Wadden.
So there’s good reason for concern, and Canadians need to think critically about what these new guidelines mean for them. They suggest most women in their 40s should not have routine mammograms because the tests may cause more harm than good because of false positive results (follow-up testing proves negative for cancer). These results might then lead to unnecessary testing such as follow-up ultrasound, MRIs or biopsies.
Does the risk of false positive results outweigh the benefit of preventing a small number of deaths from breast cancer?
What I can say is I don’t want to be the one who dies from not getting screened. Frankly, I’ll take the fear of false positives over the fear of ignorantly not knowing I have cancer anytime. Early detection can save lives. I’ve always said to my patients: dying some time is a 100% certainty but I’m not going down passively, and I want to do all I can for my patients, too.
Here’s what I advise for a breast cancer regimen:
- Screening should be based on risk factors that can begin even earlier than 40 years of age. These can range from genetics, obesity, and drug use (e.g. hormone replacement therapy), to poor lifestyle habits such as smoking, high alcohol consumption, and bad dietary habits that lead to nutrient deficiencies ( e.g. Vitamin D).
- Do self breast examinations (SBE)—otherwise how else would you know between annual check-ups that there is a lump of concern? (The task force also recommends no SBE.)
- Mammograms may be one imaging modality for breast cancer screening but there are other diagnostic tests that can be done, including ultrasound and MRIs. Getting more information from various methods reduces the inaccuracy of just one modality. Women with dense or cystic breasts should consider this approach. What is found will depend on screening frequency—i.e. every 6 months, 1, 2, or 3 years.
- Consider genetic testing especially if there is a strong family history. This will provide better insight of how to approach the type and frequency of screening.
- Metabolomics research has led to a new urine test for breast and ovarian cancer being made available. The research has shown the testing to be 98% sensitive and 99% specific.
- Live a clean lifestyle and be of healthy weight.
If the task force’s recommendations are adopted by provincial health plans as the new standard of care, what you will need to decide in the years to come is whether or not you’ll be willing to pay for screening if you fall outside of the guidelines. My answer is yes. It’s already happening. Women who feel they are at risk but don’t ‘qualify’ for OHIP coverage are now paying for their breast MRIs at between $1,000-$1,500 per test. Some genetic tests and the new urine test noted above are not covered by provincial health plans.
I understand the reality that the public health system cannot pay for all screening. It’s now up to you, the health ‘consumer,’ to decide what you want to ‘buy’.
So be proactive. Take personal control. It isn’t about money. It’s about your life—your contributions to society, friends and being there for as long as you can for your loved ones.