At its annual policy meeting on June 19, the American Medical Association (AMA) voted that women should be able to receive screening mammography starting at age 40. But does the new policy's language actually address -- or counter -- the U.S. Preventive Services Task Force's (USPSTF) controversial 2009 guidelines?
Yes and no, breast imaging experts told AuntMinnie.com.
The AMA's new policy pushes back on the USPSTF guidelines, but cautiously, said Dr. Daniel Kopans of Massachusetts General Hospital.
"[The AMA] makes a fairly strong criticism of the U.S. Preventive Services Task Force over the USPSTF position on ... mammography," Kopans told AuntMinnie.com in an email. "[Yet] I believe that the AMA is responding to pressure from groups that would like to reduce or eliminate access to mammography screening, and in order to appease these groups, they were more circumspect than one would hope. Some at the AMA bought into the idea that the 'risks' -- false positives which are almost all resolved by a few extra mammograms -- are somehow equivalent to dying from breast cancer."
The association's new policy emphasizes that the decision to screen is between a patient and her doctor, and from age 40, women "should be eligible" to receive screening mammography that is paid for by insurance. By directly stating that younger women should continue to have access to the exam, the AMA addresses part of the USPSTF's 2009 guideline, which recommended breast cancer screening begin at age 50.
"If a woman wants to receive a mammogram and the physician believes it is appropriate, she should be able to receive one," said Dr. Lee Morisy, chair of AMA's Council on Science and Public Health, in a statement.
But the updated policy is less straightforward than the association's 2002 policy, which declared that, based on clinical data, "AMA recommends annual screening mammograms and continuation of clinical breast examinations in asymptomatic women 40 years and older." Also cut from the new policy was a statement from the 2002 version in which the AMA said it "strongly endorses the positions of the American College of Obstetricians and Gynecologists, the American Cancer Society, and the American College of Radiology that all women have screening mammography as per current guidelines."
Compared to its 2002 statement, the current AMA language on mammography screening is weaker, but in the face of the USPSTF's 2009 guidance, it's strong, said Dr. Michael Linver from X-Ray Associates of New Mexico.
"Overall, [this policy statement is] very encouraging," Linver told AuntMinnie.com. "It signals that the AMA is concerned that the USPSTF understated the value of screening mammography, especially for women in their 40s. [The new policy is] still a step forward rather than a step backward."
Communication is key
In the new policy, the AMA reiterated its belief that all medical care decisions should occur only after thoughtful deliberation between patients and physicians. The AMA takes the following positions, according to the policy:
- Recognizes the mortality reduction benefit of screening mammography and supports its use as a tool to detect breast cancer
- Recognizes that as with all medical screening procedures there are small but not inconsequential associated risks, including false-positive and false-negative results and overdiagnosis
- Favors participation in and support of the efforts of the professional, voluntary, and government organizations to educate physicians and the public regarding the value of screening mammography in reducing breast cancer mortality, as well as its limitations
- Advocates remaining alert to new epidemiological findings regarding screening mammography and encourages the periodic reconsideration of these recommendations as more epidemiological data become available
- Believes that beginning at the age of 40 years, all women should be eligible for screening mammography
- Encourages physicians to regularly discuss with their individual patients the benefits and risks of screening mammography, and whether screening is appropriate for each clinical situation given that the balance of benefits and risks will be viewed differently by each patient
- Encourages physicians to inquire about and update each patient's family history to detect red flags for hereditary cancer, and to consider other risk factors for breast cancer so that recommendations for screening will be appropriate
- Supports insurance coverage for screening mammography
- Supports seeking common recommendations with other organizations; informed and respectful dialogue, as guideline-making groups address the similarities and differences among their respective recommendations; and adherence to standards that ensure guidelines are unbiased, valid, and trustworthy
- Reiterates its longstanding position that all medical care decisions should occur only after thoughtful deliberation between patients and physicians
At the policy-making meeting, AMA delegates expressed concern that the USPSTF mammography recommendations would limit access to preventive care, and they "adopted policy to encourage the panel to implement procedures to allow for greater input from specialists when drafting prevention recommendations."
ACR lauds AMA
In response to the new policy, ACR praised the AMA for recognizing the importance of beginning screening mammography for breast cancer at age 40, the college said in a statement.
"Since mammography screening became widespread in the early 1990s, the U.S. breast cancer death rate, previously unchanged for 50 years, has dropped more than 30%," said Dr. Paul Ellenbogen, chair of the ACR Board of Chancellors. "The ACR urges women ages 40 and over to receive annual mammograms. Women need access to these lifesaving exams. Government and insurers should not get in the way of this care."
The fact that AMA came out and said that it recognizes the mortality benefit of screening and reiterated its support for women ages 40 and older is very positive, according to Dr. Debra Monticciolo, chair of the ACR's Commission on Quality and Safety and president of the Society of Breast Imaging (SBI).
"We're very happy about [the AMA's statement]," Monticciolo told AuntMinnie.com. "People have different reasons for choosing particular words. But ACR, SBI, the American Cancer Society all recommend yearly screening for women ages 40 and older, and this policy is supportive of those recommendations."
The AMA's new mammography screening policy should have an encouraging effect, Monticciolo said.
"It's good for women to realize that the AMA is supportive of screening mammography, and to hear the association reiterate the benefits of it," she said. "We want women to understand that mammography saves lives, and they shouldn't pass up the screening opportunity."
