June 15, 2023 — THE American College of Radiology (ACR) And Society of Breast Imaging (SBI) having submitted common comments in response to the United States Preventive Services Task Force (USPSTF) a draft recommendation for breast cancer screening, proposed in a press release dated May 9. The joint ACR and SBI comments recognize that the proposed move toward screening average-risk women starting at age 40 is a step in the right direction, while opposing other aspects of the ACR’s recommendations. work group.
Comments were sent to U.S. Preventive Services Task Force Agency for Healthcare Research and Quality on behalf of both organizations by Stamatia V. Destounis, MD, FACR, Breast care Elizabeth Wendewho is the president, Commission on Breast Imaging, American College of Radiology (ACR) And Mary S. Newell, MD, FACR, Winship Cancer Institute of Emory University, who serves as president of the Society of Breast Imaging (SBI), as part of the ACR Breast Commission’s USPSTF Working Group. This group also includes: Lars J. Grimm, MD; Sarah M. Friedewald, MD, FACR; R. Edward Hendrick, PhD, FACR; And Bethany L. Niell, MD, PhD. The statement included comments on key areas: annual or biennial screening; Overdiagnosis; Women aged 75 and over; Screening breast MRI; and included a number of tables and figures to reinforce the working group’s comments.
In a June 8 statement from the American College of Radiology, the ACR noted:
“The very detailed and scientifically sound comments raise serious concerns about the proposed recommendation for biennial rather than annual screening, given the task force’s recognition that annual mammography screening in women aged 40 and more saves the most lives and gives the greatest number of years of life. The ACR and SBI also expressed deep disappointment that the USPSTF’s proposed recommendation continues to perpetuate confusion about when to stop mammography screening by proposing a recommendation for screening mammography in women of 75 years and over. The associations’ position is that screening mammography should continue as long as the woman is in good health and has a reasonable life expectancy.
The joint statement continues: “The comments provide an explanatory review of the available science and refute the approach and conclusions of the working group on several issues, while respectfully urging it to reconsider the evidence as detailed in the comments of the “ACR/SBI and to adopt the final recommendations assigning a grade of B. for annual mammographic screening for all women aged 40 and older who are at average risk for breast cancer”, and noted that the USPSTF will review the comments submitted before issuing final recommendations at a later date.
Here is a summary of the specific areas of concern shared in the joint statement:
Annual or biennial projections
The ACR/SBI statement offered this contribution: “We are, however, very concerned about the proposed recommendation for biennial rather than annual screening, given that the working group recognizes that annual mammography screening in Women aged forty and over save the most lives and cause the greatest number of deaths. number of life years gained – a fact demonstrated by randomized controlled trials (RCTs), observational trials and CISNET models. Additionally, we are deeply disappointed that the Task Force’s proposed recommendation continues to perpetuate confusion about when to stop mammography screening by proposing an “I” recommendation for mammography screening in women age 75. and more.
The ACR and SBI are concerned that no breast cancer experts or patient representatives were included on the panel. The Institute of Medicine (IOM) recommends that the development of reliable guidelines include a multidisciplinary panel of experts and representatives of key stakeholder groups (3). The IOM report suggests that such guideline development cannot evaluate evidence in the same way as a multidisciplinary group. The ACR and SBI believe that the presence of breast cancer experts on the panel would have, for example, avoided the USPSTF’s incorrect concept of screening intervals affecting overdiagnosis.
We believe that the draft recommendations overestimate the potential harms (potential risks) of breast cancer screening and underestimate the benefit of annual mammography from age 40 for average-risk patients in terms of reducing morbidity and of mortality. The draft recommendations reflect a biased view of the available evidence, while the Task Force’s own modeling studies conclude that annual screening confers greater benefit. Accordingly, we respectfully invite you to reconsider the evidence (which has been detailed in the statement) and adopt the final recommendations assigning a B grade to annual mammography screening for all women aged 40 and over who are at average risk of breast cancer. Finally, we respectfully request, with the final document, that comments submitted during the 30-day review period be addressed individually with explanations included for any comments not incorporated into the final guidance. The public availability of this information is important for the transparency necessary to build trust.
Screening in women with dense breasts
The joint ACR/SBI statement also included a specific section on additional screening in women with dense breasts, proposing the following:
“The USPSTF concludes that there is insufficient evidence to assess the balance of benefits and harms of additional screening with MRI (magnetic resonance imaging) or ultrasound in women with breast tissue dense, which gives them an “I” rating. This is problematic because literature has proven that women with dense breast tissue are at increased risk of developing breast cancer and, furthermore, are at risk of seeing masked cancer on a screening mammogram. Patients with extremely dense breasts are approximately twice as likely to develop breast cancer as patients with average density and 4 to 6 times as likely as patients with fatty breasts (27, 28). The Working Group takes note. Breast density is recognized as an important risk factor and has been included in most recent risk assessment tools. In addition, the sensitivity of mammography is reduced in patients with dense breasts, a fact also recognized by the working group. Mammography sensitivities are reported to be significantly lower in patients with dense breasts than in patients with fatty breasts (29, 30, 31).
Currently, 43-46% of American women aged 40 or older have dense breasts (2). In a case-control analysis of Dutch mammography screening data, a 41% reduction in mortality among women with non-dense breasts was demonstrated, compared with a 13% reduction among women with dense breasts (32). , likely reflecting both the effect of breast density a on risk and its cancer-masking effect (sensitivity). Therefore, if an equitable screening approach is desired (as outlined in the Task Force document), patients with dense breasts should have access to additional screening so that they can receive the benefits of screening in a manner more consistent with those of patients with less dense breasts. .
The Working Group did not consider annual screening mammography to be particularly important in women with dense breasts. Annual screening in this population reduces the risk of interval cancer. By increasing the time between screenings, interval cancers have more time to grow and grow, which tends to be more aggressive and lead to worse outcomes.
The task force incorrectly lumps women with dense breast tissue into recommendations for average-risk women, but women with dense tissue are at higher risk than average. Furthermore, the Working Group did not take into account the combination of risk factors; Women with dense breasts and a family history of breast cancer or other risk factors currently meet criteria for additional screening with MRI, in addition to mammography, as outlined by the ACS, NCCN, and ACR .
Promoting compliance to save lives
Offering feedback on compliance, the statement provides perspective on the challenges women and practitioners will face in the future, through this feedback.
“In the United States, compliance with testing guidelines is well below 100%, whether from the USPSTF or other national organizations. Therefore, a major focus of the USPSTF recommendation statement should recognize this lack of compliance and urge those women and health care providers who choose to accept the USPSTF recommendations to follow them as presented, in particular not to consider a biennial recommendation as equivalent to screening every 2.5 or 3 years, and not to take into account the annual recommendation for women aged 40 to 49 who choose to do so. be screened as equivalent to screening every 1½ to 2 years.
The joint ACR/SBI statement ends with these comments:
“We recognize and appreciate that this comment period is designed to receive feedback on concerns regarding the draft breast cancer screening guidelines. As no experts in breast cancer were involved in the development of the guidelines, we hope that those of us who are satisfied experts in this field will highlight, through this document, that some of the findings of the USPSTF are incorrect. Please consider our comments seriously as we believe that some of the task force’s findings and recommendations may have a negative impact on public health.
Given that the biennial screening recommendations are based on the committee’s judgment, we suggest that it be made abundantly clear to women in the United States that the greatest number of lives saved results from an annual screening strategy beginning at 40 years old for the average. woman at risk. Women should be informed that there are risks of non-screening or delayed screening, or even death. We suggest that the appropriate recommendation is: “Since most lives are saved, women should begin annual screening at age 40, unless they place a higher value on the risks potential of screening, and this choice should be individual. » Recommendation B).'”
More information: www.acr.org
Coverage of breast legislation:
Working group releases new draft recommendation statement on breast cancer screening
ACR/SBI Statement on New USPSTF Breast Cancer Screening Recommendations
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