1.  Q.  What are the goals of the “40 not 50” campaign?

  • To motivate every women to start yearly mammographic screening at age 40 (earlier if high- risk: 8) and to make certain insurance companies cover the cost. (Link to narrative: drop down 1)

2.  Q.  Who is recommending that women start screening mammograms at age 50?

3.  Q.  Who is the USPSTF?

  • A government appointed task force of primary care physicians and non-physicians.  Of note, no breast care specialists (radiologists, surgeons or oncologists on committee)

4.  What are the “stated goals” of USPSTF?

  • The stated goal is to establish “evidence” based guidelines for medical care.

5.  What are the real goals of USPSTF?

  • Cost containment: It appears that they are prepared to throw young women under the bus in in an effort to control spiraling health care costs. 

6.  What organizations are recommending that screening start at age 40?

  • The National Comprehensive Cancer Network (NCCN) is an alliance of 27 of the world’s leading cancer centers and is focused on improving the quality and effectiveness of cancer care.
  • Mayo Clinic: http://www.mayoclinic.org
  • American College of Radiology: http://www.acr.org
  • Society of Breast Imaging: https://www.sbi-online.org
  • American Cancer Society recommends starting yearly screening at age 45.  They suggest that women between the age of 40 and 45 discuss the screening options with their doctors (the problem is that most doctors do not have the time to discuss this subject) http://www.cancer.org

7.  What is the evidence that starting yearly screening at age 40 saves lives?

Multiple studies have proven beyond a shadow of doubt that starting yearly screening at age forty reduces breast cancer deaths by 30% or more

New breakthroughs in imaging technology give us the potential to reduce breast cancer mortality by more than 50%  (link to MRI, U.S.  3-D mammography).

8.  How could the USPSTF justify coming to such an illogical conclusion:

They don’t provide an explanation, but the only logical explanation for how the committee came to this conclusion is that they placed more weight on a flawed Canadian study (link) than they did on the many studies that show benefit for starting at 40.

9.    What do we mean by flawed Canadian study

The study concluded that 22% of breast cancers would have spontaneously disappeared if they had not received a mammogram, despite the fact that there has never been a documented case of a breast cancer disappearing without standard treatment

10.  What is the explanation for this seemingly preposterous conclusion

After 25 years of follow-up there was an equal number of deaths for women who received a mammogram as compared to the groups that did not receive a mammogram.  However there were more breast cancers in the mammography group.  In fact, they concluded that there were 22% more cancers in the mammography group.

11.  What are the flaws that lead to this absurd conclusion?    

Two basic flaws:

 1.  Used outdated equipment and poorly trained doctors and technicians. 

 2.  Allowed more women with suspicious breast lumps to go into the arm of the study in which they would receive a timely mammogram as opposed to what they described as “usual care in the community” (i.e. treatment delay)

12.  What are the other reasons the task force uses to justify their conclusions?

Over Diagnosis/over treatment:  The committee concludes that many breast cancers are diagnosed that will never cause harm to patients.  This is true for elderly patients who are diagnosed with small low-grade cancers and some non-invasive cancers (DCIS) (see link to first Canadian study).  However, it does not apply to women in their 40s.  Even low grade non-invasive cancer in this age group will progress to invasive cancer over time and thus represents a threat to survival.

False positive biopsy:  The committee points out that young women have a higher incidence of false positive biopsies than older women.  A false positive biopsy means that a spot was seen on the mammogram, but on biopsy it proved not to be a cancer.  It is true that young women are more likely to have a false positive than older women, but most young women are willing to accept the risk of such a biopsy if it is part of a strategy to ensure early detection of breast cancer. 

Emotional distress:  In addition to the cost involved in having a false positive biopsy, the committee points out that there is a great deal of stress involved in going through the process of having a breast biopsy.  Unfortunately, the committee does not comment on the stress associated with a delayed diagnosis of breast cancer.

13.  Should every women start screening at age 40?

No.  High-risk women like those with strong family histories of breast or ovarian cancer or a history of chest wall radiation at a young age should start earlier (these women should be followed in a high-risk clinic).  The general rule is that women should start screening 10 years earlier than the age their first-degree relative was diagnosed with breast cancer.  In other words, if your mother or sister was diagnosed at age 45, you should start yearly screening at age 35. 

 14.    How do I know my risk of developing breast cancer?

Every woman is at risk and the risk increases with age.  By age 50 approximately 1 in 43 women will develop breast cancer.  By age 80, the risk is 1 in 8.  Of note, 75% of women who develop breast cancer have no family history of breast cancer.
http://www.breastcancer.org/symptoms/understand_bc/risk/understanding).

Some women are at higher risk and knowing your family history is the key to understanding your risks.  Women with a family history of breast or ovarian cancer should consider risk assessment to determine if genetic testing or more aggressive early detection efforts are indicated.

15.  Does Breast Density influence my risk of developing breast cancer?

Breast density is not only a risk factor for the development of breast cancer, it is more challenging to make the diagnosis of breast cancer in women with dense breasts.

It is for this reason that we recommend that women with dense breasts consider additional imaging.  For average risk women we recommend whole breast screening ultrasound.  For high-risk women we recommend yearly screening with breast MRI.

16.  How do I know if I have dense breasts?

In most states it is standard policy to report density status on the mammogram

report.  Unfortunately, most doctors do not have the time to discuss density status and screening alternatives with their patients.  It is therefore important for all women to be proactive about knowing their density status.

17.  What can I do to lower my risks?

The simplest answer is:  exercise, exercise and more exercise.  Proper diet and weight control are also important as well as limiting alcohol intake  (recent studies suggest that more than three drinks a week are associated with an increased risk for breast cancer).  There is also evidence that smoking is a risk factor.  Although recent studies indicate that estrogen replacement during menopause is safe, there is evidence that taking estrogen along with progesterone (for women with an intact uterus) for more than four years increases breast cancer risk.

18.  What is new in early detection of breast cancer?

3-D Mammography:  This new technology provides a 3-D image of the breast.  This technology is not only more effective in detecting small breast cancers than standard 2-D imaging, but it decreases the need to take additional images of the breast.  Its primary benefit is in women with dense breasts.

Whole breast screening ultrasound:  This new technology can detect small cancers missed on the screening mammogram.  It is safe and relatively inexpensive.  It is primarily used in women with dense breasts.

Breast MRI:  The breast MRI is the most accurate tool we have to detect small cancers that are not seen on the mammogram.  Because of its cost, it is generally restricted to women who are at high-risk of developing breast cancer.

19.  Should I consider genetic testing?

Until recently, genetic testing was limited to women like Angelina Jolie who had very strong family histories of breast or ovarian cancers.  At the time of Angelina’s diagnosis the cost of testing was in the range of $4,000 dollars.  Now the cost has drop to $249.00 dollars and some experts, like Mary Clair King who discovered the BRCA1 gene, are recommending that all women by age 30 should consider the option of gene testing.

20.  What can I do to support 40 not 50?

Sign our petition  Tell your Friends.  Send us you ideas, comments and suggestions.  Tell us your story.  We are hoping for 1 million signatures before the end of the year.