Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer FREE

TO THE EDITOR:

The USPSTF (1) recently recommended against routine mammography screening in women aged 40 to 49 years. The recommendation was based on the relative probability of unscreened women dying of breast cancer and the reduction in mortality provided by mammographic screening. On the basis of these studies, the USPSTF issued a blanket recommendation against routine screening mammography in all women aged 40 to 49 years.

The USPSTF study lacks evidence to support a reduction in mammography screening in African-American and Latino women who are younger than 50 years (1). The USPSTF study analyzed the risk–benefit ratio of mammography as a function of a woman's age but did not consider the potential contributions of race and ethnicity (1). Investigators did not state the racial and ethnic composition of study participants and did not analyze the risk–benefit ratio of mammography in African-American and Latino women (1). It is concerning that the USPSTF issued a one-size-fits-all recommendation on breast cancer screening without considering whether the recommendation is appropriate for all women.

Our current recommendations for mammography screening are based on studies in European, European-Canadian, and European-American women. Eight randomized trials (2) studied the effectiveness of mammography in the United States, Sweden, Canada, and the United Kingdom. These studies balance the relative contributions of mammographic density (sensitivity and specificity of mammography) and the mortality rate from breast cancer (2). To our knowledge, there has been no large-scale analysis of the effectiveness of mammographic screening in African-American and Latino women.

Studies of mammography screening in women aged 40 to 49 years are complex because younger women have a lower incidence of breast cancer; denser breast tissue (which can lower sensitivity); and on average, faster growing, biologically aggressive cancer. Relative to European-American women, African-American women have lower breast density, faster-growing cancer, and a higher likelihood of dying to breast cancer (3 - 5). Because the mortality rate from breast cancer in African-American women is higher and mammographic density is typically lower, the benefit from mammography screening is probably higher in African-American and perhaps Latino women than in European-American women. So where is the evidence to recommend against routine mammography screening of African-American and Latino women younger than 50 years?

We agree with the USPSTF that change is needed. But the change we call for is the end of one-size-fits-all recommendations and the inclusion of African-American and Latino women in clinical trials testing the benefit of mammographic screening.

Victoria L. Seewaldt, MD

Duke University

Durham, NC 27708