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ROCHESTER, Minn. — Calling it "a serious gap in public health policy," and "a lack of one message nationally," a team of researchers has learned that when it comes to screening for breast cancer, just one in three states are fully consistent with expert evidence-based recommendations in their state cancer plans.
"What we found was that across the cancer plans for 50 states and Washington, D.C., not half of them actually met the recommendation that comes out of the U.S. Preventive Services Task Force," says lead author Dr. Norma Kanarek of the Department of Oncology, Johns Hopkins University School of Medicine.
All states participate in state comprehensive cancer control planning, posted strategies funded by the Centers for Disease Control and Prevention which are intended to establish an integrated, evidence-based response to combating cancer tailored to statewide rates of cancers.
Insurance coverage of cancer screening is tied to the recommendations of the U.S. Preventive Services Task Force, which recommends that average risk women undergo biennial mammography screening between 50 and 74, and that women at higher risk consider beginning at 40.
The study, published earlier this month by a team of researchers from Johns Hopkins in the journal JAMA Network Open, found that 16 of 51 plans, or 31%, fully met these three criteria. Nine, or 18%, met no part of the criteria, and 26, or 51%, only partially met the criteria.
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Asked via email to comment on Minnesota's plan, Kanarek said it "is neither specific about its guidance nor what the guidance is," with objectives oriented toward insurance, and which "do not mention the target age or frequency of screening."
The greatest departure in state cancer plans from the best evidence were among those plans that advised average risk women to start at 40, as well as those that did not advise women to stop at 75, both of which the benefits are not known to exceed the harms.
The authors say their results reflect a longstanding debate over the complex question of who best to screen for breast cancer and when, a question often overlooked in the belief that more screening, earlier and longer, has no negative consequences.
The researchers wrote that their findings effectively meant "that neither the general population nor any high-risk sub-population is benefiting from the current knowledge base for age and frequency of appropriate screening."
"With screening we always want to be able to screen to find a disease that we can treat," Kanarek said in an interview, "and one that treatment will improve lifespan or quality of life."
"With the 40 to 49 year old group for instance, there isn't evidence that screening will change your outcome," she said. "That's where designating high risk populations makes a difference."
The authors wrote of their findings that "the ages at which women should start and end mammography examinations and the frequency of mammography examinations have been a matter of political, emotional, and scientific debate for three decades."
"There are politics that get in the way," Kanarek said, "cultural factors, and even affordability ... I think there is a lot of advocacy with breast cancer. We're kind of conditioned as a society to think more is better, so if you get more screening, of course you will be safer, because your cancer will be detected even earlier."
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"But I think as we've seen in prostate cancer, we kind of overdid it with screening. Men are screened sometimes without their knowledge using the prostate-specific antigen test. PSA is not a very good test to begin with. It doesn't detect cancer well and especially aggressive prostate cancer."
"We've helped women become advocates for their own health ... (but) sending women back to their doctors to talk about it is taking it out of the public sphere, and putting it back in the lap of medical people and individuals to look after health," she said.
Of her concern that high-risk women need to become a greater focus of cancer plans, Kanarek notes there are interventions beyond mammography for those at high risk.
"They could be recommended to do breast feeding," she said. "They could take aromatase inhibitors prophylactically. They could have mastectomy."
"I'm not advocating for any of these, but there's a number of interventions for high-risk women in addition to mammography. So women should know their risk profile."
