What Women Should Now Do About Mammograms

What happens if cancer-screening recommendations start to change but doctors and patients refuse to adopt the new standards?


The U.S. is about to find out. A fierce debate is raging over whether healthy women in their 40s should get annual mammograms as they've been told to do for years or if they would be better off forgoing the screening ritual until they turn 50, at which point new guidelines suggest they cut back to every other year.


Fears quickly spread that Medicare and private health insurers would use the new recommendations to reduce coverage for mammograms, bringing swift action from female lawmakers.


On Thursday, an amendment to the Senate's health-reform legislation that would require insurers to cover women preventive services, including mammograms, with no patient co-payments passed narrowly with a vote of 61 to 39. The amendment, offered by Sen. Barbara Mikulski (D-Md.), is estimated to cost $940 million over the next 10 years.


The U.S. Preventive Services Task Force, a government-appointed panel of experts that review scientific data to make evidence-based recommendations for patients' primary care, touched off a firestorm Nov. 16 when it updated its breast-cancer recommendations to say the harms from routine screening mammography generally outweigh the benefits for most women in their 40s and that women age 50 to 74 should cut back to having a screening mammogram every other year instead of annually.


The panel also concluded that research is insufficient to recommend for or against screening in women 75 and older.


The panel said women in their 40s are often disproportionately harmed by false positives and the anxiety and overtreatment those erroneous test results can command. Women accumulate radiation exposure from multiple mammograms and are sometimes subjected to needless biopsies that also can raise their risk for the disease.


The USPSTF clarified its position Wednesday during a hearing before the House Energy and Commerce Committee and called its previous communication "poor."


"Women age 50 to 74 should have mammography every other year," the task force's chair and vice chair, Ned Calogne and Diana Pettiti, testified. "The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms."


The panel's recommendations don't sound as radical now that it's emphasizing an individual approach as opposed to a blanket recommendation against mammograms for women in their 40s. But the issue is far from resolved. Another leading authority, the American Cancer Society, or ACS, still urges all women age 40 and older to get a mammogram every year.


The task force "is telling women that mammography saves lives--just not enough of them to recommend that all women over 40 get screened," ACS Chief Medical Officer Dr. Otis Brawley said at the hearing.


The panel's analysis showed that 1,904 mammograms need to be performed in women age 40 to 49 over 10 years to prevent one breast-cancer death. But mammography also fails to detect some cancers, and scientists increasingly say it picks up some that grow so slowly that they may not go on to cause harm, possibly resulting in grueling treatments such as surgery, radiation and chemotherapy that aren't needed.


"Mammography screening is not perfect," Brawley said. "Women deserve a better test, but in the meantime we must stop sending messages that a screening and early detection test is of little or no value."


What Now?




The discrepancy in guidance leaves many midlife and older women unsure how to proceed.


"It suggests to women that we in the medical field may not know what we're doing," said Dr. Brett Parkinson, a fellowship-trained breast radiologist and medical director of the Breast Care Center at Intermountain Medical Center, the flagship facility for Intermountain Healthcare in Salt Lake City.


Parkinson said he respects the panel's expertise and agrees with its methodology, but he disagrees with its recommendations.


His advice: "Disregard the new guidelines until there is further corroboration," he said. "My recommendation is to begin annual screening mammograms at the age of 40 [and continue] until you reach an age when you would do nothing if you knew you had cancer."


He was speaking of women with no special risks for breast cancer. Those who have a first-degree relative, meaning a mother, sister or daughter, with the disease and those who know they have a BRCA gene that greatly increases their risk often should begin screening earlier, Parkinson said.


The panel overestimated the harms from routine mammography since many resulting biopsies are no longer the invasive surgical kind, which entail more health risks and set women up for more surgery than may be necessary, he said. A few years ago, Intermountain set a goal of doing at least 90% of its breast biopsies using the needle method.


"The gold standard now is core-needle biopsy for suspicious findings as opposed to open surgery where the patient goes to the O.R., has general anesthesia and runs up a huge bill," he said.


Hitting A Nerve




For many women, the new guidance went over like a lead balloon. Three out of four age 35 to 75 disagree with the panel's mammogram recommendations, with 47% of those saying they strongly disagree with them, according to a USA Today/Gallup poll of more than 1,100 women fielded Nov. 20-22. Another 22% said they agree with the recommendations, but only 5% of them strongly agreed.


The survey also revealed a robust distrust of the panel's motives. A whopping 76% of women said they thought the task force came to its conclusions mostly because of potential cost savings to the health-care system. Only 16% said the recommendations reflected a fair assessment of mammograms' health risks and benefits.


Members of the USPSTF say cost and cost-effectiveness weren't part of their analysis. But even doctors who disagree with the panel's conclusions say cost needs to be a consideration.


"Screening has to be cost-effective," said Dr. Andrea Sikon, director of primary care women's health for the Cleveland Clinic, which isn't changing its mammogram recommendations based on the new guidance.


"That's something I think we have to admit, but I don't know we have that information to say 'We should take it away; it's not cost- effective'" in the case of annual mammograms.


Breast cancer is the second-leading cause of cancer death among women after lung cancer.


Accounting For Uncertainty




The panel is right to count patient anxiety as one of routine mammography's harms, Parkinson said. "Many women who get called back [for further testing] think it's a death sentence and they're quietly planning their funerals."


The good news is the waiting time between when a patient has an abnormal mammogram and when she's called back to pursue it has improved in the last few years, he said. About 5% to 10% of women will get called back, Parkinson said, and Intermountain tries to get them back within two working days of an abnormal report.


"If you're waiting several weeks for a diagnosis of breast cancer, that could be very traumatic," he said. "But when you reduce the time the patient is anxious from a few weeks to a few days, you're doing that patient a real service."


Parkinson said the uproar over the new guidelines serves as a "wake-up call" to doctors and health systems that are resistant to tracking their patients' results and experiences.


"We need to minimize the number of patients we call back unnecessarily by educating ourselves, the way we read the films, and constantly striving to improve," he said. "It's incumbent upon the radiology community to get better."


For Sikon of the Cleveland Clinic, "the biggest controversy is no screening for an entire decade for women who would have the most aggressive cancers," she said of pre-menopausal women in their 40s. "That's a big leap."


Still, she acknowledged that mammograms, which so far offer no alternatives proven to work as well, have drawbacks.


"I tell women you're more likely to get an abnormal mammogram the younger you are," Sikon said.


"We do know mammography has reduced breast cancer rates and has reduced cancer mortality from it. The thing is, it's probably not true for all women," she said. "That's the whole next generation of medicine: Understanding our genes and why 100 people are all going to behave in this way [with cancer] but one person is going to behave in this other way."


Efficacy Oversold?




The data on mammography is confusing, and the controversy over what to do about it goes back nearly 40 years, said Dr. Robert Aronowitz, an internist and professor of the history and sociology of science at the University of Pennsylvania in Philadelphia.


"There's a whole momentum that's been built up that's spread a lot of fear and oversold the efficacy of our prevention and treatment efforts," he said. "That's made it hard to pull back from things like evidence that shows mammography in [women in] their 40s doesn't work very well."


Breast cancer in women under 50 is often more idiosyncratic, and some that's detected in this age group can afford to be left alone, said Aronowitz, author of "Unnatural History: Breast Cancer and American Society."


"It turns out screening mammography for women in their 40s relative to women who are older picks up too many of these cancers that ultimately will not harm you," he said.





"Some women's cancer looks like it has this potential for later metastasis [spread], but even though it looks that way to a pathologist, it will not behave that way. That's the problem--that it doesn't behave according to that script that seems so logical."


"This is our state of knowledge now, and because of that we're going to do a lot of unnecessary treatment on people," he added.


Aronowitz understands the desire to exert some control over cancer but said having more knowledge doesn't always bring that power. He used himself as an example, saying he goes out of his way to avoid being tested for his prostate-specific antigen (PSA) level, the equivalent and emerging cancer-screening controversy for men.


"The data in the aggregate sense shows it's not very effective," Aronowitz said. "I also know psychologically it's easier not to have PSA test knowledge than to be told 'By the way, your PSA is high' and resist getting a biopsy and ultrasound. I'm totally empathetic to women in their 40s."


http://online.wsj.com/article/BT-CO-20091204-705761.html

I would ignore the contentious debate going on in US and just continue getting them done as before. After all, the cost of this test is certainly worth every cent if it can help save a life.