Mammography debate: Local doctors weigh in

By Suzanne Wilson
Staff Writer

Published on November 27, 2009

Front-page stories last Tuesday carried the news: "Mammogram advice revised: Start at 50," the Daily Hampshire Gazette piece from the Associated Press said. "New Guidelines Suggest Fewer Mammograms: Reversal on Screening," said The New York Times.

By Wednesday, newspapers and TV broadcasts were featuring dueling doctors and confused and angry patients going back and forth about new recommendations for breast cancer screenings.

A government-funded task force, after evaluating numerous studies, said most healthy women with no risk factors for breast cancer could start getting mammograms at 50, not 40 - and that they could get them every other year, instead of annually. The task force also said that current evidence was "insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older." And it suggested that doctors should stop teaching women to examine their own breasts, citing evidence that self-exams do not reduce breast cancer mortality.

By Thursday, the recommendations had become a political football, with Republicans in Congress citing them as harbingers of disasters to come if the health care reform bills pushed by the Obama administration pass. Reform, their argument went, would mean government bureaucrats would ration care and take life-saving mammograms away from women who need them.

Many advocates for women's health who have lobbied for years for more money and research to fight breast cancer, such as the Susan G. Komen for the Cure organization, were equally up in arms. The American Cancer Society, citing the task force's own statistic that annual screenings for women under 50 reduce the risk of death from breast cancer by 15 percent, said it would continue to back annual mammograms for women 40 and over.

In an effort to quiet the uproar, Health and Human Services Secretary Kathleen Sebelius said the panel's doctors "don't determine what services are covered by the federal government. I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this decision."

By Friday, the emerging consensus seemed to be that the recommendations would wind up having little or no immediate impact. In an effort to clarify the advice of the panel - the United States Preventive Services Task Force - its vice chairman, Dr. Diana Petitti of Arizona State University, said it was not against mammograms for women in their 40s, but that it wanted to empower women, with their doctors, to make their own decisions.

In a statement that seemed guaranteed to please no one, Petitti told The Wall Street Journal, "we probably, in retrospect, could have been more clear."

By the numbers

So where did that leave things? It left doctors in this area, at least those who were the first to speak out, saying they would still urge women to get annual mammograms, starting at 40.

Dr. James Donnelly, chief of radiology at Cooley Dickinson Hospital in Northampton, predicted that the weight of the medical research and the clout of the pro-screening advocates would prompt the majority of physicians - and insurers - to continue urging, and paying for, the annual screening of women in their 40s.

At the hospital, he said, the numbers show that, between 2000 and 2008, 128 breast cancers in women between 40 and 49 were diagnosed by mammography. That's 23 percent of all the cancers detected that way, Donnelly said. "If we believe that catching breast cancer at the earliest stage is going to save lives, why would we wait until 50 to catch that 23 percent? That's the bottom line."

Donnelly said he questioned the quality of some of the studies the task force had looked at in making its recommendations. But he also said the furor over the recommendations did indeed reflect a truth: that is, that the medical establishment, including the American Cancer Society, has oversold mammography to the public, talking far more about its strengths than its drawbacks.

On the plus side, the advent of digital technology means sharper images and more accurate detection, he said. That said, mammograms are still far from perfect, with about 10 percent of them resulting in the patient being called back for more rounds of tests that often show there was no cancer after all, said Donnelly. The whole process can be unpleasant and frightening, he added, "and women understandably hate that part of it."

Radiologists aren't looking at images that come with "a little sign and an arrow" pointing to cancer. "You have to make your best educated judgment," said Donnelly. Radiologists sometimes liken reading mammograms to trying to find "a snowball in a snowstorm," he said. There are some you look at and you're 99 percent certain it's cancer, he said, but the line between normal and abnormal tissue is often hard to discern. And yes, some cancers get missed - all the more reason, in his view, to oppose any change from annual to less frequent screening. "Everyone has a memory of a breast cancer they wish they had not missed," Donnelly said. "No doctor or radiologist is perfect."

Whether a screening mechanism will come along that's more accurate, more comfortable and more cost-effective is impossible to know now, he said: "I don't have an answer for that."

News of the suggested guidelines left her initially "dumbfounded," said Dr. Sue Silverstein, who, as an ob/gyn in Northampton, refers patients for breast cancer screening. "I will tell patients that I disagree" with the suggestions, she said, and will continue to urge screening at 40. Patients, so far, seemed to agree. Several already had told her that changing the current practice struck them as "ridiculous," Silverstein said.

"It's a very emotional issue for many people," said Dr. Edward Patton, an ob/gyn in Hadley. But in the end, it's still for the most part true, he says, that earlier detection means more treatment options for the patient and a better chance of good results. "Honestly, no," he said, "I won't change my recommendations."

One story

The voices of women within that 40 to 49 age group have been among the strongest raised in recent days.

"What were they thinking?" asked Valerie Schumacher, 49, of Florence. Schumacher discovered a cancerous lump in her breast by doing a self-exam - the same procedure the panel gave short shrift to - in August. And just within the past year, she says, she's known several other women in their 40s diagnosed with breast cancer.

She's baffled and incensed, she says, by the panel's observation that scaling back on mammography would reduce the anxiety that false positive findings can trigger. "They talk about this great anxiety," she said of being called back for tests. The real anxiety is finding out you do have cancer, she says. Her advice: Get the mammogram.

Schumacher, who is currently undergoing chemotherapy treatments at Cooley Dickinson, urges women to do breast self-exams, even if the studies say few cancers are detected that way. "It only takes five or 10 minutes of your life to check around," she said. If she hadn't examined her own breasts, she says, it's possible that her cancer might have spread further before being discovered.

The oncologists

Two days after the task force recommendations had come out, oncologist Deborah Smith said she had already seen patients in her Florence office who were "outraged and livid" at the notion that women between 40 and 50 should be left hanging.

"I'm advising my patients to stick with the older guidelines at this point," said Smith. "I've seen too many young women diagnosed with breast cancer whose lives were saved by intervention." Young women, she added, with no family history of breast cancer who are often surprised to discover, contrary to widespread popular belief, that most breast cancer patients don't have that risk factor. "I run up against that misconception all the time."

Smith says that the task force noted that annual screening beginning at 40 can lead to what's called "over treatment" - which means that some cancers that are currently treated are so slow-growing and "sluggish," in Smith's word, that they would cause no harm during the woman's lifetime. The problem, she said, is that "we're not anywhere near there yet," in being able to tell the difference. In sum, she said, concerns about over treatment are irrelevant for any young woman diagnosed with breast cancer. "No doctor is going to say, let it stay there. It's all going to come out."

Which can't happen unless it's detected.

Smith said she was concerned about reports that the radiology department at Cooley Dickinson was getting calls from women canceling mammogram appointments. Asked about that, hospital spokesperson Trinchero said there had been some cancellations and no-shows, but the reasons for them weren't documented; November is traditionally a lower-volume month, she said.

Smith says she worries that some women will seize on the news about the guidelines to avoid getting screened. "A lot of women already find them physically unpleasant and very uncomfortable," she said of mammograms. She's had patients - even patients who have already endured surgery and chemotherapy for other types of cancer - who have yet to get a mammogram.

Dr. George Bowers, a Northampton oncologist, said he also took issue with the panel's statement on mammograms for elderly women. The panel said that current evidence was "insufficient" to assess the benefits and risks of screening mammograms for women over 75. Decisions about older patients should be made individually, Bowers says, taking into account the patient's overall health, the chronic diseases she may be dealing with, her level of frailty, her cardiac health and so on.

Bowers added that, even if the motivation for considering fewer mammograms for those under 50 and over 74 was to save money, the logic of that approach is flawed. "The costs of mammograms and biopsies is less than allowing a cancer to spread and treating it then," he said - not to mention the suffering and anguish of the patient. And finally, Bowers says, the recommendation that doctors not teach patients about breast self-exams is perplexing. It's still the case, he says, that 10 percent of cancers don't show up on mammograms, so why not encourage patients to use self-exams as well? "It doesn't cost a thing," he pointed out.

At the Holyoke Medical Center, Dr. Zubeena Mateen, the director of oncology, says she is "wholeheartedly against" a change in screening guidelines and that she has no intention of altering the advice she gives to patients. Mateen says the percentage of cancers in patients under 50 at the Holyoke hospital is, as at Cooley Dickinson, about 20 percent. And, she adds, breast cancers in the 40 to 50 age group tend to be more aggressive - all the more reason to find them early.

Asked if she thought the task force proposals would encourage insurers to question mammogram payments for patients under 50, Mateen says doctors would just fight even harder for their patients than they already are. "We'll try to get around it," she said. "It's the right thing to do."

Deborah Smith called worries about insurance coverage down the road "a huge concern. We find month by month that the amount of hoops we have to jump through has just become overwhelming. It's clear everyone is feeling pinched and the insurance companies are tightening the screws." But the political argument that the task force guidelines will lead to rationing overlook the fact, says Smith, that we already have a form of rationing. Many women in this country get no breast cancer screening at all because they are uninsured or underinsured. "They wind up getting the short end of the stick."

On the other hand

Though criticism of the guidelines was swift and passionate, there were some who struck a different note. One of the best-known was Dr. Susan Love of California, author of "Dr. Susan Love's Breast Book," first published in 1990, and now head of a Santa Monica-based research foundation that bears her name. The entire question of screening, she wrote in a lengthy statement on her Web site, "is not as simple as we would like to believe ... The problem with mammography for women under 50 is that it doesn't work very well." The greater density of breast tissue in women under 50 makes detection difficult, she wrote. Moreover, some cancers are slow growing and some are so aggressive that they've spread before they will ever show up on a mammogram. Mammography, she wrote, "is not a good tool for finding breast cancer in younger women and we need to put our efforts to finding something better."

Several advocacy groups - among them, the National Breast Cancer Coalition, Breast Cancer Action and National Women's Health Network - said the guidelines were the result of an effort to take emotion out of an extraordinarily complex subject.

In a statement on the San Francisco-based Breast Cancer Action's Web site, director Barbara Brenner noted that "Debates about who should have screening mammograms - those given to women with no breast symptoms - and when are not new to longtime followers of BCA's work. Our position has long been clear: Women who are pre-menopausal should not have regular screening mammograms, and everyone should know the benefits and risks of all screening methods (mammograms, breast self-exam, clinical breast exam) and make the best decisions for themselves."

Appearing Sunday on "Meet the Press," Dr. Nancy Snyderman, NBC's chief medical editor, said the job of the task force was to focus on studies and numbers. Having done what they were asked to do, she said, its members had been summarily "thrown under the bus."

The task force

The panel that devised the guidelines is the United States Preventive Services Task Force. Billed as an independent panel of private sector experts in prevention and primary care, the task force was set up in 1984 by a physician then serving in the Reagan administration. The idea was to fund a group that could operate outside of government to review ongoing research and data in an effort to determine how well certain strategies to combat disease actually worked. It was, in fact, the same task force that in 2002 suggested beginning mammography at 40.

This time around, the task force, after looking at various studies and statistical models, reached a different conclusion. The numbers show, it said, that for women between 40 and 49 one breast cancer death is prevented for every 1,904 women screened; between 50 and 74, it's one death prevented for every 1,339 women screened, and one death prevented for every 377 women from 60 to 69. It also called radiation exposure "a minor concern" but also a consideration.

Some of the debate in recent days centered on numbers. In fairness to the task force, it's really up to society at large to decide what the statistics mean, says Deborah Smith.

"One out of 1,900 - the yield is relatively low," she said. "Is one out of 1,900 worth it? Certainly it is if you're the one - and I do see the women for whom it was a life-saving test. ...

"But that's where you get in this whole murky area. If it was one life saved out of 50,000 women screened, we might say, well, that's not a wise use of resources. So where are you going to allocate your resources? We've sort of ignored that question because nobody wants to have their health care ratcheted back. That's the part of that discussion that's sort of been danced around. At what point is the expenditure worth the gain?"

The surgeon

As she came out to talk with a reporter after an afternoon of surgery, Dr. Brigid Glackin of the Holyoke Medical Center was still wearing her scrubs and carrying copies of the guidelines report published in The Annals of Internal Medicine.

She wanted to delve into the latest recommendations more deeply, Glackin said, before commenting on them in detail. On balance, though, she said, it's not bad for patients to hear about debates that used to be more tightly contained within the medical community, and it's not harmful for women to learn about the limitations of mammography as well as its benefits.

Glackin said that the practice of medicine is hardly static. In the late 1980s, she said, citing just one example, many doctors and health care organizations urged women to get what were called "baseline" mammograms at around age 35. But by 1992, the American Cancer Society had dropped the recommendation.

New ones came along - in 1993, 1997, 2001, 2002, 2007, 2008 and last week - from the American Cancer Society, from the National Cancer Institute, from studies done in Europe, from the American College of Physicians, and now from the Preventive Services Task Force.

What she was already certain of, Glackin said, was that we haven't heard the last about mammograms. "This starts the conversation," she said.

Suzanne Wilson can be reached at swilson@gazettenet.com.