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New mammogram guidelines cause confusion

Posted November 16, 2009

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— For most of the past two decades, the cancer society has been recommending annual mammograms beginning at 40.

But the government panel of doctors and scientists concluded that getting screened for breast cancer so early and so often leads to too many false alarms and unneeded biopsies without substantially improving women's odds of survival.

"The benefits are less and the harms are greater when screening starts in the 40s," said Dr. Diana Petitti, vice chair of the panel.

The new guidelines were issued by the U.S. Preventive Services Task Force, whose stance influences coverage of screening tests by Medicare and many insurance companies. But Susan Pisano, a spokeswoman for America's Health Insurance Plans, an industry group, said insurance coverage isn't likely to change because of the new guidelines.

“It flies in the face of not only their own previous recommendations, but those of several other major national, international, professional organizations,” said Dr. Gary Lyman, a breast oncologist at Duke Hospitals.

New mammogram guidelines cause confusion Panel suggests changes in mammogram guidelines

Lyman participates in guidelines work with several different medical boards and societies. He fears the panel's recommendations will only confuse women.

“We know when confusing recommendations have come out in the past, it's led to a downturn in the use of services,” Lyman said.

"Our concern is that as a result of that confusion, women may elect not to get screened at all. And that, to me, would be a serious problem," said Dr. Len Lichtenfeld, the cancer society's deputy chief medical officer.

The guidelines are for the general population, not those at high risk of breast cancer because of family history or gene mutations that would justify having mammograms sooner or more often.

The new advice says:

  • Most women in their 40s should not routinely get mammograms.
  • Women 50 to 74 should get a mammogram every other year until they turn 75, after which the risks and benefits are unknown. (The task force's previous guidelines had no upper limit and called for exams every year or two.)
  • The value of breast exams by doctors is unknown. And breast self-exams are of no value.

Medical groups such as the cancer society have been backing off promoting breast self-exams in recent years because of scant evidence of their effectiveness. Decades ago, the practice was so heavily promoted that organizations distributed cards that could be hung in the shower demonstrating the circular motion women should use to feel for lumps in their breasts.

The guidelines and research supporting them were released Monday and are being published in Tuesday's issue of the Annals of Internal Medicine.

The new advice was sharply challenged by the cancer society.

"This is one screening test I recommend unequivocally, and would recommend to any woman 40 and over," the society's chief medical officer, Dr. Otis Brawley, said in a statement.

The task force advice is based on its conclusion that screening 1,300 women in their 50s to save one life is worth it, but that screening 1,900 women in their 40s to save a life is not, Brawley wrote.

That stance "is essentially telling women that mammography at age 40 to 49 saves lives, just not enough of them," he said. The cancer society feels the benefits outweigh the harms for women in both groups.

International guidelines also call for screening to start at age 50; the World Health Organization recommends the test every two years, Britain says every three years.

Breast cancer is the most common cancer and the second leading cause of cancer deaths in American women. More than 192,000 new cases and 40,000 deaths from the disease are expected in the U.S. this year.

Mammograms can find cancer early, and two-thirds of women over 40 report having had the test in the previous two years. But how much they cut the risk of dying of the disease, and at what cost in terms of unneeded biopsies, expense and worry, have been debated.

In most women, tumors are slow-growing, and that likelihood increases with age. So there is little risk by extending the time between mammograms, some researchers say. Even for the minority of women with aggressive, fast-growing tumors, annual screening will make little difference in survival odds.

The new guidelines balance these risks and benefits, scientists say.

The probability of dying of breast cancer after age 40 is 3 percent, they calculate. Getting a mammogram every other year from ages 50 to 69 lowers that risk by about 16 percent.

"It's an average of five lives saved per thousand women screened," said Georgetown University researcher Dr. Jeanne Mandelblatt.

Starting at age 40 would prevent one additional death but also lead to 470 false alarms for every 1,000 women screened. Continuing mammograms through age 79 prevents three additional deaths but raises the number of women treated for breast cancers that would not threaten their lives.

"You save more lives because breast cancer is more common, but you diagnose tumors in women who were destined to die of something else. The overdiagnosis increases in older women," Mandelblatt said.

She led six teams around the world who used federal data on cancer and mammography to develop mathematical models of what would happen if women were screened at different ages and time intervals. Their conclusions helped shape the new guidelines.

Several medical groups say they are sticking to their guidelines that call for routine screening starting at 40.

"Screening isn't perfect. But it's the best thing we have. And it works," said Dr. Carol Lee, a spokeswoman for the American College of Radiology. She suggested that cutting health care costs may have played a role in the decision, but Petitti said the task force does not consider cost or insurance in its review.

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  • RMC10 Nov 18, 2009

    (continued - because this is an important topic) The longer a woman has cancer the more money raised for cancer research funding big cancer institutes, big charities, and big pharma. A cancer diagnosis is a "life sentence" for the patient, always fearing, always testing, always treating, always taking medication, or another round of chemo and radiation, and often getting denied or dropped by insurance. Also because of the nature of this disease, the recurrence rate is very high. Women often don't die from breast cancer, but from lung, brain, bone cancer that it metastasizes to if even one cancer cell is missed or escapes during mastectomies or reconstruction. I think the new guidelines are about right. And, they don't forbid any screening. I recently had a non-flu vaccine. My insurance won't pay for it because it is just a CDC recommendation. It was important to me - I paid for it. Where is it written others need to pay for your health.

  • RMC10 Nov 18, 2009

    Women can get mammograms, they are not "forbidding" it. If it's important to your peace of mind get the mammogram, pay for it yourself if your insurance doesn't. Keep self checking,they're not saying you cannot. Most women don't do it correctly anyway, and monthly changes in the breast are a given. I believe that if there is a questionable shadow on the mammograms, doctors are eager to diagnose as possible cancer and start biopsies and even cancer treatment too quickly (to err on the cautious side). Studies I've read link the mere disturbing of those suspicious cells can cause more DNA damage to the cells and actually encourage the cells to morph, when they could heal themselves. I would always, always use a wait and watch protocol.They say cancer deaths are down as a result of mammograms in the past 20 years,that's skewing the data more than a little. Better chemo developed, and because of that women live longer with cancer moving cancer death ages out to 50+ the new magic standar

  • iamyeary Nov 17, 2009

    Whatever the "guidelines", it's my body and my decision for what's best for me and my family.
    I'd opt for later, because there is no cancer in my family history and I don't completely trust the benefits of the standard treatments anyway- JMO.

  • WXYZ Nov 17, 2009

    From what I can currently determine: (1) There are currently about 84 million women in the US over the age of 40--and the percentage of those over 50 is rapidly rising. (2) About 67% of these women have had a mammogram (mmgrm) at an average price of $102.00, in the past 2 years (about 57 million mmgrms) (3) about 83% of these mmgrms were initally or eventually interpreted as negative. (4) Virtually 100% of women who have a positive mmgrm, undergo 1 or more additional diagnostic tests (e.g. biopsy, MRI etc). (5) About 7% of women who received mmgrms, were diagnosed with breast cancer (BCA) (6) 95% of women with BCA are over 50 years of age. (7)

  • scientistjo Nov 17, 2009

    "Curious to see if government run healthcare would do the same." freedomrings

    One does not have to get gov't run healthcare, that's why it is called the public "option". Those who have zero healthcare now would be much better off getting the public option because right now they're choosing to wait until their cancer has spread before going to the doctor. But by then the risk of death is much, much greater.

  • freedomrings Nov 17, 2009

    My mother was diagnosed with cancer at the age of 47. Her *private* insurance paid for her mammogram and cancer treatment. I found a lump in my breast when I was 29. My *private* insurance paid for my mammogram and removal of the tumor. Curious to see if government run healthcare would do the same.

  • this is my Screen Name Nov 17, 2009

    No one is forcing any woman to go get a mammogram or do the self exam at any age. However, I feel very comfortable knowing that if I want to follow my doctor's advice to have it done, insurance will pay for it. Under this recommendation, that will not be available. Will they pay for breast cancer treatment if it is diagnosed in a woman under 50, or during the two year period that an older woman doesn't get a mammogram? Or will they call that pre-existing? It scares me to see what the health care plan is actually going to cover - or not.

  • dws Nov 17, 2009

    Anyone who has experienced the ravages of cancer will immediately denounce this insane recommendation. Having lost a good friend to cancer put the disease's horror directly in front of me.

  • annieaamrm Nov 17, 2009

    I agree with the new recommendation. Someone low risk should not be TOLD that I need to have mammograms every year. I've had one and of course they saw something and I had to go back... it ended up being nothing... I can imagine going through the hype every year.

    BTW, when did weight become a 'risk' for breast cancer? Must have missed that article.

  • maggieknowlya Nov 17, 2009

    WOW!!! No health care/insurance reform legislation has even passed and a government "panel" has already got their fingers in where they don't belong suggesting that we cut back on a crucial diagnostic. Give me a break.

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