Bloomberg recently reported a story that highlighted the recommendations of the U.S. Preventive Service Task Force on yearly mammograms for women aged 40 and above. According to the story, the guidelines released by the task force suggested that annual mammograms for most women in their 40s have more drawbacks than benefits and therefore, women should wait until age 50 to start getting breast cancer screening tests every two years.
November 17, 2009
Annual mammograms for most women in their 40s have more drawbacks than benefits, said a panel of U.S. doctors that recommended women wait until age 50 to start getting breast cancer screening tests every two years.
The change in guidelines released by the U.S. Preventive Service Task Force, a government-backed physician group, said women in their 40s are more likely to get false-positive tests that can lead to unnecessary biopsies and anxiety. The recommendations, which also said that self-examinations were unnecessary, don’t apply to women who carry a high risk for breast cancer. Those women should talk to their doctors about when to get screening, the panel said.
The new guidelines, published yesterday in the Annals of Internal Medicine, pit the task force against the American Cancer Society, which insisted doctors should still advise women to undergo routine annual screening starting at age 40. About 64 percent of women ages 40 to 49 had an X-ray of their breasts during the past two years, the panel’s report said.
“This is not a blanket recommendation not to worry until age 50,” said Diana Petitti, a disease epidemiologist at Arizona State University in Tempe, Arizona, and vice chair of the panel. “It’s a recommendation to have a discussion with your physician to better understand the trade-offs between starting exams now and starting later.”
Imaging machines for mammograms, and related supplies, are marketed by Fairfield, Connecticut-based General Electric Co., Bedford, Massachusetts-based Hologic Inc. and Munich-based Siemens AG.
J. Leonard Lichtenfeld, the American Cancer Society’s deputy chief medical officer, said the panel’s guidelines may affect insurance payouts. ‘Our hope is that insurers will not make any change in coverage,” Lichtenfeld said.
WellPoint Inc., the top U.S. health insurer by enrollment with 34 million members, pays for annual mammograms for women age 40 in the majority of its health plans. The Indianapolis- based company periodically reviews its reimbursement policies and “doesn’t adhere to any one source” for guidance, said Jill Becher, a company spokeswoman in Milwaukee.
The new guidelines, if widely adopted by physicians and insurers, could reduce the number of U.S. mammogram screenings by 58 percent, from the current 37.2 million annually to 15.6 million under a “worst-case scenario,” Junaid Husain, a Boston-based analyst at Soleil Securities, wrote in a note to investors today.
Mammograms, self-breast examinations, and doctor’s exams are the three main forms of detecting breast cancer. The task force said there was no evidence that self-exams reduce breast- cancer deaths, and insufficient information exists to recommend that doctors do routine physical exams.
The mammograms are used to check for breast cancer in women who have no signs or symptoms of the disease, and also to check for breast cancer after a lump or other signs of cancer have been found, according to the National Cancer Institute.
Breast cancer is the second-leading cause of cancer-related deaths among U.S. women, after lung cancer, killing 40,480 women in 2008, according to the task force report.
The task force analyzed published research and developed computer-simulation models to evaluate the likely health outcomes if mammograms were begun at certain ages and done every one or two years.
Deaths, False Positive Tests
The study confirmed earlier research that women who have mammograms die less frequently of breast cancer than those who don’t have the tests. About two deaths per 1,000 women are averted if women begin annual screenings rather than exams every two years starting at age 40, the task force estimated.
It also estimated that women who begin getting mammograms at 40 will have about 60 percent more false positive results per 1,000 exams than women who start screenings at age 50. A false positive, in which an abnormality is seen that proves not to be cancer, typically leads to additional screenings and tissue biopsies, the panel’s researchers said.
The cancer society challenged the reliability of the task force study’s methods.
“We are reluctant to recommend changing a proven program that has helped to save lives,” Lichtenfeld said. The society questions whether the task’s force computer modeling “is sufficiently sophisticated and accurate enough,” he said.
The recommendations aren’t intended for women older than 40 who have a higher risk for breast cancer. Increased risk can come from having a gene mutation linked to breast cancer or having been exposed often to chest radiation, which can raise the probability of breast cancer.
The task force said it didn’t make recommendations for these higher-risk groups because it lacked sufficient data to know the benefits of more frequent screening tests.
Women’s health groups varied in their responses to the new guidelines.
Susan G. Komen for the Cure, the Dallas-based breast cancer advocacy group, said it won’t change its recommendation that women ages 40 to 49 get annual mammograms. “We would not want to see a change in policy or reimbursement for screening mammography at this time,” said Eric Winer, the group’s chief scientific adviser, in a statement.
The task force’s recommendations were applauded by the National Breast Cancer Coalition, a Washington-based advocacy group, which said the guidelines support its position.
‘Deserve the Truth’
“Women deserve the truth even when it is complicated,” said Fran Visco, the coalition’s president, in a statement. “They can accept it.”
The American College of Obstetricians and Gynecologists rejected the task force’s recommendations, maintaining its guidelines that women in their 40s be screened every one to two years and women age 50 and older get annual exams, according to a statement issued by the group on Monday.
Researchers and physicians know that results from the X- rays aren’t as reliable in younger women as in older women. Women in their 40s typically have denser breast tissue, making it more difficult for technicians to determine if an image is normal or cancerous.
After women enter menopause, typically about age 50, the breast tissue becomes less dense and more fat, and the X-rays can be more accurately interpreted, said Susan Love, president and medical director of the Dr. Susan Love Research Foundation in Santa Monica, California.
The panel’s suggestions for women ages 40 to 49 are “long overdue,” said Love in a telephone interview. “Most countries in the world do not do mammography screening until age 50.”
“There is a lot of anxiety created when someone tells you that there is something that showed up in a test,” said Karla Kerlikowske, an epidemiologist at the University of California, San Francisco, Medical Center who wrote an editorial accompanying the task force report.
Subsequent exams expose women to more radiation, and although biopsies are “low risk,” some patients develop infections or experience pain and bruises, she said.
Screening women ages 50 to 74 every two years “achieves most of the benefit of annual screening with less harm,” the task force said. Now women in the older age group get a mammogram, on average, every 14 months, according to the report.
In forming its guidelines, the task force’s “biggest concern” was that women would be confused by conflicting advice from health experts or wrongly interpret the panel’s message as a blanket recommendation for those ages 40 to 49 to forego screening until they turn 50, Petitti said.
Instead, decisions by women younger than 50 and their doctors should be based on “the risk for breast cancer and preferences about the benefits and harms” the task force wrote in the study.
Although the recommendations are “very clear and thoughtful,” women are likely to be confused by the different advice of health experts, Kerlikowske said.
It may be difficult to persuade many women in their 40s who have been told by their doctors for years that annual screenings are beneficial to accept the panel’s recommendations, said the cancer society’s Lichtenfeld.
“The task force is saying you can get 70 percent of the benefit if you get a mammogram every two years compared with every year,” Lichtenfeld said. “There will be women who say, ‘I want 100 percent of the benefit.’”