New Guidelines On Breast Cancer Stir Confusion

For years, health care organizations have worked to send a consistent message to women about breast cancer. But new guidelines issued by the U.S. Preventive Services Task Force, a component of the Department of Health and Human Services, have stirred confusion. The agency suggests women can now wait an additional 10 years before getting an annual mammogram — at age 50 instead of age 40 — and that some women ages 50-74 can even skip a year between exams. Dr. Diana Petitti, who leads the U.S. Preventive Services Task Force, and Dr. Wayne Frederick, an oncologist at Howard University discuss the new guidelines. Frederick shares his concern about how the changes may affect black women, who are at higher risk of breast cancer between 40 and 50 years old.

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MICHEL MARTIN, host:

From financial wellbeing, we turn now to an issue of physical health, especially for women. For years, organizations have been working to send a consistent message to women about breast cancer, and that message has been that early detection is best. Do a self-exam every month and, after the age of 40, get a mammogram every year. The American Cancer Society has been saying that for almost 20 years.

But yesterday, a group called the U.S. Preventive Services Task Force, whose members are appointed by the Department of Health and Human Services, issued new guidelines, saying that women do not need to begin annual mammograms until the age of 50, and that women aged 50 to 74 can get by with a screening every other year. They also say that breast self-exams are of virtually no value.

Needless to say, this information has caused some confusion for many women who have heard the opposite for so long. So we called the chair of the U.S. Preventive Services Task Force, Dr. Diana Petitti. She's also a professor of biomedical informatics at the at, sorry - at Arizona State University, and she joins us from her home office in Tempe, Arizona. Also joining us is Dr. Wayne Frederick. He's an oncologist and surgeon here in Washington, D.C., at Howard University, and he joins us from his office. Welcome to you both. Thank you for joining us.

Dr. WAYNE FREDERICK (Oncologist, Surgeon, Howard University): Thank you. Thanks for having us.

Dr. DIANA PETITTI (Professor of Biomedical Informatics, Arizona State University; Chair, U.S. Preventive Services Task Force): Thank you for having me.

MARTIN: Dr.�Petitti, so we assume that this is cost-benefit analysis at work here, that the new guidelines recommend against annual mammograms for women under 50 because the harm outweighs the benefit. So what's the harm?

Dr.�PETITTI: Well, first of all, this is not a cost-benefit analysis. The U.S. Preventive Services Task Force reviewed the evidence without regard to cost, without regard to insurance, without regard to coverage. Second, I wanted to correct a misperception that the task force recommended against screening women in their 40s. What the task force recommended was against routine screening. The task force thinks that the decision to be screened in the 40s should be an individualized decision that occurs after a woman has a discussion with her physician rather than automatic or routine screens

MARTIN: Okay, so why shouldn't women why do you recommend these new guidelines, which is different from what we have been told for some years.

Dr.�PETITTI: Well, I think every screening test and every medical encounter is weighing the benefits and the harms. The task force reviewed the evidence and felt that the benefits of starting in the 40s as compared with perhaps starting later was small in relationship to the harms. And some people would call the harms negatives, and those negatives are false positive mammography with all of the attendant anxiety and imaging procedures that might come with it.

Again, this is not against screening mammography in the 40s. This is about routine screening mammography in the 40s. It's about picking a starting age.

MARTIN: And you know, the new guidelines also say that self-exam is of very little value. Now, intuitively, this seems strange, and obviously, anecdotes are always dangerous, but you can sort of count many, many stories. I'm sure all of us know women who say that they first detected, you know, a lump in their breast because of self-examination. So why do you say that self-examination is of little to no value?

Dr.�PETITTI: This is about teaching doctors or any group, teaching women breast self-examination, and there have been two very large and very well-conducted studies involving almost half-a-million women that have shown that women who are taught breast self-examination and who regularly practice it, there is no reduction in mortality from breast cancer. So this is an evidence-based recommendation.

That doesn't mean that if a woman finds a lump, that she shouldn't go to her physician. It's about searching for the kinds of lumps that can be found only after being taught very careful breast self-examination.

MARTIN: Dr.�Wayne Frederick, you've joined us before to talk about the whole question of early screening and how screening sometimes is viewed very differently in different communities. Now, you are very concerned that African-American women are more at risk of acquiring breast cancer before age 40, and that even though African-American women, as I understand it, are less likely to get breast cancer than white women, they're more likely to die from it.

So first of all, why is that? And secondly, are you concerned that this particular guideline may place more African-American women at risk?

Dr.�FREDERICK: Right. I'm very concerned about the guideline, because with African-American women, as you just stated, they're less likely to get breast cancer, but they're more likely to get in the pre-menopausal age group, which would be less than 50. So for example, here at Howard University Cancer Center, in our tumor registry, over the past 30 to 40 years, we have at least 30 percent of our best cancer patients are under the age of 50, and another 23 percent of patients are in the age group of 40 to 50, which means that in our population, we have a significant number of patients that are going to fall in between the cracks if they don't get routine screening. Now, albeit that even with the current recommendation of 40, obviously we don't get mammograms on a woman before the age of 40. So that's one concern that I have.

The other concern that I have in terms of African-American women's outcome with breast cancer, is that they tend to present with later-stage disease, and the outcomes tend to be worse, even when you compare them, stage to stage. They're also more likely to have what we call triple-negative breast cancers, which again probably will be more successfully treated if we are able to treat those earlier as opposed to later.

So for those reasons, I would be a bit concerned about population. Now, I understand what the U.S. Preventative Task Force, you know, has put out, and I think it obviously is a complex issue, and I do appreciate the recommendation of speaking with the physician and the value or low value of self-breast examinations. But again, I think when you look at certain skewed populations that are under-represented in our health care system, we have to become concerned about some of these recommendations because we are already behind the eight ball.

The cost of treating these patients late is a heavy burden on the system, if you want to make it a financial issue, and then teaching self-breast exam also has the additive effect of increasing a patient's likelihood to participate in certain types of health wellness activities that I think promote general health, as well.

So I think it is a bit of a, you know, tight-rope balance that we have to be able to come to when we make these types of recommendations.

MARTIN: Sure. Dr.�Petitti, very briefly, and I apologize, we only have a minute left. Were did the task force think about the effect that this may have on different populations who may have different track records with breast cancer, and are you at all concerned that insurance companies will use this as a rationale not to screen women who should be getting it?

Dr.�PETITTI: Well, I think that the recommendation is for individualized decision-making, and I think what we've done is we've, on the air here, identified a population that needs to have a different kind of conversation.

If a woman is of African-American and is at higher risk because of breast cancer, then that is a group who needs a kind of special, more-tailored recommendation. And I'm only hoping that insurance doesn't use it that this doesn't become an insurance issue.

MARTIN: All right. Dr. Diana Petitti is chair of the U.S. Preventive Services Task Force and a professor of biomedical informatics at Arizona State University. We were also joined by Dr. Wayne Frederick, an oncologist and surgeon at Howard University in Washington, D.C. I thank you both for joining us.

Dr.�FREDERICK: Thank you.

Dr.�PETITTI: Thank you.

MARTIN: Coming up, we turn to our moms segment, and we look at the question of whether working women face greater scrutiny in child custody cases. That conversation is coming up next on TELL ME MORE from NPR News. I'm Michel Martin.

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