On Mammogram Recommendation, An Intense Debate

Recommendations from an independent panel that most women don't need mammograms in their 40s, and should get one every two years starting at 50 have spurred intense debate. The recommendation is contrary to the American Cancer Society's long-standing position that women should get annual mammograms starting at age 40. Dr. Therese Bevers, medical director of the Cancer Prevention Center at the M.D. Anderson Cancer Center in Houston, and Barron Lerner, author of Breast Cancer Wars: Hope, Fear, and the Pursuit of a Cure in Twentieth-Century America, offer their insight.

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From NPR News, this is ALL THINGS CONSIDERED. I'm Robert Siegel.

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And I'm Melissa Block.

Keep doing what you have been doing for years. That was the message yesterday from Health and Human Services Secretary Kathleen Sebelius. She was responding to newly revised guidelines for breast cancer screenings.

On Monday, a federally appointed advisory panel released a report recommending that most women under 50 do not need routine mammograms. The panel also dismissed the effectiveness of self breast examinations. Those reversals have caused considerable surprise, confusion and disagreement among patients and doctors alike.

We're going to get two doctors' views now: first, Therese Bevers. She's the medical director of the Cancer Prevention Center at the M.D. Anderson Cancer Center in Houston.

Welcome to the program, Dr. Bevers.

THERESE BEVERS: Thank you. Glad to be here.

BLOCK: And also Barron Lerner, an internist at Columbia University Medical Center in New York. He's also author of "Breast Cancer Wars: Hope, Fear and the Pursuit of a Cure in Twentieth-Century America."

Dr. Lerner, welcome to you.

BARRON LERNER: Hi, Melissa.

BLOCK: And Dr. Lerner, you pretty much agree with these new guidelines. Why is that?

LERNER: Well, the recommendations are basically pointing out that in order to save one life from women in their 40s, you need to screen something like 1,900 women for 10 years. So that's tens of thousands of mammograms to potentially save one life. And along the way, you're going to be getting a lot of something that's called false positives. So women who have false alarms on their mammograms wind up getting biopsies and - that didn't really need it. So there's a lot of potential harm along the way to potentially only save one life.

BLOCK: And, Dr. Bevers, though, you're looking at those same numbers and coming to a different conclusion.

BEVERS: That's correct. I think we all will agree that there are benefits obtained with mammographic screening. There's also harms. We acknowledge that you have to screen more women in their 40s than you do in their 50s. Dr. Lerner quoted the number of 1,900, and that is correct. But you have to screen about 1,300 women in their 50s to prevent - to find one breast cancer, so I'm not sure why that line is drawn between the 1,300 and the 1,900.

And then, there seems to be an overemphasis on the harms of mammographic screening. In my opinion, my colleagues, other clinicians that see patients - breast cancer patients and screening patients for breast cancer, we're willing to accept a number of false positives to be able to save one woman's life.

BLOCK: We have been getting a lot of email from listeners, as you might imagine. And a number of people have stories of their own. And I want to read a couple of those letters. This is one from Wendy Hickey(ph) of Pittsburgh who says that three years ago when she was 45, a mammogram identified suspicious tissue in her breast. She had a needle biopsy, excisional surgery and is now cancer-free, taking daily tamoxifen.

SIEGEL: I can't imagine what would have happened if I had delayed my mammogram for five more years. But I feel safe in guessing that the outcome and treatment would not have been as positive.

Dr. Lerner, what would you say to Wendy Hickey about that?

LERNER: If people can take away from this show the notion that what she's saying may be true but may not be true, I think they would learn a lot.

What the data is showing us is that this woman, even though the mammogram found the suspicious cells early on, the argument is that her overall prognosis would not have changed. She would have gotten treated then as aggressively or more aggressively as when it was found by mammogram, and she would have done exactly the same.

That's what the point is of this data. It's a hard conceptual leap for people to make, even for a doctor, but that's what the data show.

BLOCK: And you would assume, though, that the earlier you find something, the better your results would be.

LERNER: That has been the guiding principle of cancer research since the early 20th century, but the data for some cancers shows that things are not that simple, and that's what we're trying to deal with now.

BLOCK: Dr. Bevers, what do you think?

BEVERS: Well, I think it's right that the data is that way for some cancers but not for all. In fact, a great many cancers, by finding them early, we can change the outcome. So I understand her viewpoint, and that's why I am recommending annual mammographic screening for women beginning at age 40.

SIEGEL: So, doc, should I get a mammogram or not?

What's going to guide me in telling her if she should get a mammogram or not based on these current guidelines? We know, in fact, that the majority of breast cancers diagnosed in women in their 40s are in women who have no risk factors. So I can't go solely based on risk factors. If I did, I would miss a number of women who will develop a breast cancer and, in fact, may be caught at a larger possibly more advanced breast cancer.

BLOCK: And, Dr. Lerner, if you had that same woman in your office - no family history, no special risk factors - say, she's 40, 41 years old, she wants you to recommend whether she should get a mammogram, what would you tell her?

LERNER: Well, I try to avoid making decisions for my patients, but try to give them the best information that I can. And I would emphasize, as we said before, the pros and cons. This is what the advocates think of this test and this is why they think it's a good test. This is some of the downsides of this test.

Are you the sort of person who would want to go ahead? Are you comfortable with a test that's not as good that might not pick up something? Or are you the sort of person who wants to avoid unnecessary biopsies at all costs? I tend to find that my patients segregate themselves into those two groups.

BLOCK: And if they absolutely insisted that you give them your clinical guidance on this, what you would recommend? What would you do?

LERNER: Well, again, part of that would reflect my knowledge of the patient herself. But if you're really trying to pin me down into a corner, I think based on the current guidelines I would say that a mammogram is not necessary. But if she really wants it, it's fine.

BLOCK: There was the other recommendation that we mentioned from this panel that women not examine their own breasts; that the harms outweigh the benefits. And we got a lot of letters about that too.

SIEGEL: I was shocked that doctors are no longer suggesting self-examinations. I lost my wife to inflammatory breast cancer a couple of years ago, and if it had not been for her regular self-exams, the cancer would not have been detected as soon as it was. She found both the original case and its reoccurrence before the doctors did. If it had not been for her diligence, I would have lost her several years earlier.

Dr. Bevers, thoughts on that case?

BEVERS: Well, actually this is a recommendation from the U.S. Preventive Services Task Force that I am in agreement with. But I want to clarify what the recommendation was. It was that women should not be taught how to do a breast self-examination. And this comes about from a large randomized trial that showed women who were taught how to do a breast self-examination and, in fact, also provided reminders to do it were no better at finding breast cancers than the women who had not been taught nor received any reminders.

We do, however, recognize that women are the most likely person to find their own breast cancer. And for that reason you have been seeing a paradigm shift in recommendations from many agencies, where now the recommendation is breast awareness.

The concept is that there is no right or wrong way for a woman to find an abnormality. And, in fact, the vast majority of women, when they find that problem, were not doing a formal breast self-examination but, in fact, found it during showering or dressing, and it was more of a chance detection. But yes, they themselves found it.

BLOCK: And explain to me just a little further why it wouldn't help a woman find a lump.

BEVERS: Well, what it actually tells us is that people know their bodies. Maybe an analogy that I could give is, say that you found a lump on the back of your calf. You weren't doing a monthly self-examination of your calf when you found that lump. It was just something you came across by chance and you go, oh, what's that?

BLOCK: I guess I'm still a little confused. What is the - what would be the harm in teaching women to examine their own breasts, to make it more routine for them to do that?

BEVERS: So the harms are, in fact, false positives - the same thing that we see with mammographic screening. Why I feel that we should not be teaching women breast self-examination is because there is no benefit, but there are associated harms.

That actually differs from the mammographic argument where there are, in fact, benefits and harms, and it's the balance of those benefits and harms.

BLOCK: Dr. Lerner, this letter from Tim Hart, the outcome for his wife was, sadly, still that she died from breast cancer, but he said, look, this early detection through self-examination bought them some time together.

LERNER: If you think about finding a cancer in your breast using your fingers, especially one that's deep in the breast, it's got to be at least a centimeter in size, maybe even a little larger. We call that early detection, but it's not early. Most of those cancers, many of those cancers have been there growing for months or years, and we now know, in contrast to when early detection was invented, that a lot of breast cancers spread early on in their course.

So the notion that finding a lump in your breast is truly early, and it's before the cancer has spread, and therefore, you're going to save a life doing that doesn't make the sense that it used to. And so in a case like this, his wife absolutely did what she did, and I totally applaud that, and it's great that she was able to find that earlier and get informed, but, again, it's not entirely clear from a story like this that she prolonged her life at all by doing it because what was done was done by the time she found it, both at the original presentation and the recurrence.

BLOCK: You know - I'm sorry.

BEVERS: And I think this case is actually a good illustration where waiting till the cancer presents clinically, on self-exam or a clinical exam, it may be too late.

BLOCK: You know, these new recommendations have raised all sorts of questions about whether insurance companies are going to now stop covering early mammograms for women under 50. Do you think that's a real risk, Dr. Bevers?

BEVERS: I do. I have concerns about it because I will be telling my patients that I am recommending annual mammograms beginning at age 40 and of course counseling them about the benefits and risk. After doing so, many will want the mammogram, but they may find they won't be able to access it because now payers may use this as the basis of the reimbursement, and thus only women age 50 to 74 would be able to get a mammogram every two years, and that will be unfortunate.

BLOCK: Dr. Lerner, do you think you'll see that, as well?

LERNER: Well, it's certainly a possibility, you know, especially in a cost- cutting environment. The notion that you now have a test that's pretty expensive, that leads to unnecessary biopsies, and you can save a lot of money by not paying for it is going to be an appealing notion.

I do hope that people separate the science from the politics, though. I think that the current recommendations and the changes really reflect a bunch of scientists, biostatisticians getting together and trying to do the right thing and make the right recommendations as far as what the data show. What we as a country and a society choose to do with that information is really a political issue.

BLOCK: Dr. Lerner and Dr. Bevers, thank you very much.

LERNER: Thank you.

BEVERS: Thank you.

BLOCK: Dr. Barron Lerner is an internist at Columbia University Medical Center in New York and author of "Breast Cancer Wars: Hope, Fear, and the Pursuit of a Cure in Twentieth-Century America." And Dr. Therese Bevers is the medical director of the Cancer Prevention Center at the M.D. Anderson Cancer Center in Houston.

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Mammogram Wars: Experts Feel The Backlash

Health and Human Services Secretary Kathleen Sebelius i i

Health and Human Services Secretary Kathleen Sebelius says she'd be surprised "if any private insurance company changed its mammography coverage" because of the mammogram guidelines. Chip Somodevilla/Getty Images hide caption

itoggle caption Chip Somodevilla/Getty Images
Health and Human Services Secretary Kathleen Sebelius

Health and Human Services Secretary Kathleen Sebelius says she'd be surprised "if any private insurance company changed its mammography coverage" because of the mammogram guidelines.

Chip Somodevilla/Getty Images

Angry reaction to new government-funded guidelines on mammography has grown so hot that Kathleen Sebelius, the secretary of health and human services, is trying to put out the fire.

The guidelines came from the U.S. Preventive Services Task Force, an independent group of experts convened by Sebelius' agency.

Sebelius says the new guidelines won't change federal coverage of mammograms. She reassured critics Wednesday that the task force "does not set federal policy, and they don't determine what services are covered by the federal government."

Sebelius also said she'd be surprised "if any private insurance company changed its mammography coverage" because of the new guidelines. Private insurers often key their coverage decisions to task force pronouncements.

Not everybody thinks the expert panel was wrong when it declared this week that yearly mammograms are no longer necessary for all women younger than 50. (Women with a family history of breast cancer or other risk factors are a different story.)

The task force, after a stringent review of evidence it considers solid, also said most women ages 50 to 75 need mammograms only every two years. It makes no recommendation for women older than 75.

The storm of criticism is not surprising, given the emotional valence of breast cancer and the fact that American women over 40 have been told for a long time that they ought to report for yearly mammograms.

Dr. Susan Love is among those who don't think the guidelines are wrongheaded. Her reaction was, "It's about time!"

Love is a former breast cancer surgeon who has authored a popular book on the subject and now heads a Los Angeles foundation dedicated to finding the cause of breast cancer.

"I was never convinced that mammography screening worked that well in younger women," Love said in an interview. "And I've always suggested that women should start at age 50."

Love says mammography has been oversimplified as a lifesaving strategy for all women.

It's based, she says, on the notion "that all cancers are the same — they grow to a certain size, and then they get out of control and spread. So if you get them in time, you can save lives."

That's largely untrue, Love asserts. "There are five or six different types of breast cancer," she says. "They don't grow in a nice, orderly way. They spurt, they rest, and some are so fast-growing that you're never going to find them in time."

Love says universal mammography has been "oversold, as if every cancer could be found early. I wish that were true, but it's not."

But when Love expressed her support for the new guidelines in her blog, it was not very popular.

"Have you lost your freaking mind?" wrote one 42-year-old woman. "How dare you! May God help you sleep at night for the death call that you have just trumpeted!"

P.J. Hamel has been seeing a lot of similar outbursts. She's a patient advocate and blogger for a Web site called HealthCentral Network.

"I've been getting a lot of vitriol," Hamel says. "Just people exploding with rage, basically. 'How dare they deprive me of my life or try to deprive my daughter of her life!' and that kind of thing."

Hamel is struggling to understand the new guidelines. She finds herself pulled in two directions. She knows researchers deal in statistics. But she identifies with the plight of individual women.

"My heart is going out to all the women who I know will die because they followed these new guidelines," Hamel says. "On the other hand, my mind is saying they've done the analysis. They've put these guidelines out there. They did their job."

One thing you should know about Hamel: At the age of 47, she had a suspicious mammogram, and a biopsy showed advanced cancer.

That was eight years ago. Today she's fine.

Hamel says mammography saved her life. So, like many women, she doesn't understand why the guideline writers place so much emphasis on the downsides of mammograms — the anxiety and unnecessary surgery that false alarms can cause.

"It's almost apples and oranges," she says. "I mean, life and death is obviously very important. Whether you're worried for a few days or have some needless surgery, isn't that worth your life? To me it would be. To me, it was."

Hamel says she's going to keep telling all women to get yearly mammograms — including women younger than 50.

Robert Smith, director of cancer screening for the American Cancer Society, says his organization also is sticking with the current guidelines "because we not only looked at the evidence that the task force looked at, but we also looked at newer, modern data."

Smith says a good part of the current disconnect is due to the rules of evidence used by the U.S. Preventive Services Task Force. It's a rigorous system that values above all else the "gold standard" of large randomized trials of screening tests such as mammography.

That's all well and good, he says, but mammography screening has reached the point where these expensive trials are vanishingly rare — if not practically and ethically impossible.

Smith cites a very recent study from Sweden, where mammography has a long history and record-keeping is meticulous. It's not a randomized trial of mammography, but instead compares breast cancers diagnosed in different time periods among women who were screened for cancer with mammograms and women who weren't. "It includes hundreds of thousands of women examined over many, many years," he says.

Breast cancer deaths declined 19 percent over time among women who didn't get regular mammograms. But women who did get screening mammograms had a 48 percent reduction in breast cancer mortality.

That's very different from the U.S. task force's estimate. It says the evidence indicates that mammograms reduce breast cancer deaths by 15 percent among women ages 40 to 49.

Still, Smith acknowledges that mammography advocates may have given American women unrealistic expectations about mammograms.

"Have we oversold screening?" he says. "You know, we say, 'Screening saves lives,' and that simple statement has been criticized as overpromising. And it does, I suppose, because we don't say, 'Screening saves lives — but beware!'

"We want women to understand the shortcomings of screening," he adds, "but we don't want to be dissuading them from doing it."

Data wars are endless, of course. But this current uproar, if nothing else, might give everybody a more realistic idea about the pros and cons of mammograms.

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