Sorting Through Mammogram Confusion

Guests

Richard Knox, correspondent, NPR
Dr. Otis Brawley, chief medical officer, American Cancer Society

Almost one year after a U.S. government panel recommended that mammograms should be optional for more women, many patients remain unsure about if and when to have the procedure. Several contradictory studies about the efficacy of mammograms to prevent breast cancer deaths have created even more confusion.

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JENNIFER LUDDEN, Host:

This is TALK OF THE NATION. I'm Jennifer Ludden in Washington.

Nearly a year ago, a federally funded task force released recommendations that called into question decades of advice that women over 40 should be screened for breast cancer every year. The panel said most women should begin getting mammograms a decade later, at age 50, and even then only every other year.

Still, the American Cancer Society and other major cancer organizations continue to encourage women in their 40s to follow the old guidelines and get routine mammograms. To add to the confusion, one recent study says the benefits are minimal, another that mammograms make all the difference in preventing deaths from breast cancer.

Doctors, has your recommendation to patients changed since last fall? Women, have you put off your next screening because of this new advice? Our number here in Washington is 800-989-8255. Our email address is talk@npr.org. And you can join the conversation at our website. Go to npr.org, and click on TALK OF THE NATION.

Later this hour, reviving the long-lost physical exam. But first, Richard Knox is a health and science correspondent for NPR. His piece on the mammography debate ran Monday on MORNING EDITION, and he joins us from his office in Dorchester, Massachusetts, to help us sort through the mixed messages of the mammogram debate. Richard, welcome.

RICHARD KNOX: Thank you, Jennifer.

LUDDEN: So the U.S. Preventive Services Task Force put out these new guidelines last November, almost a year ago. Remind us: What did they say?

KNOX: Well, they said that after reviewing all of the evidence that they think is worth reviewing, you know, the best evidence there is, they said that unlike previous recommendations, as you say, women under 50, in that 40 to 50 age group, did not necessarily need to have annual mammograms.

I have to be careful to say women who had risk factors for breast cancer, such as a strong family history of breast cancer, or if they have or are known to have had the breast cancer genes that make them more susceptible, this recommendation doesn't apply to them.

But in general, women in that age group did not need to have them. It would be optional. They should talk with their doctors about it. They should be clear about the, you know, the risks and benefits of having it.

They said that women over 50, between 50 and 74, should have mammograms every other year. It wasn't necessary to have them every year. They didn't make a recommendation of women 75 and up.

They also said that there's no strong evidence that supports monthly self-examination of the breast by women, which had long been recommended by a lot of authorities.

LUDDEN: Right, we get asked about it every checkup. Why has this sparked such a debate?

KNOX: Well, I think the reasons why are pretty complicated, and they're rooted in - first of all, the emotion that surrounds breast cancer, I mean, it's a very emotional issue for a lot of people, a lot of families.

Practically everybody, if not everybody, knows somebody who has suffered breast cancer. Many have known people have died of it. Many people know survivors who attribute their survival to a mammogram that was done and caught something early. So people feel very heavily invested in this issue and, you know, with good reason.

I think another reason it's controversial is that there's a tension between the public health way of looking at a medical procedure, or in this case, a screening test, and the personal way of looking at it. Personal, meaning the women herself or her doctors; and the public health, meaning the people who, you know, sit back and look at the impact of something over a big population.

Those are very different perspectives, and they're both really important perspectives, but they can be at odds, and I think in this case, many people thought that they were strongly at odds.

LUDDEN: Well, which leads to the next question: In your reporting, what have you found in terms of are - has this changed what doctors prescribe and what women are doing?

KNOX: I don't know of any studies that really tell us what we'd like to know in terms of the impact of the guidelines. So it's really in the realm of anecdote. But the people I've talked to say it probably hasn't made a whole lot of change.

I mean, first of all, we should note that as far as I know, and as far as people have been able to tell me, there haven't been changes in insurance coverage of mammography, which a lot of people feared might happen after these guidelines came out.

LUDDEN: They will still pay for it every year?

KNOX: That's what I gather. I mean, I don't know of an insurer who has stopped paying for women under 50 or is not paying for annual mammograms of women over 50.

And I think what I'm told again anecdotally by women themselves and people who are advocates for patients is that they are still pretty much following the prior advice, that they're still getting mammograms under 50. There may be somewhat of a falloff, but it's not very clear.

LUDDEN: Now Richard, since this came out, there have been several more studies that seem to have kind of added to the confusion about the effectiveness of mammograms. Can you tell us briefly what new studies have come out, what they said?

KNOX: Yeah, well, that's why we did this update because there has been some confusion and stuff in the news. And so we thought, well, let's just look at these new studies and compare them with what happened a year ago.

One study that got a lot of attention, from Norway, actually focused on women over 50, and it strongly questioned the assumption that mammography on these women made a big difference in breast cancer deaths.

They said that the improvements in treatment have made a difference in reducing breast cancer deaths in recent years and that women's awareness and inclination to come to doctors if they feel a lump have made a difference and that mammography has - excuse me, mammography has made a difference but probably not as big as people thought, maybe as little as two percent reduction in deaths out of an overall 10 percent reduction in the time period they looked at.

Another study from Sweden, which was a very big one said - looked at women in the 40- to 49-year-old group and found that up to 29 percent reduction in breast cancer deaths could be attributed to mammography, 26, 29 percent.

LUDDEN: That's a big difference.

KNOX: It is a big difference, and, you know, the task force a year ago thought it may be a - mammography might be due to a 15 percent reduction in deaths. So it's like twice as much as that. And yet a third study from Denmark found absolutely no difference in reduction in breast cancer deaths in this same group of under-50-year-old women.

So we thought we'd, you know, sort of drill a little deeper, and we tried to do that.

I think that one striking thing to me is that when you do drill deeper, you find that the differences are sometimes more apparent than real. We can come back to this, if you'd like.

LUDDEN: What do you mean? Sure. Give us a sense of...

KNOX: Well, I think that if you talk to the experts, and we're shortly going to be talking to one of them, Dr. Brawley, from the American Cancer Society, you find that there's a fair amount of agreement about mammography, that it may have - women and doctors may have felt that it was a better test than it really is, that it made a bigger difference than it really does and that when you multiply out some of the numbers of screening versus no screening, you don't find as many lives saved as people had hoped.

LUDDEN: So for example, say if you start screening at 40 versus 50, what do you find?

KNOX: Well, if I may, I'm going to throw you some numbers, and we can - I'll try to do it carefully, because it's hard to absorb by ear.

But if - there are 23 million women in America between 40 and 50 currently. And if they all started - you know, their breast cancer risk for the rest of their life is about three percent. If all of them got mammograms regularly, it would reduce - at best - it would reduce their risk of dying of breast cancer to two percent. So that doesn't seem like such a big change in risk.

If you want to look at it another way, if you started screening those same 23 million women at age 50, and you went through to age 74, you might expect that you'd - I shouldn't say save their lives because they're going to die of something, but you'd reduce the number of women in that group who die of breast cancer by about seven deaths per 1,000 women screened.

So say okay, let's take these same 23 million women. Let's start at 40 instead of 50. How much difference does that make? Well, it's eight averted deaths per...

LUDDEN: One person difference.

KNOX: ...thousand rather than seven. So, you know, that's not a huge difference. It's a real difference. So I think, as I said, that's what I mean. When you sort of try to multiply the figures out, you find that there's probably less difference between the pros and the cons than you think.

LUDDEN: Well, let's turn Dr. Brawley. The American Cancer Society does continue to advise women in their 40s to get regular mammograms. Dr. Otis Brawley is the society's chief medical officer. He's also an oncologist and a professor at Emory University, and he joins us from a studio at the American Cancer Society headquarters in Atlanta. Welcome to you.

OTIS BRAWLEY: Hello, thank you for having me.

LUDDEN: So why didn't the American Cancer Society change its recommendations on screenings?

BRAWLEY: Yeah, we still recommend that women get an annual mammogram starting at the age of 40, and we recommend that women be aware of their breasts and very importantly go to the doctor and get it evaluated if they find a mass in their breast.

We have calculated out that screening all women in their 40s in the United States can save between 1,200 and 2,000 lives per year. And we think that's a substantial number. The taskforce would estimate it to about 1,200 lives per year. Applying the Swedish data to the United States, it would be about 2,000 lives per year. Either way, we think that's a substantial number of lives that can be saved.

And, you know, I'm an oncologist. There are very few interventions that we have in medical science where I can actually say I saved someone from dying of a particular disease. And I can actually say we'd save at least 1,200 people per year in their 40s from dying from breast cancer if we could screen them all.

LUDDEN: So were you dismayed a year ago, when these reduced guidelines came out?

BRAWLEY: No, I - see, I understand what the taskforce was trying to say. I think they communicated it badly. In many respects, they were trying to say that mammography is imperfect. The number of lives that can be saved among the 22 or 23 million women in their 40s is relatively small, 1,200.

The odds that a woman who is 40 will be saved by getting screened is fairly small for that one individual woman. Therefore, that woman might not choose, reasonably, to be screened. That's what they were trying to say.

And the American Cancer Society says we believe that women should be screened in their 40s. We also believe that women should be told of the limitations of mammography, and they should understand those limitations.

LUDDEN: All right, Dr. Brawley and Richard Knox, you're both going to stay with us. We're talking about mammograms, different recommendations and all the confusion around them.

Doctors and patients, have your conversations in the exam room changed? Call us at 800-989-8255. Or email us, talk@npr.org. I'm Jennifer Ludden. It's TALK OF THE NATION from NPR News.

(SOUNDBITE OF MUSIC)

LUDDEN: This is TALK OF THE NATION from NPR News. I'm Jennifer Ludden.

For years, women over 40 were told to get annual mammograms until last year. Many women were confused by the new guidelines from the federal panel last November. Those suggested that fewer women needed annual exams.

Today, we're talking about what has or what has not changed since then. Doctors, has your recommendation to patients changed, and women, have you put off your next screening? Our number here in Washington is 800- 989-8255, our email address, talk@npr.org. And you can join the conversation on our website. Go to npr.org, and click on TALK OF THE NATION.

Our guests are NPR's health and science correspondent Richard Knox and Dr. Otis Brawley, who is chief medical officer for the American Cancer Society.

We also have a lot of calls already on the line. Let's take one now. Jessica(ph) is in Ferndale, Michigan. Hi there.

JESSICA: Hi, how are you?

LUDDEN: Good, go right ahead.

JESSICA: I'm calling - my mother passed away eight and a half years ago of breast cancer. So my sisters and I have always been very aware of our breasts and everything going on with them.

My oldest sister got her mammogram last October, when she was 40. They found - they did find DCIS with, they found it very early. They did do a...

LUDDEN: And that is a type of cancer?

JESSICA: Yes, it is. And they found - when they did her mastectomy, they found an invasive breast cancer, which did not show up on her mammogram or anything else.

And it's - I'm 32, and it took me about eight months to finally find a doctor that would actually give me a mammogram, so...

LUDDEN: Oh, they said you're too young, come back later.

JESSICA: Yeah, exactly. So the whole age 50 thing really, I mean, it kind of appalls me because my mother was 50 when she was diagnosed. She would not go get a mammogram, and if she had between the age of 40 and 50, she would probably still be alive today.

LUDDEN: All right, well, let's put this - thank you so much for calling, Jessica. Dr. Brawley, this brings up another point.

BRAWLEY: Yeah.

LUDDEN: I mean, African-American women are also less likely to develop breast cancer but more likely to die from it and may get it younger. Here's a woman 32. What do you make of that, that she couldn't get a mammogram?

BRAWLEY: Yeah, well, first off, ductal carcinoma in situ, or DCIS, is actually not cancer, as its name implies. It's a pre-cancerous condition, sort of like pre-cervical — pre-cancerous cervical conditions.

We treat it very aggressively, like cancer. You have to remember the limitations of mammography are something that we also want to stress. It is not a very good test for younger women. It's very difficult for a mammographer to pick up a cancer in a breast in a woman in her 20s or 30s. It's difficult for mammographers to pick it up in their 40s, and it gets easier as a woman gets older.

We need better tests is what I'm really saying, and we need to support research to develop those better tests. Some women who have a high family history need to talk to doctors about the possibility of MRI or ultrasound when they're in their 30s, and only certain women need to be getting those things.

And we don't want to start encouraging all women in their 30s to start getting mammography because we will end up with a lot of women who will be frightened away from mammography later in life, when it's a much better test.

LUDDEN: All right. Let's take another call. Kate(ph) is in Salt Lake City, Utah. Go right ahead.

KATE: That's a great lead-in to my question because I'm 51 and I've had a number of mammograms, starting in my 30s when I found a lump. And because I have lumpy breasts and cystic conditions, et cetera, about 50 percent of my mammograms result in further intervention, more views of the breast and then very often some sort of biopsy in addition.

LUDDEN: I know that these are in fact themselves risk factors for breast cancer. At what point should I as an individual be drawing a line on how many mammograms and procedures I'm willing to go through?

LUDDEN: Dr. Brawley?

BRAWLEY: Well, I would really encourage you to talk to a breast specialist, preferably a radiologist who does only mammography. I would encourage you to continue staying involved in the medical system, and as I said earlier, I encourage all women age 40 and above to get an annual mammogram because it does save lives. It decreases risk of death by a bit and saves 1,200 to 2,000 lives.

The other thing I would advise women, is get a high-quality mammogram at a center that has the availability to look at your old mammograms. Looking at three, four, five years of mammograms is a lot better than looking at one single mammogram. And unfortunately, in the United States, more than half of women go to places where they can only look at the mammogram that was done today and not the one done last year, year before last, even though there were mammograms done in the past.

KATE: Wonderful. Thank you very much.

LUDDEN: All right, Kate, thanks for calling. We have a call now from Robert(ph). I believe you're a doctor in Cape Coral, Florida. Is that right?

ROBERT: That's correct.

LUDDEN: Go right ahead.

ROBERT: Thanks for taking my call. What I'd like to say is that mammograms are notoriously inaccurate for detecting breast tumors. In fact, one has to wait two to three years (technical difficulties) of the mass developing before it's detectable by a mammogram.

Ultrasound and MRIs are more accurate. Tomography is even more accurate and can detect vascular patterns.

LUDDEN: And I'm guessing they're all more expensive.

ROBERT: Vascular patterns that occur prior to a mass even starting to develop. So you can catch things maybe two to three years earlier with tomography.

Plus with mammograms, there's the danger with the X-rays. One would want to protect the breast tissue from anything that would tend to cause cancer, and X-rays, of course, we know cause cancer. Doing it every year is just ridiculous when you have more accurate and safer alternatives.

LUDDEN: So what do you suggest for your patients?

ROBERT: I recommend they have thermography as the basic screening method, and then if anything suspicious is found on thermography, then they have a structural study, in other words an ultrasound or an MRI.

LUDDEN: But have you - do you still prescribe this every year, or have you said after this study, you know, every other year for those 50 and over?

ROBERT: It really does depend on the age of the patient, their general health and what has been found, you know, whether there has been, you know, spots of inflammation or, you know, suspicious areas, you know. If they've been found in the past, then more frequent screening would be wise.

LUDDEN: Richard Knox, I was interested to read that mammography is not as effective as screening methods for some other kinds of cancer.

KNOX: That's right. It's actually - when you compare it, well, the gold standard for screening for cancer is Pap smears for uterine cervix cancer, and it reduces deaths, it is well-established, by about 90 percent. That's a high standard.

Colorectal cancer screening, and there are several different kinds, including colonoscopy and other things, reduces colon cancer or colorectal cancer deaths by about 60 percent.

So mammography doesn't measure up to those. There's another point that I think might be appropriate here in connection with Robert's call. There's - one thing that needs to be kept in mind with any screening test is that there is - you have to look at the false positives, the number of times that a test will turn up something that might be cancer, but it might not, and it results in additional tests, some of them posing risks and discomforts and anxiety and cost all by themselves.

And I'm no expert on the comparative virtues of these different breast imaging techniques, but what I gather from talking to people is that some of them do have promise, some of them are appropriate, as Dr. Brawley suggests, for certain subsets of women.

But none of them, according to the U.S. Preventive Services Taskforce, has been shown to save lives from breast cancer. And many of them do pose problems of false positives and false negatives.

Mammograms themselves miss about 20 percent of cancers that are there. So, you know, I think we have to be careful not to jump to the latest promising technology and make broad recommendations for what people should get without really understanding the downsides.

LUDDEN: Robert, thank you for your call. Dr. Brawley, as people look to different kind, you know, an alternate to the mammogram, I mean, when is it realistically, when is something else going to be on the market? And isn't cost a big factor and the other points that Richard just raised about effectiveness?

BRAWLEY: Well, first I want to second Mr. Knox' wisdom. Thermography is something that some people have advocated, but it's not been tested in a prospective randomized trial. There are at least prospective randomized trials of mammography to show that it indeed does save lives. It also, by the way, does have some limitations, and we've been talking about some of those.

I think that we need to support some of the research in the many things like thermography, like improving mammography and improving MRI or even three-dimensional ultrasound and flow studies that actually might be a better imaging study that even mammography.

But that's a scientific support question. For women who are there today, we must say that the only thing that we have good science to show can actually save lives - and this is for women over the age of 40 - is mammography.

Certain women who are at high risk, who have certain breast problems, a mammographer or a breast doctor may recommend that they get ultrasound or may recommend they get MRI as a screening tool to see if they can find cancers early.

LUDDEN: We've got a couple of emails here. Leslie in Bowling Green, Ohio, writes: My insurance company, Medical Mutual, has changed their coverage and now only covers a mammogram every two years. I am over 40, and now get a mammogram every other year.

And another email from Sarah, who says: Please talk about the negative effects of getting radiation from a mammogram.

BRAWLEY: Yeah.

LUDDEN: Dr. Brawley?

BRAWLEY: Yeah. Well, first, I'm much more concerned that women get regular mammograms and get high-quality mammograms, where the film can be looked at from previous mammography then I am that women get it every year. I would like to see women get it every year. But if I have to make a choice, every other year with high-quality is better than no mammography at all. The second - what was your second question?

LUDDEN: Radiation from mammography.

BRAWLEY: Ah, radiation. The amount of radiation that is absorbed when a woman gets a mammogram on an annual basis is not that much, and since we have prospective randomized trials that compare groups of women who were screened with groups of women who were not screened, and you have less dead in the screened arms versus the unscreened arms, that means that even if radiation were harmful, the net benefit in terms of life saved to mammography still favors mammography.

LUDDEN: Okay. Let's get another call in here. Pat is in Hubbardston, Michigan. Hi, there.

PAT: Hello. This is Patricia, and your last speaker was right on as far as, you know, the dangers from an X-ray. And I'm a 21-year survivor of breast cancer, and I - at 40. And I can't urge women enough to have a mammogram. Yes, you said 20 percent might be incorrect, but - and that's very sad. But the rest, you know, think the rest of us that are still here is, you know, a joy.

LUDDEN: Okay. Well, thank you for your phone call. Let's go to another - Sara in Zion, Illinois. Go right ahead.

SARA: Okay. When I was 32, which was in 1996, I had a lump. I found a lump. And the first thing the doctor did was send me to get a mammogram, which didn't show anything. And both the technician and the doctor said, well, we wouldn't expect to see anything because you're so young and you have so much breast tissue, then you can't see it on a mammogram at that age. So, I'm like, well, whatever. I mean - and it just, like, exposed me to all that radiation, which I am concerned about, regardless of what you say.

And then I found a book shortly afterwards. It was published in '94. It's called "Patient No More." It was about the politics of breast cancer. And she said, yeah, when you're under 50, especially under 40, that's the way it is with breast tissue, and there's no reason to get them at that age because it's just - it's useless and it's risky. And she said this just because the insurance companies want doctors to give you all the possible tests so that they're protected against a malpractice suit. So that's my perspective on it.

LUDDEN: Before getting reaction here, let me just say you're listening to TALK OF THE NATION, from NPR News.

So, a quandary for younger people there.

BRAWLEY: Yeah. It is a quandary. I would, again, point out a large number of breast cancers are discovered because a woman appreciates a mass in her breast. Many of those masses which are cancerous are not going to be seen on a mammogram. Some will, and that - our routine procedure, by the way, when a women comes in, no matter what her age is and she has a mass, is to get a mammogram, a diagnostic mammogram to see if we can see that mass better or see other things. That's very different from a screening mammogram. It's even paid for differently, by the way.

Many of these things are going to need to be biopsied, and, please, if the listeners can realize, many masses are - or many cancers are going to be discovered by the woman taking a shower or getting dressed and not by the mammogram, but the mammogram can still save lives.

KNOX: Dr. Brawley...

LUDDEN: Go ahead, Richard.

KNOX: I want to ask Dr. Brawley a question, because although we talked last week, we didn't actually address this one. And I'm sure it's something I'm curious about. The task force did not recommend continued self-examination by women...

BRAWLEY: Right.

KNOX: ...and I wondered what the Cancer Society's take on that issue is.

BRAWLEY: Yeah. The task force spoke about monthly breast self-exam. Monthly breast self-exam was something that was advocated until about 15 years ago by all organizations, and that involves a woman spending about a half hour, one day a month, doing an extensive examination of her breasts. There are several prospective randomized trials that shows that that increases anxiety, increases the number of biopsies, but does not decrease risk of death.

What most organizations now advocate - and I think the task force would agree with this - is that women being aware of their bodies, and if they happen to find a mass, getting it checked out is the important thing. We have a lot of people who find things and just live with it, don't get it checked out, and those things turn out to be breast cancers. Sometimes, several years, people will watch these masses grow in their breasts, and they're actually frequently diagnosed as breast cancer.

You can think of breast awareness as a daily, low-intensity breast self-exam, but that's part of the three things that's lowering the risk of death. Remember, a woman in the United States has a risk of death that's 30 percent lower today than in 1990, and it's because of mammography, women realizing they have a problem and coming in early and improvements in treatment.

LUDDEN: All right. So we're just about out of time here, but continuing with the old recommendations, more of an awareness.

So, Dr. Brawley, do you think that anything could change over time, very briefly, even though it hasn't? A year out from these recommendations, might that change?

BRAWLEY: I'm actually hopeful that this whole discussion will make people be a little bit more aware of health issues, number one, and actually encourage more research that will find something better than mammography at this time.

LUDDEN: Dr. Otis Brawley is chief medical officer for the American Cancer Society. He joined us from Atlanta. And Richard Knox is a health and science correspondent for NPR in Massachusetts. Thanks so much to both you.

KNOX: Sure.

BRAWLEY: Thank you.

LUDDEN: And we have a health care theme on today's show. Up next, the dying art of the physical exam.

I'm Jennifer Ludden. It's TALK OF THE NATION, from NPR News.

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