Confused by all the fighting over the value of mammography? There’s been an active — even fierce — debate about the value of mammography, especially since the November 2009 U.S. Preventive Services Task Force recommendations to change screening guidelines to every other year starting at age 50. Breastcancer.org has been a strong proponent of the current guidelines of annual mammography starting at age 40 for women in general and starting earlier for women at elevated risk.
The critics say that annual mammograms are unnecessary because they result in too many false alarms and too much treatment, causing unnecessary harm and stress for women and leading to excess healthcare costs. For sure, mammograms are imperfect. But we’ve come a long way. Even past studies using old-fashioned techniques demonstrated a significant survival benefit with early detection. And today, an even greater survival benefit is likely with fewer side effects because of much improved mammography and other diagnostic techniques combined with more advanced treatment options. Plus, many women in this country are already at significant risk for breast cancer by age 40, when they’re in the prime of their lives with children and other loved ones who depend on them. The reality is that only 50% of women are following the current guidelines — putting themselves at even greater risk. They can’t afford to push off mammograms until 50.
Breastcancer.org has been invited to lead the debate this week in The Wall Street Journal, and I have graciously accepted an invitation to join their group of thought leaders called The Experts. Breastcancer.org is proud and determined to embrace this important opportunity to encourage more women to take advantage of regular mammography screening. So many lives are at stake as breast cancer is the most common cancer to affect women. Please join me in today’s Wall Street Journal debate, “Should All Women Over 40 Get Annual Mammograms?” I also want to thank my colleague, Dr. Emily Conant, for her expert contribution to this important discussion.
We welcome your comments below. How do you feel about regular mammograms?
I found I couldn’t comment over at the WSJ without subscribing. I was as interested in the comments as the discussion. Several people suggested only testing high risk women — risk being assigned by genetic testing. I would have loved to enter the discussion to explain that many women with breast cancer have no known genetic markers indicating higher risk — I’m one of them. But I was diagnosed with breast cancer at 44.
Another piece of the discussion that is missing is the problems of diagnosis for relatively young women with dense breasts. My tumor was not visible on my mammograms, but found in a physical exam.
So I say — yes to mammograms starting at age 40 and YES to further research into better screening techniques.
Dr. Weiss, I’m curious to know if you have read Dr. Welch’s book, Overdiagnosis or perhaps Otis Brawley, MD’s book, How We Do Harm. Furthermore, I’d like to know if you are familiar with Eric Topol, MD’s book, The Creative Destruction of Medicine? I have read all three books and I believe all of them are enlightening and should be read, cover to cover, by all health care professionals. Furthermore, I’m sure you are familiar with Britian’s breast cancer screening controversy and the independent review by their health csar, Sir Michael Richards. Britian invites patients to screen between the ages of 50-74 every THREE years. There has been discussion of lowering the age to 47. Here is what their commission concluded:
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61775-9/fulltext
Notice that their recommendation is more closely alligned with The U.S. Preventive Services Task Force’s 2009 recommendation.
IMHO I think statements like the one you make, “Plus, many women in this country are already at significant risk for breast cancer by age 40, when they’re in the prime of their lives with children and other loved ones who depend on them” are inflammatory and obfuscate from the facts.
You are aware that Dr. Welch’s wife is a breast cancer survivor and her tumor was found on a diagnostic mammogram several months after her “regular” mammogram. For younger women, it is a fact that DIAGNOSTIC mammograms save lives. Regular mammograms, according to all of the published data save fewer lives.
I think a woman outside of the ages of 50-74 needs to assess her risk/ benefit with her physician and decide what screening, how often, and at what age is appropriate for her….which is EXACTLY what the U.S. Preventive Services Task Force recommends, as well as the Health Minister of Britian.
Considering I was not particularly high-risk yet diagnosed with breast cancer at age 45 via a routine annual mammogram I am definitely in favor of them. Had I waited until age 50, who knows how far advanced my cancer would have been – thanks to the mammogram it was caught at a very early, treatable stage.
Perhaps if we were better at defining what it means to be high risk in younger women, the recommendations to wait would be reasonable, but I’m not sure we are at that point yet.
I think mammograms should be declared obsolete. We should move straight to ultrasound and MRI technology for imaging. Debates like these waste the public’s time, which could be better used fighting for a cure to the actual cancer – instead of bickering about who/which machine found it. These debates strike me as self-serving, probably to keep employment for a certain segment of the radiology and medical device manufacturing professions. Yes, women are “at risk” and get breast cancer before 40 – that’s what better imaging is for.
I was not high-risk, yet my 1st mammo at age 43 found mirco-calcs that alerted me to DCIS. It did not show on an MRI. A few years ago, I may have had a different view, but today, I firmly believe in mammos yearly starting at 40. I wish I had been among the 80 percent who gets a benign result on their biopsy.
Thank you for all of your comments!
The WSJ debate is specifically focused on the role of screening mammography for the general population of women. At another time, we’ll focus on the role of diagnostic mammography — that is, in woman undergoing a workup for a potential breast abnormality detected by physical exam, self exam, or by an imaging modality, or women who are at high risk because of a predisposition or a prior history of breast cancer.
Any analysis of a test is a value judgement based on assumptions of pros and cons. I believe that Dr. Welch, the Task Force, and other groups cited have adopted assumptions that minimize the benefits, exaggerate the harms, and base future recommendations on past studies with old technology, inconsistent followup, and which are biased against mammography (such as the invited-to-be-screened studies). There are many reasons to believe that modern day technology utilizing digital mammography, as well as other diagnostic imaging studies as needed, are likely to improve our ability to diagnose breast cancers more quickly and accurately with fewer false positives and false negatives.
The value of a test depends on how many years of life are at stake. Once your risk is significant, it matters how much more life you have to lose or gain. Young women ages 40-50 are already at significant risk of breast cancer, especially in some of our populations, such as African American and Jewish women, who are more likely to be at risk earlier in life. These populations are underrepresented in the many of the European published studies.
Ultrasound and MRI are highly valuable tools for breast cancer surveillance in high risk women and for assessing the extent of disease in women already diagnosed. They are unproven as stand-alone screening tests for the general population.
I am struggling with the usesfulness of mammograms. I had a perfectly normal one the day I was diagnosed with breast cancer. The radiologist was about to clear me and send me home when he asked his technician to do a quick sonogram because I was complaining about a lump.
And there it was, breast cancer–and I was told it probably had been there for a few years at least. Those were years I was having my annual mammograms. I don’t think I can trust the technology anymore
I was diagnosed this past December 2012 with stage II breast cancer – estrogen/progesterone positive and her2 neu positive. I could not feel a lump of any sort and neither could my doctor. Due to the location of the lump and it size, the mammo caught it. I am 54 years old, non smoker and non drinker. Two of my doctors told me I was very fortunate to have caught the cancer early, especially the her2 neu. My yearly mammo saved my life. I had a lumpectomy and I am now in chemo treatments along with herceptin.
I have talked to many women since December in person, on the phone, email and on the message boards. I know there are lots of women out there that are diagnosed with cancer that are older than myself – but the one thing I have noticed is that there is a large number of women getting cancer which are in their 30′s and 40′s. It is distressing to see this happening and the bigger question is WHY ??? Is it our American diets, lifestyle, stress of women’s lives, but regardless if a women wants a mammo in their 30′s, maybe because their mother had breast cancer, there should be no reason why insurance cannot take care of the cost. We all know in life – an ounce of prevention is worth a pound of cure. Whatever group recommended several ago for mammos to start at age 50 and only scheduled for every two years – does not have breast – especially the kind especially used for nursing children and has never sat in a doctor’s office and receiving the news “you have breast cancer”. One thing I have learned in the past months, is the women that have come before me in this battle with breast cancer are strong warriors. Even though this is a club I would never chose to be in, I am proud to be a member. I never want my young daughters, my nieces or my sisters to every have to go through breast cancer. Women are still tool easily swayed to go with the status quo in life – why should this even be a debate with health insurance companies.
I had a stage III cancer at age 49 that did not show on diagnostic mammogram, but did show on ultrasound and MRI. I discovered it because it was a palpable lump, which was either missed or not present in my clinical exam four months prior to discovery.
I was angry about a couple things. The new mammogram guidelines gave me the impression I didn’t need to worry about breast cancer until age 50. My breast surgeon explained to me that part of the rationale for waiting is that cancer before 50 is likely to be fast growing enough that it will form a palpable lump, whereas mammograms are meant to find cancers that can’t be felt. So I didn’t understand that regular self-exams are important before age 50.
Also, I was never informed that the mammograms I had in my 40′s showed dense breast tissue, which makes mammograms far less able to see cancer, as well as being a risk factor in itself. I should have been informed of this and educated about the risk, the importance of self-exams, and referred for additional imaging.
At this point (after treatment for BC) I was told I still need mammograms because they find microcalcifications that will not show in other imaging. Also, now that I’m on tamoxifen for breast cancer, my breast density will be reduced. So ironically, mammograms are useful for me *after* having breast cancer, but not so much before.
I am all for having Mammography every year. In my case I had missed my Mammogram in 2011. At that time I felt it was not necessary to have Mammogram every year plus I had no family history. So when I visited my PCP he asked me to get one done in 2012. Was I lucky to have listened to him !!!!. My cancer was detected first with Mammogram and after various tests it was confirmed that it was at a very early stage so I had my Surgery and am just finishing my Radiation and I have been told I am on the path of CURE. I have been so lucky and ever since I have encouraged my relatives and friends to go in for their annual mammograms after consulting their doctor.
I am “on the fence” about the importance of mammograms. I was diagnosed with IBC at the age of 53. I found the growth myself through self-examination. I was sent for a mammogram and nothing showed. I belong to a cancer support group and a majority of the women in the group found their cancers through self-examination. I believe that self-examination is the first and most important step. Get to know your breasts first.
As Pbrain mentioned, we can make use of the ultrasound/sonogram to detect cancer tumors; it found one of mine. Also very useful is the Breast MRI, available in many locations. There’s no pressure on the breasts, and no radiation like the mammograms. It’s supposed to be very accurate; it’s detected 4 cancer tumors (4 different times) in my breast on first try. It’s supposed to be better for the dense breast people. Takes picture “slices.” Then there’s the Thermogram; no pressure on breasts; but harder to find a location for taking the pictures.
I couldn’t agree more. The Affordable Care Act is only going to make things worse. Now doctors will face a fines and even imprisonment if they violate the guidelines set forth by bureaucrats whose main concern is to lower costs, not to insure the best care for patients. We are all going to regret the implementation of this law.
I think the question is not ‘When and how often should women have mammograms?’ but “How should we treat very early cancers and pre-cancers when they are found?”
We are finding many more early stage non-invasive cancers because of mammogram screening, but how many of those cancers would never have progressed, if not treated? Why aren’t we doing more to learn which PRE-cancers can safely be left alone?
Many women are undergoing mastectomies and lumpectomies, radiation, and chemo for conditions that would not have progressed.
What are the costs to women’s long-term health and well being associated with these treatments? (Long-term risks of radiation, chemo, etc… )
Are we helping or hurting women?
Miglioretti and associates (J.NCI 2007) showed that when 123 radiologists in 72 US centres performed 36,000 diagnostic mammograms between ’96 and ’03 they still missed 21% of breast cancers and 4.3% had biopsies and other interventions with benign lesions. So, at best, mammograms has an 80% detection rate whilst also diagnosing all DCIS lesions as cancer requiring surgical interventions, could be excessive. Women having annual mammograms from age 40 will inevitably be exposing themselves to repeated radiation with the actual increased risks of inducing breast cancer. Another investigation is therefore needed that is both user-friendly and equally useful in young women with dense breasts. This is where modern thermal imaging can play its part i.e. Mammovision by InfraMedic AG (EU registered Class 1 Medical Device) that has the latest computer technology combined with Jenoptik (Zeiss) cameras. It should also be noted that even with the comparitive primitive thermal camera equipment of the ’80s, skilled physical examination combined with thermography resulted in an 80% (Haberman 1980) and 87% (Ciatto 1987) detection rates. At the very least, combining these two technologies will help determine which DCIS lesions could be left alone. In addition, if thermography was routinely used for younger women, it would pick up unhealthy “hot” estrogen dominant/progesterone deficient breasts where judicious use of iodine and natural progesterone could see subsequent reversal to normal.
My first mammogram at age 40 turned up DCIS. A follow up MRI showed more of it. I am headed for mastectomy. Mammograms should start EARLIER! However, with many of us having kids in our 30s and breastfeeding, I can see why most wouldn’t leap to get a mammogram till 40. Can’t see the logic of waiting!
A great book about the mammography debate is The Big Squeeze by Handel Reynolds, MD:
http://www.amazon.com/Big-Squeeze-Political-Controversial-Mammogram/dp/0801450934
Dr. Reynolds is a radiologist and VERY courageous for writing the book!
Dr. Weiss, I wholeheartedly agree that women aged 40-50 ARE at INCREASED risk of developing breast cancer. Furthermore, I also agree, there are certain groups, such as African American women and Jewish women who are at an even higher rate of developing breast cancer. And yes, with BETTER technology, we will one day, hopefully sooner than later, be able to detect those tumors, using SCREENING mammography that are critically important to detect. But for the GENERAL population of women between the ages of 40 and 50, SCREENING mammography does save lives, but not as many as we would hope it would do. And as long as women cheer for screening mammography for ages 40 – 50, without understanding that the present technology is woefully impaired for this age group, lives will continue to be lost. The Preventative Task Force does not say that women between 40 and 50 should NOT be generally screened. Instead, women in that age group should be aware that SCREENING mammography does NOT save as many lives as it does for women who are 50-75. They deserve better! And that’s why I am so adamant.
If you read the comments following your comment, you will see that many of the women who commented were FAILED by mammography screening.
And regarding Obamacare….Make no mistake about it. This is NOT a debate about rationing care. If one reads Otis Brawley, MD’s amazing book, How We Do Harm, one will realize this debate is about RATIONAL healthcare.
@voraciousreader, More pre-cancers are being detected and treated in that age group but this has not decreased fatalites. To me (a layperson) this means that the pre-cancers would not have advanced even without treatment. How many women are undergoing mastectomies for ‘cancers’ that would not have advanced anyway?
I recently consulted with a colleague, Dr. Ali Esmaili, a radiologist at the Breast Care Center of the Desert in Rancho Mirage, CA, to get his thoughts on the mammography debate. Here is his response:
“Screening mammography is far from perfect. Screening mammography does not detect all breast cancers and can also lead to additional imaging evaluation for findings that do not end up being breast cancer. This can lead to unnecessary anxiety for screening participants. That being said, screening mammography is one of the most beneficial advances in medicine in our lifetime. Mammograms save lives.
“The introduction of mammography screening in the United States has directly resulted in a 30% decrease in breast cancer mortality over the period of 1990-2005, according to statistics from the Surveillance Epidemiology and End Results program. This is phenomenal when considering we are dealing with the most common cancer and the second leading cause of cancer deaths amongst women. Studies show that 1 in 8 women will develop breast cancer in their lifetime. However, the majority of these women (75-90%) do not have a family history or risk factors that would place them in the high risk category.
“So why has this great advance in medicine been one of the most scrutinized screening tests to date? I am not so sure, but it has created lifelong careers for many so-called scientists that oppose it. Countless studies of the highest caliber have again and again demonstrated the benefits associated with screening mammograms.
“At the same time studies have also shown no benefits or even detrimental effects related to screening mammograms. However, the devil is in the detail. Many of these negative studies, which I will not go into, are based on studies that do not pass the rigorous standards of a well designed scientific study. One of the largest studies performed in Canada failed to comply with the process of designing a randomized controlled study. Some studies have used small populations, which statistically do not provide power to their results. Studies have also done short-term follow-up, when it is known that the benefits of screening do not become apparent until 5-7 years after implementation. Scientific studies have been performed that have used arbitrary assumptions as the base of their entire study. There is no science in an assumption! Another study diluted the benefits of screening patients aged 40-49 by including patients under the age of 40 within this cohort to arrive at their desired conclusion showing that there was no benefit from screening in this age group.
“A simple study by Laslo Tabar in Sweden analyzed the real population comparing 3 different decades. The first decade, 1968-1977, no screening mammogram was offered to anybody in the population. The second decade, 1978-1987, some of the population were invited to screening. The third decade, 1988-1996, the entire population was eligible for screening. This study showed that the death rate from breast cancer declined 63% from the decade of no screening being available to the decade when everyone was eligible for screening. By the way, the age of the screened population was 40-64.
“In 2009, the United States Preventive Services Task Force dropped their recommendation for screening women aged 40-49 and instead recommended biennial screening for women aged 50-74. I am not sure why women in their 40s were left out? Reviewing statistical data for breast cancer occurrences show that no decade accounts for more than 25% of breast cancers. So are we ignoring 25% of the breast cancers? Did they collectively decided not to screen them, since the false positives would be more of an inconvenience to women in this age group compared to older women? Our callback rate is 7-8% and is no different for women screened in their 40s than 60s. Nothing changes as far as breast cancer risk from a patient’s 49th birthday to their 50th birthday. The age 50 is just an arbitrary number selected since it allows nice organization of patients in age cohorts for each decade. Otherwise, there is nothing magical about the age of 50 and breast cancer risk. However, this was the cut-off age selected by this so-called panel of experts. An expert panel that did not have a single healthcare professional involved in breast cancer therapy or care. Not sure how they can be called experts when they don’t even practice in this field of medicine. However, it seems that they have been misguided and chose to base their “scientifically based” recommendation on fundamentally flawed studies that I alluded to above. Meanwhile, a conglomerate of studies again from Sweden specifically focused on screening women in their 40s showed a statistically significant 29% decrease in mortality as a result of the screening program. In my opinion it is offensive to exclude women in their 40s from screening, implying that their life is less valuable than older women when they clearly benefit from screening. A 30% decrease in mortality translates to 15,000-20,000 lives per year in the United States. That is roughly equivalent to the population of Calabasas, CA.
“Mammography is the current gold standard for screening and there is no imaging technology to replace it. Ultrasound and MRI are adjunctive screening tools to be used alongside mammography and do not have any proven benefit when used alone, although they do show benefits when used in conjunction with mammography in high-risk women. Findings such as calcifications associated with ductal carcinoma in situ (25-30% of detected breast cancers) are only visualized with mammography. Applying screening mammography only for high-risk patients would result in excluding 75-90% of women that develop cancer. By definition this would make screening ineffective since the majority of the women that would benefit would be excluded. In conclusion, screening mammography is not perfect but it does have proven results. Mammography saves lives, however mammography will be continued to be scrutinized.”
“The introduction of mammography screening in the United States has directly resulted in a 30% decrease in breast cancer mortality over the period of 1990-2005, according to statistics from the Surveillance Epidemiology and End Results program.”
I have never seen data like that from SEER. Can Dr. Esmaili explain? This is one of many unsupported statements I see in his exlpanation. The age- and population-adjusted death rate for breast cancer hasn’t budged more than 5 percentage points between 1950 and 2005 acording to a study by the NYT using SEER data.
Calling mammograms one of the most “beneficial advances of medicine in our lifetime” is a gross misstatement – or a misleading one at best. First of all, a mammogram is a screening/diagnostic tool and it is essentially an x-ray. X-rays are certainly one of the best advances, but not because of breast cancer. And it is disingenious to compare mammograms with, say, AIDS drugs, a heart transplant or open heart surgery.
Mmmograms are unreliable diagnosers and even more dubious screeners. (Anbs I personally had no problem with mine – it very clearly showed my lump).
Women over 40 are only at “significant” risk when the word “significant” is used the way statisticians use it – to mean basically any data deviation that cannot be entirely explained chance. But as the public and the world use the word “significant,” as in”very high” it is NOT true that, as a general statement, women over 40 at are a very high risk of breast cancer. It may be true that one in eight or nine women get bc, but it does NOT follow that our risk is high over our lifetime. At most stages, it is low, and only higher after menopause.
Dr.Weiss….Thank you for your continued interest in discussing the debate regarding screening mammograms. Regarding, your post containing radiologist Ali Esmaili’s comment,”… In my opinion it is offensive to exclude women in their 40s from screening, implying that their life is less valuable than older women when they clearly benefit from screening. A 30% decrease in mortality translates to 15,000-20,000 lives per year in the United States. That is roughly equivalent to the population of Calabasas, CA….” once again, I find it inflammatory and repugnant to resort to claiming how “valuable” the lives are of women ages 40-49! There is NO argument how “valuable” ANYONE’S life is! Again, the task force did not say that these women should NOT have annual screening. The task force recommends that patients 40-49 discuss the RISKS and BENEFITS and then CHOOSE if ANNUAL mammography is right for them. Plain and simple, the statement made by Dr. Asmaili adds nothing to the controversy except rhetoric! And as commenter, GREENPLANNER questions the serious issue of overdiagnosis, patients 40-49 should be AWARE of the issue of overdiagnosis before agreeing to be screened. More often than not, patients are NOT made AWARE of the limitations of screening mammography. Furthermore, several weeks ago, The Journal of the American Medical Association published two interesting studies regarding screening done on the elderly. In one study, researchers found that physicians need to be thoughtful about how they tell older patients that cancer screenings are no longer necessary. When interviewed, older adults were opposed to STOPPING screening because they felt ” a moral obligation” to continue. Elderly patients EXPECTED their physicians to recommend screening despite the potential risks and lack of benefit. It appears that our country’s physicians have done an EXCELLENT job of recommending screening, but an AWFUL job of discussing the risks and benefits for certain age groups and explain to patients when it’s appropriate to stop screening.
How many more studies do we need to tell us that physicians need to do a better job at explaining EXACTLY who benefits greatly from all types of screening and who doesn’t AND with the patient’s input decide what modality of screening is right for them?
Radiologist Handel Reynolds in his terrific book, The Big Squeeze does an excellent job of explaining how politics has squashed this important discussion:
“When, under intense political pressure, the National Cancer Institute changed its position on mammograms in 1997, recommending the screens every other year for women in their 40s, the primacy of politics over science in this matter was firmly established.
In the future, if a conclusion based on scientific data was politically untenable, it would simply be overruled by political leaders.
Thus, in the fall of 2009, when mammography for women younger than 50 again became embroiled in controversy, the federal government swiftly resolved the matter by taking the “pro” side. I predict this will turn out to have been our last heated national debate on mammography screening.
A very curious thing happened that October. In a moment of unprecedented candor for an official of the normally message-disciplined American Cancer Society, Otis Brawley, its chief medical officer, made a startling admission. In a New York Times interview, he said, “I’m admitting that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated.” He went on to say that even though mammography can save lives, “if a woman says, ‘I don’t want it,’ I would not think badly of her, but I’d like her to get it.”
Brawley was responding to an article that had just been published in the Journal of the American Medical Association, in which researchers argued that 20 years of widespread breast and prostate cancer screening had failed to deliver the promised health benefits. In both cases, screening had led to a huge increase in the incidence of early-stage disease, with only a very slight decrease in late-stage disease.
This is significant because the basic rationale for screening has always been that identifying and treating more early-stage cancers will lower the number of late-stage cancers. That this has not happened suggests that screening detects many nonaggressive cancers that would not have progressed if left undetected. The practical result of large-scale screening, in other words, was overdiagnosis and overtreatment.
Then, on Nov. 16, 2009, in a move that seemed to shock everyone, the U.S. Preventive Services Task Force, a group of experts that periodically reviews the scientific justification for clinical preventive services, rescinded its 2002 recommendation that women younger than 50 should have screening mammography. Analyzing the data, the task force found that screening mammography in women under 50 resulted in a 15 percent reduction in breast cancer mortality. Although this was the same reduction seen in women 50 to 59, it was significantly smaller than the 32 percent reduction in women 60 to 69.
Furthermore, because breast cancer is less common in women under 50, the task force found that in order to avert one death, 1,904 women in their 40s would have to be screened – compared with 1,339 women in their 50s and 377 women in their 60s.
The task force also considered the possible harms of screening mammography, including radiation exposure, pain, anxiety and false positive or false negative results. Women under 50, the panel found, were much more likely than older women to receive a false positive mammogram – an abnormal report that requires additional imaging or biopsy but turns out to indicate nothing serious. With this in mind, the task force recommended against routine screening mammography in women 40 to 49, giving this activity a grade of C.
The panel’s timing, dictated by the publishing schedule of the medical journal in which the recommendation was announced, could not have been worse. During the last half of 2009, Congress was debating President Barack Obama’s health-care- reform legislation, and, over the summer, members of Congress had faced loud and hostile constituents in town-hall meetings. The conversation had devolved into ominous warnings about “death panels” and “pulling the plug on Granny.” So it was no surprise that the new mammography guidelines were denounced as an ominous instance of health-care rationing to come.
“This is how rationing begins. This is the little toe in the edge of the water. This is when you start getting a bureaucrat between you and your physician,” Representative Marsha Blackburn, a Tennessee Republican, said. Other critics of the health-care-reform bill pointed to language in the Senate version that required health plans to cover only those preventive services that received an A or B grade from the task force.
A news release from the American College of Radiology characterized the new guidelines as “a step backward,” posing “significant harm to women’s health.” Brawley of the American Cancer Society, despite his public mea culpa a month earlier, asked in an op-ed article, “How many mothers, sisters, aunts, grandmothers, daughters and friends are we willing to lose to breast cancer while the debate goes on about the limitations of mammography?”
The community of advocates for breast cancer research and treatment was divided. Nancy G. Brinker, founder of Susan G. Komen for the Cure, predicted “mass confusion and justifiable outrage.” But Fran Visco, president of the National Breast Cancer Coalition, welcomed the change, arguing that there had been too much emphasis on giving women an unambiguous message on screening. “While messages need to be simple, they need to be truthful,” she said.
Susan Love, the renowned breast surgeon and founder of the Susan Love Research Foundation, strongly supported the task force, both on her blog and in a round of news media interviews. On ABC’s “Good Morning America,” she stated categorically that mammography had “never been shown to work in women under 50″ and said, “We’ve sort of oversold the notion of early detection.”
In response, Love’s blog was flooded with angry messages, including one that screamed, “Have you lost your freakin’ mind?” In her next post, Love found it necessary to declare, “I had nothing to do with formulating these guidelines” and “I have not been influenced or received any donations from any insurance companies, nor have I been bought off by our federal government.”
These few voices of support notwithstanding, public opinion ran overwhelmingly against the guidelines. Seventy-six percent of women 35 to 75 disagreed with them, a USA Today-Gallup poll found in the days after their release. Eighty-four percent of women 35 to 49 said they would ignore them. Most significantly, 76 percent of them believed that the new protocol had been proposed as a way to save money. Thus, even though the task force review of mammography guidelines had been completed during the George W. Bush administration, a line was drawn in the public’s mind to health-care rationing proposed under “Obamacare.”
The Obama administration, which had come to power stressing a new respect for science, found itself in a quandary: accept the scientific panel’s advice and watch health-care reform go down in defeat, or reject the advice and risk comparisons to the Bush administration in its controversial handling of stem cell research. Within 48 hours of the task force’s announcement, Health and Human Services Secretary Kathleen Sebelius disavowed the guidelines. “Mammograms have always been an important life- saving tool in the fight against breast cancer, and they still are today,” she said. “Keep doing what you have been doing for years.”
The controversy died quickly. In July 2010, after the Affordable Care Act had been passed, Health and Human Services announced that insurers would be required to cover mammography in accordance with the 2002 guidelines, which recommended routine screening beginning at age 40. In October 2010, in his annual Breast Cancer Awareness Month proclamation, Obama reiterated this message: In women 40 and older, he said, regular mammograms and clinical breast exams every year or two are “the most effective way to find breast cancer early, when it may be easier to treat.”
It is unlikely we will ever have another major national controversy on screening mammography in women younger than 50. After all, it has already been studied in excruciating detail. In any case, the debate has always been about access. Political leaders have now decided that American women have a right to screening mammography starting at age 40, so its status is secure – at least until a replacement technology comes along.”
Until we develop better testing technology, we have to use what we have. Mammography doesn’t catch all cancer, mri shows too many lumps and bumps, etc…….bottom line is women need to be checked. Recent research is telling us cancer is on the rise in our younger women. I want them to have access to testing. Breast cancer doesn’t just strike people with risk factors. I had none. No family history, my weight is good, I workout, eat a great diet, breast fed my children, had them both in my twenties, etc. I am one of those people would have been lost with the change in guidelines. We must push for better technology, but we must protect our access to what is available now.
The cover story of The New York Times Sunday Magazine for this weekend (April 27), written by a breast cancer survivor is devoted to the mammography screening debate.
I applaud Peggy Orenstein for writing the article and share her sentiments:
“It has been four decades since the former first lady Betty Ford went public with her breast-cancer diagnosis, shattering the stigma of the disease. It has been three decades since the founding of Komen. Two decades since the introduction of the pink ribbon. Yet all that well-meaning awareness has ultimately made women less conscious of the facts: obscuring the limits of screening, conflating risk with disease, compromising our decisions about health care, celebrating “cancer survivors” who may have never required treating. And ultimately, it has come at the expense of those whose lives are most at risk. “
This is a great debate and I thank Dr. Weiss for opening this forum to this controversial topic. The following comments are based on scientific literature reported in peer reviewed journals (different from the New York Times).
When widespread mammography screening was introduced in the 90s, a subsequent decrease of 30% in the mortality rate could be seen by looking at National Cancer Institute SEER mortality data year after year. Of course this was not seen in the first year, but there is a gradual downward trend, and when plotted out to 2009 the reduction can be seen. The graph can be seen in this article that is also well worth the read:
The 2009 US Preventive Services Task Force (USPSTF) guidelines are not supported by science: the scientific support for mammography screening. Radiol Clin North Am. 2010 Sep;48(5):843-57.
Mammography represents an important advance in medicine. It has come a long way since it was first introduced. And it has a long track record of improvements and benefits. The original mammogram was done by xerography at high radiation doses to the patient. We have now advanced to a digital era with lower radiation and better resolution for evaluation. This has led to significant increase in the detection of breast cancer, specifically at earlier stages (easiest to treat and essentially curable). However, it is true this may lead to overdiagnosis, but the problem is that there currently is no reliable way to determine which cancers will progress and be more aggressive versus the more docile tumors that will never cause any harm. Therefore, it is better to err on the side of removing all tumors until this advance in medicine is available.
Some of the best breast cancer screening research was performed in Sweden since they were population-based studies, rather than mathematical models, which many of the studies that are cited in this debate are based on. The problem with mathematical models is that variables that are used are arbitrary or assumed values that are not based on scientific fact. In a mathematical model it is easy to manipulate data to arrive at your hypothesis (if you would like, I can go over the studies you are interested in and show you what the major flaws are). However, a population-based study replicates the real world and leaves less room for manipulation. I urge all the followers of this debate to review these two studies, which both have over 15 years of follow up and are based on large population studies (therefore the results have power):
1.) Tabar L, et al. Beyond randomized controlled trials: organized mammographic screening substantially reduces breast carcinoma mortality. Cancer 2001; 91:1724-31.
2.) Hellquist BN, et al. Effectiveness of population-based service screening with mammography for women ages 40 to 49 years: Evaluation of the Swedish mammography screening in young women cohort. Cancer 2010; 117:714-22.
Once again it is my firm belief that mammography does save lives and it should start at the age of 40 on an annual basis, as demonstrated by the current clinical trial results. Mammography is not perfect, but it is the best screening method we have for early detection in the general population. We’re working hard on something better. More research needs to be done to determine what lesions can be left alone in the breast and which ones absolutely need to have treatment. Until then, it is hard to justify ignoring cancers seen on mammogram or other imaging modalities.
Following Peggy Orenstein’s article, she wrote further in The NY Times WHY she wrote her article. The following are two opposing comments by physicians. The first is written by radiologist Daniel Kopans. He is the leading proponent of the status quo. The second comment is from a public health physician, Susan Marantz. Obviously, I agree with Dr. Marantz. Sadly, based on what Dr. Kopans says, I don’t think that this debate is going to end any time soon.
______________________________________________
Daniel Kopans, M.D.
MGH
..
Ms. Orenstein’s eloquent description of her views on breast cancer screening unfortunately, contains much misinformation. No invasive breast cancer has ever “gone away on its own”. The New England Journal of Medicine has ignored numerous experts who have called for the withdrawal of one of the papers she cites that falsely claims mammography screening causes over-diagnosis.
1. The authors had no idea who had mammography, nor which cancers were detected by mammography and no scientific validity.
2. Scientific studies show that mammography leads to little if any overdiagnosis.
3. They mixed invasive cancers with DCIS to dilute and mislead. Ms. Orenstein raises legitimate issues about DCIS, but finding invasive cancers when small saves lives.
4. They estimated incidence from a 3 year period soon after Happy Rockefeller and Betty Ford had breast cancer making it completely unreliable.
5. 40 years of data prior to screening show the rate increasing at 1% per year, four times the estimate used by the authors. Since 2006 the incidence has returned to a 1% per year increase confirming its validity. Using this correct number and excluding DCIS, there has been NO overdiagnosis of breast cancer. The authors used the wrong extrapolation and their conclusions should be withdrawn.
Women need to be provided with facts-not the fiction that some are promoting. Mammography screening is not the ultimate answer to breast cancer, but it is here today and saving thousands of lives.
April 29, 2013 at 6:07 p.m.
Recommended4
..
Susan Marantz MD, MPH
Chicago
..
As a women , a physician and an individual who has a Public Health degree and has worked Public health policy I was ecstatic to read this article. Finally someone has in a well research, touching and well thought out article explained to the women of America the truth about Breast Cancer. Women need to know the risks,the benefit and nature of the disease.
Knowledge is power and fear only clouds one’s ability to make informed decisions .
Women are getting so many conflicting messages. Their own Doctors do not want to be sued for missing a breast cancer so they feel more is better. Companies that do mammography need to pay for their machines so they do what ever is need to get more patients, such as mammography units in department stores so you can get your Mammo , while you shop. The US GOVERNMENT’s
own panel advised new recommendations for screening mammography but the US government did not in the end support their own panel’s recommendation and changed their position because political .
I tell patients all the time to review recommendations from other countries such as Britain, other European countries and Canada as their health care policy are based on the science and much less so on politics and profits.
I only hope that this informations is disseminated wildly so more women can make the right choices for their health care based on the facts and not fear.
April 29, 2013 at 1:17 p.m
Dr. Esmaili,
Thank you for your additional information regarding mammography.
I don’t think anyone is suggesting that we “ignore” certain cancers seen on mammograms or other imaging modalities. And I greatly appreciate that other types of screening modalities are being worked on that will hopefully, one day soon, be incorporated into wellness care. I do appreciate what you and other radiologists are doing…that is, help saving lives.
However, I think what this mammography “debate” is NOT about… is saving lives. No one is going to “argue” that mammography doesn’t save lives. That’s silly. What the “debate” IS about…. is
EXACTLY how many lives DOES SCREENING mammography actually save AND what is it that we need to do going forward to actually SAVE MORE LIVES? The “debate” should invite a discussion between physician and patient about WHO ACTUALLY SHOULD BE SCREENED AGGRESSIVELY and WHO SHOULD NOT.
Have you noticed recently that more and more cancer screening studies are promoting LESS SCREENING for some groups, while zeroing in on those who should have MORE? Just this week, the American Urological Association, which was a strong advocate of PSA screening, just relaxed it’s recommendation. They based their decision on the studies that said there was NO high level of evidence to recommend it for many age groups.
Over the last decade or two, patients have become their own advocates and that’s a wonderful trend. The message that screening saves lives has resonated with the public. But with that message, what is not discussed as much between physician and patient is that we are finding out that screening saves lives, BUT NOT AS MANY AS PREVIOUSLY BELIEVED and based on that knowledge, how does that affect ME, the patient. And while I agree with you that cancers picked up on imaging or through testing should NOT be ignored, everyone should be aware of their risk factors for illnesses and decide with their physicians how aggressive they need to be with their screening.
Visionary physician, Eric Topol, MD wrote about screening in his fantastic book, The Creative Destruction of medicine. If you haven’t read it, I highly recommend that you and your colleagues read it. What he says is we need more PRECISE information about a patient BEFORE we recommend all kinds of screening. In the near future, because the cost of genetic screening is plummeting, we will, one day soon, assess one’s INDIVIDUAL risk of getting a disease and then decide what kind of screening and how often they will need it.
We are going to move away from eminence based medicine, which is what we pretty much have now to a type of PRECISE evidence based medicine based on genomes.
Until then, radiologists need to simmer down! They need to come on board on this new journey. They need to stop being derisive of every new study that QUESTIONS the importance of screening mammography. They need to accept that the “message” needs to be tweeked and stop reminding us about how “valuable” any specific group of patients lives are. Every life is valuable. And I’ll leave you with this one little story about WHY I think the “message” that mammograms save lives needs to be tweeked.
Recall that there was a recent study in The New England Journal of Medicine that said a majority of elderly patients believe they are “morally obligated” to be screened for illnesses. Most elderly folks were middle age in the 1970′s when screening was beginning to be advocated. Radiologist Handal Reynolds, MD does a great job in his book, The Big Squeeze, of explaining the historical foundation of how screening mammography began and how it rapidly spread. When one looks at the historical foundation of how and why screening became popular, it is no wonder why elderly people believe they are “morally obligated” to have screening. The medical community and advocacy groups have done a stupendous job at trying to “save lives.” But somewhere along the way, as “evidence” began to accumulate, a quieter message was lost on physicians and the public and that is, screening saves lives and not as many as first believed.
Now my mother, an 88 year old, retired nurse (mind you, I don’t think nurses actually ever really retire) is one of those elderly patients who believes she is “morally obligated” to get screening. At her most recent visit to her internist, I asked if it was time for her to stop having ANNUAL mammograms. Mind you, my mother, over her lifetime must have had a half a dozen breast biopsies, all benign. The internist said to us that because she is a healthy 88 she should continue having screening mammograms, but she doesn’t need to go EXACTLY every year. She could push out her exams a few months if she would like to. I ask you, Dr. Esmaili, considering she STILL drives herself, isn’t it more likely for her to have a car accident on her way to the radiologist office than for her to be diagnosed with breast cancer and die from it?
For me there is no mammography “debate” about saving lives. For me the mammography “debate” is all about RATIONAL health care. And it seems to me we’ve lost our way on that journey.
voraciousreader, you do really live up to the name — you definitely are well-read on this subject matter and a voracious writer, no less. Your post is great with the two differing opinions from the physicians. I am quite familiar with the writings of Dr. Daniel Kopans, and I included one of his articles in my previous post for you to read if you get the opportunity. Dr. Kopans is the director of breast imaging at Massachusetts General Hospital and is an expert in the field of breast imaging. Dr. Susan Marantz, from what I gather, is a pulmonologist, so I am not sure how much expertise she has in breast imaging. I’d probably side with the expert in the field on this matter.
The recommendation to examine the breast screening guidelines in Canada, UK, and other European countries shows a uniting theme amongst these systems. They are all single payer healthcare systems, and the control of cost is paramount for the feasibility of these systems.
It makes me wonder if increased intervals between screening mammograms or starting them at a later age influenced their guidelines based on the cost savings. This may however come at the expense of detecting breast cancers earlier, but spending more later to treat more advanced cancers. Even within the U.S. there are health maintenance organizations and county hospital systems that have changed their screening recommendations to start screening at 50 and screen at 18 or 24 month intervals. The fact that they are the first to adopt these changes, despite recommendations of the American Cancer Society and other prominent medical societies, also makes me suspicious that these changes are financially motivated.
As far as determining the lives saved by mammography, unfortunately there have been major oversights by the peer-review journals in the studies that they have accepted for print. This has led to the public being mislead about the efficacy of screening mammography and the lives saved. For instance, the USPSTF based their mathematical model to calculate the number of mammograms needed to save one life using a mortality rate reduction of 15%. This is definitely the lower end of the spectrum, when other higher quality studies show that mortality reduction goes as high as 33%. Therefore, they calculate that 1,500-1,800 mammograms are needed to save one life, when if they used more accurate numbers it would be as low as 700-800.
I agree with you that screening should be more aggressive in populations that are determined to be at higher risk. There are risk assessment models that are available to determine if you have a higher lifetime risk of developing breast cancer compared to the average population. Also, as you correctly state, genetic testing can also determine if you are more prone to developing breast cancer with gene mutations in BRCA1 and BRCA2 genes. Women who have a mammogram alternating with MRI at 6-month intervals are screened more aggressively. However, as I previously stated, to just focus on this high-risk population that only account for 10% of breast cancers would overlook the other 90% of patients who develop the disease. This would not be an effective screening program.
As far as radiologists needing to simmer down, I would point you towards the Choosing Wisely campaign. The American College of Radiology has spearheaded an initiative called Choosing Wisely in conjunction with the American Board of Internal Medicine Foundation and 8 other major medical groups. This initiative identified 45 tests or treatments that were felt to be overused, 24 of which were related to diagnostic imaging. Screening mammography was not on that list.
For your mother, I agree with her internist that she should continue to have her mammograms. If they would like to increase the interval between screening that is fine and that is a discussion and decision that they should have together. It sounds like your mother is a healthy 88-year-old and, as you state, still driving and probably keeping up with her activities of daily living. Therefore, she would benefit from screening. I would recommend screening as long as you still have a life expectancy of 7-10 years. There are no data or studies on this subject matter, which may be an interesting topic to research for the future. However, it is inappropriate to continue screening patients with terminal illness or in hospice care. There is no benefit from screening this population. It seems like you did accompany your mother to her primary doctor’s visit, and if you are concerned with her having a car accident on the way for her mammogram screening I suggest you drive her. From a statistical standpoint, her risk of having a car accident while driving to have her mammogram is no greater than the risk of having a car accident driving for any other reason. I don’t think your argument is valid, and only serves a dramatic illustration.
Screening mammography is the gold standard for breast cancer screening. Scientifically valid studies that are population based have shown that it does indeed save lives. Women who are at higher risk of developing breast cancer need to undergo more vigilant screening and clinical exams. With time there will be technology to help determine what lesions will remain docile if not treated with surgery, radiation, or chemotherapy. I don’t think that we have strayed from the journey of rational and evidence-based healthcare, but it is an ongoing journey with the destination improving every day.
Thank you to all of our commenters for your thoughtful, well-researched opinions on the mammography debate. Our experts will no longer be responding to the debate, but we are leaving comments open so that you may continue to respectfully discuss the matter.
Best,
Caroline
Content Manager