New advice: Skip mammograms in 40s, start at 50

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Another news story:New advice: Skip mammograms in 40s, start at 50http://news./s/ap/20091117/ap_on_he_me/us_med_mammogram_advice_8

By STEPHANIE NANO and MARILYNN MARCHIONE, Associated Press Writers Nano And Marilynn Marchione, Associated Press Writers

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1 hr 58 mins ago

NEW YORK – Most women don't need a mammogram in their 40s and should get one every two years starting at 50, a government task force said Monday. It's a major reversal that conflicts with the American Cancer Society's long-standing position.

Also, the task force said breast self-exams do no good and women shouldn't be taught to do them.

For most of the past two decades, the cancer society has been recommending annual mammograms beginning at 40.

But the government panel of doctors and scientists concluded that getting screened for breast cancer

so early and so often leads to too many false alarms and unneeded

biopsies without substantially improving women's odds of survival.

"The

benefits are less and the harms are greater when screening starts in

the 40s," said Dr. Petitti, vice chair of the panel.

The new guidelines were issued by the U.S. Preventive Services Task Force, whose stance influences coverage of screening tests by Medicare and many insurance companies.

But Pisano, a spokeswoman for America's Health Insurance Plans,

an industry group, said insurance coverage isn't likely to change

because of the new guidelines. No changes are planned in Medicare

coverage either, said Dori Salcido, spokeswoman for the Health and

Human Services department.

Experts expect the task force revisions to be hotly debated, and to cause confusion for women and their doctors.

"Our

concern is that as a result of that confusion, women may elect not to

get screened at all. And that, to me, would be a serious problem," said

Dr. Len Lichtenfeld, the cancer society's deputy chief medical officer.

The guidelines are for the general population, not those at high risk of breast cancer because of family history or gene mutations that would justify having mammograms sooner or more often.

The new advice says:

_Most women in their 40s should not routinely get mammograms.

_Women

50 to 74 should get a mammogram every other year until they turn 75,

after which the risks and benefits are unknown. (The task force's

previous guidelines had no upper limit and called for exams every year

or two.)

_The value of breast exams by doctors is unknown. And breast self-exams are of no value.

Medical

groups such as the cancer society have been backing off promoting

breast self-exams in recent years because of scant evidence of their

effectiveness. Decades ago, the practice was so heavily promoted that

organizations distributed cards that could be hung in the shower

demonstrating the circular motion women should use to feel for lumps in

their breasts.

The guidelines and research supporting them were released Monday and are being published in Tuesday's issue of the ls of Internal Medicine.

The new advice was sharply challenged by the cancer society.

"This is one screening test

I recommend unequivocally, and would recommend to any woman 40 and

over," the society's chief medical officer, Dr. Otis Brawley, said in a

statement.

The task force advice is based on its conclusion that screening

1,300 women in their 50s to save one life is worth it, but that

screening 1,900 women in their 40s to save a life is not, Brawley

wrote.

That stance "is essentially telling women that mammography at

age 40 to 49 saves lives, just not enough of them," he said. The cancer

society feels the benefits outweigh the harms for women in both groups.

International guidelines also call for screening to start at

age 50; the World Health Organization recommends the test every two

years, Britain says every three years.

Breast cancer is the most common cancer and the second leading cause of cancer deaths in American women. More than 192,000 new cases and 40,000 deaths from the disease are expected in the U.S. this year.

Mammograms can find cancer early, and two-thirds of women over

40 report having had the test in the previous two years. But how much

they cut the risk of dying of the disease, and at what cost in terms of

unneeded biopsies, expense and worry, have been debated.

In most women, tumors are slow-growing, and that likelihood

increases with age. So there is little risk by extending the time

between mammograms, some researchers say. Even for the minority of

women with aggressive, fast-growing tumors, annual screening will make

little difference in survival odds.

The new guidelines balance these risks and benefits, scientists say.

The probability of dying of breast cancer after age 40 is 3

percent, they calculate. Getting a mammogram every other year from ages

50 to 69 lowers that risk by about 16 percent.

"It's an average of five lives saved per thousand women screened," said town University researcher Dr. Jeanne Mandelblatt.

Starting at age 40 would prevent one additional death but also

lead to 470 false alarms for every 1,000 women screened. Continuing

mammograms through age 79 prevents three additional deaths but raises

the number of women treated for breast cancers that would not threaten

their lives.

"You save more lives because breast cancer is more common, but

you diagnose tumors in women who were destined to die of something

else. The overdiagnosis increases in older women," Mandelblatt said.

She led six teams around the world who used federal data on

cancer and mammography to develop mathematical models of what would

happen if women were screened at different ages and time intervals.

Their conclusions helped shape the new guidelines.

Several medical groups say they are sticking to their guidelines that call for routine screening starting at 40.

"Screening isn't perfect. But it's the best thing we have. And it works," said Dr. Carol Lee, a spokeswoman for the American College of Radiology. She suggested that cutting health care costs may have played a role in the decision, but Petitti said the task force does not consider cost or insurance in its review.

The American College of Obstetricians and Gynecologists

also has qualms. The organization's Dr. Hal Lawrence said there is

still significant benefit to women in their 40s, adding: "We think that

women deserve that benefit."

But Dr. Amy Abernethy of the Duke Comprehensive Cancer Center agreed with the task force's changes.

"Overall, I think it really took courage for them to do this,"

she said. "It does ask us as doctors to change what we do and how we

communicate with patients. That's no small undertaking."

Abernethy, who is 41, said she got her first mammogram the day

after her 40th birthday, even though she wasn't convinced it was

needed. Now she doesn't plan to have another mammogram until she is 50.

Barbara Brenner, executive director of the San Francisco-based Breast Cancer Action,

said the group was "thrilled" with the revisions. The advocacy group

doesn't support screening before menopause, and will be changing its

suggested interval from yearly to every two years, she said.

Mammograms, like all medical interventions, have risks and benefits, she said.

"Women are entitled to know what they are and to make their best

decisions," she said. "These guidelines will help that conversation."

___

Medical Writer Marilynn Marchione reported from Milwaukee.

___

On the Net:

Government advice: http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm

>> On one hand, I feel vindicated (I've never gotten a mammogram).On the> other hand, I feel less confident that the medical recommendations we> are given are ever right, when they are constantly revised!> > Note the REASON for the revision: aimed at reducing harm from> overtreatment! In other words, the risks associated with getting> mammograms. Make up your own mind about it....> > http://www.nytimes.com/2009/11/17/health/17cancer.html?_r=1> In Reversal, Panel Urges Mammograms at 50, Not 40 > <http://www.nytimes.com/2009/11/17/health/17cancer.html?_r=1#> > <http://www.nytimes.com/auth/login?URI=http://www.nytimes.com/2009/11/17\> /health/17cancer.html> By GINA KOLATA> <http://topics.nytimes.com/top/reference/timestopics/people/k/gina_kolat\> a/index.html?inline=nyt-per> Published: November 16, 2009> Most women should start regular breast cancer> <http://health.nytimes.com/health/guides/disease/breast-cancer/overview.\> html?inline=nyt-classifier> screening at age 50, not 40, according to> new guidelines released Monday by an influential group that provides> guidance to doctors, insurance companies and policy makers.> > [190] Dalton for The New York Times> , a nurse in the breast cancer division of the MD > Cancer Center in Houston, went over the files of Starla Trayal, a> patient.> New Guidelines on Breast Cancer Draw Opposition> <http://www.nytimes.com/2009/11/17/health/17scre.html?ref=health> > (November 17, 2009)> The new recommendations, which do not apply to a small group of women> with unusual risk factors for breast cancer, reverse longstanding> guidelines and are aimed at reducing harm from overtreatment, the group> says. It also says women age 50 to 74 should have mammograms> <http://health.nytimes.com/health/guides/test/mammography/overview.html?\> inline=nyt-classifier> less frequently — every two years, rather> than every year. And it said doctors should stop teaching women to> examine their breasts on a regular basis.> > Just seven years ago, the same group, the United States Preventive> Services Task Force <http://www.ahrq.gov/clinic/uspstfab.htm> , with> different members, recommended that women have mammograms every one to> two years starting at age 40. It found too little evidence to take a> stand on breast self-examinations.> > The task force is an independent panel of experts in prevention and> primary care appointed by the federal Department of Health and Human> Services> <http://topics.nytimes.com/top/reference/timestopics/organizations/h/hea\> lth_and_human_services_department/index.html?inline=nyt-org> .> > Its new guidelines, which are different from those of some professional> and advocacy organizations, are published online in The ls of> Internal Medicine <http://www.annals.org/> They are likely to touch off> yet another round of controversy over the benefits of screening for> breast cancer.> > Dr. Petitti <http://sci.asu.edu/directory/page.php?profile=794> ,> vice chairwoman of the task force and a professor of biomedical> informatics at Arizona State University> <http://topics.nytimes.com/top/reference/timestopics/organizations/a/ari\> zona_state_university/index.html?inline=nyt-org> , said the guidelines> were based on new data and analyses and were aimed at reducing the> potential harm from overscreening.> > While many women do not think a screening test can be harmful, medical> experts say the risks are real. A test can trigger unnecessary further> tests, like biopsies, that can create extreme anxiety> <http://health.nytimes.com/health/guides/symptoms/stress-and-anxiety/ove\> rview.html?inline=nyt-classifier> . And mammograms can find cancers that> grow so slowly that they never would be noticed in a woman's> lifetime, resulting in unnecessary treatment.> > Over all, the report says, the modest benefit of mammograms —> reducing the breast cancer death rate by 15 percent — must be> weighed against the harms. And those harms loom larger for women in> their 40s, who are 60 percent more likely to experience them than women> 50 and older but are less likely to have breast cancer, skewing the> risk-benefit equation. The task force concluded that one cancer death is> prevented for every 1,904 women age 40 to 49 who are screened for 10> years, compared with one death for every 1,339 women age 50 to 74, and> one death for every 377 women age 60 to 69.> > The guidelines are not meant for women at increased risk for breast> cancer because they have a gene mutation that makes the cancer> <http://health.nytimes.com/health/guides/disease/cancer/overview.html?in\> line=nyt-classifier> more likely or because they had extensive chest> radiation. The task force said there was not enough information to know> whether those women would be helped by more frequent mammograms or by> having the test in their 40s. Other experts said women with close> relatives with breast cancer were also at high risk.> > Dr. Petitti said she knew the new guidelines would be a shock for many> women, but, she said, "we have to say what we see based on the> science and the data."> > The National Cancer Institute said Monday that it was re-evaluating its> guidelines in light of the task force's report.> > But the American Cancer Society> <http://topics.nytimes.com/top/reference/timestopics/organizations/a/ame\> rican_cancer_society/index.html?inline=nyt-org> and the American> College of Radiology both said they were staying with their guidelines> advising annual mammograms starting at age 40.> > The cancer society, in a statement> <http://www.cancer.org/docroot/MED/content/MED_2_1x_American_Cancer_Soci\> ety_Responds_to_Changes_to_USPSTF_Mammography_Guidelines.asp?sitearea=ME\> D> by Dr. Otis W. Brawley, its chief medical officer, agreed that> mammography had risks as well as benefits but, he said, the> society's experts had looked at "virtually all" the task> force and additional data and concluded that the benefits of annual> mammograms starting at age 40 outweighed the risks.> > Other advocacy groups, like the National Breast Cancer Coalition, Breast> Cancer Action, and the National Women's Health Network, welcomed the> new guidelines.> > "This is our opportunity to look beyond emotions," said Fran> Visco, president of the National Breast Cancer Coalition> <http://www.stopbreastcancer.org/index.php?option=com_content & task=view & \> id=134 & Itemid=62> . The task force "is an independent body of> experts that took an objective look at the data," Ms. Visco said.> "These are the people we should be listening to when it comes to> public health messages."> > Some women, though, were not pleased. "I know so many people who had> breast cancer and survived, and what saved their lives was early> detection," Janet Doughty, 44, of San Clemente, Calif., said in a> telephone interview. She said she had had an annual mammograms since her> late 30s and would not stop now.> > The guidelines are not expected to have an immediate effect on insurance> coverage but should make health plans less likely to aggressively prompt> women in their 40s to have mammograms and older women to have the test> annually.> > Congress requires Medicare> <http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthto\> pics/medicare/index.html?inline=nyt-classifier> to pay for annual> mammograms. Medicare can change its rules to pay for less frequent tests> if federal officials direct it to.> > Private insurers are required by law in every state except Utah to pay> for mammograms for women in their 40s.> > But the new guidelines are expected to alter the grading system for> health plans, which are used as a marketing tool. Grades are issued by> the National Committee for Quality Assurance <http://www.ncqa.org/> , a> private nonprofit organization, and one measure is the percentage of> patients getting mammograms every one to two years starting at age 40.> > That will change, said Margaret E. O'Kane, the group's> president, who said it would start grading plans on the number of women> over 50 getting mammograms every two years.> > The message for most women, said Dr. Karla Kerlikowske> <http://cancer.ucsf.edu/people/kerlikowske_karla.php> , a professor in> the department of medicine, epidemiology and biostatistics at the> University of California, San Francisco> <http://topics.nytimes.com/topics/reference/timestopics/organizations/u/\> university_of_california/index.html?inline=nyt-org> , is to forgo> routine mammograms if they are in their 40s.> > Starting at age 50, Dr. Kerlikowske said, "the message is to get 10> mammograms in a lifetime, one every two years." That way they get> the most benefit and the least harm from the test. If women are healthy,> she added, they might consider having mammograms every two years until> age 74.> > Nearly two-thirds of all women in their 40s had mammograms within the> last two years, as did 72 percent of women age 50 to 65, according to an> editorial by Dr. Kerlikowske that accompanies the report.> > In order to formulate its guidelines, the task force used new data from> mammography studies in England and Sweden and also commissioned six> groups to make statistical models to analyze the aggregate data. The> models were the only way to answer questions like how much extra benefit> do women get if they are screened every year, said A. Berry> <http://www.mdanderson.org/education-and-research/departments-programs-a\> nd-labs/departments-and-divisions/division-of-quantitative-sciences/inde\> x.html> , a statistician at the University of Texas> <http://topics.nytimes.com/top/reference/timestopics/organizations/u/uni\> versity_of_texas/index.html?inline=nyt-org> M. D. Cancer> Center and head of one of the modeling groups.> > "We said, essentially with one voice, very little," Dr. Berry> said. "So little as to make the harms of additional screening come> screaming to the top."> > The harms are nearly cut in half when women have mammograms every other> year instead of every year. But the benefits are almost unchanged.> > The last time the task force issued guidelines for mammograms, in 2002,> the report> <http://www.nytimes.com/2002/02/22/us/guidelines-by-us-urge-mammograms-f\> or-women-at-40.html?scp=1 & sq=thompson%20breast%20mammograms & st=cse> was> announced by Tommy G. > <http://topics.nytimes.com/top/reference/timestopics/people/t/tommy_g_th\> ompson/index.html?inline=nyt-per> , the secretary of health and human> services. When the group recommended mammograms for women in their 40s,> some charged the report was politically motivated. But Dr. Alfred Berg> of the University of Washington> <http://topics.nytimes.com/top/reference/timestopics/organizations/u/uni\> versity_of_washington/index.html?inline=nyt-org> , who was the task> force chairman at the time, said "there was absolutely zero> political influence on what the task force did."> > It was still a tough call to make, Dr. Berg said, adding that "we> pointed out that the benefit will be quite small." In fact, he> added, even though mammograms are of greater benefit to older women,> they still prevent only a small fraction of breast cancer deaths.> > Different women will weigh the harms and benefits differently, Dr. Berg> noted, but added that even for women 50 and older, "it would be> perfectly rational for a woman to decide she didn't want to do> it."> > Researchers worry the new report will be interpreted as a political> effort by the Obama administration to save money on health care costs.> > Of course, Dr. Berry noted, if the new guidelines are followed, billions> of dollars will be saved.> > "But the money was buying something of net negative value," he> said. "This decision is a no-brainer. The economy benefits, but> women are the major beneficiaries."> > Roni Caryn Rabin contributed reporting.>