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NEW MAMMOGRAM GUIDELINES FUEL CONTRADICTION, CONFUSION

THE BALTIMORE SUN

In a change of existing guidelines, an influential government panel said Monday that women do not need mammograms in their 40s and discouraged teaching breast self-exams - decisions that have sparked controversy and confusion among some breast cancer specialists and patient advocates.

The U.S. Preventive Services Task Force, a government panel that issues federal recommendations on preventive medicine, said that breast cancer screening in a woman's 40s does not save many lives and can do more harm than good.

For younger women, mammography has a high rate of false positives, which can trigger unnecessary biopsies, painful treatment and mental anguish. In addition, screening can find cancers that are so small that they may never kill a woman or cause her any harm or discomfort.

"For women 40 to 49, the task force found it was a very close call in that age group," said Dr. David Grossman, one of the members. "The benefits are relatively small in that age group, and women should be aware of the potential harms that are associated with it. By routinely recommending mammography, we are subjecting women to a regular risk of harm that is more so than for older age groups."

The task force also came out against teaching breast self-exams, saying instructing women to do them has not been shown to decrease cancer deaths.

In addition, the group advised that women 50 through 74 should have mammograms every two years. But as for mammograms in older women, the task force has doubts about that as well. More data is needed to recommend whether women older than 74 should have breast X-rays at all, the panel concluded.

The guidelines, which update 2002 recommendations, do not apply to women in high-risk groups, such as women who have a genetic mutation that leaves them susceptible to developing breast cancer.

The decisions, based on an extensive review of national data and published in the latest issue of the Annals of Internal Medicine, are intended to guide physicians' advice to patients.

For years, government recommendations said all women 40 and older should get mammograms every one or two years. And while the issue was debated in academic circles, the mantra in most doctors' offices, among patient advocacy groups and breast cancer survivors has been: mammograms save lives. To them, the new guidelines reflect a dramatic and unwelcome change. Breast cancer, they remind patients, is the second-leading cause of cancer death among women.

"If I had waited until I was 50, I wouldn't be here," said Lillie Shockney, the administrative director of the Johns Hopkins Avon Foundation Breast Cancer Center and a two-time breast cancer survivor whose first tumor was detected by mammogram at age 38. "We have to persuade women now to do their breast exams, and to come in here and get their mammograms. This will give them the excuse they are seeking not to do it. This will keep me awake at night."

But the benefits of mammography differ by a woman's age, the panel concluded. The take-away message to women: Educate yourself on the harms and benefits of mammography and consult your doctor about when to begin the screening, Grossman said.

Women younger than 50 tend to have more dense breast tissue, making it difficult for mammograms to find tumors. Researchers found in women in their 40s, 1,900 women need to be screened for 10 years to avoid one breast cancer death. For women in their 50s, that figure is 1,300 screenings to avoid one death. Overall, mammography cuts the risk of dying by 15 percent.

Cancers in younger women

Dr. Nagi Khouri, director of breast imaging at Hopkins, said those figures don't take into account the 18 percent of cancers diagnosed in women in their 40s. At Hopkins last year, nearly 27 percent of the 620 cancers were found in women in their 40s, he said.

While Khouri agrees that some cancers are harmless, others are deadly and there's no way for doctors to detect the difference.

"There is no doubt that some are unlikely to kill a person," he said. "But the majority will progress into invasive cancers, grow larger, spreading and killing a person."

While the merits of breast self-exam have been debated for years, Khouri said he fears women will interpret the task force advice as a reason not to advocate for their health.

"The more a woman is aware of herself, the more likely she maintains her health," he said. "In my view, telling the woman about being familiar with her breasts and how they feel is important. If anything feels different, show it to your doctor. Many women discover their cancer not through mammography, but because they felt something."

Khouri said he fears the guidelines could encourage insurance companies to back off from covering routine screening for women starting at 40.

"We may be at the beginning of a bad trend."

The panel's advice comes amid intensifying debate over the merits of cancer screening in general and the hotly debated question of mammograms for women in their 40s, in particular.

Last month, the American Cancer Society made waves after reports that its chief medical officer said the benefits of prostate and breast cancer screening have been overstated, and that it was planning to revise its screening guidelines. The group issued a statement a day later saying it stood by its existing recommendations that women should start getting annual mammograms at age 40.

The American College of Radiology also recommends annual mammograms start at age 40. But two years ago, the American College of Physicians, which represents 126,000 internists, said the breast X-rays should not be recommended for women in their 40s. Instead, physicians and their patients should consider a woman's breast cancer risk and weigh the benefits.

The National Cancer Institute, which recommends mammograms every one to two years for women 40 and older, issued a statement Monday saying it doesn't plan on revising its advice.

All this results in more confusion for women.

"This doesn't clear it up too much, does it?," said Dr. Jean Warner, director of the Tyanna O'Brien Center for Women's Imaging at Mercy Medical Center. "For me, it muddies the waters. I think it would be really hard for a woman to go in-depth and understand the issues. It's hard for me, and I'm a radiologist; I am not trained in statistical analysis and public health epidemiology."

Primary care doctors don't always have the time to walk their patients through the intricacies of screening guidelines, particularly when advice conflicts, she said.

No time to take histories

"To be honest, I don't think this goes on," she said. "You can look in the literature and find that women, even when they go to their doctor regularly, they aren't being asked these questions, such as what's your family history of cancer. There is basically no time in a doctor's visit."

Warner said most of her patients don't worry about the harms of screening.

"It's not pleasant - nobody likes having a biopsy and having it turn out to be benign," she said. "But a lot of women have the attitude they want to find out what's going on. This disease is so prevalent. We all know someone in our family or our friends who are touched by it."

Dr. Richard Colgan, a family physician and an associate professor at the University of Maryland School of Medicine, said while the task force is respected as the "gold standard" of advisory panels, primary care doctors are inundated with recommendations on hundreds of diseases. Sometimes they follow them and sometimes they don't.

Before the new recommendations, he said, he always recommended mammograms to patients starting at age 40. Today, he plans to use the guidelines to discuss the issue. He hopes other doctors do the same.

"Maybe I'm idealistic," he said, "but not only can they have this conversation with their doctors, they should."

New breast cancer screening guidelines

The U.S. Preventive Services Task Force issued new guidelines on breast cancer screening:

* Mammograms are no longer recommended for women in their 40s.

* Women 50 to 74 should have mammograms every two years.

* There's not enough evidence to recommend mammograms for women 75 and older.

* Teaching women to do breast self-exams is not recommended.

* All women should consult their doctor about when to start mammograms.

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