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

TN doctors may ignore task force's new guidelines By Stephanie Nano and Marilynn Marchione • ASSOCIATED PRESS • November 17, 2009 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. For most of the past two decades, the cancer society has been recommending annual mammograms beginning at 40, but the panel of doctors and scientists concluded that getting screened for breast cancer so early and so often leads to too many unneeded biopsies without substantially improving women's odds of survival. 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. Some Middle Tennessee doctors said they will ignore the new guidelines for now. "We've seen women in their 20s, 30s and 40s, and there is no simple recommendation that going to apply to all of them," said Dr. Denise Yardley, program director at the Sarah Cannon Research Institute in Nashville. "We recognize limits of the mammogram, which is an imperfect test, but it has a long track record." The guidelines also said women shouldn't be taught to do monthly breast self-examinations, a suggestion a breast cancer oncologist at Baptist Hospital in Nashville said baffled her. Dr. Laura Lawson said many of her patients have been the first to find something wrong. "Would their survival be any different than if they waited another nine months? We don't know," Lawson said. "But I am sure that women don't want to find out." No changes planned Susan 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 today's issue of the Annals of Internal Medicine. Advice is challenged 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. Breast cancer is Tennessee's third-deadliest form of cancer, claiming nearly 4,500 Tennesseans from 2001-05, the latest cancer death reporting period. Benefits debated 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. "It's an average of five lives saved per thousand women screened," said Georgetown 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. Breast cancer is Tennessee's third-deadliest form of cancer, claiming nearly 4,500 Tennesseans from 2001-05, the latest cancer death reporting period.