Breast Exams: New guidelines call for less testing
Tuesday, November 17, 2009; 12:00 PM
Women in their 40s should stop routinely having annual mammograms and older women should cut back to one scheduled exam every other year, the U.S. Preventive Services Task Force has concluded, challenging the use of one of the most common medical tests.
But the American Cancer Society, the American College of Radiology and other experts condemned the change, saying the benefits of routine mammography have been clearly demonstrated and play a key role in reducing the number of mastectomies and the death toll from one of the most common cancers.
What should women do? Who do you listen to?
Washington Post staff writer Rob Stein was online Tuesday, Nov. 17, at Noon ET to discuss the findings and explain the details.
Rob Stein: Hello everyone. Thanks very much for joining us today. These new guidelines about mammography have cleared caused quite a stir, and a lot of confusion and questions. So let's get started.
La Plata, Md.: Who created the "Federal Task Force"?
Rob Stein: The U.S. Preventive Services Task Force a 16-member panel of independent experts put together by the Agency for Healthcare Research and Quality, which is part of Health and Human Services Department.
Alexandria, Va.: This is incredibly reckless of this govt. panel to suggest self-exams are useless. I am 46 years old. Six months ago, I underwent a lumpectomy for stage 1 ductal carcinoma. I found the lump myself. On my annual mammogram last Dec., nothing unusual showed up. Then in March, I had a pain in my right breast, pressed in where the pain was, and felt a pea-sized lump. I had not been doing self-exams up to that point and was solely relying on the mammograms. Even after finding the lump, it still looked like normal tissue on a follow-up mammogram, so we did an ultrasound. It was quite noticeable on the ultrasound and a biopsy proved the lump was cancer. I do routine self-exams now. Yes, I have a family history (mom and grandmother), but we don't have the BRCA-1 or -2 gene mutation.
I don't want women to think the mammogram is not worthwhile. It didn't see my cancer but mammogram was how my mom's cancer (stage 0 ductal carcinoma) was found. Please, please, ladies, continue your monthly self-exams. Ask your doctor to show you how to do it if you don't know how.
Rob Stein: No one is saying mammograms are useless. Quite the opposite: the task force concluded that mammography is highly effective and has played a role in reducing the death toll from breast cancer. The task force did conclude, however, that much of the benefit of mammography can be achieved by more judicious use of the exams. The task force also stressed that many women should get regular exams, especially if they are at increased risk for breast cancer.
Bridgeport, Conn.: Because my mother was diagnosed with breast cancer early (at age 42 -- it was aggressive and caught early because of a mammogram), I have always been told that I should begin getting mammograms at age 30 or 32. Would that still be the case under these new guidelines, or has it changed for people with high risk factors, too?
Rob Stein: The recommendation to put off routine mammography until age 50 is only for women who have no reason to think they are at increased risk for breast cancer. Those who do have risk factors for the disease, such as a familiy history, should talk to their doctors about starting mammography sooner, according to the task force.
Mclean, Va.: My mother had breast cancer 11 years ago, only the lump was removed. Her 2 sisters also had breast cancer, one was 45 years old (30 years ago). None of them died. I was recommended to have yearly mammograms screening, do I continue doing so?
Rob Stein: Yes, if you have a family history of breast cancer and your doctor recommended yearly mammograms then you should continue getting them. The recommendation to consider less frequent mammograms is really aimed at women who have to reason to think they may be at increased risk.
Chambersburg, Pa.: Rob, do you feel that the new guildelines for less testing have been set up so that less payments will be authorized by insurance and government run health-care programs, which already seem to want to limit preventive care?
After seeing this report on last night's news broadcasts, my first comment to my wife was, I bet they are changing this so insurance companies or government-run programs won't have to pay as much for preventive and early monitoring for diseases. It's easier for them if the patient just dies of cancer. If everybody is tested, has treatments etc. ... they will live longer and cost the government programs or insurance companies more money. It seems very suspect for this change in policy to come out at this time. What do you think?
Rob Stein: The task force's mission is to only examine the scientific evidence of the risks and benefits of preventive medical services -- not the costs or rembursement issues. Certainly, there is concern by proponents of screening that the recommendations could affect insurance coverage for mammograms. So far that hasn't happened. But it is certainly a possibility.
Alexandria, Va.: So the "danger" is just false positives, not a result of the procedure itself?
Rob Stein: Mammograms do expose women to radiation. But the levels are very low. So the concern is not primarily about the radiation exposure. The bigger concern is the anxiety caused by false-alarms and the follow-up testing and treatment that often ensues. Many women who get a postive mammogram end up getting a biopsy, only to discover that it isn't cancer. And even when it turns out to be cancer, it remains unclear how often that necessarily needs to be treated. Some cancers grow so slowly that they never pose a risk to a woman's health.
Tucson, Ariz.: Every woman I've talked to suggests at some point in our conversation that these recommendations are coming from the insurance industry, which doesn't want to pay for regular screening.
Convince me otherwise.
Rob Stein: The task force is a completely independent group of experts with no association to the insurance industry.
Rockville, Md. : Even IF -- and that is a HUGE "if" in my mind -- there is a valid reason behind delaying regular mammograms what possible rationale could there be for telling women not to do regular self-exams?
That makes absolutely no sense whatsoever.
Rob Stein: The task force is not saying women should not examine their breasts. What the task force concluded was that the evidence suggests that doctors teaching women to do regular standardized breast self-exams did not appear to have any benefit, and there was insufficient evidence to know whether there was any benefit to doctors doing the exams. That said, if a woman finds a lump in her breast she should see a doctor.
Washington, D.C.: It seems to me that if the committee found that screening women under the age of 50 using mammography causes more harm than good, than the focus needs to be on finding a more adequate test for women in that age range. 470 false positives out of 1000 women is simply unacceptable. But not coming up with a better test for younger women is unacceptable as well. We DO need a test that RELIABLY catches breast cancer early. In your research, have you come accross any new ideas in this area? Thanks.
Rob Stein: Yes, there is a lot of interest in coming up with better tests. Unfortunately, while there are some promising new approaches, it remains to be seen if any are better. Another key advance that many experts say is needed is a better way to determine which tumors actually require treatment. Mammography picks up many very small tumors and even precancerous growths and currently there's no way to know which require treatment and which may never pose a threat to a woman's life.
Alexandria, Va.: My family has a history of breast cancer and I have been told now that I am in my 40s that I must have a mammogram every year because of this.
How do the new guidelines affect women whose families have a history of breast cancer?
Rob Stein: Women who are at increased risk for breast cancer for whatever reason, such as having a family history of the disease, should talk to their doctors about routine mammography, according to the task force.
Madison, Wisc.: Hi, I have no history of breast cancer in my family but I turned 40 this year and was planning to schedule a mammogram. What does this report mean for someone like me?
Rob Stein: According to the new guidelines, someone like you should talk to their doctor about whether to get a mammogram or not instead of just getting one without talking about it first. If you're worried about breast cancer you may decide to get a mammogram anyway. But under these guidelines it would be OK to wait too.
Bethesda, Md.: Can you help me understand why the task force believes the benefits of screening women in their 40s don't outweigh the risks? Presumably there is statistical analysis behind this, with the value of a human life weighed there somewhere. I'm sure some women will die because they don't get mammograms in their 40s, but are they saying that there are enough false alarms and unnecessary treatments to justify a certain number of deaths?
Rob Stein: The task force is saying that women can get most of the benefits of mammography -- about 81 percent -- by waiting until age 50 to start getting the exams routinely.
Lankin, Md.: I'm floored by this study. I'd like to know how the study was funded. Thanks.
Rob Stein: The task force is funded by the federal government, specifically the Health and Human Services Department.
Northern Virginia: I am delighted by this study. As someone in her late 40s, I have had the usual (underline usual) number of really frightening, somewhat costly and time-consuming, scares where there was a tiny mark that I was openly told was not indicative of any problem, but which automatically triggered worrying repeated mammograms over a year or more before a clean bill of health was restored. Other friends have gotten as far as the biopsy stage.
The worst part was that providers at all points would explain privately that this was defensive medicine, legally required, etc., but that this or that mark, while once considered a cause for concern, now isn't. So not to worry, but still do these unnecessary follow-ups.
It has been a source of real anger and frustration for me to have these mixed messages and regular scares. I am relieved that this data analysis sounds like it will bring the recommendations back in line with reality, even though I feel bad it will cost the radiologists a lot of money in (many) fewer routine mammograms.
Rob Stein: Yours is exactly the kind of situation the task force had in mind.
New York: How can a "slow growing" cancer be looked at as not needed to be treated? There are many factors that affect the growth of a cancer and these factors differ from individual to individual. Can you be 100 percent sure that my low-grade, stage 0, DCIS will not continue to grow and become "more harmful"? Cancer is cancer. To remove a cancer at its earliest stage and grade to me would be the choice to take. Rob, if you had a low grade, stage 0, DCIS diagnosed in your breast (and men can get breast cancer) would you let it sit untreated?
Rob Stein: That's one of the terrible difficulties of breast cancer treatment today -- knowing when treatment is necessary and knowing when it isn't. Unfortunately, today there's no way to know so women have no choice to get treated even though it's clear that many of these abnormalities would actually never become a problem.
Silver Spring, Md.: The U.S. "Preventive Services" Task Force by the Department of Health and Human Services... I think people might interpret this as one way the government is going to enforce "efficiencies" in the health-care process and lower overall costs -- by diagnosing and thereby treating fewer people. It seems like bad timing to release this and bad naming of the task force in regards to the health-care legislation. (Yes, I understand that a "screening" is a preventive service, but it will now sound like this task force is trying to prevent screenings and other services.)
Shouldn't the DDHS have met with the ACS and ACR to arrive at some consensus or at least suggest a study to compare annual versus biannual screening? It just seems like they bungled this release.
Rob Stein: The task force actually began work on this several years ago but because the results were released during the health reform debate it is clearly raising questions in many peoples minds.
Toronto, Canada: What is the radiation risk from frequent mammograms?
Rob Stein: The risk from the radiation from mammograms is very low.
Cumberland, Md.: But in the past these and other studies have been used for Medicare and insurance companies to deny payment for certain treatments like virtual colonoscopy. What is to stop Medicare and insurance companies from denying payment for mammogram taken after age 74 and before age 40?
Rob Stein: Medicare is required to pay for mammograms. But, yes, insurance companies could potentially use these guidelines to justify changing their reimbursement policies.
State College, Pa.: Three years ago I had my first mammogram at age 30 because every female on my mom's side has had breast cancer. I went back for 2 more mammograms, an ultrasound, and a needle biopsy over the space of a month. The "anxiety" that this produced was 1 million times less than one day of my mom's pain during her two years of treatment for stage 4 breast cancer, which only was picked up by ultrasound because the cancer was diffuse and never formed a lump. It is ridiculous to suggest that my anxiety was more detrimental than actually having cancer.
Rob Stein: This is exactly the kind of decision that the task force wants more women to think about when deciding to get a mammogram. Many women, after considering the possible risks and possible benefits will decide to go ahead anyway. But some may not if it's presented to them more as an option.
Rockville, Md.: This doesn't seem to be a new finding -- the Los Angeles Times published an article in August about research from the British Medical Journal and sited experts in the United States who basically said the same thing.
Rob Stein: Yes, this has been an issue that has been debated for a long time. In fact, in 1997 and expert panel brought together by the National Institutes of Health reached similar conclusions, only to be overturned after its conclusions touched off intense criticism.
Riverdale, Md.: What I find most surprising is not the results of the study, but the reaction of the public. People seem to interpret the recommendations as meaning women should never get mammograms, and that we're all going to be ignored and left to die.
I'm a woman in my late 40s with no family history of breast cancer. I have yet to get a mammogram because I wasn't convinced that it was critical. My insurance will pay for it, but I'm not keen on excessive medical intervention. I've got a degree in a medical science.
Thank you for providing calm answers to the public overreaction!
Rob Stein: You make a good point: The task force is not saying women should not get screened or should be denied screening if they want it. The task force is just saying that women should weigh the risks and benefits individually and make a decision for themselves.
Cumberland, Md.: What do you see as the political repercussions from this study? Will it influence the health reform debate?
Rob Stein: It's hard to know. These guidelines are certainly getting caught up in the debate about health care reform, and fears about rationing.
Lindenhurst, N.Y.: What reason could there be for recommending that doctors not teach women to do breast self-exams? Then who should? To not recommend self-examinations is like not telling us what the warning signs are for heart attacks.
Rob Stein: This panel is charged with examining the scientific evidence supporting preventive medical services and in this case there just isn't scientific evidence to support the value of teaching women to do formal self-exams. That doesn't mean women shouldn't examine their breasts on their own, and see a doctor if they find something suspicious. There just doesn't seem to be much scientific evidence supporting the formalized teaching of breast self-exams.
Lansdowne, Va.: At first I looked at this and thought that is an underhanded way that insurance companies were trying to get out of paying for diagnostic tools to save women's lives. My question is this: will this lead to insurance companies following THIS advice and no longer allowing women to get mammograms yearly? The earlier you detect breast cancer, the more survivable it is. This seems so dangerous. It makes me angry.
Rob Stein: That's certainiy one of the concerns about these guidelines. Another concern is that under health care reform legislation pending in Congress the task force's recommendations would be used as the basis for determine the basic package of benefits that insurance companies would have to offer. But that doesn't mean insurers would be barred from covering mammograms.
Philadelphia, Pa. : Wow, this discussion has turned into a microcosm of our national health-care debate. I'm beginning to think that our foremost challenges in this country in terms of sustaining and improving our quality of lives are:
- We're not a consensus-based culture, but rather we're fairly paranoid but simultaneously unduly credulous one -- as in, the government and insurers have it in for me; I know this because I read it on some blog or heard it on Talk Radio.
- We're not comfortable with any degree of risk or accepting of uncertainty about our existence, but we won't take a coldly rational look at what constitutes risk and what increases uncertainty -- as in, oh my gosh I have a one percent chance of dying if I do X, I say to myself as I drive in my car in rush hour traffic.
I would say this is human nature, but it just isn't. Other nations bring forth different characteristics about stuff like this.
Rob Stein: Yes, this is definitely bringing up a lot of the same issues.
Washington, D.C.: As an answer to people who are saying this is so that insurance does not have to cover mamography, most of the insurance cos. have already issued press releases that they intend to continue coverage for routine mamograms.
As for the false positive, I found a lump doing a self-exam last year (I'm early 30s). Got a mamogram and ultrasound, and its just thicker tissue. Sure, I was scared for a few weeks and I wasn't thrilled about the mamogram (I was sore on the lumpy side for a week afterwards), not sure that's a reason to discontinue routine testing.
Rob Stein: That's exactly the kind of decision-making that women have to consider when getting a mammogram.
Punta Gorda, Fla.: I believe the recommendation is wise. I was 38 when I had breast cancer surgery. I found the lump myself. It never showed up on the mam -- even on the very day I was diagnosed. I think all that radiation causes more harm then good. We have to be aware of unintended consequences. It's been 25 years now and I have chosen to have mams every couple of years since then but I worry about the radiation damage to the arteries and veins around my heart where cholesterol collects rom damage. Just my opinion.
Rob Stein: There's always some risk from radiation exposure, but that's not the main concern about mammograms. The bigger concern is the unnecessary anxiety and treatment they lead to. Also, some women mistakenly think if they have gotten a mammogram and it came back negative then they don't have to ever worry about breast cancer, which of course isn't the case.
Princeton, N.J.: I am a 71-year-old retired mathematician. I do not know a lot about breast cancer, but I do know a bit about prostate cancer which I believe is similar. Prostate cancer also has a test, PSA, for early dedection. In the U.S. it is given regularly; in Europe only if there is some reason, so it is given much less frequently. We dedect a lot more cancer and treat a lot more, but our mortality rates from prostate cancer are no better than most European countries and worse than many. Because of this situation we spend a lot more, money for no better results. The quality of life for those treated is frequently pretty bad. I suspect the situation is similar for breast cancer
Rob Stein: Yes, the PSA test for prostate cancer is analogous to the mammography for breast cancer situation in many ways. There's a growing consensus that PSA testing is overused as well.
Washington, D.C.: What is ACOG's response to the recommendations?
Rob Stein: ACOG (American College of Obstetricians and Gynecologists) disagrees with the task force's recommendations and continues to recommend women in their 40s get screened every year or two and women in their 50s get screened annually.
Glen Allen, Va.: I'm 49. At 46 I was diagnosed with breast cancer. I had no risk factors or family history. Only the routine mammogram caught it. I can't believe it would have been okay to not discover the cancer until age 50 or later. At best I'd have had a much more advanced case and at worst I'd be dead.
Rob Stein: That's the argument that proponents of mammography make.
Washington, D.C.: I really don't understand why this study is coming out now when sooooooo many lives are being saved by early detection. If this recommendation was in place, I can personally count 7 close sister-friends that would NOT be alive by the time they reached 50. Is this another ploy by the health-care industry?
Rob Stein: Many women know other women whose breast cancer was detected through a mammogram, which is part of the reason why this is such a difficult issue.
North Potomac, Md.: Regarding the comment that the task force is recommending less screening to save money for insurers -- it costs insurers a lot more to pay for treatment for someone with a later stage of cancer than when it is caught earlier.
Rob Stein: Mammograms are relatively inexpensive, although altogether about $5 billion is spent on mammography each year in the United States.
Salem, N.H.: Almost all of these kinds of findings are based on someone's determination that savings from reduced mammography will exceed the value of the woman-years of more premature deaths that will result from the change, but we are never told what those numbers are. So tell us the numbers!
If the proposed 50-year standard is followed, compared to the previous 40-year standard, for 100,000 women in each group, how many more woman-years will be lost to premature death in the 50-year group versus the 40-year group?
Somebody making the recommendation to change should be able to use the data that was the basis for the recommendation to make that calculation/estimate, and then publish the number for all to see whenever the recommendation is proposed.
And then give us a link to the report/analysis/study, available to us ordinary mortals, so we can see the basis for the proposal.
Rob Stein: Here you go: http:/
washingtonpost.com: Annals of Internal Medicine
Chicago, Ill.: Seems like a lot of the negative reaction to this study has to do with the negative "spin" put on the results. Women who are worried about breast cancer are basically being told that the current system of regular mammograms and self-exams isn't very effective, so we should scale back. But we are not given positive instructions of what to do instead.
Rob Stein: The bottom line really on the new guidelines is that each woman should decide for herself, in consultation with her doctor, whether to get a mammogram instead of just getting one every year without thinking about it.
Rob Stein: Well, we've just about run out of time. I'm sorry I wasn't able to get to all your questions. But I really appreciate your interest and all thoughtful questions. I'm sure this is an issue we'll be revisiting.
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