Dueling guidelines from national health organizations about breast cancer screening may be confusing patients, but doctors from three area hospitals say that the science driving when to begin tests is imprecise. Patients and doctors should decide among themselves what’s best.
“A woman and her physician need to sit down and have a discussion so that the health care provider can go through the confusing data and then tailor her screening to her,” said Dr. Lindsay Rockwell, a medical oncologist based at Cooley Dickinson Hospital in Northampton.
While stressing that mammography is an important tool in diagnosing cancer, she said that discussion is vital. “Women should be familiar with the known benefits, limitations and potential harms connected to breast cancer screening.” In recent weeks the American Cancer Society, which since 2003 has urged women to get annual mammograms beginning at age 40, upped the age for women with average risk to 45. The cancer society now advises these women cut back their testing to every other year starting at age 55. After a woman turns 74, the guidelines say, her overall health and her 10-year life expectancy should determine whether she continues and how often. They add that breast exams conducted by physicians on patients of any age are unnecessary.
The recommendations were published in October in the Journal of the American Medical Association.
Six years ago, the U.S. Preventive Services Task Force, which influences federal insurance programs caused a flurry of controversy when it said women shouldn’t start getting mammograms until they turn 50 and then get them every other year until age 74.
The American College of Obstetricians and Gynecologists and the national radiology group recommend annual screening beginning at age 40.
“There is clearly no right or wrong answer across the board,” said Dr. Nikolaus Kashey, medical director of population health at Baystate Regional Medical Center based in Springfield. “What the span out there tells me is that very smart people with statistical backgrounds and all the expertise in the world took the same data, went into different rooms and came out saying different things.” Kashey was involved in setting guidelines at Baystate which suggest women start getting mammograms at 50 and repeat them at least every two years.
“Mammography is a great tool for detecting breast cancer,” he said. “But after you start testing regularly you can incur harm. What we want people to understand is that more testing isn’t always better.” In the United States an estimated 23,000 women will be diagnosed with breast cancer this year; 40,000 will die of it, according to the American Cancer Society. Overall, 1 in 8 women will be diagnosed with the disease at some point and chances increase with age.
The harm Kashey refers to is the false positives that turn up far more frequently in the breast cancer screening of younger women than cancerous tumors that can be successfully treated.
“The biggest risk factor for cancer is age,” he said. “The older you become, the more likely it is that when we find something it is cancer.” Younger women have denser breast tissue, the doctors say, so spotting something suspicious on a mammogram is not unusual. That often causes anxiety when a repeat test is ordered, and even more stress, pain and risk of infection when biopsies or even surgery is done on lumps that are harmless, they say.
“We currently don’t have the ability to distinguish the tumors that will be more aggressive from those that may not need treatment,” Kashey said. “Some of those findings we are treating as cancer could have been left alone and they probably would have gone away on their own. But we can’t tell the difference, so we treat it. We’re doing lumpectomies and radiation and the full on ‘you have cancer,’ and there are a lot of downstreet complications from that.” In addition, when cancer is found via mammogram in a younger woman, no matter the size of the growth, it is generally more aggressive. Studies have shown that 85 percent of women in their 40s who die of breast cancer would have died regardless of whether or not they had mammograms.
“It comes to like five cases out of 10,000 for women in their 40s and 10 cases out of 10,000 for women in their 50s,” said Dr. Zubeena Mateen, medical oncologist at Holyoke Medical Center. “So the benefit would be for just 15 percent. It does not have a major impact” on survival.
Rockwell, who says she treats many young women with breast cancer, agrees. “All the studies say that [screening younger women] doesn’t improve survival or mortality rates,” she said. “If our intention is to save lives — and that’s what screening is all about — then we have to prove that screening women between 40 and 50 years old saves lives and does more good than harm — and I don’t think we have consistent data that shows that.” Still, she knows that some women like the peace of mind a mammogram can bring.
The American Cancer Society guidelines say those women, once they turn 40, should still be allowed to choose to be screened and so far, most insurance will continue to pay for that, despite the U.S. Preventive Services Task Force’s 2009 stance. Whether the American Cancer Society’s revised advice will change that remains to be seen.
“I see a skewed population of people and they are very pleased to be studied more and then reassured,” said Rockwell. “But there are other women who say, ‘It scared the bejesus out of me to get a call back (for retesting). I’d rather do this a whole lot less because I don’t want to go on that roller coaster.’” Such women, she said, can make that choice in consultation with their physicians and now have the backing of the American Cancer Society, along with the U.S. Preventive Services Task Force.
“The most important piece is communication” between doctor and patient, she said.
Which, all the doctors interviewed agreed, includes discussing risk factors such as family history and genetic mutations.
“For women with family history, [the guidelines] all go out the window,” Kashey said.
The American Cancer Society is expected to deliver recommendations for high-risk women next year.
Rockwell acknowledges that though she supports the revised recommendations and understands the scientific rationale, she still will advise a more aggressive screening routine for her patients.
“I think you can argue that I am not being true to the data,” she said, “but maybe because I treat a lot of 40-somethings and even 30-somethings with breast cancer I land with the more aggressive strategies. I want every woman’s breast cancer to be caught early.” For Kashey, a primary care doctor, the change in guidelines that began with the U.S. Preventive Services changes in 2009 has meant a different approach with patients. “I have a more detailed conversation with them now,” he said. “I used to say, ‘you’re 40, go get and mammogram,’ and they’d say, OK. Now I tell them, ‘there are varying recommendations. It’s shades of gray.’ ” If it puts his patient at ease to begin testing in her 40s, Kashey will say go for it. “That’s absolutely reasonable,” he said. “I just want them to understand they may be opening up Pandora’s Box.” Will that choice be removed if insurance companies are swayed by the new guidelines to limit coverage?
Rockwell says maybe. “I don’t know what the insurance companies are going to do,” she said, “I completely acknowledge it opens the black box. I don’t know where we’re going to land on that.
Mateen says doctors will have to advocate for their patients. “We will have to fight the insurance companies in that situation,” she said.
Kashey doesn’t think it will be an issue. “My sense is that this is enough of a hot-button issue that the insurance companies won’t touch it,” he said. “The cost of mammograms isn’t terribly expensive. The insurance companies are much more interested in trying to contain more expensive modalities, like MRIs.”
As far as the cancer society’s advice about physicians skipping the clinical breast exams that have long been part of a woman’s physical examination, opinion was mixed. Kashey, who hasn’t yet studied the reasons why, says he can see how that exam, too, can become a vehicle for needless scares.
“When you start asking people to look for something on a regular basis, chances are they are going to find something,” he said. “It’s hard to do a breast exam and determine what’s normal and what’s not.” On the other hand, he said, patients know their own bodies and should alert their doctors when something changes.
Rockwell says she won’t stop doing them.
“That’s going to be a tough one for all of us hands-on practitioners to let go of. I would argue that if doing it reassures a patient, I’m good with that.” Mateen says she will keep doing them, too. “How long does it take, three minutes? If you feel something it could be life-changing for the patient, so I won’t stop it.” All of the doctors said more precise technology, such as 3-D mammograms, continue to develop and the hope is that screening, even in younger women, will become more reliable.
“People are working very hard at improving the technology for screening so that it is not controversial,” said Rockwell.
In the meantime, doctors and patients just need to talk more.
“The upside is that we are tailoring health care,” Rockwell said. “The downside is we lose the hard and fast concept that one thing is good for everybody.” Kashey says Baystate’s guidelines are designed to account for the range of professional opinions. “It is not a boilerplate ‘you must do this or you’re not taking care of yourself.’ You need to think about it and understand it. It is confusing, and our job is to make it the least confusing as possible.”•
Debra Scherban can be reached at dscherban@gazettenet.com.
