Big questions surround mammogram debate

For years, public health groups have largely been in sync on recommending screening mammograms starting at age 40.
In November, the U.S. Preventive Services Task Force started singing off a different sheet, downgrading its recommendation on screening mammograms for women under 50. The group cited research that showed little benefit in saving lives and potential harm in exposing women to unnecessary tests and procedures.
A chorus of well-respected medical and health advocacy groups – American Cancer Society, American College of Radiology, American College of Obstetricians and Gynecologists, American Medical Association, Komen for the Cure Foundation and more – have responded loudly in defense of annual screenings at 40.
Many physicians in Northeast Mississippi who have been fielding questions from patients and the general public say they are still going to recommend annual mammograms starting at age 40.
“The oncology community is very united in that mammography is useful and effective,” said Oxford radiation oncologist Dr. John Cantrell.
For Tupelo radiologist and breast imaging specialist Dr. Susan Shamburger, the benefits of starting screening mammograms at 40 are clear. Before the screening became commonplace in the early 1990s, the death rate for breast cancer had been steady.
“Since 1990, the death rate from breast cancer has decreased by 30 percent,” Shamburger said. “Forty percent of those women were between 40 and 50. Most of the credit goes to screening mammograms.”
There’s been less uproar over new recommendations for cervical cancer screening from the American College of Obstetrics and Gynecology, which push back the starting age and expand the interval between screening for women with normal results.
Many physicians and patients are worried about a potential roll back in coverage for preventive screenings, although no insurance companies or public programs have changed their policies so far.
“The biggest concern is that it’s a harbinger for things to come,” Cantrell said.

Mammography research
The bar for population screening is set very high. The tests have to be very safe and very accurate to test people who have no symptoms of disease.
And it’s not the first time the efficacy of mammograms has been questioned. European and international guidelines typically recommend starting mammograms at 50.
The recommendations made by the task force don’t say women shouldn’t get annual screening mammograms between 40 and 49, but that the group no longer recommends them. Patients are encouraged to discuss the risks and benefits with their doctors.
The recommendations were shaped by research done by six teams who used federal data to develop mathematical models of what would happen if women were screened at different ages and time intervals.
Starting screening mammograms 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.
By focusing solely on mortality, the study is missing some key quality of life elements for both younger and older women.
“As far as life and death, the outcome may be the same, but you’re more likely to lose the breast,” Tupelo gynecologist Dr. Brandy Patterson said. “That’s very important for women.”
When breast cancer is caught at very early stages, surgeons have the option of removing just the tumor. More advanced disease usually requires mastectomy.
Mammography typically finds tumors a year to two years before women can feel them, Cantrell said.
On the other end, deciding when mammograms are no longer a benefit involves a more complex conversation than a woman has reached her 75th birthday, Shamburger said.
“As long as they are in good health, they should get mammograms,” Shamburger said.
Cantrell said he also feels the task force over estimates the burden of false positives.
“That presumes that women can’t handle a little bit of anxiety in their lives,” Cantrell said. “… We’re less concerned with false positives than missing malignancies.”
All three physicians also were concerned about the task force’s findings that self-breast exam has no benefit.
“I can’t prove it’s saving lives,” Cantrell said, but he’s seen too many cases of women finding tumors to discount it. A 38-year-old woman who found a superficial lump and was able to catch breast cancer at a very early stage is Cantrell’s most recent example.
“It costs nothing,” Cantrell said. “I still advocate self-breast exam, particularly for women not getting a mammogram.”

Cervical cancer
Shortly after the preventive services task force released its mammogram recommendations, the American College of Obstetrics and Gynecology released new guidelines on the Pap test, used to detect abnormal changes on the cervix that can lead to cervical cancer.
Cervical cancer is caused by HPV, a sexually-transmitted virus. Previously, the group had recommended starting annual tests within three years of becoming sexually active.
Now the group is recommending the test start at 21. Women 21 to 29 with a normal test need only to be screened every other year. Women over 30 with normal results can stretch the interval to three years.
“We’re not saying no annual exam,” Patterson said. “They still need a pelvic exam and a clinical breast exam every year.”
The United States has a very low mortality rate from cervical cancer because of the Pap test. Most of the deaths occur in women who don’t get screened regularly.
“A review of the evidence to date shows screening at less frequent intervals prevents cervical cancer just as well, has decreased costs, and avoids unnecessary interventions that could be harmful,” said Dr. Alan G. Waxman of the University of New Mexico in Albuquerque who was part of drafting the new recommendation.
For Patterson, the most important finding was that the expanded time frame didn’t change how the cancer was treated.
“It didn’t make a difference in the treatment options,” Patterson said.
The organization was particularly concerned about treating adolescents, who have a higher incidence of the precancerous lesions. However the lesions often resolve on their own without treatment, and treatment can impact their ability to carry a pregnancy in later years.
The screening guidelines don’t apply to women who have had abnormal test results or fall into other high risk categories, Patterson said. Nor should women ignore symptoms like unusual bleeding that could signal a problem.

Contact Michaela Gibson Morris at (662) 678-1599 or michaela.morris@djournal .com.

Michaela Morris/NEMS Daily Journal