Mammograms: The Year of Living Dangerously?
Three years ago, a health task force sparked a heated debate when it recommended that women between 40 and 50 stop getting mammograms every year. Did timing, insurance, and emotion quash their findings?
MY 65-YEAR-OLD MOTHER’S BREAST CANCER was detected after a routine annual mammogram. In the weeks after diagnosis, we were ushered in to see radiologists, a medical oncologist, a surgical oncologist, the insurance liaison, and more nurses than I could count. They all smiled reassuringly and told my mother something resembling, “The good news is that we caught it early!”
Those words were a comfort. “Early detection” has become a rallying cry for women, breast cancer survivors, and supporters alike, across the United States and beyond. As breast cancer has evolved into one of the most publicized issues in women’s health, we have been bombarded with messages of hope and promise—provided we do our part and get into the habit of annual mammography screenings as soon as we turn 40.
So in late 2009, when the U.S. Preventive Services Task Force, an independent panel of medical experts formed by congressional mandate to review health-care services, published new guidelines calling for screenings once every two years starting at age 50, there was a heated response. Some in the women’s health community went as far as to say these guidelines would needlessly “kill” thousands of women.
Of course the task force’s decision was not made lightly. After reviewing the scientific evidence, the group found that the mortality rates of women screened annually and those screened biennially were quite similar, whether those screenings started at 40 or 50. The task force also placed great weight on the risks of early detection, including the psychological harms of false-positive results and unnecessary follow-up procedures—and the discomfort of the mammography procedure. These factors led the group to change the previous recommendation of annual screenings starting at 40 to biennial screenings for women starting at 50.
Virginia Moyer, the current chairperson of the task force, helped review the evidence that led to those changes. “We try to revisit all of our guidelines every five years,” she says, “sooner if new data becomes available.” Moyer was surprised by what she called the ensuing “brouhaha.”
So why did it happen? Consider the timing: the Patient Protection and Affordable Care Act was being debated on the Senate floor when the new guidelines were released, and some pundits and talk-show hosts suggested that the guidelines were tantamount to health-care rationing. The other issue was wording: the initial task force report specifically recommended against annual screenings, which led women’s groups and cancer organizations to raise their voices in alarm.
In response, the task force reworded the guidelines, softening its language to suggest that women simply needed to discuss the benefits and risks of mammography with their physician in order to make an informed decision about when and how often to get a mammogram.
But many women still protested, arguing that biennial screenings would reduce the benefits of early detection, lessen insurance coverage, and, ultimately, put more women at risk.
So, almost three years later, has what Moyer calls a small change resulted in a big difference for women?
Today, the task force stands by its 2009 guidelines. “A woman between 40 and 50 needs to sit down and talk with her physician about the risks and benefits of an annual mammogram and then make an informed decision for herself,” Moyer says.
Karuna Jaggar, executive director of Breast Cancer Action, one of the few national breast cancer organizations that fully supported the task force back in 2009, also still backs the recommendations. “Breast Cancer Action takes a science-based perspective and looks at what makes sense for the whole population,” she says. “Mammograms every two years starting at 50 is appropriate for the majority of women.”
Len Lichtenfeld, deputy chief medical officer for the American Cancer Society, says that under the Affordable Care Act, the task force’s recommendation did provide the “floor,” or the minimum coverage that insurance carriers are legally obligated to provide their customers.
Yet insurance companies haven’t rationed mammogram coverage.
Douglas Hadley, a national medical officer with CIGNA, a global health-insurance and health-services company, says women, starting at age 40, can count on his organization to pay for annual mammograms. “Ultimately, we had to contrast the [task force’s] guidelines with [those of] other organizations like the American Cancer Society and National Comprehensive Cancer Network,” he says. With dissension within the cancer community when it comes to the frequency of mammograms, CIGNA has opted to continue coverage for annual screenings starting at 40.
Certainly, almost every woman over 40 I know is still going in for an annual mammogram—and their physicians are recommending that they do so. Therese Bevers, medical director of the M.D. Anderson Cancer Prevention Center in Houston, Texas, confirms that while there have been more questions from women about screenings, she has not seen a significant drop in women getting mammograms every year, starting at age 40. But she cautions that it may be a year or two before any hard statistics are available to back up her personal experience.
“Over 70 percent of breast cancer diagnosed in women between 40 and 50 is in women with no risk factors or significant family history,” she says. “And when you talk to women, they don’t see those same ‘psychological harms’ that the task force mentions. They tell us that they don’t mind the additional mammograms or even the biopsies when they have the chance to catch cancer early, at a point when it is small, more treatable, and more breast conservation is possible.”
Bevers’ point is critical. There is a tremendous difference in treatment options and outcomes when cancer is caught early. And Judith Malmgren, an epidemiologist and president of HealthStat Consulting in Seattle, Washington, says that the Task Force guidelines have focused too much on mortality rates—on the number of women who perish from breast cancer—rather than those who must live with the disease. Malmgren and colleagues decided to take a closer look at all disease outcomes by following nearly 2,000 women whose breast cancer was detected between 40 and 49 years of age. The results, published in the March 2012 issue of Radiology, found that earlier detection resulted in more breast conservation (partial versus full mastectomies), less-invasive treatments, and better overall prognoses.
“The objective of any screening program is to find disease in an early, more treatable stage,” Malmgren says. “That’s what we found in this study—better treatments and better outcomes for women. I’d like to see the task force expand their definition of outcome to not just look at mortality but also the benefit of early detection and less treatment.”
While Moyer admits Malmgren’s study is compelling, she says it won’t change the task force stance. “If all cancers progressed in the exact same way, then I agree it would be great to have less-invasive treatment,” she says. “But unfortunately, they don’t all progress in the same way. This was not a clinical trial. There is no way of knowing that earlier treatment made any difference at all in a person’s survival.”
Jaggar adds, “We recognize that mammography is the best tool that we have at the moment. But it is an imperfect tool. We need the national conversation to move beyond simple screening and place more emphasis on preventing breast cancer in the first place.”
Given the disease is the second leading cause of cancer death in women, it’s difficult to consider the science without sentiment. But as I watch my mother go through her second week of radiation therapy, her chest covered in clinical warpaint and the beginnings of a treatment-induced rash, I can’t help but echo the cheers that her cancer was caught so early. Her masses were small enough to forgo chemotherapy and its insidious side effects. Her surgeries, outpatient and relatively low in follow-up care, were more of an inconvenience than a trauma. She goes about her days in good energy and good cheer. This is not a woman you’d think has “the big C.” Especially when you compare her with some of the other women sitting in the cancer center waiting room—many of whom might have waited until they felt a palpable mass in their breast before seeking treatment.
When I ask my mother what she thinks of the task force guidelines, she doesn’t hesitate: “Women have families and work and dreams. It’s sad when cancer gets in the way of them—in any way. So I hope that women, even at 40, get screened so that they have more options available to them. And even if they are diagnosed, cancer won’t get the chance to get in the way of those dreams.”