Caring Currents

Breast Cancer Controversy: No More Routine Mammograms for Women Ages 40 to 49?!

Last updated: Nov 18, 2009

:) What am I?
Image by LovinArizona used under the creative commons attribution license.

This week a decision was made that could affect many lives. Currently mammograms are recommended as a yearly screening technique for women starting at age 40. If you have health insurance, it tends to happen pretty much automatically; your doctor sends you a reminder, and off you go to the radiology lab. Now all that might change.

The preventive services task force issued a recommendation that women under 50 shouldn't have routine screening mammograms unless individually recommended. And after age 50, mammograms should only be performed every two years instead of annually, the panel said.

What that means is that women between ages 40 and 50 won't be offered mammograms as a routine part of their wellness health care. And after age 50, they'll be offered mammograms only every two years, which is a long time for a tumor to grow.

As with so many health care decisions, this could come down to money. What I -- and many breast cancer advocates -- are worried about is that health insurers may stop covering mammograms outside these guidelines unless a woman can demonstrate that she's at some sort of elevated risk. This puts the burden on us to demand mammograms, or even prove somehow that there's enough cause for concern that we should have them. Many women aren't going to know to ask, and women who do ask may have to "prove" there's cause for concern. And what if you can't prove it? What if you're just worried?

To think about the impact this decision might have on your own life, ask yourself how you'd answer these questions:

  1. How many women do you know who've been diagnosed with breast cancer between the ages of 40 and 50?
  2. How many of your friends and family members who've had breast cancer were first alerted by a mammogram?
  3. Of those women, how many had some type of risk factor that would have caused them to demand screening if it wasn't routinely offered?
  4. Have you, or someone else you know ever had a concerning mammogram and had to have additional exams? Do you feel safer, having had that care?

You probably see what I'm getting at. Yes, routine mammograms do turn up "false positives" and can lead to scares that then turn out to have been unnecessary. And yes, you can argue that having a mammogram every year -- if we don't turn out to have breast cancer -- exposes us to extra radiation. There are cases where a woman ends up having a biopsy that turns up negative, and now she has a scar.

But when you put that against the number of women between 40 and 49 whose cancer will now not be caught and treated as soon, it seems like we're putting practicality (and possibly money) over safety.

Almost more disturbing to me was the final and less-talked-about pronouncement of the task force. Their new guidelines also call into question physical breast exams. They say breast exams by doctors should be discontinued, as it isn't clear that doing breast exams is a valuable diagnostic tool. And in addition, they also state that teaching women to do their own breast exams should also be discontinued. I just have to ask: What's the downside to doing a physical breast exam?!

But this again could become a significant money issue. Now that we have Gardasil, the cervical cancer vaccine, and many younger women don't need to go in for annual pap smears anymore, annual breast exams may quickly fall by the wayside too. And if insurance companies can get away with not covering annual exams, and doctors aren't required to take the time to perform breast exams and teach young women how to do them, we've removed one of the only tools available for women under 40 to discover they have breast cancer.

I'm not a medical expert; it's possible I don't understand all the pros and cons. So I turned to oncologists and other cancer experts and found them up in arms. "Tens of thousands of lives are being saved by mammography screening, and these idiots want to do away with it," said Daniel Kopans, a radiology professor at Harvard Medical School. "It's crazy - unethical, really."

Could money and insurance be factoring into what should be, pure and simple, a public health issue? Consider this: Under the health care reform legislation pending in Congress, the conclusions of the 16-member task force would set the standard for what preventive health care services insurance plans would be required to cover at little or no cost. Yikes.

The controversy started brewing so fast that experts at cancer centers were already saying they wouldn't abide by the guidelines. The M. D. Anderson Cancer Center in Texas voiced concern and announced they aren't changing their screening protocol. "We disagree with their conclusions," said physician spokeswoman Therese Bevers. "You have to screen more women. It's the value we put on zero women dying."

Len Lichtenfeld, a physician blogger for the American Cancer Society, analyzed the task force's data in his blog post and summarized the ACS point of view on the controversy with a rational, point by point approach:

  • Mammograms are indeed successful in reducing deaths from breast cancer in all age groups

  • Since the actual incidence of breast cancer is less in women ages 40-49, the absolute/actual numbers of lives saved is also less; but lives are saved.

  • All this means is, you have to screen more women to get the same benefit.

  • Stated another way, the Task Force agrees that mammography reduces deaths in women ages 40-49; it just doesn't save enough lives, in their opinion.

Lichtenfeld ends with this conclusion: "Until we have something better, what we have to work with to detect breast cancer early is the screening mammogram.  Is it imperfect? Yes.  Has it saved lives and reduced deaths from breast cancer?  Absolutely. And that is the fact that simply cannot be ignored."

Lichtenfeld's blog generated a lot of comments from patients and doctors. Many are from women ages 30 to 50, detailing their battles with breast cancer, diagnosed via mammogram and breast exam. But this one from a Dr. Hampton says it all:

"As a breast surgeon focused on benign and malignant disease, and treating a young population of women, these guidelines will undo all of the work done thus far. I read in a CNN article that not one of the members of the task force is an oncologist (doctor who treats cancer).... I have plenty of patients in their 40's who might be dead if they had waited."

I'd love to hear the thoughts of members on what's sure to become one of the biggest breast cancer controversies yet.