New guideline: mammogram at 50

An influential federal panel said that most women under 50 do not need routine mammograms -- a direct contradiction to long-standing advice from doctors and cancer groups.

In addition, the U.S. Preventive Services Task Force said there's no evidence that breast self-exam leads to fewer deaths, and the group suggested that doctors quit teaching women how to conduct the examinations at home.

The recommendations drew immediate outrage from many researchers, doctors and patients, who cited personal experience that the screening methods caught otherwise undetected cancers and led to successful treatment. Most authorities have called for regular screenings after the age of 40.

Some questioned the timing of the recommendations, coming as lawmakers in Washington debate ways to save money in the nation's health care system, possibly by curbing procedures or treatments that have no scientific evidence of benefit.

"This makes no sense to me," said Dr. Etta Pisano, a mammography researcher at UNC-Chapel Hill who published an influential national wider use of digital mammography technology. "I am tired of the debate over this. There is plenty of evidence that mammography reduces breast cancer mortality."

Pisano cited studies showing that even mammogram screenings done by older technology reduce death rates by at least 15 percent for women in their 40s.

But the task force looked at larger population studies and concluded that the evidence of benefit isn't convincing in the younger age group, particularly when weighed against the potential harm of false alarms, unnecessary radiation exposures and caustic treatments for relatively non-aggressive cancers.

"Although false-positive test results, overdiagnosis and unnecessary earlier treatments are problems for all age groups, false-positive results are more common for women aged 40-49 years," the task force reported.

The task force, a panel of public health doctors and academic medical center experts in prevention and primary care, has issued guidelines since it was formed in 1984. Its recommendations have helped frame the advice issued by professional societies, health organizations and medical quality review groups.

Cancer society disagrees

The current findings are meeting strong resistance. The American Cancer Society, which has its own screening recommendations, issued a statement Monday reaffirming its call for women to begin regular mammography at 40.

"The American Cancer Society acknowledges the limitations of mammography, and we remain committed to finding better tests," Dr. Otis W. Brawley, chief medical officer of the cancer group, said in a prepared statement. "In fact, data show the technology used today is better than that used in the studies in this review. ... As scientists work to make mammography even more effective, the American Cancer Society's medical staff and volunteer experts overwhelmingly believe the benefits of screening women aged 40 to 49 outweigh its limitations."

Danger in confusion

Dr. Gary Lyman, director of health services outcome research at Duke University Medical Center and a member of medical panels that have set breast cancer screening guidelines, said he fears that women will be confused by conflicting recommendations.

Already, Lyman said, prevention efforts are flagging, so a mixed message could further erode progress.

"Women out of sheer confusion or uncertainty will not do routine mammography," he said, noting that early detection has long been a proven life-saver. Cancers that are caught early, before they spread, are easier to treat and can often be wiped out.

Lyman and other doctors questioned the motive of the task force, because one of the topics in the U.S. health-care debate is the high cost of unnecessary scans. Last month, questions about the benefits of prostate cancer screenings ignited a similar furor.

"In the future, as a society, we have to talk about resources," said Dr. Lisa Tolnitch, a surgeon in Raleigh who specializes in breast cancer. "Can you in a dollar-and-cents way prove you save lives? That's a hard thing to pin down. Then you have to say how much is a life worth? That's what we're talking about. If it's your life, it's worth a lot to you."

The task force's findings, published in the Annals of Internal Medicine, are not without precedent. Across Europe and in Canada, screenings for most women are not started until after 50.

Dr. Amy Abernethy, director of the Duke Comprehensive Cancer Care Research Program, said she applauds the task force for a recommendation based on evidence, not emotion. She said she worked abroad in Australia, and women there were unperturbed by the recommendation to begin mammograms after age 50.

Abernethy said it will be harder to change practices in the United States.

"It is such an empowerment issue," she said. "We all want so bad to have something we can control. The phenomenal and wonderful thing about breast cancer is that awareness has really risen. The problem once you increase awareness, is a greater sense of risk. People need to have something to help control the risk."

For younger breast cancer patients, many of whom credit mammography or self-exam with detecting lumps, the idea that such screenings are scientifically questionable is beyond reason.

"What?" gasped Sherry Sawyer, 49, a Clayton resident who was diagnosed with breast cancer 14 years ago. "That's ridiculous."

Julie Doyle, who was diagnosed in May at age 43, said her breast cancer was detected by a routine mammogram.

"I felt no lump, nothing," said Doyle, a nurse who lives in Wake Forest. She had a mastectomy, plus chemotherapy. "I am the poster child for routine mammogram."

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