MARGARET WARNER: Science and medicine have long grappled with the tradeoffs involved in cancer screening. What’s not clear is whether today’s new Pap smear guidelines, coupled with another panel’s recommendations earlier this week to scale back mammograms for women under 50, mark an important milestone in that debate.
We explore that now with Dr. Douglas Kamerow of Georgetown University — he’s a former assistant surgeon general and chief scientist at RTI International, a research institution — and Dr. Julie Gralow of the American Society of Clinical Oncology. She is the director of breast oncology at the Seattle Cancer Care Alliance.
And welcome to you, both.
Dr. Kamerow, the fact that we have had these two new sets of guidelines in the same week, is this just a coincidence, or is there some new thinking going on more broadly about how to at least weigh the tradeoffs in cancer screening?
DR. DOUGLAS KAMEROW, Georgetown University: Well, the answer to your question is, it’s a coincidence, two different organizations. They have nothing to do with each other. They came out with these at that time.
But you’re right. It raises the point, what is a good screening test and who gets it and when do you get it?
MARGARET WARNER: Well, OK, how would you define that? And is there a consensus emerging that maybe — this seems to fly in the face of everything we have been told about the value of preventive screening, preventive care, early. How do you jibe those two?
DR. DOUGLAS KAMEROW: Well, it’s nice to think that all prevention is good. But the answer is, it isn’t. You need to have a proven test and you need to have a disease that is amenable to screening. In both these cases, both breast cancer and cervical cancer, we have a disease that is pretty good at being screened, that is, has a long, usually a long asymptomatic phase, especially in cervical cancer.
And that’s good for a screening test. But then you have got to have an accurate screening test as well.
MARGARET WARNER: Dr. Gralow, what is your thought about the sort of broader message from these two new guidelines this week?
DR. JULIE GRALOW, Seattle Cancer Care Alliance: I think an important message is that we need to be talking to our individual patients about the risks and benefits to be gained and to be lost with all of these procedures.
I think these are two very different cases. Cervical cancer picked up by a Pap smear is found at usually a very pre-invasive phase that will take many years to evolve into a dangerous invasive cancer. And these guidelines today don’t really surprise us. We have a lot of new information that has come into play since some of the older guidelines reflecting annual screening of Pap smears were made.
MARGARET WARNER: But you feel it is different with breast cancer?
DR. JULIE GRALOW: Breast cancer, we have got good, solid randomized trials of, mammography or not, that show that we save lives.
Most breast cancers picked up on mammograms are already invasive, meaning they can spread throughout the body and they can lead to death. We don’t have as long a pre-clinical phase as we do in cervical cancer, where we can watch it for a while or we can have a few years. Most breast cancers picked up even by annual screening mammography have already moved to the invasive, the risky, life-threatening phase.
MARGARET WARNER: So, Dr. Kamerow, why would this panel conclude that, for women under 50, routine exams are not indicated?
DR. DOUGLAS KAMEROW: Well, I think you heard when you last talked about this with the co-chair of the panel — I’m not on this panel — that they probably didn’t word their recommendations as well as they could have.
And they didn’t say not to screen in the 50s. What they said is exactly what Dr. Gralow said, is that, for the best evidence, for women 50 and over is to get routine mammograms, pretty much everybody. But, for people younger than that, women younger than that, they need to talk to their doctors and discuss it, so they can understand what the benefits are and what the risks are.
Statistics versus care
MARGARET WARNER: I guess what I'm asking here, though, is, is there a conflict between an approach that says the statistics show that only one case in 1,900 in a woman under 50 actually turns into a fatal form of cancer, so, therefore, cost/benefit, risk/benefit analysis suggestions don't do that routinely, and, over, 50 it is one in 1,300, I mean, that approach vs. what many Americans and many human beings feel, which is, we should go to every step we can to save every, any life we can?
DR. DOUGLAS KAMEROW: Well, I think that, first of all, it's not a decade kind of thing. That was done for convenience. And it's arbitrary.
But the risk is a continuum. And I think everyone agrees on what the science says, which is, as you get older as a woman, you are more likely to have breast cancer. And your breasts are easier to examine, so the mammography is better as you get older.
But, that said, if you could have any chance in one in a million, you wouldn't do it, right? So, if it's not something you would do in one in a million, where do you draw the line? That is just the question. Is it one in 14,000, 6,000, 200? Where do you draw the line?
MARGARET WARNER: Dr. Gralow?
DR. JULIE GRALOW: I think we're all trying to practice evidence-based medicine here, but what we where seeing is that, depending on your perspective, you view the evidence, the science differently.
If you take a public health policy standpoint, where you are looking at how many exams do we need and how many biopsies do we need to do to find a case of breast cancer, you would weigh out like the U.S. Preventative Services Task Force. If you are a clinician in the trenches who struggles with identifying women 40 to 50 and knowing who really is at increased risk, then you are probably going to lean toward doing the screening regularly in all women, because we don't know how to really assess risk in that group very well.
MARGARET WARNER: What does the furor over this, Dr. Kamerow, say, do you think, about the prospect of reshaping our health care delivery system, so it is more -- quote -- "evidence-based," when, as Dr. Gralow says, it just depends kind of which end you look at the evidence from?
DR. DOUGLAS KAMEROW: Well, that's right.
And it is going to be an interesting challenge as we try to rationalize our health system, which, right now, is a crazy quilt system, where people get what they get. And we have got no budgets. And you just get what you get.
And what is going to happen when we try to make it a little clearer what makes sense and what doesn't make sense? It's going to be a challenge to do that. And this to some extent may give us a picture of what happens, because we're used to, in this country, of getting everything we can afford.
And some -- some time, that is probably going to have to stop. These may not be the perfect examples of that. But they do make people think about, what is worth it, what is not worth it? What makes a difference, not just in terms of money, but in terms of health and outcomes, and inconvenience and side effects?
Impact on insurance coverage
MARGARET WARNER: Dr. Gralow, to what degree do recommendations like this drive insurance company coverage decisions?
Now, I should point out to our viewers that I think, in every state but Utah, it's actually the law requires coverage of mammograms for women over 40. So, that particular case probably is not -- it's not going to be effected.
But, in general, do recommendations like this ultimately drive insurance company decisions?
DR. JULIE GRALOW: It would be a tragedy if, in the end, either insurance companies or government legislation were what decided what is a very important discussion and decision between a physician and a patient.
Although you are correct that virtually all of the U.S. states require coverage for screening mammography beginning at age 40, that doesn't mean that that is what will be recommended. And, so, we have to be careful that we -- this could be a very healthy dialogue. We have to be careful that we don't turn patients off, that we don't give a message that mammograms and cervical cancer, oh, we're not even sure if they work or not, you know, the screening for cervical cancer, so why don't -- I just won't get it at all.
I do like the comment made earlier that the gynecologists are the ones doing a lot of the primary care for our younger women. And if they get the message, you only need your Pap smear once a year, that doesn't mean you don't need a lot of your other health screening on an annual basis. And so that would be a poor message to come out of all of this as well.
MARGARET WARNER: Brief final response for you: Is there a danger that that is the message some women will take away from this?
DR. DOUGLAS KAMEROW: Well, I think that that is a concern.
But the important thing is that women or men talk to their doctors about what is important for them and useful for them and will make a difference to them to keep them healthy and improve their health.
MARGARET WARNER: But to a lot of women or men, going in for that test is short of a shortcut. You think of it as the shortcut.
DR. DOUGLAS KAMEROW: Right. But, as Dr. Gralow says, it is not the linchpin. You should be seeing your doctor regular -- primary care doctor regularly to get health maintenance kinds of things not tied to a specific test.
MARGARET WARNER: Dr. Douglas Kamerow and Dr. Julie Gralow, thank you, both.