JIM LEHRER: Now: new recommendations for breast cancer screening.
Betty Ann Bowser of our Health Unit gets us started. The unit is a partnership with the Robert Wood Johnson Foundation.
DR. SHAWNA WILLEY, Lombardi Comprehensive Cancer Center: Hello. How are you?
PATIENT: I’m good.
BETTY ANN BOWSER: The questions started at 7:00 this morning for Dr. Shawna Willey, a breast surgeon at the Lombardi Cancer Center at Georgetown University Hospital in Washington, D.C. Patients wanted to know what to do, after a government task force yesterday recommended most women wait until they’re 50 years of age to get a mammogram.
DR. SHAWNA WILLEY: And there’s a lot of concern about this.
BETTY ANN BOWSER: Dr. Willey’s patients had questions because the new recommendations reversed the task force’s earlier guidelines on breast cancer screening practices made in 2002.
DR. SHAWNA WILLEY: The women are confused about what, I think, the outcomes are that are related to this paper. The take-home message may be that mammography doesn’t detect breast cancer. And this does not say that at all.
In fact, it says that mammography does detect breast cancer and it does decrease mortality across all age groups. So, I think the take-home message may be that — that mammography doesn’t work. And I don’t think that’s the intended take-home message.
So, the average-risk patient is trying to decide all of a sudden, what are we going to do? What is my doctor going to do? What is my insurance company going to do?
BETTY ANN BOWSER: The new guidelines came from the U.S. Preventive Services Task Force, an independent government-appointed panel under the Department of Health and Human Services.
The task force said most women in their 40s should not routinely get mammograms, unless there is a high genetic risk of breast cancer. Women 50 to 74 should get a mammogram every two years. The task force gave no recommendation for women 75 and over and advised women not to be taught to do breast self-examinations. The group also said there’s no evidence that breast exams performed by doctors yield any significant medical benefits either.
Reaction from women in the D.C. suburb of Arlington, Virginia, was mixed today.
JULIE KERN: It’s concerning because it’s been something that has just been driven into our, you know, kind of women’s health care ,that that’s something that you really need to get checked out, that, if you catch it early, it’s treatable.
DIANE FREEMAN: I think it’s awesome. I think mammograms should be like every other year. Well, personally, I asked my doctor that. And she said she would rather that I do it once a year. But I would rather have it every other year.
LEAH NOONAN: So, I’m not really sure what the details are, but it seems like it would be better to check sooner, because I know women, of course, that have gotten breast cancer before 50.
Anger over new guidelines
BETTY ANN BOWSER: But Julie Langley had no confusion about mammograms whatsoever. The 43-year-old mother of two was diagnosed with breast cancer four years ago. After undergoing a lumpectomy and chemotherapy, she's now cancer-free.
And, when she heard about the new guidelines, she was stunned.
JULIE LANGLEY: I was upset, disheartened, disgusted, because no one should have to miss an early detection. It's so important.
It's a diagnostic tool that saves lives. Not doing it will ensure you don't know anything. Doing it can help thousands of women and men live longer.
BETTY ANN BOWSER: But the task force said over-screening could be harmful, leading to unnecessary treatments.
The new guidelines could influence how Medicare covers mammogram screenings, as well as how insurance companies pay for them. The new advice conflicts with the American Cancer Society's longstanding recommendation that women begin getting annual mammograms at the age of 40. About 35 million women undergo mammograms each year, at a cost of more than $5 billion.
JIM LEHRER: And to Gwen Ifill.
GWEN IFILL: So, when is screening for breast cancer a good idea, and when does it fall short?
Here to help us sort all that out are Dr. Diana Petitti, a professor of biomedical informatics at Arizona State University -- she's also vice chair of the task force that released the recommendations -- and Dr. Otis Brawley, chief medical officer of the American Cancer Society and a professor of oncology, hematology, and epidemiology at Emory University School of Medicine.
Welcome to you, both.
Dr. Petitti, since this is your report, I -- I want you to respond to some of what we just heard in Betty Ann's piece. Do you understand the confusion?
DR. DIANA PETITTI: I -- I do understand the confusion.
And I think part of it is because of the subtlety of the language of the task force. The task force recommended against routine screening of women starting in their 40s. What they recommended in favor of was a discussion of a woman with her physician about what age to start screening.
The recommendation has been widely misinterpreted as saying women shouldn't be screened ever in their 40s. And that, in fact, is not what the recommendation was about.
GWEN IFILL: A congresswoman from New York -- or from Florida, Debbie Wasserman Schultz, who is a breast cancer survivor and an activist on these matters, today said she thought that the recommendations were clear as mud.
And a lot of women seem to agree. What do you say to that?
DR. DIANA PETITTI: Well, I -- I apologize for the lack of clarity. I -- I think that hearing the media feedback about the recommendations and how they're being interpreted makes it clear that we need to have better messages.
Again, this is for a recommendation against routine screening of women starting automatically in their 40s. It's a recommendation for a conversation that a woman might have with her physician about when to start screening, and an informed choice about what the tradeoffs are of the benefits of starting earlier vs. the benefits of starting later, and the risks or negatives or harms of starting earlier compared with starting later.
Who should screen
GWEN IFILL: Dr. Brawley, as you read this report and heard about this -- this cost-benefit balance that the task force was attempting to make, did you agree with their conclusion?
DR. OTIS BRAWLEY, chief medical officer, American Cancer Society: No, I don't at all.
I respect the task force; don't get me wrong. But I do believe and the American Cancer Society believes that women should be informed of the potential benefits and potential harms, but women should also start screening annually beginning at the age of 40.
GWEN IFILL: Well, one of the things that they found in this report is how few of the diagnoses that are -- are as a result of mammograms, that 1,900 women might have a mammogram, and only one person is found to actually have cancer.
Is that a good use of diagnostic tools?
DR. OTIS BRAWLEY: Well, Dr. Petitti, perhaps you can clarify. I thought it was 1,900 women screened for one life saved among women in their 40s, and 1,340 women screened for one live saved for women in their 50s.
GWEN IFILL: That's correct. Is that worth it to you, Dr. Brawley?
DR. OTIS BRAWLEY: Me, it's very -- it's -- it's very difficult for me to say that there's a cutoff between 1,340 and 1,900 in which we stop screening.
I -- it is my preference that we screen women in their 40s and women in their 50s, and try to save that one life that can be saved for every 1,900 women in their 40s screened.
GWEN IFILL: Dr. Petitti, help us understand exactly how we come up with a cutoff. Why is there a connection between age and detection?
DR. DIANA PETITTI: Well, I think, first of all, I want to clarify. The task force is not saying there's a cutoff. It is not recommending against ever screening women in their 40s.
The task force has made a recommendation against routine screening, that is, screening where a postcard comes in the mail and the woman is told that she must be screened every year. Again, we do not disagree at all about the need for women to make an informed choice about being screened at any age.
That conversation should begin in the 40s. And women who want to be screened, after understanding what those benefits might be against the harms or the negatives, should be screened. We don't disagree. There is no cutoff. There was no magic number. And this was not a cost effectiveness analysis.
Consult a doctor first
GWEN IFILL: There are so many women who can tell stories and men who can tell stories of women they know under the age of 50 who were diagnosed with breast cancer.
What are those women -- what are people who hear those stories -- which, you know, anecdotes sometimes are more powerful than numbers -- what are they to do with those numbers?
DR. DIANA PETITTI: Well, I -- I think we agree that these -- that women need to be able to make a choice, that the discussion should be about the benefits and the harms. The message should be that this is something that has a benefit, the benefit may be small, and that it's a discussion starting at age 40 about when to start being screened.
GWEN IFILL: So, how do women -- Dr. Brawley, how would you recommend women make this choice?
DR. OTIS BRAWLEY: First, the -- one of the problems here is that mammography is a good test, but it's not a great test. And women deserve a great test.
So, scientists need to work to develop something that is better. Until we have something better, it is the ACS position that mammography is the best thing that we can use. The task force and the ACS have an agreement here that mammography in women in their 40s decreases the relative risk of death by 15 percent.
We happen to think that that means that all women in their 40s ought to get screened annually. They should be informed of the potential harms, the potential for over-diagnosis, the potential for false positives or for false alarms. If they're informed of this beforehand, it will decrease the anxiety. And then we can have that 15 percent decrease in mortality.
GWEN IFILL: Dr. Petitti, let's talk about self-exams. That's something every woman is taught that she's supposed to perform on herself once a month. And you say that they're not -- it's not very useful at all.
DR. DIANA PETITTI: Well, I think, here, the task force was on excellent evidence grounds.
Since 2002, when the task force last addressed this topic, two very large randomized trials of teaching women breast self-examination in order to prevent death from breast cancer were published. And both of those studies showed that, in fact, teaching women breast self-examination does not decrease the risk of death from breast cancer.
There are no obvious harms from breast self-examination, but, in the absence of benefit, the teaching time spent could be better used with other kinds of educational messages.
Pros and cons of self-exams
GWEN IFILL: I want to get back to you about what kind of messages we should be talking about, but I also want Dr. Brawley to respond to this -- this question about self-exams.
Is that something that you would also agree with the task force on?
DR. OTIS BRAWLEY: Well, we would agree with the task force, that then -- the two well-designed clinical trials.
We would advocate that women not do breast self-exam, which is a scheduled exam every time, you know, the first of every -- the first day of every month. We would advocate that women be aware of their breasts and be aware of breast mass if they develop.
Most women, by the way, in their 40s who are diagnosed with breast cancer are not diagnosed through mammography. They usually are diagnosed through finding a mass in the shower. And we actually need to encourage women who find a mass in their breast to get to a doctor quickly for evaluation.
So, I'm not in favor of breast self-exam, per se. I am very much in favor of breast awareness and keeping observation looking for masses in one's breast.
GWEN IFILL: Is there something better that's on its way, Dr. Brawley?
DR. OTIS BRAWLEY: Well, I think one of the things that the task force really does point out here is that there are some problems with mammography. I happen to believe it's the best test that we have right now.
I happen to believe there's been a complacency in medicine, feeling that mammography was perhaps better than it actually should be. And we do need to stimulate the physicists, we need to stimulate the engineers to try to find something that is better, because American women, women in general, deserve something better than that we have now.
But, for now, the best thing that we can do is get a mammogram annually beginning at the age of 40.
GWEN IFILL: Dr. Otis Brawley, Dr. Diana Petitti, thank you both very much.
JIM LEHRER: You can ask Gwen's guests what the new guidelines will mean for you in a special forum on our Web site, NewsHour.PBS.org.