JANUARY 24, 1997
Should women under the age of 50 routinely get mammograms for early detection of breast cancer? National experts conferred this week,but the cost/benefit debate remains unresolved. A background report is followed by a discussion between health experts and Charlayne Hunter-Gault.
CHARLAYNE HUNTER-GAULT: Now to our debate. Dr. Edward Sickles is a professor of radiology at the University of California in San Francisco Medical Center. And Dr. Carolyn Westoff is a gynecologist and epidemiologist with the Columbia Presbyterian Medical Center. She was a member of the panel that released this report yesterday. And starting with you, Dr. Westoff, in the simplest terms, why did the panel come to the conclusion that it did?
A RealAudio version of this NewsHour segment is available.
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DR. CAROLYN WESTOFF, Mammogram Panel Member: (New York) Well, we weighed the scientific evidence as thoroughly as we could, and this is basically a near thing.
The panel believes quite unanimously there is a small mortality benefit, a small reduction in breast cancer deaths, or rate of deaths in women who are screened, but the problem with the benefit that might be called small is that that will be in the eye of the beholder, and we felt given the size of the benefit, which is smaller than for older women, and the risks and inconveniences that women will need to have information on, on how much of a benefit they could individually experience, and for a woman who says oh, yeah, I want that kind of protection, she should certainly have a mammogram, but we didn't feel the size of the benefit was so large that all women should really be told this is something they want to be doing at this age.
CHARLAYNE HUNTER-GAULT: Dr. Sickles, you disagree with the conclusion.
DR. EDWARD SICKLES, UCSF Medical Center: I certainly do.
CHARLAYNE HUNTER-GAULT: Why?
DR. EDWARD SICKLES: First of all, the evidence for benefit is actually very convincing. The studies that were done in order to demonstrate it demonstrates just what the most carefully controlled scientific studies, that the level of the benefit demonstrated so far with mammography from ten to fifteen years ago provides maybe 2/3 of the benefit that it provides in women who already everyone agrees should get mammograms.
So we're talking about what is being called small, but really what is 2/3 of what is already widely accepted. The second piece of evidence which the panel didn't seem to consider very strongly is that modern mammography, that which is done now in the 1990s, seems to show it works just as well for women in their 40's as it does for women 50 and older.
CHARLAYNE HUNTER-GAULT: Dr. Westoff, how do you respond to that, that small is really 2/3 of the group that it benefits who are 50 and older, and that the--you heard what he said about the modern mammography being much more efficient?
DR. CAROLYN WESTOFF: Well, I think those are important points that I partly agree with. I'm not exactly--
CHARLAYNE HUNTER-GAULT: What part do you agree with?
DR. CAROLYN WESTOFF: I agree with both of them to some extent.
The mammography is not quite as sensitive for younger women as it is for women above 50, and when you multiply a smaller level of protection along with a death rate that is already fortunately lower, you add up to a much smaller savings in lives. And, yes, we do want to save lives.
And everybody agrees with that now. While it's, I think, difficult in this setting to come up with some numbers, I would like to provide some numbers to give your viewers an idea of where we thought the benefit lies. And if ten thousand American women would be regularly screened throughout their 40's for the whole decade, we estimated that in the long run somewhere between zero and ten lives would be extended. Now zero and ten, you know, reflects the uncertainty.
And I think that almost everybody agrees approximately where the benefit is, although not everybody agrees about how large the uncertainty is. And there are some other people, such as Prof. Sickles, who might say, well, it's really between two and eight. And the panel wanted to say between zero and ten. But we do agree there's a range of benefit; however, for women in their 50's, for the same ten thousand women to be regularly screened, approximately twenty to thirty women would have a decrease in mortality.
So that's a substantially larger benefit. And that's--that's one reason we felt cautious about recommending this. Now, many women might look at that level of benefit and say, oh, yeah, that is a benefit I wish to experience. That sounds worth it to me. Other women may feel it's not worth it for them.
CHARLAYNE HUNTER-GAULT: All right. But let me ask you--what is your concern--I mean, if there a benefit, are you saying that there's a risk that outweighs that benefit? I mean, what is the risk in the younger women that causes this real--well, what has been registered as a surprising amount of caution on the part of this panel?
DR. CAROLYN WESTOFF: There are several things, and they do range from mild to more serious, and I must say they're things we don't know enough about yet. There are simple things like just the, you know, the inconvenience and time and energy of going to get the testing; however, what we're more concerned about is a substantial number of women will need additional tests. Now, in Dr. Sickle's hands--he's a real expert--he has a lower rate of false positives than most people do. But in many studies and many series the rate of false positives is up to 10 percent on the first screen.
CHARLAYNE HUNTER-GAULT: And why is that bad?
DR. CAROLYN WESTOFF: Because a woman has to go and get additional tests, and because let's say our ten thousand women, our hypothetical ten thousand women, about a thousand of them in the course of a decade would end up with a biopsy, which is a lot to go through, a lot of discomfort and procedure to go through, and a lot of worry to go through, even without finding something.
CHARLAYNE HUNTER-GAULT: So that's the most extreme concern that you have, the worry and the inconvenience?
DR. CAROLYN WESTOFF: That's just one of them. I think that's one of the more common. Now, there are several other issues. One that is really unstudied at this point is the possible contribution of the radiation exposure, itself, to the development of additional cancers later. That is probably a small risk.
It is not a well-measured risk, and that did not enter greatly into our concerns, but I just mention it because it is an issue for some people. Another issue is that very minor early forms of breast cancer can be detected through mammography. And while most people say that's terrific, the other side is that women might get very extensive treatments younger than they actually needed to.
CHARLAYNE HUNTER-GAULT: All right. Let me just on those get Dr. Sickles to respond. Those concerns, how do you respond to them, Dr. Sickles?
DR. EDWARD SICKLES: Okay. There were actually several inaccurate statements made there. First of all, the amount of biopsies that are done as a result of abnormal mammography are nowhere near as high as what was stated. That was very much overstated. The rate at which abnormal interpretations are made also was overstated because the panel was presented with the most current evidence and simply didn't seem to work with it. The most current evidence would suggest that the level of abnormality is half of what was stated.
DR. CAROLYN WESTOFF: Dr. Sickles--
DR. EDWARD SICKLES: Yes.
DR. CAROLYN WESTOFF: --in your practice that may be true, and in Sweden, that may be true. But as we look at larger series, additional series in the United States, we see biopsy rates of 1 to 1.5 percent, and we see abnormal rates that easily go upward to 10 percent in other series. I know your practice, sir, that's not happened.
DR. EDWARD SICKLES: You were presented by me and also by Dr. Lee from the Centers of Disease Control with current results that showed half that rate. And these were from general practice radiologists, not experts like me. The general practice--
DR. CAROLYN WESTOFF: Dr. Lee's rates were higher.
DR. EDWARD SICKLES: --radiologists and these--the total amount that you were presented was like one million mammograms. These were huge numbers of cases. And the rates that you were shown were quite a bit lower. The rate is higher the first time mammography is done.
DR. CAROLYN WESTOFF: We both agree.
DR. EDWARD SICKLES: But the rate is much lower on the subsequent ones. Dr. Lee didn't have that much experience with subsequent ones; we did.
CHARLAYNE HUNTER-GAULT: So, Dr. Sickles, are you saying the panel just ignored evidence that would have changed the decision that they made?
DR. EDWARD SICKLES: I hesitate to use the word "ignored" because I wasn't sitting there with them. But they certainly didn't give it the weight which I would or which most other people would. The evidence for benefit and also I believe they were very much over-cautious on the evidence for risk. Most looks at evidence for risk show only very minor changes in risk for women in their 40's, compared to say women in their 50's.
CHARLAYNE HUNTER-GAULT: Over--
DR. EDWARD SICKLES: Again, we have to remember that we're comparing here a group of women in their 40's with a group of slightly older women for whom everyone agrees it's good. And the levels of risk are not that different, you know, 1, 2 percent different, and the levels of benefit, although they may be slightly lower if you look at the older data, probably are not that much different at all, if you look at the modern data.
CHARLAYNE HUNTER-GAULT: Over-cautious, Dr. Westoff?
DR. CAROLYN WESTOFF: Well, I think there are two points. I think we were cautious. I wouldn't like to be over-cautious. I'm a woman in my 40's, and I'm interested in protecting myself as much as everybody else. And the panel all really did consider this in terms of how they would handle things personally. But I guess there are two things I would take--like to point out. I think one thing Dr. Sickles was perhaps alluding to is there is a continuum in terms of risk and benefit.
Unfortunately for mostly statistical reasons, the data tends to get broken down into these large tenure age groups. A lot of those divisions are artificial, and it is quite likely that both the risks and the benefits of mammography are changing quite gradually over a number of years. And the use of a certain age cut-off is not going to be optimal, and the panel encouraged that all the clinical trial researchers could combine their data so that analyses could be done that look at things more continuously.
CHARLAYNE HUNTER-GAULT: Dr. Westoff, what do you think is going to be the harm of this? I mean, Eleanor Holmes Norton talked about the--that the panel should have erred on the side of risk. And later in that press conference she talked about the impact that this is going to have on insurance. Do you see that impact, Dr. Westoff?
DR. CAROLYN WESTOFF: Yes.
CHARLAYNE HUNTER-GAULT: Or, Dr. Sickles--I'm sorry.
DR. EDWARD SICKLES: That's a potential problem. I think when one looks at this information and thinks carefully about the benefits and the potential harms, and I'm struck by the fact that the panel was advised right at the beginning that they should consider that above all else they should do no harm. The problem is in giving too much consideration to that, they wind up doing no good.
As far as the insurance is concerned, there is a potential problem, although the panel very clearly stated that they believe that women who chose--it was advisable to have mammography for themselves--it's quite possible that insurance companies might not take this sort of half-hearted endorsement of mammography to heart, and they might just choose not to support it. That would be very unfortunate.
CHARLAYNE HUNTER-GAULT: Dr. Westoff--
DR. CAROLYN WESTOFF: I agree with that. One point I would like--
CHARLAYNE HUNTER-GAULT: Well, let me just ask you--we may be running out of time--and I just want to know--you said you were a woman in your 40's. What are women in their 40's supposed to make of all of this? Because there have been these flip-flops for two decades, and now there's this intense criticism about your report.
DR. CAROLYN WESTOFF: Part of what the flip-flopping actually tells us is that, you know, scientists and investigators who are really trying to answer this question are so sort of close to the edge here that it's hard to get a precise final answer. If the benefit were huge, we would have all figured it out years ago and told women what to do years ago.
CHARLAYNE HUNTER-GAULT: So what should women do now?
DR. CAROLYN WESTOFF: This controversy, itself, is a sign that the benefit is modest.
CHARLAYNE HUNTER-GAULT: All right. Excuse me, but what should women do now, very briefly?
DR. CAROLYN WESTOFF: What should women do now? Very briefly, it's still incumbent on the panel and educational organizations to get the information, the numerical information out there in a form that women and their doctors can see for them. What's the risk of biopsy? What's the risk of cancer? What's the probability of decreasing my breast cancer mortality? And a woman can say, oh, yeah, that's good enough for me, I want a mammogram, or a woman says, no, that doesn't sound so good, I don't want it.
CHARLAYNE HUNTER-GAULT: All right.
DR. CAROLYN WESTOFF: But we can't just look at the studies we like best and the studies that had the best results.
CHARLAYNE HUNTER-GAULT: All right. Well--
DR. CAROLYN WESTOFF: We have to look at the whole spectrum of information.
CHARLAYNE HUNTER-GAULT: All right. Well, there's going to be more on this in about two months from other cancer organizations, so we'll revisit it at that time. Thank you.