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There is no argument that women over 50 clearly benefit from annual routine mammograms. But a debate has raged for close to two decades over women in their 40's. This week the issue was revisited when the American Cancer Society said women in their 40's should receive annual mammograms. And today the National Cancer Institute's Advisory Board agreed. Charlayne Hunter-Gault reports.

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JIM LEHRER: Finally tonight, a return to the mammogram question and to Charlayne Hunter-Gault.

CHARLAYNE HUNTER-GAULT: Mammograms are X-rays of breast tissue, and they are one of the primary ways to detect breast cancer. There is no argument that women over 50 clearly benefit from annual routine mammograms. But a debate has raged for close to two decades over women in their 40's, with the major cancer organizations, public and private, flip-flopping in their advice. To help resolve the longstanding controversy the National Institutes of Health convened a special consensus panel to make recommendations. But that panel only fueled the fire in January when it failed to reach a definitive conclusion, saying women should decide for themselves after consulting with their physician. But many researchers and advocates vehemently disagreed.

DOCTOR: Over 180,000 American women--

CHARLAYNE HUNTER-GAULT: This week the issue was revisited when the American Cancer Society said women in their 40's should receive annual mammograms. And today the National Cancer Institute's Advisory Board agreed. In issuing its new recommendations today the presidentially-appointed advisory board said that women in their 40's should be screened every one or two years. Women with a higher risk of breast cancer should seek advice about possibly receiving mammograms before the age of 40. And clinical breast examination should be a part of regular, routine health care. The panel also called on health insurers to pay for mammography for high risk women at any age and for all women beginning at 40. President Clinton said the government would make those recommendations a part of policy and urged compliance.

PRESIDENT CLINTON: In the Medicare budget I'm sending to Congress today I'm making annual screening, mammography exams, beginning at age 40 a covered expense, without co-insurance or deductibles. Today I am directing the Office of Personnel Management to require all federal health benefit plans to comply with the National Cancer Advisory Board's recommendations on mammogram screenings beginning next year. The federal government is doing its part to make sure women have both coverage and access to this potentially life-saving test. I want to challenge private health insurance plans to do the same.

CHARLAYNE HUNTER-GAULT: And now for more on today's recommendations and the reasoning behind them we turn to Dr. Barbara Rimer, the chairwoman of the National Cancer Institute's Advisory Board. She's also the director of cancer prevention at the Duke University Comprehensive Cancer Center. Thank you for joining us. Why is this advisory board now recommending something that the board in January refused to?

DR. BARBARA RIMER, National Cancer Advisory Board: Well, the board--the consensus panel was really designed to sift through all the evidence and to come to a judgment about the evidence, not to make policy recommendations or recommendations for the National Cancer Institute. As the National Cancer Institute's board of directors, if you will, we were asked to look at all the evidence and to come up with recommendations that the American public, particularly American women and their providers could use. And so we looked at the evidence in a somewhat different way. We looked at the reductions in mortality, but we also looked at how to put it in terms and in a way that women could use that for making decisions, so we had a somewhat different agenda and a different purpose than that other board did.

CHARLAYNE HUNTER-GAULT: So how did you--what did you arrive at, and how was it different? I mean, how was the evidence different that you looked at?

DR. BARBARA RIMER: Well, let me just stress that almost everybody who's looked at this evidence recently, the American Cancer Society, the consensus panel, the National Cancer Advisory Board are very close in what they agree in terms of the evidence. We all agree there's a benefit. We all agree that the benefit is in the range of 16 to 18 percent. So--

CHARLAYNE HUNTER-GAULT: You mean in the reduction--

DR. BARBARA RIMER: Yes. So we're very close. We looked at basically the same evidence they did, but we also had to look at how do you translate that evidence into recommendations. So that was not part of their job, but it was part of our job. But we all looked at meta analysis. We looked at seven randomized clinical trials that have been done around the world since 1963 to see what reduction in mortality ensued for women in their 40's.

CHARLAYNE HUNTER-GAULT: Is there one thing, though, that made--that this decision turned on? I mean, their decision was that, well, we leave it up to women and their doctors. You all said very definitively that women should get a mammogram once a year or every two years.

DR. BARBARA RIMER: Right. Every one to two years. We have a board of people who have been immersed in cancer for a number of years as professionals and as consumers. So we're a little bit different than they were, and I think people on our board had a much stronger feeling that women needed a specific recommendation; that we could no longer sit on the fence and step back and say just make your own decision; that we had to give people guidance.

CHARLAYNE HUNTER-GAULT: Well, about the political pressure? Because after that decision in January there was an uproar from politicians, from health advocacy groups and others, and even today the Women's Health Network said that they thought the decision that your group has made was based more on politics than science.

DR. BARBARA RIMER: I think that's wrong. There is no question that this has been a charged atmosphere; that it's been extremely heated. The mammography issue has raised passions for years. And we were aware of the context and the politics of the context, but we stepped back from that, and we kept coming back to what does the science tell us, and I think the checks and balances worked very well. We have 18 members. And every time one of the members was in danger of being led by the politics somebody stepped back and said no, we have to be--we have to be driven by the science, not by the politics.

CHARLAYNE HUNTER-GAULT: And the science is that these reductions of 16 percent, what does that translate into really, what are you getting by making this recommendation?

DR. BARBARA RIMER: If you looked at women in their 40's, it could translate into saving anywhere from 1600 to 2000 lives a year. And most people believe that that is not a trivial life saving and that we--given that--that we really need to come forward with the recommendations.

CHARLAYNE HUNTER-GAULT: Now how confident can women be about this, given all of the flip-flops over the years and within the last few months?

DR. BARBARA RIMER: Well, our statement starts out saying that these guidelines or these recommendations are, by necessity, interim. We want people to get away from the idea that we're getting tablets etched in stone; that once you give recommendations you'll never give them again. These trials are evolving. We have more information today than we had last year. It's not that we're going to come back in two weeks and say things are changing, but we want American women to view new information as progress.

CHARLAYNE HUNTER-GAULT: But is there any likelihood that you could come back and say, now we don't think you should get a mammogram every one to two years, or it just will change some other way?

DR. BARBARA RIMER: No. I think as these trials mature, we may learn more about exactly when in the 40's the benefit is stronger. We may learn eventually that we can give a more definitive recommendation about the interval which we can't do now. As we have more data, we have more information.

CHARLAYNE HUNTER-GAULT: Now you had a recommendation for women who had higher than average risk.

DR. BARBARA RIMER: Yes.

CHARLAYNE HUNTER-GAULT: Who are they and what is the recommendation, briefly?

DR. BARBARA RIMER: Okay. We felt that women needed more guidance about who is at higher risk, and we identified several categories with the help of Dr. Mitchell Gale, who's specialty this is, and they include women who've had a previous personal history of breast cancer--and that's really among the most important risk; women who have a genetic mutation or alteration that predisposes them to breast cancer, such as the breast cancer one and two genes; women who have a strong family history of breast cancer, one or more first degree relatives; women who've had certain kinds of benign conditions like atypical hyperplasia; and women who've had a first birth after age 30. But those are ranked in order of importance.

CHARLAYNE HUNTER-GAULT: And the recommendation for them is?

DR. BARBARA RIMER: Is they talk to their doctor about whether they need to start mammograms before age 40 and how often in the 40's to get mammograms.

CHARLAYNE HUNTER-GAULT: Not that they shouldn't have them?

DR. BARBARA RIMER: No, no.

CHARLAYNE HUNTER-GAULT: And finally there was a recommendation about the reimbursements.

DR. BARBARA RIMER: Yes.

CHARLAYNE HUNTER-GAULT: President Clinton said that he's going to direct Medicare and Medicaid. That's federal. How about private insurers, do you anticipate much problem with them in reimbursing for this?

DR. BARBARA RIMER: Well, most of them are now covering mammograms for women in their 40's. And 40 states have legislation to require coverage for women in their 40's. And four more states have pending legislation, but we were delighted to see what President Clinton did today because we don't want cost to be a barrier. You can't have informed decisions if cost stands in the way of getting mammograms.

CHARLAYNE HUNTER-GAULT: Well, Dr. Rimer, thank you.

DR. BARBARA RIMER: Thank you very much.

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