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Experts Answer Your Questions on Mammograms

BY   November 24, 2009 at 11:06 AM EDT

Race for the Cure participants; file photo

The breast cancer screening guidelines, released by the U.S. Preventative Services Task Force, generated immediate controversy, as politicians claimed they represented the beginning of health care rationing.

Doctors, advocacy groups and others had mixed reactions to the changes. Some welcomed the shift, but others, including the American Cancer Society, said they would continue to recommend annual mammograms for women over 40.

Two doctors answered your questions about the study, and explained why “reasonable experts” can look at the same data and draw different conclusions.

Read excerpts of their answers here or listen to the full audio of the interview .

Dr. Otis Brawley is the chief medical officer at the American Cancer Society and a professor of oncology at Emory University.

Dr. Jeffrey Tice is an assistant professor of medicine at the University of California, San Francisco, where he studies breast cancer screening.

Question: I’ve heard and seen several statements that there are risks or harms related to screening mammography as well as benefits. Could you please discuss these risks or harms to give readers a more clear idea of what those might be? — Louise Nelson, Herndon, Va.

Listen to the full answer and read excerpts below:

Dr. Otis Brawley, American Cancer Society:

If you screen 1,000 women annually over a 10-year period of time, it is estimated that you’re going to call back at least 650 for repeat exams; you’re going to biopsy between 300 and 350.

Overwhelmingly, most of those biopsies and most of those call-backs are ultimately going to be false alarms. So some of the harm is inconvenience and anxiety caused by those false alarms.

Some of the harms are there is an entity called ductal carcinoma in situ, which […] are precancerous lesions. Some DCIS’s are lesions that are going to regress.

And we have, with screening, created an epidemic of DCIS among women in their 40s. And it’s clear that some of the DCIS that we are treating is DCIS that if never treated would have never bothered the woman. So there are some women who are getting needless lumpectomies and needless radiation therapy because we screen a lot of women in their 40s.

Dr. Jeffrey Tice, University of California, San Francisco:

The other thing that we’re missing – it’s not exactly a harm but it’s sort of the opportunity cost. Because even today, with the pretty effective marking of mammography for most women, the recent estimates suggest that only about 72 percent of women in the age groups we all agree [should get regular screening], 50 to 69, only 72 percent of those women have had a mammogram in the last 2 years.

So we’re not doing a good job right now reaching the women that we need to reach. And a lot of the cancers that we’re missing that are going to be detected late and actually shorten a women’s life are in these women who are not getting appropriate screening, even with the new recommendations — every 2 years, 50 to 69.

So[…] if we spend a lot of our energy and resources just saying, every year, every year, every year starting at age 40, we’re not focusing on identifying and motivating the [older] women who aren’t getting mammography to get it.

Question: Nortin Hadler, a practitioner of evidence based medicine, maintains that everyone has cancer after the age of 60, and there are two kinds of cancer, the kind that kills you and the kind that you die with. Do you believe that there will ever be a truly effective screening device to discriminate between the two? — John Lutschak, Burlington, Wis.

Listen to the full answer and read excerpts below:

Dr. Jeffrey Tice:

In breast cancer, thankfully, we’re starting to be able to differentiate. […] For a certain subset of cancers which you already know are relatively low-risk […] we’re now able to say, well, this group, about half of them are really low-risk, and this woman does not need chemotherapy; whereas, another percentage are intermediate-risk and another percentage are high-risk, and the women with the high-risk cancers clearly benefit from chemotherapy.

So we’re getting there but we still have a tremendous amount to learn […] we’re in our infancy in characterizing the different types of tumors and their likely behavior.

Dr. Otis Brawley:

Hopefully, this discussion that we’ve had over the last week or two will actually motivate increased funding to help us figure out the cancers that need to be treated versus the cancers that need to be watched.

Question: My doctor has suggested a thermogram instead of a mammogram. What is a thermogram and is it recommended instead of a mammogram? — Alison Moore

Listen to the full answer and read excerpts below:

Dr. Otis Brawley:

A thermogram, as the name implies, looks at heat as it comes off of the breast with the idea that if the heat is given off in a pattern that’s irregular, it might indicate there’s a tumor.

Thermography for screening has never, to my knowledge, been approved [by the FDA] — only thermography for diagnosis if someone’s suspected of having a tumor. That being said — I want to say this very carefully — quite honestly, I know of no major breast medical center that uses thermography.

Dr. Jeffrey Tice:

I think many new medical technologies are heavily marketed, and we all recognize that even though mammography is the best we have, it’s imperfect. And so there’s a lot of marketing to women of new potential alternatives; this being one, there are many, many out there.

And it’s one of the potential advantages and disadvantages of our society. We allow direct-to-consumer and direct-to-doctor marketing of new technologies like this, which generates interest in them, but, sometimes, makes it harder to study the true effectiveness of these new technologies. […] Because often they have some value but they may be marketed far beyond their true value.

Question: What is the difference between doing monthly BSEs and being “breast aware?” Can one be “aware” without routine exams? — Erika Koch, Antigonish, NS Canada

Listen to the full answer and read excerpts below:

Dr. Jeffrey Tice:

What we mean by breast awareness […] we certainly want women to be comfortable enough with the appearance and feeling of the texture of their breast that they’re able to notice a difference, a change, and bring it to doctors’ attention.

Breast self-exam is a standard approach to make sure you are feeling all the breast tissue at all different levels and doing it systematically — usually on a monthly basis.

Why they came out against teaching a detailed self-breast exam is because […] what we consider the highest-quality study type — the randomized trial — there are two randomized trials, neither of which showed even a trend toward a decrease in breast cancer mortality when women were taught and then reinforced on how to examine their breasts on a regular basis.

Dr. Otis Brawley:

The American Cancer Society started de-emphasizing breast self-examination about a decade ago and currently, we list it as something that is optional.

We actually believe that encouraging women to be aware of their breasts and[…] if they notice a difference, get an evaluation, is the more appropriate thing to do, versus teaching breast self-exam.

Question: Will insurance companies use these task force guidelines to stop paying for yearly mammograms, even if a woman’s doctor thinks they are necessary? — Alice Riley, Long Beach, Calif.

Listen to the full answer and read excerpts below:

Dr. Jeffrey Tice:

By law now, I think almost in every state, insurance companies are required to cover annual mammographies starting at age 40. And I work in a high-risk clinic and so I see women at very high risk and we don’t have trouble getting mammograms in the 20s if we think it’s appropriate. So I do not think insurance will be an issue at all.

Dr. Otis Brawley:

I totally agree.

Question: Does the “risk” associated with mammograms in the study have anything to do with radiation exposure from the test? — Joan Hamilton, Berkeley, Calif.

Listen to the full answer and read excerpts below:

Dr. Jeffrey Tice:

I think this is a very difficult and controversial question. There have been many attempts to quantify the risk and we think there is a risk, but it’s probably very, very small. That’s what the task force said and that’s what most thoughtful reviews of this topic have said.

Dr. Otis Brawley:

I think that there is a risk of radiation. The ACS has recognized that if you do mass mammography for women in their 40s, 50s, 60s and beyond, you will cause a few cancers. […] It’s very small. And again, I would point to the nine randomized studies that tell us that if you screen a population, their risk of death from breast cancer will be lower than if you don’t screen the population.

Question: I would like to know who are the people on the Health Task Force? Do they receive a salary? How long are their terms? What are their work backgrounds and what brought them to the task force. What sources do they rely on to gather data to make their decisions, and does anyone oversee their decisions. — Lynne, Boston, Mass.

Listen to the full answer and read excerpts below:

Dr. Jeffrey Tice:

It’s a mix of experts in prevention and primary care and epidemiologists, family practice docs, internists, OB/GYNs — mostly academic. You know […] then they commission what we call systematic reviews — complete reviews of all the literature from sites called evidence-based practice centers that have expertise in finding every last shred of evidence and summarizing it. So it’s as objective a process as can be gone through to do this.

Dr. Otis Brawley:

I started my letter to ACS volunteers last week with the statement “reasonable experts can look at the same data and come to different conclusions.” And that’s what happened last week – reasonable experts [disagreed].

Question: Very little was said about the new guideline recommendations for women over 75. My mother and sister both died of breast cancer under 50 years of age. I feel I am in a high risk group and should be screened every year. What is your recommendation? — Shirley Jones, Lafayette, Calif.

Listen to the full answer and read excerpts below:

Dr. Jeffrey Tice:

The first thing I would say to her individually is, she should probably see a genetic counselor to at least talk about her risk and the risk recommendations based on that very strong family history.

[…] It’s complicated because as women get older, they are at risk for other diseases– heart disease and strokes in particular. And we know from most of the screening trials that it takes somewhere between seven and 14 years to start to see a benefit from mammography in terms of saving women’s lives.

So if a woman’s life expectancy is only 5 years, she probably doesn’t benefit from mammography. If her life expectancy is 15 years or 16 years. I think the latest data in the United States suggest that the average 70-year-old woman has a 16-year life expectancy. So the average 70-year-old women probably benefits. And as women age, their expected benefit goes down.

So [on] both ends of the age spectrum, it starts to get grayer– in other words, the benefits and the risks start to come together somewhere around age 75 for most women and somewhere between 40 and 50 for most women. That’s why we don’t recommend routine screening– nobody recommends it for women younger than 40 and very few people recommend it for women over 75 routinely.

A very healthy, robust 75-year-old woman who has no health problems and is quite active probably should continue mammography because her personal life expectancy is probably greater than 10 years and so she will probably benefit.

Dr. Otis Brawley:

The American Cancer Society position would be very similar. We recommend that women stop getting mammographic screening when their life expectancy is less than 10 years. And healthier, older women should continue, whereas less healthy, younger women might want to not get mammography.