Mammogram recommendations spark controversy, confusion

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As Alice Park reported for TIME, the U.S. Preventive Services Task Force released new recommendations for breast cancer screening yesterday, suggesting that women begin routine screenings at age 50, as opposed to age 40, as long recommended by the American Cancer Society. Additionally, the group recommends that women between the ages of 50 and 74 get mammograms every two years, as opposed to annually, as was previously recommended. And, in keeping with earlier research questioning the value of physical breast exams, the task force suggests that doctors no longer encourage their patients to conduct self-breast exams, as the practice hasn’t been proven to significantly reduce breast cancer deaths, and may cause unnecessary alarm and anguish.

Yet, while the recommendations—which apply to women with average breast cancer risk, not those at high risk—were intended to improve breast cancer screening and diminish unwarranted worry for patients, they have instead created an uproar of alarm and anguish in the medical community, among patients who credit a self-breast exam with saving their lives, and for doctors who question why women should wait until age 50 for something that has proven to save lives among younger women. As Dr. David Dershaw, director of breast imaging at Memorial Sloan-Kettering Cancer Center in New York City, told TIME yesterday:

“I am appalled and horrified. There is no doubt that mammography screening in women in their 40s saves lives. To recommend that women abandon that is absolutely horrifying to me.”

And, considering that the task force’s 16 health experts didn’t include a single oncologist, as CNN reports, women and doctors alike are confused about what to make of the recommendations. As Kelly Brewington writes for the Baltimore Sun:

“So what’s a woman in her 40s to think? That’s the tenor of the emails I’ve been getting in response to this story. Women are confused. For years, doctors, patient advocates and every public service announcement with a pink ribbon on it has urged women to get annual mammograms and check their breasts for lumps. So, now what? Talk to your doctor, says the panel.”

Some physicians question whether these new recommendations aren’t simply a matter of putting economic efficiency ahead of saving human lives, as, they say, ample evidence suggests the benefit of screening women in their 40s. Alice Park breaks down the specifics of the task force’s data and recommendations by age and effectiveness:

“Overall, the analysis suggests that mammography reduces the risk of dying from breast cancer 15% among women 39 to 49 years old. But the task force determined that while mammograms certainly reduced risk of death, that reduction was small in this age group in light of the risks associated with the screening. In order to save one life among 40- to 49-year-olds, doctors would have to perform yearly mammograms in 1,904 women over 10 years. Among older women, between ages 50 and 74, one death could be prevented for every 1,339 women screened for 10 years. Risks of screens include anxiety over inconclusive images that require additional testing, as well as the psychological and physical costs of further testing based on false-positive results of the screen.”

While the psychological cost may be considerable, some experts wonder if it is ancillary to the arguably more important issue of lives saved. Dr. Otis Brawley, Chief Medical Officer of the American Cancer Society, which is maintaining its recommendations that women get annual breast cancer screenings beginning at age 40, views it as a blatant issue of cost efficiency over human life. As he told CNN:

“With its new recommendations, the [task force] is essentially telling women that mammography at age 40 to 49 saves lives; just not enough of them.”

Another issue at the heart of the uproar over the new recommendations is whether they will prompt insurance companies to deny mammogram coverage for women under 50. As the Wall Street Journal reports, the new recommendations will not likely change Medicare and Medicaid coverage of breast cancer screenings, but could result in less coverage from private insurance companies. A spokeswoman for a health insurance industry trade group told the Journal that, while it is likely that coverage of mammograms for women under 50 will continue, the promotion of screenings—”such as the reminder postcards they used to receive about getting their annual mammogram”—will decrease.

Yet whatever unfolds in terms of insurance coverage of mammograms based on these new guidelines, the upheaval of long-standing policies may have the negative effect of losing patients in a haze of uncertainty. As Alice Park writes for TIME:

“But every time recommendations are changed, or when respected medical organizations endorse conflicting guidelines on issues like screening, say experts, many patients opt out of the controversy altogether, preferring to forgo testing than wade through the confusing information and options presented to them.”

What do you think? Will the new recommendations influence the likelihood that you would pursue a mammogram, or encourage a loved one or friend to do so? And how should cost factor into recommendations and personal decisions? The American College of Radiology estimates that $3.3 billion was spent on mammograms in the last year alone, according to the Wall Street Journal. If screening women ages 40 to 49 every year isn’t cost-effective, should doctors recommend it anyway if it saves lives?</p