Local experts disagree with downplaying mammograms

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Local breast cancer experts were "shocked" and irritated by a federal task force recommendation that women ages 40-49 do not necessarily need routine, yearly mammograms, as is currently advised. But they were equally concerned about the estimated 30 percent of those 40 and older who aren't tested.

"I think that's the most important message you can help us with: One of our biggest concerns is the one-third of women who don't do anything," said Dr. Nancy Davidson, director of the UPMC Cancer Center and the University of Pittsburgh Cancer Institute. "One of our biggest jobs is to bring them into the screening tent."

The U.S. Preventive Services Task Force report, in yesterday's Annals of Internal Medicine, found that although there is a potential benefit of reduced chance of dying from breast cancer that is related to screenings and early detection, there are potential risks such as "false-positive results that lead to treatment for cancer that would not have become clinically evident during the patient's lifetime, radiation exposure, false reassurance and procedure-associated pain."

Dr. Donald Keenan, breast surgeon at the Western Pennsylvania Hospital, said the trend toward getting the recommended mammograms "is downward."

Why? "In the old days a woman probably didn't have to go as far to get one. Mammography to a health care system is at best a break-even operation or a money-loser," he said. "The little ones all went under. Women had to travel for mammograms.

"A second thing is the economics of people who are underinsured, another reason they're not getting mammograms."

Even with coverage, many women do not get tested. Medicare and Medicaid cover the cost of mammograms for older women and qualifying low-income women -- and have an ongoing campaign that targets health-care providers to promote screening mammography among their patients. The campaign stepped up efforts to convince women 65 and older to be screened.

Dr. Adam M. Brufsky, interim co-director of the Magee Breast Cancer Program of UPMC Cancer Centers and medical director of the Women's Cancer Center at Magee-Womens Hospital of UPMC, also said the 30 percent of the women not getting their mammograms should be drawing more attention than the federal commission's statement.

"We ought be trying to figure out why," he said. "That's a far more important thing to address.

"There's a variety of reasons [women don't get mammograms]. They're afraid of it; they're afraid of radiation; what they're going to find -- they don't want to know."

The experts acknowledged they were surprised by the advisory and found it to be patronizing to women. But a few noted that this kind of recommendation has been made before.

"Shocked -- although one can say that with exclamation points," Dr. William R. Poller, director of breast imaging at Allegheny General Hospital, said yesterday of his reaction to the task force advisory.

"Every 10 years or so, the same controversy comes up. [Then] it gets knocked down because scientific evidence in literature from a host of screening studies ... show that screening makes a difference."

Dr. Keenan said the report doesn't take into account women's ability to choose for themselves.

"By saying you don't need mammograms, they took a patronizing approach by saying to women it's worse to have a negative biopsy than a test that could reduce breast cancer mortality by 15 percent," Dr. Keenan said.

The task force report said the below-50 age group sees a smaller reduction in breast cancer risk through mammograms and advised an individualized approach: "The decision to have screening mammography should be guided by the balance of benefits and harms for an individual woman."

The experiences of doctors throughout Western Pennsylvania inform their positions.

"I am unsure of the motives of the U.S. Preventive Services Task Force," Dr. Dianna Craig, medical director of Windber Medical Center's Joyce Murtha Breast Care Center, said in a statement. "The task force claims to set standards for preventive health. However, we do not believe that their suggestions are consistent with the best practices for breast cancer detection and early intervention. In the course of my own practice, I have seen patients develop cancerous tumors within one year. These are tumors that can be discovered with annual exams."

Dr. Davidson took a more positive attitude to the report.

"I think what we're seeing is a wish to take our knowledge about mammography and bring it to individual patients to think about how best to use it to improve our health," she said. "It's part of our message of tailoring medical care to an individual and taking into account her preferences.

"No one disputes it should be recommended by health providers and no one disputes it should be covered by insurance," she added. "What we're discussing is how to bring these guidelines to individual women."

She said she doesn't anticipate a change in insurance coverage or screening standards.

"I'm not too concerned. Guidelines are guidelines. They're something to assist doctors to make their best possible [decisions], not as a reason to limit coverage."

To read the full report, go to the Annals of Internal Medicine at http://www.annals.org/content/146/7/511.full.

Pohla Smith can be reached at psmith@post-gazette.com or 412-263-1228.


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