Annual mammograms still going strong a year after doctor-patient review proposed
October 25, 2010 4:00 AM
By Sean D. Hamill Pittsburgh Post-Gazette
Like many women, Diane Demmler, 46, was confused by the federal task force recommendation a year ago that women in their 40s did not necessarily need annual mammograms, self-examinations weren't needed, and that women over 50 only needed biannual exams.
"I immediately put it on my list of things to ask my OB/GYN at my next appointment," said Ms. Demmler, a securities analyst for BNY Mellon who lives in Fox Chapel. "My first question was: How does it apply to me as someone who had a grandmother with breast cancer? I had a lot of questions."
She is part of the generation of women who have been taught by their physicians and various cancer-related groups, such as the American Cancer Society and Susan G. Komen for the Cure, that the best way to detect breast cancer early was to start regular annual mammograms -- "like going to the dentist every year," Ms. Demmler said -- when they turned 40 and to regularly perform a self-exam.
As a result of that, the recommendations from the U.S. Preventive Services Task Force in November caused a political firestorm and intense debate in the medical and cancer community.
The day after the report was announced U.S. Secretary of Health Kathleen Sebelius declared that the task force didn't change federal policy. Various senators proposed a bill to ensure the federal government would ignore the task force. Most of the major medical and not-for-profit cancer groups lined up to angrily denounce the report.
Even though several prominent groups including the National Breast Cancer Coalition and the American College of Physicians agreed with the findings, the task force report "was widely misquoted and misunderstood," said Diana Petitti, vice-chair of the task force and an epidemiological expert at Arizona State University.
"We did not say that women in their 40s should not have a mammogram. We recommended that women in their 40s consider having it after a discussion with their physician," said Dr. Petitti, who was so frustrated by the way the debate has gone she wasn't sure she even wanted to talk about it anymore.
"We had hoped this would move it more toward a more personalized decision rather than women simply getting a postcard in the mail saying, 'It's time to come in for your mammogram,' " she said.
Although one prominent Pittsburgh cancer researcher said she sees the value in the task force report, seven other Pittsburgh-area physicians contacted for this story said they were continuing to recommend that women start having annual mammograms starting at 40.
But they all said the report had accomplished one of its goals of generating discussions between doctors and patients, even if it wasn't for the reason the task force had hoped.
"People do continue to question it," said Margaret Clark, a radiologist who has worked at Latrobe and Westmoreland hospitals for Excela Health for 16 years. "It has created a fair amount of confusion."
"Most of the time they're just asking for my opinion because they're concerned and they wanted my professional opinion," she said. "I tell them I disagree with it and they should continue to get annual screenings every year starting at 40."
Dennis English, a gynecologist who has been practicing for 30 years at Magee-Womens Hospital of UPMC, said that has been the norm in the Pittsburgh area.
"I think most of us are still supportive of the yearly exams starting at 40," he said. "But when [the report] first came out there was some confusion. Patients brought it up and it has been a point of discussion."
Like Ms. Demmler, patients have been peppering their gynecologists, internists, family physicians and radiologists all over the Pittsburgh area with questions about the report.
And, perhaps in part as a result, all of the hospital groups contacted said even though none of the insurance companies had said they wouldn't pay for annual mammograms, the hospitals saw a small falloff in the number of mammograms given in the last year of perhaps 1 percent, which is about the same as national reports have shown.
"The volume of patients coming in for a mammogram has gone down in the last year," said William Poller, director of breast imaging for the West Penn Allegheny Health System. "But we believe the economy is playing a part. People don't want to pay their co-pay."
Dr. Poller has been one of the most outspoken advocates in the region of maintaining the guideline that women start having regular mammograms at age 40 and continue to self-examine. He talks to groups of residents, has e-mailed colleagues, and convened a grand rounds for his entire health system in July in part to talk about the issue.
"If anything, over the last year [my position] has hardened," he said.
He said when he talks, he typically goes through the list of reasons why the task force made its recommendation, disagreeing with everything from whether the radiation of the mammogram is harmful (it isn't, he said), to whether there are too many false positives causing women great stress (they aren't, he insists).
As for the idea that too many mammograms result in unnecessary biopsies that cause pain and stress for the patients, he said: "How many of our patients have called back after they got their negative biopsy results and said, 'You gave me an unnecessary biopsy'? None of them. They're happy it was negative and they get on with their life."
But Nancy Davidson, director of the University of Pittsburgh Cancer Center and a breast cancer researcher, said the task force recommendation has value.
She recalled that when she was 35 years old the recommendation then was to start having annual exams at 35 -- "but that went by the wayside," she said.
"I'm a big believer in personalized medicine," she said. "So, if there's a woman of low risk [for breast cancer] in her 40s, I wouldn't push [having a mammogram] on her."
"But these are guidelines, right? Not rules. So women and their physician should be talking about this."
John Fisch, an OB/GYN who has practiced for 22 years at Forbes and Magee hospitals, said it is his everyday experience of seeing patients that is guiding him.
"Frontline physicians don't want to give the message to patients, 'Oh mammograms are worthless. Self-exams are worthless.' Because we've all had patients come in who say, 'Hey, I feel something,' and it's cancer," he said.
For her part, Ms. Demmler, who finally saw her OB/GYN just last week, said after discussing the task force recommendation with her doctor -- who told her she was most concerned about getting women in their 40s used to the routine of going for a mammogram -- she's decided on something of a middle ground.
"I figured I'll go every 18 months to two years," she said. "I still want to be safe."