Conflicting advice on when to begin undergoing mammograms

January 13, 2016, 4:49am

By Sumathi Reddy, the Wall Street Journal on Business Day Live
Photo: Thinkstock on Business Day Live

NEW YORK — An influential federal panel issued its final recommendations on Monday for when women should start getting mammograms, underscoring the conflicting advice on the issue coming from major cancer and women’s health groups.

One of those groups, the American College of Obstetricians and Gynecologists, has invited more than 30 organisations to participate in a conference later in January to try reach a consensus opinion.

It said many women had been confused by the groups’ disagreements, including on what the best age was to begin mammograms and how frequently to undergo them.

The final recommendations from the US Preventive Services Task Force say mammograms should be done every two years for women aged 50 years to 74 years.

Women in their 40s at average risk for breast cancer should consider the test depending on their comfort level.

The recommendations, published in the journal Annals of Internal Medicine, are mostly similar to the task force’s previous guidelines, from 2009, but allow more leeway for women in their 40s to consider the test.

The American Cancer Society in October revised its own guidelines, pushing back the recommended start time for mammograms to age 45 from 40. It recommends the test every year until age 55, and then every two years.

Other influential groups, including the American College of Obstetricians and Gynecologists, and the National Comprehensive Cancer Network — a nonprofit alliance of leading cancer centres — recommend that mammograms begin at age 40 and be done every year.

Medical groups decide on guidelines by weighing the potential benefits of breast-cancer screening — mainly lives saved through early cancer detection — against possible harms, including false positives that can lead to unnecessary tests and treatment. Weighing the various factors differently can change the conclusions. The guidelines are designed for women of average risk.

A primary-care provider at Brigham and Women’s Hospital in Boston, Nancy Keating, said in the past couple of years a "substantial" number of her female patients in their 40s had delayed undergoing regular mammograms to a later age.

"Many women are confused (by the various recommendations) and it is challenging," she said.

Dr Keating said she worked with patients to assess their cancer risk and to give them a sense of whether they were at average or above-average risk.

Generally, recommendations from the Preventive Services Task Force must be offered as part of private insurance plans under the 2010 Affordable Care Act.

To allay concerns about mammogram coverage, however, Congress added an exception to the law that requires insurers to cover annual mammograms starting at age 40.

An OB-GYN with Northwell Health System in Long Island, Jill Rabin, said she followed the American College of Obstetricians and Gynecologists recommendations in advising most of her patients to start annual mammograms at age 40.

She said being screened every other year could lead people to miss a test, "and that can be very, very dangerous because a lot can happen in that time".

"I know that I’ve saved lives" by diagnosing patients with breast cancer who were younger than 45 and with no risk factors, Dr Rabin said.

"We can’t let these people down by postponing their chance at early detection."

Experts have long stressed that early detection of cancer can save lives. Studies have estimated that annual screenings can cut the risk of death 15% to 40%.

Medical groups’ mammogram guidelines historically were largely in sync, but recent research has caused them to diverge.

"We have tried to really clarify what the science is telling us about the benefits of mammography screening for women aged 40 to 74," said Kirsten Bibbins-Domingo, vice-chairwoman of the Preventive Services Task Force and a professor of medicine at University of California, San Francisco.

While regular mammograms for women in their 40s were effective in reducing deaths from breast cancer, the benefit was less than it is for older women and the potential harms were greater, the task force noted.

Dr Bibbins-Domingo said the task force’s latest recommendations aimed to clarify its 2009 guidelines, which "were widely misinterpreted as a recommendation against screening for women in their 40s".

An American Cancer Society study published in December in the American Journal of Preventive Medicine found that four years after the task force first stopped recommending mammograms for women in their 40s the prevalence of the tests did not significantly change for women in that age group.

The study, which compared federal data from 2008 to 2013, the latest available, did find that there was a significant decrease in physicians recommending mammograms to women in their 40s.

The chairwoman of the breast cancer screening and diagnosis guidelines panel for the National Comprehensive Cancer Network, Therese Bevers, said she planned to attend the American College of Obstetricians and Gynecologists conference on mammogram guidelines, but believed it might be difficult to reach a consensus among the various groups.

The conference, in Washington, DC, is planned for January 28 and 29.

"We look forward to a positive outcome of this conference that helps to avoid the confusion that currently exists among the women we treat," the American College of Obstetricians and Gynecologists said on Monday.

Dr Bevers said she recommended women start annual mammograms at age 40. "We just feel that the task force placement on the harms is a bit excessive," she said.

Harms such as a false positive requiring a repeat ultrasound or a needle biopsy are outweighed by the potential for lives saved, she said.

In a separate study also published in the Annals of Internal Medicine on Monday, researchers found that false-positive results were highest among women 40-49 years old, leading to additional imaging.

The study analysed data from more than 400,000 women aged 40 to 89.

But Dr Bevers said that based on clinical experience and research, after the additional tests performed following a false positive, there was very rarely a wrong diagnosis.

Stephanie Nichols, a patient of Dr Keating’s at Brigham and Women’s Hospital, decided at about age 40 to wait until she turned 45 to have her first mammogram after learning she was at low risk for developing breast cancer.

Ms Nichols, now 44, says she was also influenced by talking about false positives and the additional testing and stress those can lead to.

"I didn’t want to go through that," she said. "I decided I would just keep doing breast self-exams and see her (doctor) regularly."

The task force guidelines do not specifically recommend regular mammograms for women 75 years and older and call for more research in this area.

"There is not enough evidence for us to say with certainty what the benefit is," Dr Bibbins-Domingo said.

Susan Boolbol, chief of the division of breast surgery at Mount Sinai Beth Israel in New York City, disagreed with that conclusion by the task force.

She said she presented research recently at the San Antonio Breast Cancer Symposium showing that mammograms in women age 75 and older were justified.

Dr Boolbol reviewed the mammography results of 2,057 women age 75 and older over two years at Mount Sinai. The breast cancer detection rate was 4.9 per 1,000 screenings, nearly double the rate the American College of Radiology uses as a standard for when mammograms should be used, she says.

"We should not base recommendations on an age limit," Dr Boolbol said. "It should really be based on the woman’s expected lifespan and her health status."

The Wall Street Journal