Gov't Says No Mammograms Needed For Women Under 50

NEW YORK - Most women don't need a mammogram in their 40sand should get one every two years starting at 50, a governmenttask force said Monday.

It's a major reversal that conflicts withthe American Cancer Society's long-standing position.

Also, the task force said breast self-exams do no good and womenshouldn't be taught to do them.

For most of the past two decades, the cancer society has beenrecommending annual mammograms beginning at 40.

But the government panel of doctors and scientists concludedthat getting screened for breast cancer so early and so often leadsto too many false alarms and unneeded biopsies withoutsubstantially improving women's odds of survival.

"The benefits are less and the harms are greater when screeningstarts in the 40s," said Dr. Diana Petitti, vice chair of thepanel.

The new guidelines were issued by the U.S. Preventive ServicesTask Force, whose stance influences coverage of screening tests by

Medicare and many insurance companies.

But Susan Pisano, a spokeswoman for America's Health InsurancePlans, an industry group, said insurance coverage isn't likely tochange because of the new guidelines. No changes are planned inMedicare coverage either, said Dori Salcido, spokeswoman for theHealth and Human Services department.

Experts expect the task force revisions to be hotly debated, andto cause confusion for women and their doctors.

"Our concern is that as a result of that confusion, women mayelect not to get screened at all. And that, to me, would be aserious problem," said Dr. Len Lichtenfeld, the cancer society'sdeputy chief medical officer.

The guidelines are for the general population, not those at highrisk of breast cancer because of family history or gene mutationsthat would justify having mammograms sooner or more often.

The new advice says:

-Most women in their 40s should not routinely get mammograms.

-Women 50 to 74 should get a mammogram every other year untilthey turn 75, after which the risks and benefits are unknown. (Thetask force's previous guidelines had no upper limit and called forexams every year or two.)

-The value of breast exams by doctors is unknown. And breastself-exams are of no value.

Medical groups such as the cancer society have been backing offpromoting breast self-exams in recent years because of scantevidence of their effectiveness. Decades ago, the practice was soheavily promoted that organizations distributed cards that could behung in the shower demonstrating the circular motion women shoulduse to feel for lumps in their breasts.

The guidelines and research supporting them were released Mondayand are being published in Tuesday's issue of the Annals ofInternal Medicine.

The new advice was sharply challenged by the cancer society.

"This is one screening test I recommend unequivocally, andwould recommend to any woman 40 and over," the society's chiefmedical officer, Dr. Otis Brawley, said in a statement.

The task force advice is based on its conclusion that screening1,300 women in their 50s to save one life is worth it, but thatscreening 1,900 women in their 40s to save a life is not, Brawleywrote.

That stance "is essentially telling women that mammography atage 40 to 49 saves lives, just not enough of them," he said. Thecancer society feels the benefits outweigh the harms for women inboth groups.

International guidelines also call for screening to start at age50; the World Health Organization recommends the test every twoyears, Britain says every three years.

Breast cancer is the most common cancer and the second leadingcause of cancer deaths in American women. More than 192,000 newcases and 40,000 deaths from the disease are expected in the U.S.this year.

Mammograms can find cancer early, and two-thirds of women over40 report having had the test in the previous two years. But howmuch they cut the risk of dying of the disease, and at what cost interms of unneeded biopsies, expense and worry, have been debated.

In most women, tumors are slow-growing, and that likelihoodincreases with age. So there is little risk by extending the timebetween mammograms, some researchers say. Even for the minority ofwomen with aggressive, fast-growing tumors, annual screening willmake little difference in survival odds.

The new guidelines balance these risks and benefits, scientistssay.

The probability of dying of breast cancer after age 40 is 3percent, they calculate. Getting a mammogram every other year fromages 50 to 69 lowers that risk by about 16 percent.

"It's an average of five lives saved per thousand womenscreened," said Georgetown University researcher Dr. JeanneMandelblatt.

Starting at age 40 would prevent one additional death but alsolead to 470 false alarms for every 1,000 women screened. Continuingmammograms through age 79 prevents three additional deaths butraises the number of women treated for breast cancers that wouldnot threaten their lives.

"You save more lives because breast cancer is more common, butyou diagnose tumors in women who were destined to die of somethingelse. The overdiagnosis increases in older women," Mandelblattsaid.

She led six teams around the world who used federal data oncancer and mammography to develop mathematical models of what wouldhappen if women were screened at different ages and time intervals.Their conclusions helped shape the new guidelines.

Several medical groups say they are sticking to their guidelinesthat call for routine screening starting at 40.

"Screening isn't perfect. But it's the best thing we have. Andit works," said Dr. Carol Lee, a spokeswoman for the AmericanCollege of Radiology. She suggested that cutting health care costsmay have played a role in the decision, but Petitti said the taskforce does not consider cost or insurance in its review.

The American College of Obstetricians and Gynecologists also hasqualms. The organization's Dr. Hal Lawrence said there is stillsignificant benefit to women in their 40s, adding: "We think thatwomen deserve that benefit."

But Dr. Amy Abernethy of the Duke Comprehensive Cancer Centeragreed with the task force's changes.

"Overall, I think it really took courage for them to do this,"she said. "It does ask us as doctors to change what we do and howwe communicate with patients. That's no small undertaking."

Abernethy, who is 41, said she got her first mammogram the dayafter her 40th birthday, even though she wasn't convinced it wasneeded. Now she doesn't plan to have another mammogram until she is50.

Barbara Brenner, executive director of the San Francisco-basedBreast Cancer Action, said the group was "thrilled" with therevisions. The advocacy group doesn't support screening beforemenopause, and will be changing its suggested interval from yearlyto every two years, she said.

Mammograms, like all medical interventions, have risks andbenefits, she said.

"Women are entitled to know what they are and to make theirbest decisions," she said. "These guidelines will help thatconversation."


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