U.S. Revises Its Advice on Mammograms
The National Cancer Institute on Thursday reversed itself and recommended that women in their 40s undergo routine mammogram screening, a decision that it hopes will lay to rest one of the most fractious national debates in recent medical history.
The institute, part of the federal government’s National Institutes of Health, said women of average risk should be screened every one to two years beginning at age 40 and women whose risk is higher--such as those with a family history of the disease or a genetic predisposition for it--should consider having mammograms even earlier.
President Clinton, whose mother died of breast cancer, said the recommendations “give clear, concise guidance to women in our national fight against breast cancer.” He announced a series of steps aimed at making mammograms more readily available to the targeted age group.
The institute’s announcement followed a Sunday announcement by the American Cancer Society urging women in their 40s to have the procedure annually, a change from its previous recommendation of one to two years. The institute and the cancer society--regarded as the nation’s two most influential cancer policy-making groups--issued a joint statement Thursday saying their advice should be regarded as compatible.
The institute had been under pressure from members of Congress, the medical community and patient-advocacy groups to rescind a 1993 recommendation that women 40 to 49 years old need not undergo annual mammogram screening. At the time, it cited studies showing no difference in breast cancer death rates among women who began screening at age 50 and those who started earlier. But recent studies have shown a reduction in breast cancer deaths among women in their 40s who have regular mammograms.
On Thursday, Dr. Richard Klausner, the institute’s director, said: “There is no doubt that screening mammograms are capable of saving lives. The question that has been difficult to resolve is when women should begin. . . . We hope these new recommendations will clarify what has been a confusing issue for women in their 40s.”
Clinton said the federal government would launch a national breast cancer education program to get the latest information to the public and to health care workers. He also said his administration would assure state directors of Medicaid--the health program for the poor--that federal money is available to help pay for mammograms for women in their 40s.
He promised to require federal employee health insurance plans to cover the procedure for this age group, and he challenged private-sector plans to do the same. Many insurers already do, in part because an estimated 40 states require them to cover all or part of mammogram costs for women in their 40s.
Mammograms generally cost between $40 and $150.
In the United States, breast cancer is the most commonly occurring form of cancer in women. Among all women, it is the second-leading cancer killer, after lung cancer. It is the single-leading cause of death for women 40 to 49.
Last year, 184,000 women in the country were diagnosed with breast cancer. About 31,000 of these were 40 to 49 years old. The cancer, when it occurs in this age group, is often more aggressive than it is in older women.
The cancer institute changed its mammogram policy based on a recommendation from the National Cancer Advisory Board. Board members said they based their recommendation on a reexamination of data from seven studies around the world that suggested about a 17% reduction in breast cancer among women in their 40s who had regular mammograms.
Not all experts view these findings as statistically significant but “the board concluded that there is enough evidence to support a woman’s decision to begin screening in her 40s,” said Dr. Barbara Rimer, director of cancer prevention, detection and control research at Duke University and the head of the cancer advisory board.
The new data was released during an international consensus conference on breast cancer in January. The dispute about the significance of the test results prompted the consensus panel--which is different from the cancer advisory board--to refuse to recommend routine mammograms for the 40-49 age group. Instead, it said that women should make their own decisions on screening.
This recommendation provoked an outcry from women’s health advocates, clinicians and lawmakers. Klausner, the cancer institute director, signaled that he disagreed with the decision by the consensus panel and promised a reevaluation of the new test data by the cancer advisory board.
In late February, the board predicted that the issue would take about two months to resolve. That prompted an angry letter from Sen. Arlen Specter (R-Pa.), chairman of the Senate Labor and Human Resources Committee’s subcommittee on appropriations, urging the board to act as soon as possible.
The board acted more swiftly than expected, but Rimer and Klausner denied that political pressure was a factor or that it influenced the substance of their final recommendation.
Dr. Lawrence W. Bassett, director of the Iris Cantor Center for Breast Imaging at UCLA, said he was happy “to see this resolution of the conflict,” which, he said, confirms the validity of the new research.
Breast cancer risk increases with age, particularly after 60.
In the above-50 age group, studies have shown consistently that death rates are reduced by at least one-third in women having mammograms.
The problem with mammograms in younger women is that their breast tissue is usually much denser than that of older women, making the pictures more difficult to read. The scientific community agrees that women younger than 40 should not routinely have mammograms, unless their risk is high, and that women 50 and older should have them every one to two years.
