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American Cancer Society Abandons ‘One-Size-Fits-All’ Advice On Mammograms

American Cancer Society Abandons ‘One-Size-Fits-All’ Advice On Mammograms

By Karen Kaplan, Los Angeles Times (TNS)

After a thorough review of the benefits and limitations of mammograms, the nation’s top cancer-fighting organization is advising women that they can wait until they are 45 years old to start using the tests to screen for breast cancer.

New guidelines from the American Cancer Society also assure women that they can have fewer mammograms over the course of their lives.

The guidelines, published in Wednesday’s edition of the Journal of the American Medical Association, are designed for women who are in good health and have no reason to suspect their risk of developing breast cancer is above average. They represent a departure from the group’s previous recommendation that all women with an average risk of breast cancer get annual mammograms starting at age 40.

Although the American Cancer Society still endorses that course for women who prefer it, the group acknowledged that some women favor a less aggressive approach to breast cancer screening. If so, it said, they can delay their first mammogram until they are 45 and wait two years between screenings starting at age 55 without fear that doing so will put their health in jeopardy.

Either way, regular mammograms should continue as long as women have a life expectancy of at least 10 years and are good candidates for breast cancer treatment, the guidelines say.

“We moved away from a one-size-fits-all approach to something that is more personalized or individualized,” said Dr. Kevin Oeffinger, director of the Cancer Survivorship Center at Memorial Sloan-Kettering Cancer Center and lead author of the guidelines.

The coming decade will see medicine become more tailored to a patient’s particular biology, genetics and environmental influences, Oeffinger said, and “this is a step in that direction.”
The new recommendations bring the American Cancer Society into closer alignment with the U.S. Preventive Services Task Force, an independent panel of experts convened by the federal Agency for Healthcare Research and Quality.

The task force touched off an emotional debate about mammograms with its 2009 recommendation that women at average risk for breast cancer be screened only once every two years, primarily between the ages of 50 and 74. Screening may begin at age 40 if women so choose after discussing the pros and cons with their doctors, it said.

“There is substantial agreement now,” said Dr. Albert Siu, who heads the task force. “Both of these guidelines indicate that the mammogram is a good test, although it’s not perfect.”

Mammograms save lives by finding cancers that can be cured if caught at an early, treatable stage. But they also find tumors that are not destined to become dangerous if left alone, as well as tumors that can’t be stopped by surgery, radiation, chemotherapy or other drugs.

The problem is that lots of these tumors look the same on a mammogram, so doctors wind up treating them all. That leads to a certain amount of unnecessary care, which doctors call overtreatment.

Many recent studies have weighed the benefits of identifying dangerous but treatable cancers against the harm of overtreatment. In general, they have found that the younger the woman, the greater the chance that the benefits of early detection will be small while the harms of overtreatment will be large.

For instance, evidence from randomized clinical trials suggests that for women in their 40s and 50s, screening mammograms reduce the risk of dying of breast cancer by a modest 15 percent. That means 85 percent of the women in this age group who die of breast cancer would succumb to the disease whether they had a mammogram or not.

Some women see this as a good reason to cut back on mammograms. Other women would rather accept the risk of potentially unnecessary treatment to maximize the chance that a mammogram would make a lifesaving discovery. Both decisions are reasonable, Oeffinger said. In his own family, he said, he has one sister who is sticking with annual mammograms and one sister who has scaled back.

“We don’t want to make people feel wrong or guilty if they opt not to” get a mammogram every year, he said. “We support a woman going to a health care provider and having a discussion and making an informed decision.”

That type of thinking mirrors an overall shift in medicine toward tailoring care for each patient based on his or her values and needs, said Dr. Patricia Ganz, director of the Center for Cancer Prevention and Control Research at UCLA’s Jonsson Comprehensive Cancer Center.

“We can’t do cookie-cutter medicine,” she said.

Photo: A technician stands next to a machine at a breast cancer treatment center. Spectrum Health via Flickr

Study: Mammograms Can Find Cancer At Earlier Stages In Older Women

Study: Mammograms Can Find Cancer At Earlier Stages In Older Women

By Carol M. Ostrom, The Seattle Times

SEATTLE — When a mammogram detects breast cancer in a woman age 75 or older, it’s more likely to be early stage disease that can be treated less aggressively, according to a study of thousands of patients in a Seattle cancer registry.

Dr. Henry Kaplan of the Swedish Cancer Institute and Judith Malmgren, an epidemiologist from the University of Washington’s School of Public Health and Community Medicine who has long worked with Kaplan, published the study in the journal Radiology on Tuesday.

“If you do mammograms in the older group, you will find a lot of cancer, the cancers will be early or lower stage, and the patients will therefore need less therapy,” Kaplan summarized.
Mammograms, compared to detection by patients or doctors, typically catch tumors at an earlier stage. That’s important, because older women often can’t withstand the chemotherapy treatment used in later-stage cancer, said Malmgren, the study’s lead author.

“For older women, who have fewer treatment options, you really do want to catch it early,” Malmgren said.

The paper adds a bit of fuel to raging debates in the United States and other countries over mammography screening — what age to begin and to stop, how often women should be screened, whether the risks of treatment outweigh benefits, and of course, the cost to the health care system overall. A recent paper put the cost of mammography screening in the United States in 2010 at $7.8 billion.

Although older women are at higher risk of breast cancer, with higher death rates from the disease, Malmgren noted, the U.S. Preventive Services Task Force, a panel of independent health experts convened by the federal government, does not recommend mammography screening in this age group, saying there is insufficient evidence to weigh risks and benefits.

Not only does most breast-cancer research not include older women, in some regions of the world — the United Kingdom, for example — women older than 70 are rarely treated for the disease, Kaplan noted.

In the United States, many women 75 and older simply don’t get mammograms, he said.

It’s a calculation that may have made sense when life spans were much shorter, Kaplan said. But now, at age 75, the average woman in the United States can be expected to live 13 years.

“It’s really pretty surprising if you’re healthy at 75 how much longer you’re expected to live. It’s very significant and very different than it was 20 years ago.”

Over the past 15 years, deaths from breast cancer have dropped by 30 percent, Kaplan noted. But it’s not clear whether the drop is a result of more widespread use of mammograms or better treatments.

As the population ages, the debate over mammograms becomes more critical, Kaplan said. “For all the debate about what’s appropriate for a 40-year-old, there is an analogous debate about what to do with a 70- or 80-year-old.”

Early diagnosis for invasive cancer is key, he said. “If they have advanced breast cancer, they do crappy, just like 24-year-olds. And if they have an extensive cancer, you can’t treat them, because they can’t tolerate the treatments as well.”

The American Cancer Society recommends that women continue mammography screening, the paper notes, as long as they have no serious chronic conditions or shortened life expectancy.

But at this point, there are no clear guidelines for mammography screening for women 75 and older, Kaplan said. “Even though our study is not a randomized trial, it’s indirect evidence that it’s probably a good thing to do.”

The research used Swedish’s breast-cancer patient registry, which has compiled records for more than 14,000 breast cancer patients since 1990. More than 1,000 patients age 75 and older were identified and tracked for the study, which was funded by the Kaplan Cancer Research Fund, supported by patients and families.

Dr. Constance Lehman, director of imaging at Seattle Cancer Care Alliance, who was not involved in the research, said she was pleased with the paper’s conclusions and focus on older women.

“It’s an important study, a good study,” she said. “A lot of research groups say, ‘Who cares when they’re 75 and older?’ Well, we care! Many older women live incredibly active, vital lives.”

She sees many patients confused by the constant barrage of conflicting information about mammograms, she said. As a result, some just stop having them.

The disagreements among researchers are about which age to begin, the intervals for screening, and which age to stop, she said.

“But there is so much we all agree on,” she said, including that mammography offers women the best chance for early detection. In older women, she said, the rate of false positives — which can lead to unnecessary diagnostic tests, including surgical biopsies — is very low.

But she noted that the study included women diagnosed with ductal carcinoma in situ, or DCIS, a noninvasive breast cancer. Over time, while the incidence of more advanced Stage II and Stage III cancers detected by mammography dropped, the incidence of DCIS detected increased by 15 percent.

She’s worried about overtreatment in that group, she said, particularly in older women, where the cancer likely won’t progress significantly. Overtreatment is a serious concern, she said, because all treatments have risks, and particularly in older women, may affect quality of life.

“We’re treating women a lot the same,” when the women — and the cancers — are different, she said. “We think patients with DCIS are an ideal population in which to reduce overtreatment. I think there are very safe alternatives for low-intensity intervention.”

It’s difficult to quantify how many cancers could be safely ignored, Kaplan said. Computer simulations produce wildly varying estimates.

In the end, Kaplan said, he hopes the debates will lead to specific recommendations that take into account older women’s health and breast cancer risk factors.

Photo: Paul Falardeau via Flickr

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Mammograms Save Lives, But They’re Also Overrated, New Study Says

Mammograms Save Lives, But They’re Also Overrated, New Study Says

By Karen Kaplan, Los Angeles Times

LOS ANGELES — The idea that American women would benefit by having fewer mammograms — and having them less frequently — remains controversial. A new study tries to help women and their doctors understand why less can be more when it comes to breast cancer screening.

The U.S. Preventive Services Task Force was pilloried for suggesting that doctors were ordering too many mammograms to screen their patients for breast cancer. So far the expert panel hasn’t changed many minds. But in the four-plus years since that controversial recommendation, additional studies have backed it up.

A new report in Wednesday’s edition of the Journal of the American Medical Association should help women and their doctors understand why screening mammograms aren’t the cure-all that many people take them to be. In fact, after reviewing hundreds of studies on mammograms published since 1960, the study authors conclude that the benefits of the test are routinely overstated while the harms are understated.

Yes, mammograms do save lives when used to screen women for breast cancer, “but the benefit is modest,” write Drs. Lydia Pace and Nancy Keating, both physicians at Brigham and Women’s Hospital in Boston.

To understand the imperfect nature of screening mammograms, they suggest that doctors emphasize these points to their patients:

  • “Some cancers will be missed, and some women will die of breast cancer regardless of whether they are screened.”
  • “Many cancers will be found, but most women diagnosed with breast cancer will be cured regardless of whether the cancer was found by a mammogram.”
  • “Some cancers that are found would have never caused problems.”

That last point refers to a problem known as “overdiagnosis.” A woman who has been overdiagnosed is treated for breast cancer through some combination of surgery, radiation and chemotherapy — and by definition, none of that treatment is necessary. Based on the most recent studies available, Pace and Keating estimate that about 19 percent of women diagnosed with breast cancer fall into this category. The problem, they acknowledge, is that there’s no way to tell which patients are properly diagnosed and which are overdiagnosed. That’s why all of them get treated.

In the JAMA article, Pace and Keating recommend that doctors share some statistics to help their patients understand the benefits of mammography, which vary by age. If 10,000 women were to get regular mammograms throughout their 40s, about five of them would be saved from dying of breast cancer. If those women were in their 50s, about 10 of them would avoid death, and if they were in their 60s, about 42 would avoid death.

They also recommend that doctors tell their patients: “If you do decide to have a mammogram, you can anticipate that you will have at least one false-positive finding for which you are called back for additional images and perhaps a biopsy. Most of these findings are false alarms.”

Instead of fighting about mammograms, it would be more useful to focus on the fact that “better breast cancer screening tests are needed,” especially ones that could identify the cancers that are harmless and don’t require treatment, Pace and Keating conclude.

Photo: Kristiewells via Flickr