Breast-cancer advice shifts

Upending one of the most widely followed medical directives for women, an influential panel of experts is recommending that women 50 and older get screened for breast cancer only once every two years and that most women in their 40s skip the test altogether.

The panel also concludes that breast self-exams — a drill that women for decades have been told to perform each month — do not reduce mortality from breast cancer, but instead lead to more biopsies producing results that are benign.

The new guidelines, published online Monday in The Annals of Internal Medicine, go against long-standing recommendations from cancer groups, radiologists and other experts that women get annual mammograms starting at age 40.

The American Cancer Society, for one, is sticking to its current recommendations, disagreeing with the national panel's conclusion that for the younger women, potential harm from routine screening outweighs the benefits.

Dr. Constance Lehman, medical director of radiology at Seattle Cancer Care Alliance, flatly rejected the panel's guidelines as a disservice to women's health. Lehman said early detection is key to surviving breast cancer, particularly for black women.

"In our hands, we absolutely see the evidence that mammography saves lives," Lehman said. "We can't take the risk of just not looking."

But several patient advocacy groups and many breast-cancer experts praised the shift, saying it represents a growing recognition that more testing, exams and treatment are not always beneficial and, in fact, can harm patients. Mammograms produce false-positive results in as many as 10 percent of cases, the panel found.

The conflicting recommendations are certain to confound and confuse millions of women.

Breast cancer is the most commonly diagnosed cancer in American women, excluding skin cancer. It also kills more women than any other cancer except lung cancer. Last year, more than 182,000 American women were diagnosed with invasive breast cancer while 40,000 died of it. The guidelines come from the United States Preventive Services Task Force. The group, while it has no enforcement authority, holds great sway as an independent body charged by the federal government to conduct impartial assessments of scientific evidence on preventive medical services.

According to the task force, mammography screening in women ages 39 to 49 reduces the risk of death by 15 percent. That translates to one cancer death prevented for every 1,904 women who are screened.

The benefits of mammography rise for older women, the panel said. Among those ages 50 to 59, 1,339 women would need to be screened to prevent one death, compared to just 377 ages 60 to 69.

But that one life saved comes at a cost to many others, said Dr. David Grossman, medical director of preventive services at Group Health Cooperative in Seattle and a member of the task force.

Younger women have the highest rates of false positives, suspicious test results that turn out to be benign. Grossman also said that some women are diagnosed with breast cancer when in fact they have an abnormal lesion that may never become lethal enough to kill them.

"A major issue with breast cancer is overdiagnosis," Grossman said.

Grossman said the task force is not advising against all breast-cancer screening but against routine screening.

Every misdiagnosis or unnecessary treatment exposes patients to pain from biopsies, anxiety and distress, and radiation from repeated X-rays, the task force said.

Lehman, of Seattle Cancer Care Alliance, acknowledged that any standardized screening guidelines have an element of arbitrariness. But Lehman, who will turn 48 on Saturday, was emphatic that women her age and younger should continue to get annual mammograms.

That's particularly important, Lehman said, for black women, who tend to get breast cancer at an earlier age than women of other races. "If I have breast cancer, I want to catch it early when it can be treated," Lehman said.

Daniel Kopans, a radiology professor at Harvard Medical School, was even more blunt:

"Tens of thousands of lives are being saved by mammography screening, and these idiots want to do away with it," Kopans said. "It's crazy — unethical, really."

Critics also worried the new guidelines would prompt Medicare and private insurers to deny coverage of many mammograms.

The new recommendations take on added significance because, under health-care-overhaul legislation pending in Congress, the conclusions of the 16-member task force would set standards for the type and frequency of preventive health-care services that insurance plans would be required to cover at little or no cost.

About 39 million women undergo mammograms each year in the United States at a cost of more than $5 billion a year.

Grossman said health-care costs were not part of the task force's consideration.

He said women in their 40s should consider their personal risk factors in deciding whether to seek regular mammograms. The new guidelines would not apply, for instance, to women who have a gene mutation that elevates their chances of cancer or who have had close relatives diagnosed with breast cancer.

Diana Buist, a scientific investigator at Seattle's Group Health Research Institute who has written about breast cancer, predicted that the new recommendations will pose a wrenching dilemma for many women.

"This is a very emotional decision for women," Buist said. "Every woman knows someone whose life has been saved from mammography and (someone) who has died from not having their breast cancer detected early."

Nonetheless, "there are important harms of screening that women need to understand."

Kyung Song: 206-464-2423 or ksong@seattletimes.com

Material from The Washington Post is included in this report.