Headlines
As reported by the New York Times, November 17, 2009.
Many Doctors to Stay Course on Breast Exams for Now
By Pam Belluck
Despite new recommendations that most women start breast screening at 50 rather than 40, many doctors said Tuesday that they were simply not ready to make such a drastic change.
"It’s kind of hard to suggest that we should stop examining our patients and screening them," said Dr. Annekathryn Goodman, director of the fellowship program in gynecological oncology at Massachusetts General Hospital. "I would be cautious about changing a practice that seems to work."
The recommendations, issued Monday by a federal advisory panel, reversed widely promoted guidelines and were intended to reduce overtreatment. The panel said the benefits of screening women in their 40s — saving one life for every 1,904 women screened for 10 years — were outweighed by the potential for unnecessary tests and treatment, and the accompanying anxiety. Women considered at high risk should continue to have early screening, the panel said.
Several doctors said that while they understood the panel’s risk-benefit analysis, their patients would not see it that way. "My patients tell me they can live with a little anxiety and distress but they can’t live with a little cancer," said Dr. Carolyn Runowicz, director of the Neag Comprehensive Cancer Center at the University of Connecticut.
The idea that one cancer death is prevented for roughly 2,000 women screened "doesn’t mean anything until you’re the one," said Dr. Jacques Moritz, director of gynecology at Roosevelt Hospital in Manhattan. "No doubt about it, I’m going to say, ‘Well, you really don’t need it,’ and they’re going to say: ‘You don’t understand. I’m getting the mammogram. I’m not going to take the chance to be the one person that has it.’ "
Most of the doctors, however, said they would inform younger women that the recommendations said they did not need mammograms if they were low-risk. They said they would also point out that groups like the American Cancer Society and the American College of Obstetricians and Gynecologists are sticking to the earlier guidelines.
"If we don’t give them both views, they will not trust our judgments," said Dr. Ozgul Muneyyirci-Delale, associate professor of obstetrics and gynecology at SUNY Downstate. Dr. Muneyyirci-Delale said she worried that the conflicting advice might add to negative feelings many women have about mammograms, because of the pain of the test, exposure to radiation or a general distrust of medicine.
A few doctors, however, could see benefits for some women.
Dr. Deborah Gahr, a gynecologist in private practice in New York, said the guidelines would make the estimated 10 to 15 percent of women who resist have mammograms more confident in their decision. “In a sense, that’s good,” Dr. Gahr said. "Nothing is black and white in medicine."
Patients are already trying to figure out what the recommendations mean. Dr. Daniel Kopans, a professor of radiology at Harvard Medical School and a strong proponent of mammography, said "one woman came all the way from Bermuda and said, ‘I’m not sure if I should be screened.’ "
Dr. Therese Bevers, medical director of the Cancer Prevention Center at the M. D. Anderson Cancer Center in Houston, said, “I had clinic this morning, walked in the room, and women in their 40s were saying, ‘I can still get a mammogram today, can’t I?’ They were afraid we were going to say, ‘You wasted your trip.’ ”
Some doctors said patients were worried that insurance would no longer cover mammograms for younger women, something doctors said could be a possibility, although not right away.
Dr. Runowicz said that for many of her patients, "the subtleties just go right over their heads, and all they hear is ‘Oh, I guess mammograms are not good for us anymore,’ which is really unfortunate because it could actually undo a lot of good that has been done in the past few decades."
Some doctors objecting to the recommendations said they were based on an analysis of older data and did not take into account new digital mammography, which might pick up more cancers in the denser breast tissue of younger women and possibly save more lives (although the technique might also generate more false positive test results). Others objected to what they considered the stark tone.
"They’re saying this is how many lives we save and we’ve made a decision whether it’s worth it," said Dr. D. David Dershaw, director of breast imaging at Memorial Sloan-Kettering Cancer Center, adding that the recommendations did not suggest "something to replace it with that has an advantage over mammograms."
Dr. Sharon Diamond, a gynecologist in New York, worries about the cases that might be missed, like the patient whose mammogram, clean the previous year, detected a small tumor.
Although the recommendations did not mention costs, Dr. Joanna Cain, a gynecologic oncologist at Women and Infants Hospital in Providence, R.I., was among doctors who said they saw value in pointing out the issue of where to spend resources.
"To catch the one extra breast cancer, are we willing to give up the funds that might fund immunization" or another health measure? she said. "Those are real concerns. But here’s the other side of anxiety: Many of our patients have already said to us, ‘I saw that, but I’d be too anxious not to have a mammogram."