As reported by The Hartford Courant, November 17, 2009.

Call for Cancer Screening Starting at Age 50 Criticized

By Jenna Carlesso

A Connecticut breast cancer specialist is lashing out against an influential federal task force's findings that women in their 40s should stop having annual mammograms and older women should cut back on scheduled exams.

Dr. Kristen Zarfos, director of the Comprehensive Breast Health Center at St. Francis Hospital and Medical Center in Hartford, said the recommendations made by the U.S. Preventive Services Task Force were a step back for health care that has helped lower the breast cancer-related death toll 3.3 percent each year for women aged 40 to 50 over the past 12 years.

The task force recommended that women 50 and older cut back to one scheduled exam every other year, and it has reported that there was insufficient evidence to continue routine mammograms beyond age 74.

"To withhold a tool that finds breast cancer in its earliest stage in women with the highest risk one has to wonder what their goal is," Zarfos said of the panel. The highest incidents of breast cancer occur in women in their 60s, 70s and 80s, she noted.

In its first re-evaluation of breast cancer screening since 2002, the panel which sets government policy on prevention recommended the radical change, citing evidence that the potential harm to women undergoing annual exams beginning at age 40 outweighs the benefits.

"We're not saying women shouldn't get screened. Screening does save lives," said Diana Petitti, vice chairwoman of the task force, which released the recommendations Monday in a paper being published in today's Annals of Internal Medicine. "But we are recommending against routine screening. There are important and serious negatives or harms that need to be considered carefully."

The task force's new guidelines, which also recommend against teaching women to do regular breast self-exams, triggered intense debate.

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 about 10 percent of cases, causing anxiety and often prompting women to undergo unnecessary follow-up tests, sometimes disfiguring biopsies, and unneeded treatment, including surgery, radiation and chemotherapy.

But the American Cancer Society, the American College of Radiology and other experts condemned the change, saying that the benefits of routine mammography have been clearly demonstrated and play a key role in reducing the number of mastectomies and the death toll from one of the most common cancers.

"Tens of thousands of lives are being saved by mammography screening, and these idiots want to do away with it," said Daniel Kopans, a radiology professor at Harvard Medical School. "It's crazy unethical, really."

Zarfos said the benefits of ruling out cancer far outweigh the few risks involved in a biopsy. The risk of infection from a biopsy is low, she added, and the degree of radiation that women are exposed to while undergoing a mammogram does not increase their risk of developing breast cancer or other cancers.

"Taking care of breasts is an imperfect science," Zarfos said. "Believe me, no surgeon wants to unnecessarily put a patient through surgery."

Although the findings might be influential in the field, Susan Tannenbaum, medical director of the Clinical and Translational Breast Program at the University of Connecticut School of Medicine, said they probably won't take away from the years of proof demonstrating that mammograms save lives.

"It might have an impact on women's lives, and we think it will," she said. "But right now there is no other screening tool. Mammography saves lives."

Some questioned whether the new guidelines, coming in the midst of a national debate about the health care system and costs, were designed more to control spending than improve health. They worried that the move, in addition to prompting fewer doctors to recommend mammograms to their patients, would prompt Medicare and private insurers to deny coverage of many mammograms.

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

Connecticut's health care advocate, Kevin Lembo, said Monday night he hopes that insurance carriers will not "latch onto" the task force's recommendations as a reason not to provide coverage to patients.

"I think we need to look into [the issue]," Lembo said.

About 39 million women undergo mammograms each year in the United States, costing the health care system more than $5 billion a year.

"I think it's more cost-related than it is related to actual evidence, which says lives are saved through mammography," said Andrew Salner, director of the Helen & Harry Gray Cancer Center at Hartford Hospital. "Why should we put our heads in the sand and not diagnose tumors that could be treated? These recommendations fly in the face of everything we know."

Petitti, vice chairwoman of the federal task force, denied that the panel was influenced by the health care reform debate or cost issues.

The new guidelines were based on a comprehensive analysis of the medical literature that included an update of a Swedish study involving about 70,000 women, new results from a British trial involving more than 160,000 women and data from more than 600,000 women from the U.S. Breast Cancer Surveillance Consortium.

In addition, the task force commissioned an unusual study funded by the National Cancer Institute that involved six independent teams of researchers conducting separate mathematical modeling studies of the risks and benefits of 20 different screening strategies.

Although annual mammography for all women beginning at age 40 reduced the death rate from breast cancer by at least 15 percent, the modeling studies indicated that the added benefit of starting before age 50 was modest, the researchers concluded.

For every 1,000 women screened beginning at age 40, the model suggested that just 0.7 deaths from breast cancer would be prevented, while 480 women would get a false-positive result and 33 more would undergo unnecessary biopsies.

"What isn't in the model but is an issue is how many extra imaging tests are done to follow up on things that turn out to be falsely positive and the harm of the anxiety that goes along with that," Petitti said. "Then there's the whole other line of problems that come into play, which is where there are some breast cancers detected that grow very slowly and would never have killed you."

Staff writer Matt Sturdevant contributed to this story. A Washington Post report also is included.