Task Force Responds to Mammogram Controversy

Panel member defends recommendations, says point was to inform women.

November 18, 2009, 11:43 AM

Nov. 19, 2009— -- A member of the panel that unleashed a firestorm of controversy when it recommended a change in the age and frequency at which women should get mammograms today answered critics' claims that the new recommendations could prove harmful to women.

"This is not a recommendation to not screen. It's a recommendation to provide women with the facts," Dr. Timothy Wilt , a member of the U.S. Preventive Services Task Force, told "Good Morning America." "Our recommendations support an individualized decision-making process with the women so that they have knowledge about the risks and benefits associated with mammography screening."

The recommendations, issued Monday, suggested among other things, that women between the ages of 40 and 49 should not necessarily get regular breast cancer screenings and that 50- to 59-year-old women should have them every two years instead of every year, as the American Cancer Society recommends.

Since the recommendations were published Monday the panel has come under fire from critics, some of whom claim the new guidelines were influenced by insurance and health care costs, and that they were based on a single study. Wilt denied both allegations.

"Cost is not considered at all. This is about providing high-quality health care for the individual [and] providing the information they need to know to make an informed decision," he said. "The information is based on eight very large, randomized, controlled trials of mammograms in women, a series of six different databases and a variety of other studies."

Wilt said that according to the task force's research, the benefits of saving about one life out of every 2,000 through mammograms for women between the ages of 40-49 "needs to be balanced" with the sometimes serious harms that come with incorrect treatment and overtreatment.

"We place great value in being able to reduce a death occurrence in breast cancer, [but] that occurs very rarely -- one in about 2,000. The other 1,999 wouldn't benefit," Wilt said. "Up to 30 percent of breast cancers would never progress to the point that they would ever be noticed in a woman's lifetime. We often treat those. They may be unnecessary treatments [resulting in] pain and disfigurement from surgery.

"Those harms that occur with many women need to be balanced out with the benefits for a few," he said.

Unnecessary treatment was also a concern to the panel when it suggested women should not be taught to perform breast self-exams, Wilt said.

"There have been several large, well-designed trials that have looked at teaching breast self-exam. Women who did more breast self-exams, did more high-quality exams, found more lumps, had more biopsies, had more breast cancer surgeries," Wilt said.

But, according to Wilt, the heightened self-testing "did not have a reduction in breast cancer mortality."

"Not to say that if a woman doesn't feel a lump she shouldn't bring it to the attention of her physician," he added.

Wilt's comments come the day after Health and Human Services Secretary Kathleen Sebelius defended the panel's methods but clarified the guidelines as recommendations, not policy.

"The United States Preventative Service Task Force have done what they've been asked to do, which is routinely review data and look at preventive services across the board and make recommendations," Sebelius said. "They don't make policy. Do what you have always done. Figure out your own health situation with your doctor, your family history. Those are really the important ingredients."

Experts, Officials Weigh In on New Recommendations

Wednesday, Good Morning America consulted its medical team -- ABC News chief medical editor Dr. Timothy Johnson, ABC News senior health and medical editor Dr. Richard Besser and ABC News medical contributor Dr. Marie Savard -- to find out their opinions of the new recommendations.

What all three doctors said was that the updated recommendations, while they may be well-intentioned, raise significant concerns and that women, at least for the time being, should adhere to previous guidelines.

"I was so surprised about these recommendations," Savard said. "I think women should stay put in terms of what they're doing."

Johnson said that a question that naturally accompanies such a change concerns alternatives to mammography, of which, he said, there are currently no good ones.

"Right now, a screening mammogram is the best tool we have," he said. "That's why we recommend it."

And Besser said that in terms of lives saved -- 1 in 1,300 for women 50 and over, one in 1,900 for women 40-49 -- he does not believe there is enough difference in benefit between these groups to warrant a difference in recommendations.

Meanwhile, the American Cancer Society and the American College of Obstetrics and Gynecology are among the many groups that supported the old guidelines and have stood firmly by them since the Preventive Serivces Task Force released its new recommendations.

"When you see two prestigious bodies, this task force and the American Cancer Society, looking at the same information and coming up with wholesale different conclusions, that raises red flags for me in saying, 'OK, smart people can disagree; let's not do anything rash before these are looked at in great detail,'" Besser said.

It's not just professional organizations that are bucking the new guidelines. Since they were issued Monday, the changes in recommendations have met a groundswell of rejection from many medical centers, breast cancer survivors and numerous doctors, some of whom have advised their patients to ignore the recommendation.

According to most of the medical centers that ABC News has heard from, they will not follow the new screening guidelines. MD Anderson, the Mayo Clinic, Baylor, Beth Israel Deaconess Medical Center and Fox Chase Cancer Center were among many hospitals that said they are sticking with the current guidelines, recommended by the American Cancer Society.

The task force has defended its rationale for the change. Dr. Diana Petitti, vice chairwoman of the task force, said it reviewed a number of studies to compile the benefits of mammograms, such as how many cancers were detected and how many lives were saved, and the "harms" of mammograms, such as how many false positives popped up, how many unnecessary tests were done and how much extra radiation women were exposed to during the false positive testing.

The task force then used calculations and mathematical models to see how these benefits and "harms" would change if women started getting routine mammograms at different ages and different intervals.

The recommendations are also only for women considered to be at normal risk for breast cancer. Women who are at a known high risk -- for instance, women who tested positive for the BRCA-1 and BRCA-2 genes -- would not fall under the guidelines.

In recent months, some sentiments have arisen opposing increased screening. A study released in September brought to light some of the potential risks of false positives. While efforts have been made to increase cancer screenings, many patients are unaware of the potential consequences of false positives, including unnecessary anxiety, testing and possibly treatment.

"[Some] women don't understand how screening can cause problems," said Dr. Bob Crittenden, an associate professor in family medicine at the University of Washington. "Personally, I think this is symptomatic of many people in medicine promising good health if you get screened. As we know with PSAs and other screenings of asymptomatic people, we have only a few things we can do that actually help extend life and then usually only marginally."

Crittenden explained that in his own practice, patients are screened on request before age 50 and screenings are strongly encouraged after that age.

Several family doctors contacted by ABC News said the recommendations reflect some of the sentiment against screenings because of the possibility of unnecessary treatments, and expressed hopes that they will lead to more open conversations with pateints about mammograms and cancer screening.

Sources of Medical Opposition

Dr. Gary Lyman, a breast cancer oncologist at Duke University who researches comparative effectiveness, said guidelines like those issued by the task force may cause a great deal of harm.

"This is a reversal of the position they took in their previous recommendations, and this flies in the face of previous guidelines from other groups in the U.S.," he said. "[While] the risk of breast cancer is less in the younger age group, 40 to 50, mammograms save lives in those age groups."

Lyman said his primary criticism is that in between the last set of screening guidelines in 2002 and the current ones, only one study has come out in the area, and it did nothing to change what doctors know about mammograms.

"I'm puzzled why, when the evidence hasn't really changed, when the estimate in benefit and risk hasn't really changed, why they reversed their position," he said.

Lyman said he was also worried about potential confusion among women over 50, since under the new guidelines they are being told to get screened every other year, while previously they had been told to get screened every year.

"I don't know if we know that's going to cause harm or not," he said. "What I'm worried about the most, however, is confusion on the part of women and their physicians that may make them question whether mammograms will do anything."

His concerns were borne out in at least one New York hospital Tuesday.

"I spoke to our breast imaging department today, and they said that the 'no-show' rate doubled today," said Dr. Susan K. Boolbol, the chief of breast surgery at Beth Israel Medical Center in New York. "That means that twice as many patients today decided not to show for their mammogram appointment. That is a very concerning rate. We will monitor this to see if it continues."

But Boolbol said she is also worried that "controversies such as these really create a feeling of mistrust for the medical community at large."

Lyman said the benefits of mammography have been clear, particularly since insurers and Medicare began reimbursing for them, noting that mortality rates have fallen by 25 percent since then.

"I can't say all that's due to mammography, but it's pretty clear that part of that and maybe most of that is due to early detection with routine mammographic screening," he said.

Breast Cancer Screening Recommendations 'Devalue' Lives, Survivor Says

Doctors' offices and hospitals have been fielding calls from women wanting to know what these new guidelines will mean for them.

One of these calls came not from a woman concerned about getting breast cancer but from one who has already had it. Beth Thompson, 44, a mother of four who lives in the suburbs of Baltimore, was first diagnosed with breast cancer following a mammogram at age 40.

"I had no risk factors and no family history," Thompson told ABCNews.com. "Under the new guidelines I wouldn't be screened. That's why I'm so upset about this. I firmly believe I would not be here today if I had not had a screening mammogram at 40."

Thompson explained that in removing the tumor detected by the mammogram, doctors found a faster-growing tumor underneath, one that would not have been found until it became a palpable lump.

"It really makes me shudder to think of what a different situation I would have been in if that were the case," she said, explaining that she needed four surgeries, four rounds of chemotherapy and took Herceptin, an adjuvant for an aggressive form of breast cancer, for a year.

"That's the treatment that I needed even for an early-stage cancer," Thompson said. "There's just no reason that I would have been screened and no way that it would have been found at the time, except for mammography."

While false positives may create problems for some patients, many seem to believe that those are outweighed by the deaths that can result if the screening is not done, something that would present a challenge to any desire to change screening guidelines.

"At the Methodist Breast Center, we diagnose and/or treat about 500 patients with breast cancer every year," said Dr. Luz Venta, medical director of the Methodist Breast Center in Houston and fellow at the Society of Breast Imaging, in a statement. "And about 21 percent of these are women under age 50. Should these women be sent away and told the cost of screening for breast cancer is not justified in the number of lives that can be saved?"

That sentiment was echoed by many, some of them survivors of breast cancer, who flooded the message boards of breast cancer groups like breastcancer.org and the Susan Love Foundation to protest the new guidelines.

Thompson, whose sentiments run along those same lines, said she worries about getting her own daughters, the oldest of whom is in her teens, proper screening when they reach the right age, and is concerned that future recommendations might change how soon they get screened.

"I will move heaven and earth to have them screened at 30," said Thompson, affirming the recommendation that women with a first-degree relative with breast cancer get screened 10 years before cancer first appeared in that relative.

But Thompson, reflecting the sentiments of other survivors of breast cancer, also said she worries that any recommendation for screening that would have excluded her also devalues the lives of other potential breast cancer survivors.

"It's disheartening to hear the new guidelines, when they talk about the few lives that are saved," she said. "It's hard not to feel a little devalued by that."

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