Stop Annual Mammograms, Govt. Panel Tells Women Under 50

Recommendations set off a debate over the costs and benefits of mammography.

November 16, 2009, 4:26 PM

Nov. 16, 2009— -- For the first time in 20 years, a government panel is telling women in their 40s to stop getting routine mammograms and recommending that a host of other breast cancer screenings slow down.

The United States Preventive Service Task Force announced Monday that it recommends against annual mammograms for women age 40 to 49 because, they say, the benefits of testing do not outweigh the "harms" and risks.

USPSTF still recommends doctors start screening all women over age 50, but with a mammogram once every two years instead of annually.

The task force also recommends against teaching breast self-exams for all women and said evidence was insufficient to recommend mammograms for women older than 74.

The recommendations were 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.

Family doctors often abide by the task force's recommendations in their practices, and insurance companies routinely turn to USPSTF -- a panel of independent medical experts -- to guide coverage plans.

But the recommendations announced today, which contradict the American Cancer Society, have already pitted doctors, women, insurers and radiology groups in a fierce debate about who should get a mammogram and when.

"These new recommendations are long overdue. Most countries do not support mammography screening under 50 and do it every other year after 50 in their government-sponsored screening programs," said Dr. Susan Love, founder of the Dr. Susan Love Research Foundation.

"I hope that the insurers will change reimbursement, because it is probably the only way that women will be spared the extra radiation exposure of too many mammograms," Love said. "Since our system pays the radiologist, hospital or mammography center and biopsying surgeon by the more they do, there is no incentive for this to come from the medical profession."

But others feel quite differently.

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Some Furious Over Recommendation to Halt Mammograms

"Their justification: these new guidelines capture 81 percent of mammography's benefits, save a lot of resources, with only a 3 percent drop in survivorship from the most common cancer to affect women," said Dr. Marisa Weiss, president and founder of "But what really is the cost? And who is paying that price? It could be you, your mom, daughter, sister, aunt or grandmother, or all of us."

Anecdotally, most people in the United States can think of a woman they know who caught breast cancer through a routine mammogram long before she turned 50. Many patient advocates wonder if money fueled the decision.

"I think a lot of it is about money, and we know that we need to make health care cuts, but this isn't the way we need to make money," said Hillary Rutter, director of the Adelphi New York Statewide Breast Cancer Hotline and Support Program.

However, Dr. Diana Petitti, vice chair of USPSTF, said the task force never looked at costs in their research or their recommendations.

"The task force doesn't deal with insurance and coverage," Petitti said. "Cost was not a part of what the task force looked at."

Instead, the task force 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 did 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. Based on those results, Petitti said, the USPSTF made the recommendations as part of a five-year review cycle for current cancer screening recommendations.

"The recommendation was voted on almost a year-and-a-half ago," she said. "It is, in reality, entirely an accident that it is coming out on the heels of a lot of information about breast cancer screening, and certainly accidental in relationship to anything that's being talked about in politics."

Despite current politics and costs, Petitti said she hoped the recommendations would lead to "a better understanding" of the trade-offs in breast cancer screening.

"The reason to do it less often is to decrease the harms and the negatives -- false positive tests -- and the anxiety that goes along with it, the biopsies that will be done and the unnecessary tests," said Petitti. "Those harms and negatives are both common and serious."

While many women find the yearly mammograms a painful hassle they'd rather avoid, some debate the "harm" of a false positive.

"My evidence is anecdotal and there may be women who say, 'my goodness, I'm so upset that I went through that when I didn't have cancer after all,' but I've never heard a woman say that," said Margaret C. Kirk, president and CEO of the Breast Cancer Network of Strength.

"I've never heard from anybody who regretted it," she said.

In fact, the first thought on many women's minds once they heard the news was whether insurance would stop paying for mammograms before their 50th birthday.

Cancer Survivor Worries About Diagnostic Tests for Daughter

Andrea Evans, 54, survived several stage II tumors in one breast after being diagnosed by a routine mammogram at age 46. After a preemptive double mastectomy to keep the cancer from spreading, doctors found a cancerous tumor in the other breast, which they had thought was tumor-free.

Although Evans does not have the two genes known to put women at a higher risk (BRCA-1 and BRCA-2) she does have a large family history on her father's side.

"My doctor thinks it is a gene, but it hasn't been found yet," Evans said. "Even now, several years later, I could go back and be retested because they find new genes all the time."

Now Evans hounds her doctor to get her 24-year-old daughter screened, even though routine screening isn't recommended for her yet.

"I am constantly asking my oncologist if the recommendations have changed," Evans said. "Insurance companies won't pay for you to have a diagnostic test sooner unless there's a proven reason."

In a way, Evans is both right and wrong on insurance companies' obligations.

"In much of the country, insurance coverage for mammographic screening is mandated by law. For women in these areas, there will be no immediate change," said Dr. David Dershaw, director of Breast Imaging at Memorial Sloan-Kettering Cancer Center. "As the American Cancer Society has stated that this report will not result in any modification of its screening recommendations, hopefully insurance coverage will not be changed."

Forty-nine states mandate that health insurance companies cover routine mammograms. The laws vary from state to state on whether the insurance company pays all or part of the costs, but the vast majority require a baseline mammogram for an insured woman at age 35 and above, routine mammograms every two years for women age 40-49 and annual mammograms for women older than 50.

The law does not apply to millions of women who get insurance through an employer who is "self-insured," meaning the employer pays for the health care but a third party health insurance group manages the care.

Still, laws mandating mammogram coverage in all states, except Utah, pack a powerful punch. The USPSTF also recommends mammograms be performed on an individual basis, if the doctor recommends one.

Health insurance lobbyist group America's Health Insurance Plans, doesn't foresee a change in coverage soon.

"We don't believe that payment will vary depending on whether a woman who gets a screening is in the target age group or outside the target age group," said Susan Pisano, vice president of communications for AHIP.

What Insurers Will Do With New Mammogram Recommendations

Pisano predicts that health care groups will stop encouraging women in their 40s to get yearly mammograms and will refocus those targeting efforts -- such as sending reminder postcards to get a mammogram -- to women in their 50s. But that doesn't mean women in their 40s or younger would not be covered.

"Occasionally, a woman who is not high risk, and she's 32, wants it done," Pisano said. "In those cases, the woman might have a discussion with her doctor and talk about the risks and benefits. ... At the end of the discussion, if the doctor orders a mammogram for that woman, then it's typically covered."

ABC News' Reynolds Holding contributed to this report.

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