Task Force Chief Defends Controversial Mammogram Recommendations

By Lisa Tobin
Nov 18, 2009, 1:14 PM
10 Comments

BOSTON — The chairman of the task force recommending that most women start breast screening at 50 rather than 40 says he is not surprised by the controversy the new guidelines have generated, but he stands behind them as “the best recommendation that the science would support.”

“Understanding the amount of advocacy that goes on around breast cancer screening, I think we were pretty certain this would cause a stir,” Dr. Bruce N. Calonge, chairman of the U.S. Preventive Services Task Force, told On Point host Tom Ashbrook in an interview. “We felt that the recommendations are supported by the evidence and the science.”

The recommendations, issued Monday by the independent federal task force, reversed guidelines American women have been given for decades: advising against routine mammograms for women under 50 without special risk factors. For women age 50 to 74, the panel now recommends breast screening every two years, rather than every one to two years as previously advised.

The point, Calonge said, is that the 15 percent mortality reduction that results from regular mammography for women in their 40s — an age group for which breast cancer is relatively rare — does not outweigh the “definite harms” associated with the exams.

“We felt we had to put out the best recommendation that the science would support.”

–Dr. Bruce N. Calonge, U.S. Preventive Services Task Force

He said the task force had carefully constructed the wording of the recommendation to advise against routine screening for women under 50, not against mammograms in general.

“The decision to start screening before the age of 50 should be an individual choice,” Calonge said, “taking into account patient characteristics, patient history, family history, hormonal status — all the issues that will help a woman decide.”

“If you think about that,” he said, “I have a hard time understanding the controversy around: A woman should understand the limits of the test, the harms of the test, the potential benefits, and then make her own decision.”

Women who undergo regular screening are more likely than other women to go for a biopsy, Calonge said, yet “most of those biopsies do not translate to benefit,” meaning the mortality rate is not significantly different from that of women who do not have a biopsy. “The vast majority of breast biopsies in that age group aren’t making a woman live longer,” he said.

In another surprise reversal, the task force Monday said doctors should stop advising or teaching women to regularly examine their own breasts. As with regular screenings, Calonge said, self-examinations result in more unnecessary biopsies — without any impact on mortality.

“If you set aside the anecdote and you actually look with the lens of science, you say, ‘Boy if I teach one group of women to do breast self-exam and another group of women to not … the group I teach does have more breast biopsies, but their mortality is not changed at all,’ ” he said. “Rather than saying there’s not evidence of effectiveness, we have good evidence of no effectiveness.”

That advice should not be interpreted to mean that if a woman finds a lump in her breast, she should not go to the doctor, Calonge stressed. “Absolutely women should,” he said.

Listen to Ashbrook’s full interview with Dr. Calonge, Nov. 18, on “On Point.”

Please follow our community rules when engaging in comment discussion on wbur.org.

Richard Williams

Bruce Calonge has just made recommendations for the death of women. What an immoral jackass. His medical credentials should be revoked! This panel recommendation is outrageous!
James

What apparently causes confusion is the “15% mortality reduction”. This doesn’t mean that routine screening saves 15% of women in their 40s. It means that of those in their 40s who are DISCOVERED to have cancer by routine mammogram screening, there’s a 15% mortality reduction; the actual percentage who are found to have cancer FAR below 15%.

The tiny numerical mortality reduction is being weighed against the greater harm that mass screening leads to. False positives lead to a great many necessary biopsies, which can have their own complications. Additionally, there’s statistical evidence that exposing millions of younger, health women with no cancer risk factors to regular radiation may actually INDUCE a certain number of tumors.

They’re saying that when health risk is weighed against health benefit, routine screening for a specific group of women does not statistically come out as a plus. The previous recommendation could be doing more harm than good.

Individuals in that group should talk to their doctors about their individual situations, and make individual decisions.

Sadly, people seem to want to make this observation a political issue.
Rudolf

The knee jerk reaction against the findings are predictable but don’t reflect an understanding of the study. To make it simple suppose, out of a 1000 women, aged 40, one will get breast cancer by age 50. Suppose further that the radiation from the X-Rays, 10,000 for the 1000 women for once a year in the ten years from age 40 to 50 results in two cancers. Then screening caused two cancers while there is only one with no screening.
David Stricker

The study cites that the risk to women in having breast cancer screening is exposure to radiation. But what if there was an equally effective method that did not involve Xray or other forms of radioactive radiation? Then the risk would be nil but the benefit would be the same. Well, there are other methods, including MRI, that do not emit radioactive radiation. Therefore, purely on a scientific basis, using MRI or another non-radioactive form of screening would provide indisputable benefit with no harm. Yes the alternatives are more expensive, but that evokes the issue of cost vs. health? The panel has been somewhat quiet on this debate.

As to the increase of biopsy with increase in screening, what woman would not want to take the risk associated with a biopsy if a “safe” screening method were used? Does it not come down to an actuary issue, not an issue of “science”.
http://wbur.org Patsy Covelli

Not only is this task force ridicously disgusting about their recent decision to play “GOD” with my life — (the mammograms saved my life), but every one of these folks needs to be FIRED and replaced with reputable and honest professionals. What is this country (AND GOVERNMENT) coming to???? GET RID OF THE US PREVENTATIVE TASK FORCE!
Eleanor Martinelli

This task force doesn’t know what they are talking and advising on!!! I, myself, would have lost a breast or worst growth removed at 47 could have turned into to cancer by the time I would have the first age 50 mammo.
I, also, lost a dear friend to breast cancer, she was 58 and went thru the treatments and chemo three times before it took her!
There are so many women who have early problems with cancer and growths of the breast that have been found long before this new recommended age…don’t they have a right to get the best medical help at the earliest…to live a normal and long life!!!!!!!????????????
How many men vs women are on this task force anyway!?
Truly,outrageous!!!!!!!!!!!!!!!!!!!!!!!!!!
Sally

Actually, the study indicates a 3% improvement in overall mortality- and a 15% improvement in breast cancer mortality. To me, 3% is not a negligible amount and note that is NET of any possible bad effects of mammograms, biopsies, etc.

The risks identified were not radiation, but stress and pain from false positives that might require an additional mammogram or a biopsy – in most cases, a needle biopsy.

I do not feel that “stress” is a good enough reason to increase mortality rates 3%. However, I am one of the 3%, which does tend to bias me, since I do regard being dead as a “harm.”
Sally

Clarification – a 3% reduction in mortality when screening 40-49 year olds – in case improvement is not a clear word.
David Goodman

Hello, are any of these male?Drs. really thinking, do they not understand that cancer in the 30′s for women is not all that unusual. Just one extra death women’s death from cancer not caught early at 40 is unacceptable. I am sure that most women would rather get a false positive and then find out it was wrong rather then waiting until 50, when the diagnosis was correct. Do they also fail to understand that the insurance companies will probably no longer cover screenings at 40 due to their “study.
Jonathan

Rudolf, you are actually quite wrong about “only 1 in 1000 women get breast cancer from 40-50. It’s actually about 1 in 61 over the entire decade. True, many people who don’t know anything about statistics and randomized trials are having knee-jerk reactions, but so are many professionals. No I do not believe the task force is evil or writing death sentences and I do believe they mean well, but personally, I disagree with them. And I disagree with them because of what they officially designated as a “harm”. Added anxiety and false positives, whether requring diagnostic mammograms or fine needle biopsies, are no doubt “downsides”, but they are still relative. Pitting them against the one benefit – a 15% reduction in mortality – doesn’t make much sense because it treats each consequence of screening, good or bad, as equals. They are not. Women and their doctors are not going to find a higher risk of death, due to denied screening, as acceptable.

That being said, I think the one good thing that has resulted from this report is that women will learn that mammography is a very limited tool and is not a guarantee of survival. However, it’s the best we have right now. Let’s not put it in a museum until AFTER the state-of-the-art improves.