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Panel: Begin Mammograms At 50, Not 40

In something of a reversal, the U.S. Preventive Services Task Force recommended that the average woman wait until age 50 to begin routine screening for breast cancer, and only get screened every two years. The previous recommendations — in place since 2002 and backed by the American Cancer Society, radiologists and health professionals — said women should begin routine screening at age 40. Now, to the consternation of some in those groups, the task force says the overall benefit of screening women aged 40 to 49 doesn't outweigh the risks.

The new guidelines also say that women need not perform breast self-examinations. Some studies find that they lead to more mammograms and biopsies that haven't been shown to have any benefit. Additionally, mammography screening of women older than 75 is not considered necessary, since those women may be diagnosed with a cancer that is unlikely to cause a problem in their lifetime.

These guidelines are not for women who have a higher risk of breast cancer, says task force Vice Chairwoman Diane Petitti. Mammograms shouldn't be done without doctors fully informing women of the benefits and risks, she says. It's a conversation that they need to have before they make the decision.

Until now, the independent voluntary task force funded by the Department of Health and Human Services recommended mammography every one to two years for women aged 40 or older. The U.S. Preventive Services Task Force now advises against routine screening mammography in women between the ages of 40 and 49, saying the benefits are small, and the screenings could do harm.

* Note these recommendations are intended for those who do not have signs or symptoms, or family history of breast cancer.

More On The Recommendations:

-- Women aged 50 to 74 should have mammography every two years. The benefit of mammography every two years is nearly the same as that of doing it every year, and less-frequent screenings are about 50 percent less likely to do harm.

-- No more breast self-exams. The recent analysis found no evidence that self- or clinical examination reduces breast cancer death rates.

-- More evidence is needed on whether mammography is beneficial after age 74.

-- Not enough information to know whether newer types of mammography or magnetic resonance imaging are any better than regular film mammography results.

The Research

-- Since the last recommendation in 2002, the task force has evaluated new studies on the three types of breast cancer screening, as well as commissioning research with computer-simulation models. That research compared the expected health outcomes of mammography screening at different ages and frequencies (every year or every two years).

-- For women aged 50 and older, having a mammogram is associated with lower odds of dying of breast cancer.

-- However, the analysis found that for women aged 40 to 49, the benefits were small, and not necessarily worth the risk. Mammogram screenings could have potentially harmful effects, including false-positive results that could lead to unnecessary procedures. Additionally, some results can lead to a diagnosis and treatment of cancer that never would have surfaced on its own within a woman's natural lifetime.

--Kathleen Masterson/NPR

Weighing Harm With Saving Lives

The task force looked at a number of recent studies done in the United Kingdom, Sweden and at six cancer centers here in the United States, all of which achieved about the same result. They found that the deaths from breast cancer were reduced by about 15 percent for women who start screening both at age 40 and 50. But cases of breast cancer rise with age.

Women who start at 40, however, are much more likely to experience the anxiety of an abnormal mammogram, which suggests a woman might have cancer when she doesn't, and have to have additional screening. She may have to undergo a biopsy and not have cancer, or she could be overdiagnosed and have a tumor that never harms her.

"If saving lives is the only goal, then doing more screening will save more lives," says Jeanne Mandelblatt, of Georgetown University, the lead author of the modeling conducted by the cancer centers. A larger societal goal that has to be considered, she says, is whether the cost of saving lives is worth the harm caused.

It's a risk that the American Cancer Society's Terry Fontham is willing to live with. She has had an abnormal breast mammogram and had to be screened again. "Breast cancer is the most commonly diagnosed cancer in women. It's the No. 2 [cancer] killer," Fontham says. "Despite the increased anxiety, the bottom line is saving lives."

Key Groups Divided On New Guidelines

Both the American College of Obstetricians and Gynecologists, and the American College of Radiology also say they will continue to recommend that women get mammograms every one or two years after age 40.

Women in the United States are being diagnosed with breast cancer earlier than their mothers were, as well as women in certain minority groups, says American College of Radiology chairwoman Dr. Constance Lehman. "Black women in the U.S. develop breast cancer at a significantly younger age than Caucasian women do." This was not addressed or acknowledged by the task force, she says.

Some groups and experts welcome the task force guidelines, including the American Academy of Family Physicians.

"There are no studies that indicate that mammograms will reduce the deaths from aggressive tumors in young women. "It's not whether women under 50 get breast cancer. They do," says Dr. Susan Love, an author and UCLA clinical professor of surgery.

"The question is whether mammography is the best way to find them and really change the outcome," she says. She would put more money into understanding why women develop breast cancer and in treating it.

More than half of all women between the ages of 40 to 65 get mammograms to screen for breast cancer. Mammography is considered one factor in the continuing decline of breast cancer deaths.

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Transcript

MELISSA BLOCK, host:

From NPR News, this is ALL THINGS CONSIDERED. I'm Melissa Block.

ROBERT SIEGEL, host:

And I'm Robert Siegel.

First this hour, the latest in the decades-old controversy over when women should get mammograms. Today, a panel of leading health experts funded by the government announced new recommendations. They say the average American woman can wait until she's 50 to start getting mammograms. That differs from current recommendation which suggest women begin getting screened at age 40.

NPR's Brenda Wilson explains.

BRENDA WILSON: Just last month there were news reports that the American Cancer Society was wavering on annual screening for breast cancer. They're not. Now comes the U.S. Preventative Services Task Force, which is changing their guidelines.

Dr. DIANE PETITTI (Vice Chair, Preventative Services Task Force): The task force is now recommending that women age 40 to 49 not be routinely screened for breast cancer.

WILSON: Task force Vice Chair Dr. Diane Petitti says the key word here is routinely. The guidelines are for the average woman who doesn't have a high risk for breast cancer, such as women with a family history of breast cancer and African-American women. She says the average woman can start later and doesn't need to be screened every year.

Dr. PETITTI: It's recommending that women age 50 to 74 be screened every other year, rather than every one to two years as was previously recommended.

WILSON: Petitti says the task force changed its existing policy because of a number of recently published studies. The most important, she says, was conducted in the United Kingdom and followed more than 160,000 women who were randomly selected for mammograms.

Dr. PETITTI: It showed, as other trials have showed, that mammography starting at those ages reduces breast cancer mortality. What's important about it is it permitting more precise estimate of the size of the benefit from starting screening at age 40 to 49, compared with starting later.

WILSON: Along with others studies, that more precise estimate tipped the balance against yearly screening under age 50. Even though mammograms reduce the death rate by roughly 15 percent for women in both their 40s and 50s, more women in their 50s develop breast cancer. Petitti says the benefit of screening women over 40 is small when it's compared to the very real harm of having something detected that isn't cancer.

Dr. PETITTI: The harms are related to false positive tests. In the process of moving from a positive test to a false positive test, there are the psychological anxiety, digital imaging tests and ultimately perhaps even a biopsy.

WILSON: But some people think it's worth it.

Dr. TERRY FONTHAM (President, American Cancer Society): I'm one of those women who has certainly screened positive on mammograms and did not have breast cancer, and I've had to go back for re-screens.

WILSON: Terry Fontham of the American Cancer Society says the society is continuing to recommend annual screening for women 40 and older, because that's the best way to detect cancer at an early stage.

Dr. FONTHAM: Breast cancer is the most commonly diagnosed cancer in women, the number two killer. So, despite the increased anxiety and increased follow-up, we think the bottom line is saving lives.

WILSON: Fontham says the task force's recommendation could cost women.

Dr. FONTHAM: If a woman wanted to begin in her 40s, she would certainly be free to do so, but that would not be reimbursable.

WILSON: Insurance coverage and cost did not factor in the task force's recommendation, Petitti says, and emphasize that women can still choose to be screened at 40.

Dr. PETITTI: I hope that women will see the recommendation as being about better information, for better decision making and for better choices between starting at age 40 to 49 compared with starting later.

WILSON: There will be future opportunities, she says, if new evidence emerges. And she hopes that it helps identify women who are at high risk, so that even fewer women have to be screened for breast cancer.

Brenda Wilson, NPR News. Transcript provided by NPR, Copyright NPR.

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