Expert panel statement confuses breast cancer prevention policies
Health professionals fear false security among 40-something women
When an expert panel issued a statement last January recommending against routine mammograms for 40- to 49-year-old women, it sent a double message: To scientists, it was a reasoned conclusion based on well-documented findings. To women’s health professionals, it was a mandate to step up their emphasis on assessment of personal risk factors instead of applying general guidelines to all patients in that age group.
The statement, released by the National Institutes of Health Consensus Development Conference on breast cancer screening for 40- to 49-year-olds,1 calls the 40s a transitional period during which the benefits of mammography are less clear-cut than at other ages. "The scientific benefits of routine mammography for all women under [age] 40 are not clear. For women over 50, they’re clear," says Susan Y. Chu, PhD, MPH, a conference member and associate director of the Center for Health Studies at the Seattle-based Group Health Cooperative.
Further ambiguity arises from the time at which cancers appear with most significant frequency within the 40 to 49 age group. According to the consensus report, the incidence of breast cancer approximately doubles from 40 to 49; however, the greatest occurrence is in the late 40s. Those numbers suggest that the most benefit from mammography would accrue to women in their late 40s.
"The difficulty," Chu adds, "is that in younger women the test is far less accurate than in older women."
The consensus report explains that for every eight biopsies investigating abnormalities found by mammographies of women ages 40 to 49, one invasive and one in situ breast cancer is found. On the other hand, the report discloses that mammographies miss up to 25% of all invasive breast cancers in 40-something women, compared with 10% in 50-something women. The consensus group distilled its statement from the findings of eight randomized clinical trials conducted over the past 30 years in the United States, Sweden, Canada, and Great Britain.2
Compounding the confusion surrounding false positive mammographies, Chu says, is the risk of overtreatment for noninvasive cancerous lesions identified by mammographies ductal carcinoma in situ. (For information on a study that argues for annual mammography screening beginning at age 40, see Women’s Health Center Management, December 1996, p. 149.)
"The most appropriate treatment for ductal cancer is lumpectomy," she explains. "But a woman often gets mastectomy because she thinks it’s safer. Then she thinks she’s saved [from recurrence], and her doctor thinks he saved her. That’s not true! Cancer can come back even after a mastectomy."
Chu goes on to clarify the function of the consensus conference statement: "The public health officials’ job is to come up with clear definitions of the risk and benefit of [screening programs] so women can make decisions for themselves in conjunction with their providers."
Statement could justify procrastination
Though the conference committee clearly understands the intent of its statement, women’s health providers fear public misinterpretation. Those who spoke with WHCM note that the popular media highlighted just one dimension of the statement: that routine mammography for all 40- to 49-year-olds is not useful. (For figures on the incidence of breast cancer in women ages 40 to 49, see chart, p. 43.)
The media don’t tell the whole story, contends Lee Marki, MSN, director of women’s health at St Luke’s Medical Center in Milwaukee.
"It’s fine to say you should discuss your case with your doctor, but a lot of women aren’t even seeing a doctor regularly," Marki says. "And we’re not anywhere near 100% compliance on monthly breast self-exams."
The official implication that women don’t need routine mammograms until they’re 50 replaces ignorance and fear with a false sense of security, asserts Jan Clemons, family health services coordinator at St. Mary’s Health Network in Reno, NV.
"A lot of women are scared to get mammographies, and a lot of women don’t know when they should be getting them," Clemons says. I know doctors are worried about the quality of the mammographies for younger women, but I’ve seen young postpartum women in their 30s with breast cancer."
"Too bad the report lends credence to postponing mastectomies, because in our community, waiting until you’re 50 is not a good move," says Becky Stump-Cutchin, OCN, nurse clinician for women’s health at St. Joseph Medical Center in South Bend, IN.
Stump-Cutchin explains that for unknown reasons, 23% of the newly diagnosed breast cancers in the South Bend area’s cancer registry show up in women under age 50. "One-half of the breast cancer patients I take care of, or with whom I have contact, are under 50," she says.
The conference statement concludes by tossing the responsibility for interpreting its guidance to individual women and their health care providers. But that’s "nonadvice, and it serves to further confuse women," Stump-Cutchin contends.
Melinda Noonan, RN, MS, director of women’s services at Swedish Covenant Hospital in Chicago, views the conference statement as a mandate to do "what we’ve always done, anyway: educate our patients and help them assess their individual risk factors."
Assessments must consider family history of breast cancer and other events that might pose risks, says Noonan.
"If a woman had a hysterectomy in her 30s, her breasts will show changes [such as less density] we would expect to see in an older woman," she says. "Also, women who take hormone replacement therapy in their 40s will show breast changes, and they should consider mammography."
The conference statement supports Noonan’s emphasis on case-by-case assessment of risk factors. It says that subgroups tested in the studies from which it drew its conclusions found a higher detection for mammographies of 40- to 49-year-olds who have a family history of breast cancer.
Noonan teaches her patients that early detection of breast cancer is a threefold process, and she doesn’t plan to change her message.
"We show the difference between cancers identified by mammography, a physician’s examination, and breast self-examination," she points out. "Since mammography detects cancers at earlier stages than the other methods, I would not tell someone not to get a screening mammogram."
Education coupled with baseline mammograms at age 45 are routine for women without apparent risk factors at St. Mary’s, Clemons says. The conference statement will not alter her organization’s philosophy of encouraging women to make their own decisions, she says.
"If a woman is aware of a change in her breasts, she should have the right to get a mammogram," Clemons says. "We know the risk of false positives in younger women, but we believe it’s good to consider personal variables rather than make it a yes or no situation for everyone."
Economic concerns play a pivotal role in breast cancer, whether at the detection stage or in treatment. Mammography is pricey no matter who pays the bill. Marki notes that it averages $80 to $140, depending on the region of the country.
"Part of our role as health professionals is to suggest creative ways to circumvent the financial barriers, especially when they can’t get third-party payers to cover the costs," she says. "We can advise our patients to ask for the money for anniversary presents or Mother’s Day or other special occasions. We also need to be aware so we can refer our patients to low-cost mammography screenings at health fairs and community fundraisers.
"We need to prepare to do anything we can legislatively, because third-party payers might take the [conference] statement as permission not to pay for mammography for women in their 40s."
Women also can use their clout in the workplace, Marki says. "If their employer’s plan doesn’t cover mammography, they could organize and present the case for including it."
The case, she explains, involves the savings of early detection and treatment compared to the expense of dealing with advanced breast cancer. Lumpectomies range from $4,800 to $6,600, Marki says, compared to the average of $5,500 to $7,500 for mastectomies. To treat metastasized or terminal cancer, she estimates bills of $50,000 to $100,000, depending on the duration and extent of treatment.
Women must not let breast cancer prevention policies be designed by forces outside their control, Clemons says, adding that feminine voices are strong when they speak in unison. "Doctors might have the guidelines," she says, "but women have the wants and they drive the process."
References
1. National Institutes of Health Consensus Development Conference Statement: Breast Cancer Screening for Women Ages 40-49, Bethesda, MD; 1997.
2. Andersson I, Duffy S, Nystrom L, et al. Breast-cancer screening with mammography in women aged 40-49 years. International J Cancer 1996; 68:693-699.
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