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The Untold Truth Behind the Mammogram Dispute

March 13, 1994|Susan M. Love | Susan M. Love, a doctor, is director of the UCLA Breast Center.

The national angst over whether women aged 40 to 49 should undergo regular mammography cancer exams surfaced again last week. Some members of Congress took turns criticizing the National Cancer In stitute for "irresponsibly" recommending that these women need not be routinely tested. "They (the NCI) play it very fast and loose with women's health," Rep. Patricia Schroeder (D-Colo.) told a House subcommittee looking into the institute's new guidelines. "This is one of the final insults."

One byproduct of this controversy is endangering lives. All the tumult and emotion have buried an important message. Every study of mammography screening on women 50 and older has shown the exam's potential to save lives. Yet, only about one-third of these women are getting mammograms. Why? Because we are obsessed with cancer risks faced by younger women.

Almost every woman's magazine article about breast cancer is illustrated with a photograph of a 25-year-old. The public-service announcements on television all feature a 30-year-old discovering cancer. The older women most likely to develop breast cancer simply don't identify with these women. The message is lost on them--and will continue to be unless we change the way information about mammography is delivered.

Still, what should women under 50 do? Last December, the NCI reviewed the data on pre-50 mammogram exams. As a result, it backed off its 1987 recommendation that women 40 to 49 should automatically be tested every other year.

This change in policy was not prompted by a desire to save money in President Bill Clinton's health-care reform, as many critics have charged. Nor was it an "insult" to women. Nor was it intended to deny younger women their God-given right to radiation. Rather, it was about telling the truth: We simply do not have the answers.

In 1982, the American Cancer Society, on the basis of a few inconclusive studies, decided that mammography screening might save younger women's lives. It recommended mammograms for women at age 35, and exams every year and a half to two years for women 40 to 49.

Over the years, these guidelines, although more the product of wishful thinking than good science, became etched in stone. Women believed they were rooted in established fact. Many professional organizations uncritically echoed the guidelines.

Eight major studies of mammography screening, however, have failed to demonstrate a single benefit for women 40 to 49 five to seven years after their first mammogram. Ten to 12 years later, the benefit is marginal, at best.

In response, the American Cancer Society quietly dropped, in 1991, its recommendation for a mammogram at 35. But it clung steadfastly to its advice of "Once a Year for a Lifetime" for women 40 to 49.

When a long-awaited Canadian study recently confirmed the results of all previous investigations, the cancer society came face-to-face with the contradictions between its guidelines and the data. Astoundingly, it declared that women would be "too confused" if they were told the truth and that the guidelines should thus stand. For its part, the National Cancer Institute acknowledged that women younger than 50 are capable of reviewing the pros and cons and making their own decisions.

What are the pros and cons faced by a 45-year-old woman weighing her options? Mammography can detect small or early cancers in some women. But that is not the issue. Rather, it is whether finding such lesions early can actually save lives. The answer is consistently no. In some women, cancer is so slow growing that it doesn't matter whether it is found this year or next; they will live, either way. In others, the cancer is so aggressive they will die no matter when diagnosed.

There may be other benefits to considering mammography, however. What if screening detects a cancer that can be treated without mastectomy, thereby improving the quality of a woman's life even if it cannot extend her years? That difference may be important to some women, making screening worthwhile.

But there is a real risk that stems from imperfect technology. Many mammograms will be read as negative when there is, in fact, a tumor because the breast tissue is dense, lulling women into a false sense of security. Other mammograms are read as suspicious, leading to extra X-rays and unnecessary biopsies. These issues will be weighed differently by different women. A 45-year-old with a family history of breast cancer may find the risks worth taking, while a low-risk woman with dense breasts may not.

Women over 50 need to be encouraged to get yearly mammography screenings. Younger women need to review the issues and make up their own minds. True prevention of breast cancer requires that women be given the truth about medical tests, and that means better-funded studies rather than fiery rhetoric.

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