YMG experts tell women to get mammograms

[December 2009] Yale Medical Group physicians are urging women not to change their breast cancer screening routines after a government task force reversed long accepted breast cancer screening guidelines, and prompted a heated debate over when women should get mammograms.

“Patients should know that nothing has changed, and they shouldn’t stop doing what they’re doing,” says Liane Philpotts, M.D., chief of breast imaging for the Yale Breast Cancer Program, in response to recommendations published the in the November 17 Annals of Internal Medicine. Philpotts became especially concerned when some patients called to cancel their mammograms after the news broke.

“For breast cancer screening, mammograms are still the gold standard,” Philpotts said. “Out of all the tests in medicine, mammograms are the most widely studied test to show a decrease in mortality. We know that if we don’t do mammograms for women in their 40s, we will definitely lose lives. Those younger women have a lot to lose. Many have young families and a lot of life ahead of them”

Highlights of the report from the U.S. Preventive Services Task Force, a government appointed expert panel:

• Most women in their 40s should not get routine mammograms.
• Women ages 50 to 74 should have routine mammography screenings every two years.
• The risks and benefits of mammography for women over 75 are unknown. There is insufficient evidence to assess the benefits of clinical breast examination for women, and clinicians should not continue to teach women to perform self-exams.

The task force, which did not cover high risk women, reversed recommendations it made in 2002 that women should start routine mammography at 40. In its recent statement, the task force reasoned that early, frequent screenings cause false alarms, unnecessary biopsies and resulting anxiety for women without substantially improving their odds of surviving breast cancer.

Testifying before the health subcommittee of the House Energy and Commerce Committee two weeks after making the recommendations, task force members apologized for the controversy, saying that its “communication was poor.” While they continued to defend their position that screening is more effective for women ages 50 to 74, they emphasized that women 40 and older should receive a mammogram whenever they and their physicians believe it is appropriate.

Don’t make sudden changes

Philpotts and YMG colleagues Lyndsay Harris, M.D., and Donald Lannin, M.D., all caution patients against making any sudden changes in their screening routines based on the task force’s advice.

All three physicians feel the benefits of routine mammography starting at age 40 still outweigh the risks, and many women over age 74 have healthy life spans ahead of them and probably benefit from continued screenings.

While the physicians agree with the panel that there is no good statistical evidence on self-exams reducing mortality, there is anecdotal evidence, says Harris, co-director of the Yale Breast Cancer Center and an oncologist. “We see women with breast cancer on a daily basis diagnosed after they found an abnormality conducting their own exam,” she says. “The bottom line is that when a patient detects a lump and her physician is concerned, then it needs to be further evaluated, and that’s the standard of care."

Listen to the message

One take-away message may be that while routine mammography is the best screening tool available, it’s not a simple solution.

Mammography has made a significant impact, said Lannin, co-director of the Yale Breast Cancer Center and a surgical oncologist. “There is pretty good data to show that since 1990, breast cancer has fallen by about 30 percent,” he said. “Whatever we’re doing, we’ve reduced mortality by 30 percent. As far as we can tell, screening is responsible for about half of that, and better systemic therapy—both hormonal and chemotherapy—are responsible for the other half.”

Doctors have known for years that mammography picks up more cancers in women in their 50s than in their 40s. Data show that routine mammography saves one life for every 400 women screened in their 60s, one life for every 1,400 women screened in their in their 50s, and one life for every 1,900 women screened in their 40s, Lannin says.

“You do have to screen all those women to save one life. But who is to say whether or not you should screen to save that life?” he says.

If anything, the guidelines prompt important discussion about screenings, Harris says. “Maybe the question is not who should we screen, but how can we improve our screening techniques. And how should we screen women who have a more aggressive form of cancer that might not easily be picked up on a mammogram? We don’t have good enough markers for who is at risk.”

Look for changes in the future 

In the future, one solution may be better screening methods that reduce false positives and anxiety for women. An example is breast tomosynthesis, a three-D mammography that is currently under FDA review and not yet available to patients. Tomosynthesis shows “a whole series of slices of the breast,” instead of overlapping tissues,” says Philpotts, who has been studying the technology. “It’s like the pages of the book. It’s like looking at one page at a time instead of the whole thing at once.” Tomosynthesis would allow radiologists to see breast tissue more clearly and potentially reduce callbacks due to suspicious mammograms.

In addition to their work with genetic testing for the BRCA1 and BRCA2 mutations, YMG physicians are looking ahead to more personalized screening based on evolving knowledge of how breast cancer develops.

 “As we understand more about the molecular biology of tumors, we might find out why more of them don’t show up on screening mammograms,” Lannin says. “So there are hopes that we eventually will have a better idea of who should be screened and how frequently, and will even be able to make recommendations other than screening for some women at risk for breast cancer.” 

Sorting out the confusion

Meanwhile, Philpotts is concerned that conflicting recommendations are causing confusion for women that could hurt the progress physicians have made in encouraging routine screenings.

She points to a bill passed in Connecticut on October 1 that requires letters be sent to patients whose mammograms show dense tissue advising  them to talk to their doctors about further screening with ultrasound and breast MRI, a strategy she says hasn’t been proven to reduce mortality and will lead to more false positives than mammography.  
“So you have one group, the task force, being very conservative, and other groups recommending more screenings,” she says.

“The most important thing for patients to know is that nothing has really changed,” Philpotts said. “We still want women to get routine mammograms starting at age 40. We may have some false alarms, but we will be better able to find cancer early, when it is easiest to treat.”