http://www.nytimes.com/2002/02/22/health/22MAMM.html
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February 22, 2002 Guidelines by U.S. Urge Mammograms for Women at 40
By SHERYL GAY STOLBERG
The guidelines, announced by Tommy G. Thompson, the secretary of health
and human services, stem from an analysis by an independent committee of
experts that advises the health agency on preventive medicine. The guidelines
are the federal government's official policy on mammograms. "Mammography is not a perfect tool," Mr. Thompson said,
acknowledging that recent studies have raised "legitimate issues"
about breast cancer screening. But, he added, "Mammography is an
important and effective early detection tool that helps to save lives." Annual mammograms have long been routine for millions of American women,
but the question of whether they truly reduce breast cancer deaths has been
debated for years. The controversy was renewed last October, when a group of
scientists in Denmark said they had found serious flaws in seven large
studies that doctors believed had proved the benefits of mammography. The Danish study prompted a group of American cancer experts to conclude
in January that the benefits of breast cancer screening did not necessarily
outweigh the risks, which include unnecessary surgery to remove tumors that
might never have caused a problem. But after a review of the same studies
that began in 1999, the preventive medicine committee reached a very
different conclusion. "Our bottom line," said Dr. Janet Allan, vice chairwoman of the
committee, "is that mammograms reduce deaths from breast cancer." The committee's recommendation, that women ages 40 to 69 undergo
mammograms every one to two years, rests on its willingness to accept a
number of studies that the group in Denmark discounted. While acknowledging
that these studies had flaws and that "the flaws were problematic,"
the committee said the problems were not severe enough to dismiss the work. Over all, Dr. Allan said, the committee concluded that women who received
mammograms routinely were 23 percent less likely to die from breast cancer
than women who did not. Thus the committee said it had found "fair
evidence" that screening every 12 to 33 months "significantly
reduces mortality from breast cancer." The 15-member committee, called the United States Preventive Services Task
Force, published two earlier breast cancer screening recommendations, in 1989
and 1996. Both endorsed screening for women ages 50 to 69, and today the
panel said the evidence in favor of mammography was strongest for that age
group. Because the risk of breast cancer is lower in women under 50, the benefits
of regular mammography are smaller for this age group. But evidence is
emerging from continuing studies that younger women also benefit, Dr. Allan
said. While the committee's report said it was "difficult to determine
the incremental benefit of beginning screening at age 40 rather than age
50," the panel nonetheless recommended that women do so. That Mr. Thompson announced the panel's recommendations is unusual.
Typically, such reports are published in a medical journal. Advocates for
breast cancer patients said they expected the committee's findings to be
published in April, in The Annals of Internal Medicine. Mr. Thompson, whose wife was successfully treated for breast cancer seven years
ago after a tumor was identified by a mammogram, made clear today that he
felt a responsibility to speak out. "Women are confused as to whether they should have a mammogram or
not," Mr. Thompson said. "I feel that, as secretary of health and
as someone who has personally been through this, it was the right thing to
do." Breast cancer is the most common cancer among women in the United States
and, after lung cancer, the second-leading cause of cancer-related death,
according to the health and human services agency. In 2001, the department
said, the cancer was diagnosed in 192,200 women, and 40,600 died from the
disease. Today's recommendations, and Mr. Thompson's endorsement of them, were
greeted warmly by advocates for breast cancer patients and doctors who care
for them, who have worried that a recent drop in breast cancer deaths will
turn around if women stop seeking mammograms. Some feared that the controversy would result in financing cuts to
programs that promote mammography and would prompt insurance companies to
stop covering the tests. Today's recommendations are likely to prevent that
from happening, advocates said. "I'm very happy," said Dr. Carolyn Runowicz, a
gynecologist-oncologist and breast cancer survivor who serves on the board of
the American Cancer Society. "It's a very well-respected group," Dr. Runowicz said, referring
to the committee. "They examine data very carefully and they come up
with what they feel is good evidence- based medicine, and they are
politically independent." Zora Brown, founder of the Breast Cancer Resource Committee, an advocacy
group that seeks to lower breast cancer rates among African- American women,
said, "Hopefully this will put to rest some of the controversy." Others predicted the controversy would only grow. Among them was Dr.
Donald Berry, chairman of the department of biostatistics at M. D. Anderson
Cancer Center in Houston and a member of the so-called P.D.Q. panel of cancer
experts that in January cast doubt on the validity of mammograms. "They pooh-pooh some of the criticism of the trials, and I'd like to
know on what grounds," said Dr. Berry, who has emerged as an outspoken
critic of mammography. The idea behind mammograms is that there is a benefit to detecting tumors
early on, when they are smaller. But there are downsides, the federal
committee found. The large majority of abnormal mammograms, 80 percent to 90
percent, are false positives, which can prompt a woman to undergo invasive
procedures, like breast biopsy, that may be unnecessary. The P.D.Q. board, which does not make policy recommendations but writes
information for the National Cancer Institute, highlighted these drawbacks in
January. The panel said that it was rational for women to decide to have
mammograms and that it was also rational for them to decide not to. Today, Dr. Berry said the panel would write up its findings, despite the
new federal guidelines. At the same time, however, officials at the National
Cancer Institute affirmed their support for mammography, even as they spoke
of the need to "seek improved methods of diagnosis and treatment of
breast cancer." In addition to addressing mammography, the panel examined the benefits of
self-examinations and clinical breast exams performed by doctors. It said
that while these techniques detected some additional cancers there was not
enough data to determine whether they reduced deaths from breast cancer. |
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