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http://www.nytimes.com/2002/06/23/health/womenshealth/23SHER.html

Doubts on Mammograms Do Not Affect Their Use

By MARCIA SHERMAN, M.D.

N October last year, the medical journal The Lancet published a study asserting that mammograms do not save lives and, in fact, cause many women to undergo painful and unnecessary treatments. Because this news directly challenged orthodox belief, the community of breast cancer experts and advocates was thrown into turmoil.

Distinguished expert panels declared that their confidence in mammography was shaken. A prominent oncologist announced that she had no immediate plans to continue having routine mammograms. The president of a national breast cancer advocacy group publicly regretted the mammogram that diagnosed her own cancer years ago.

In reality, there has always been disagreement over many aspects of breast-cancer screening. Not everyone is in favor of routine mammography for women under 50 because it is not as effective for younger women as it is for older women. What the Lancet study questioned was the practice of using mammography for any woman, young or old. Even the National Cancer Institute seemed to sway briefly while it reconsidered the evidence.

Then the dust settled. Two federal agencies — the Cancer Institute and the United States Preventive Services Task Force — affirmed their belief in the value of mammograms for women over 40. Life went on as usual. Or did it?

"Women may feel confused, but I don't know anyone saying, `Based on this study, I refuse to have a mammogram,' " said Dr. Rogerio Lobo, the director of obstetrics-gynecology at Columbia-Presbyterian Medical Center in New York. Pointing to a widespread misperception that breast cancer is the leading killer of women — heart disease and lung cancer are — Dr. Lobo added: "There's so much panic about breast cancer. Women are going to err on the side of early diagnosis and treatment."

"I have a few patients who dread mammograms and put them off, but eventually almost everyone I see has one," he said.

Nationwide, the number of women who are screened continues to rise. In 1987, fewer than a third of women over 50 reported having had a mammogram in the last two years. By 1994, that number had more than doubled, largely because of campaigns promoting mammograms as potentially lifesaving tools. Now, almost three-quarters of eligible women are screened, at a cost of $3 billion a year. The National Committee for Quality Assurance, an independent agency that sets standards for the health care industry, wants to increase that to 81 percent.

For women with private insurance and access to health care, that may not be unrealistic. Oxford Health Plans, the insurer, reported extremely high rates of compliance for its membership in New Jersey and Connecticut in 2001 — 97 percent and 83 percent, respectively. When any Oxford member misses her annual mammogram two years in a row, she is sent a reminder from her insurer. Other insurers have similar programs.

"Some of my patients refuse colonoscopy when I recommend it," said Dr. Judith E. Weisfuse, an internist in Summit, N.J. "No one protests a mammogram."

She added: "The problem is some people are overly reliant on mammograms. I have to keep reminding people that it's only a part of screening for breast cancer" along with self-exams and examinations by a doctor.

Some doctors suggested that widespread acceptance of mammography may not only have to do with fear of breast cancer but may also reflect an increasing awareness of breast cancer as a treatable disorder.

"Everyone knows that the death rate from breast cancer has dropped dramatically in the last 10 to 20 years," said Dr. Elissa J. Santoro, a breast surgeon at St. Barnabas Medical Center in Livingston, N.J. "You can't prove that better survival is all due to mammography; it obviously has something to do with better treatments. But women are seeing their friends getting early diagnosis and surviving. The ones whose mothers or sisters died from breast cancer are especially conscious of this. It's an awareness."

The Lancet study drew attention to the possibility that beyond unnecessary biopsies, some women diagnosed with cancer in its earliest stages may be having mastectomies or even aggressive medical treatments whose necessity is not established.

But most people fear dying more than being overtreated. "The least common call we get is from someone who can't understand why she's being offered the same drugs as someone else who's further along," said Cindy Pearson, the director of the Women's National Health Network.

DR. SANTORO added: "I think the tragedy of overtreatment lies in the past, when we were taking women to the operating room for open biopsies when we found something suspicious on the mammogram. The way we do biopsies now is far less invasive."

Ms. Pearson and the doctors who were interviewed for this article said that the Lancet study mainly bolstered the beliefs of the naysayers, mavericks who have never put much stock in mammography. But they also thought that, in general, the public may be waking up to the complexities of a common disease that is still not well understood.

"People ask me, `What's the real deal here?' " Ms. Pearson said. "There's a sort of awareness that the mammography issue is not as nice and tidy as we'd like it to be."

Asked about the impact of the Lancet study, Zora Brown, the director of the Breast Cancer Resource Committee, sighed. Ms. Brown's group addresses the need for more aggressive diagnosis and treatment in African-American women, who suffer disproportionately from breast cancer mortality.

"This study just muddied the waters for women who don't have access to health care," she said. "The real issue isn't mammography. In my opinion, it's an adequate screening tool, and women have bought into it."

"The real issue," Ms. Brown said, "is what happens after the mammogram for the woman who has just been diagnosed and who does not have access to treatment."

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