Shots - Health Blog
6:37 am
Tue May 1, 2012

Studies Reignite Mammography Debate For Middle-Aged Women

Should women in their 40s routinely get mammograms to detect breast cancer?

Two studies released Monday aim to help resolve that question, which is one of the most intense debates in women's health. The studies identify which women in their 40s are most likely to benefit from routine mammograms.

For years, the mantra was that regular mammograms save lives. So many people were stunned in 2009 when an influential panel of experts questioned that assumption.

The U.S. Preventive Services Task Force recommended against all women in their 40s getting a mammogram every year or two.

"The benefit of mammography in the 40s is not as large as it is later in life and is not as large as most people assume it to be. And there are some harms associated with mammography," said Michael L. LeFevre of the University of Missouri School of Medicine, a task force member.

Those harms include frightening women with false alarms, prompting them to come back for repeated exams and unnecessary biopsies. Mammograms may also cause women to undergo unneeded surgery, radiation, and chemotherapy.

"Mammography may pick up small tumors that never would have progressed to harm them in their lifetimes," said Jeanne Mandelblatt, an oncologist at Georgetown University. "Yet they'll undergo treatment for breast cancer when that disease if it had been never detected would have never bothered the woman."

The task force did conclude that a mammogram every other year is warranted for for women in their 50s because their risk for breast cancer is higher.

So Mandelblatt and her colleagues decided to see if there were some 40-somethings who had about the same risk as women in their 50s. They analyzed data from millions of women, mammograms, and breast cancer cases from dozens of published studies and huge databases.

"The studies were designed to identify what was the risk level that would be the tipping point so that the benefits and harms would be the same as what's currently recommended for starting at age 50?" Mandelblatt said.

In two papers published in the Annals of Internal Medicine, the researchers found that two types of women would benefit from regular mammograms in their 40s: those who have very dense breasts, and those who have a close relative — a mother, sister or daughter — who had breast cancer.

"They're twice as likely to develop breast cancer as the average woman, and that higher risk of developing breast cancer tips the balance to having more benefit to the harms," she said.

The studies will help guide women and their doctors, according to Karla Kerlikowske of the University of California, San Francisco, who worked on the studies.

"If you're a 40-year-old who's at high risk of breast cancer then undergoing mammography every two years makes sense for that person. If you're a 40-year-old person who's at very low risk waiting til you're 50 is reasonable," she said.

But for a lot of women, the answer still remains far from clear, said Fran Visco of the National Breast Cancer Coalition.

"There's no absolute answer for women in their 40s or even in their 50s," said Visco. It's not as simple as "you fall into this category — you should be screened. That will save your life," Visco said.

Others disagree with the papers, too.

"These papers are just several more in a series of papers that I think are misleading women and their physicians," said Daniel B. Kopans, a radiologist at the Harvard Medical School. "And I think if women really appreciated what they're being told they would be outraged."

Carol Lee of the American College of Radiology worries the research could end up costing lives.

"This may discourage women who don't have an identifiable risk factor from seeking screening, and therefore the potential lifesaving benefit of screening won't be realized," Lee said.

The American Cancer Society still recommends all women in their 40s get screened every year. And Otis W. Brawley, the society's chief medical officer, says he's not ready to change that profile.

"I don't think we're ready to actually have as a widespread policy that we would use these profiles to determine who should get screened and who should not get screened," said Brawley, who wrote an editorial published with the studies.

But, he says, the new studies are clearly a step in that direction.

"I could easily see in the next several years that we would be using these profiles," Brawley said.

In the meantime, it's up to doctors and their patients to weigh the pros and cons of mammograms for women in their 40s for themselves.

Copyright 2013 NPR. To see more, visit http://www.npr.org/.

Transcript

AUDIE CORNISH, HOST:

It's ALL THINGS CONSIDERED, from NPR News. I'm Audie Cornish.

ROBERT SIEGEL, HOST:

And I'm Robert Siegel.

New research suggests that some women in their 40s would benefit from routine mammograms every two years. As NPR's Rob Stein reports, researchers are trying to resolve a long debate over the benefits and harms of mammography in younger women.

ROB STEIN, BYLINE: For years, the mantra was that mammograms save lives. So many people were stunned back in 2009, when an influential panel of experts basically said, wait a minute. The panel questioned whether all women in their 40s should routinely get a mammogram every year or two. Michael LeFevre is on that panel.

DR. MICHAEL LEFEVRE: The benefit of mammography in the 40s is not as large as it is later in life, and it's not as large as most people assume it to be. And there are some harms associated with mammography.

STEIN: Those harms include scaring women with false alarms, making them come back for repeated X-rays, getting biopsies, surgery, radiation and chemo they don't need.

DR. JEANE MANDELBLATT: Mammography may pick up small tumors that never would have progressed to harm them in their lifetimes.

STEIN: That's Jeane Mandelblatt of Georgetown University.

MANDELBLATT: Yet, they'll undergo treatment for breast cancer when that disease, if it had been never detected, would have never bothered the woman.

STEIN: The expert panel did conclude that a mammogram every other year is a good idea for women in their 50s. So Mandelblatt and her colleagues decided to see if there were some 40-somethings who had about the same risk as women in their 50s. They analyzed data from millions of women - mammograms and breast cancer cases - from dozens of published studies and huge databases.

MANDELBLATT: The studies were designed to identify what was the risk level that would be the tipping point so that the balance of benefits and harms would be the same as what's currently recommended for starting at age 50.

STEIN: Their conclusion? Getting a mammogram every couple of years does make sense for some women in their 40s - those who have very dense breasts, and those who have a close relative - a mother, sister or daughter - who had breast cancer.

MANDELBLATT: They're twice as likely to develop breast cancer as the average woman. And that higher risk of developing breast cancer tips the balance to having more benefit to the harms.

STEIN: The researchers say the findings will help guide women. Dr. Karla Kerlikowske is a San Francisco breast cancer expert who worked on the studies.

DR. KARLA KERLIKOWSKE: Whether you're in your 40s, 50s or your 60s, your screening should be based on what your risk is. And if you're a 40-year-old who's at high risk of breast cancer, then undergoing mammography every two years makes sense for that person. If you're a 40-year-old person who is at very low risk, waiting till you're 50 is reasonable.

STEIN: But for a lot of women, according to Fran Visco of the National Breast Cancer Coalition, the answer still remains far from clear.

DR. FRAN VISCO: There is no absolute answer for women in their 40s, or even in their 50s. There is no absolute answer. You fall into this category, you should be screened, that will save your life - it's just not that simple.

STEIN: But not everyone agrees. Radiologist Daniel Kopans, at Harvard, argues screening all women in their 40s, clearly, saves lives.

DR. DANIEL KOPANS: These papers are just several more in a series of papers that, I think, are misleading women and their physicians. And I think if women really appreciated what they're being told, they would be outraged.

STEIN: Dr. Carol Lee, of the American College of Radiology, worries the research could end up costing lives.

DR. CAROL LEE: This may discourage women who don't have an identifiable risk factor from seeking screening and therefore, the potential life-saving benefit of screening won't be realized.

STEIN: The American Cancer Society still recommends all women in their 40s get screened every year. Otis Brawley, the society's chief medical officer, says he's not ready to change that profile.

DR. OTIS BRAWLEY: I don't think that we're ready to actually have, as a widespread policy, that we would use these profiles to determine who should get screened and who should not get screened.

STEIN: But, he says, the new studies are clearly a step in that direction.

BRAWLEY: I can easily see, in the next several years, that we would be using these profiles.

STEIN: In the meantime, it's up to doctors and their patients to weigh the pros and cons of mammograms for women in their 40s themselves.

Rob Stein, NPR News. Transcript provided by NPR, Copyright NPR.