Why Women Reject the Mammogram Recommendations

Most adult women know a woman in her 40s who was diagnosed with breast cancer and died. So the news this week that mammograms and self–breast exams do little to protect women under 50 against breast cancer—and that doctors have nothing new to offer in their stead—felt like a real slap to women who have been diligently doing everything they were told to do to protect themselves. So perhaps that's why, despite the fact that an expert panel insists that its recommendations are designed to reduce young women's exposure to radiation and unnecessary biopsies, and despite strong evidence supporting new guidelines, many women across the country have been rallying against the U.S. Preventive Services Task Force recommendations, demanding that access to mammograms for women under 50 continue.

In many respects, the sense of betrayal rivals the news back in 2002 that hormone therapy—long pushed by doctors as a way for women to keep their aging hearts strong, despite a lack of strong evidence—turned out to increase the risk of heart disease, breast cancer, stroke, and blood clots. When conventional wisdom about sensitive health issues is turned on its head seemingly overnight, is there any surprise that women are upset and angry?

"We spent 20 years telling women to be afraid, be very afraid, of breast cancer, and that they could save their lives through early detection," says Cindy Pearson, executive director of the National Women’s Health Network. But in fact, the evidence has been mounting since 1992, when a Canadian National Breast Cancer Study concluded that mammograms had no effect on mortality for premenopausal women 40 to 50 years old. Scientists have long known that mammography becomes more effective after menopause; as estrogen and progesterone levels drop, the breast becomes less dense and easier to screen. The initial recommendation to begin mammograms at age 40, made in 1983 by the American Cancer Society, was based on a documented rise in breast-cancer rates, not because of compelling data that mammograms were highly effective for the younger age group.

"We started telling our members in 1993 that there was good evidence that mammograms didn't work well for women in their 40s," says Pearson. "It took 16 years for another study to be done to verify that it doesn't work well for younger women. What women should be upset about is that we lost 16 years when we could have been looking for another screening tool for younger women."

But they're not. What the majority of women seem to be upset about is that what they believed was a lifeline could be taken away. Part of women's shock at the new recommendations, Pearson says, is that for years women have been misled into thinking that the evidence for mammography is better than it really is. While many women know someone who found a tumor through a self-exam, careful studies have shown that monthly exams do not reduce breast-cancer mortality rates. It's medically accepted that mammography only reduces breast-cancer mortality by 15 percent for women ages 40 to 49, while resulting in a very high rate of false positives, unnecessary biopsies, and anxiety in women whose cancers are so slow-growing or so inconsequential that they'd never become a threat. Mammograms, like X-rays, also expose patients to radiation, so the risks must be weighed against the benefits, particularly for younger asymptomatic women with no family history of the disease.

Dr. Karla Kerlikowske, director of the Women's Veteran's Comprehensive Health Center at the San Francisco Veterans Affairs Medical Center, who wrote an editorial that accompanied the publication of the new guidelines in the Annals of Internal Medicine, says she's stunned at the negative reaction to the new guidelines. "The real problem is that mammography has been oversold as this great thing, when in reality, it's only a moderately accurate thing, not nearly as effective as something like Pap smears are in detecting cervical cancer," she says, noting that younger women would be better served by reducing their alcohol intake, exercising more, and maintaining a healthy weight than by getting a mammogram.

Not all doctors agree. Largely outside the public view, expert panels have been arguing for years about whether to raise the mammography age to 50. "What we see is a continuum across the age group. As women get older, the benefits of mammography get better and the harm gets less," says Dr. Heidi Nelson, who conducted the meta-analysis of breast-cancer studies that led to the new recommendations. "Where you [draw] that [cutoff] line is a hard one to interpret." The American Cancer Society and the American College of Radiology have steadfastly insisted that the benefits outweigh the risks for 40-year-olds, while the American College of Physicians and the National Women's Health Network have been among the most outspoken critics. Without a clear consensus among the experts, the public message remained the same: start getting mammograms between age 40 and 50.

Despite the new guidelines, consensus remains elusive, and that's increasing the confusion level by the hour. Within hours of the release, the American Cancer Society, the American College of Obstetricians and Gynecologists, Susan G. Komen for the Cure, and other groups issued position statements opposing the new recommendations. The American Cancer Society has been particularly vigorous in its defense of the status quo. Dr. Otis Brawley, the chief medical officer of the ACS, noting that 4,000 women a year die of breast cancer in their 40s, even accused the task force of undervaluing women's lives in an editorial in Thursday's Washington Post: "With its new recommendations, the task force is essentially telling women that mammography at ages 40 to 49 saves lives—just not enough of them to recommend that all women get screened." He also said that the task force relied too much on older studies, conducted before modern mammography's improvements.

The furor may also stem from frustration that women's health research has been underfunded for years. It is beyond distressing to many that despite all the pink ribbons and fundraising they've done over the last decades, breast cancer remains such a mystery and doctors have little to offer beyond mammography, which can detect cancerous tumors as well as precancerous cells but often can't provide doctors with the kind of information they need to determine when to intervene and when to watch and wait.

One thing all the experts agree upon is that the best decision for any individual woman is made in partnership with her doctor after reviewing her own health and cancer history. Women with a particularly high risk of cancer may decide with their doctor that early mammograms make sense, while women at low risk might choose to put off mammograms until they are older. No matter what they decide to do about mammograms, all women should continue to get annual doctor-administered breast exams as their first line of defense against the disease. Amy Allina of the National Women's Health Network says she hopes all women will use this news to press harder for researchers to find a new screening process that works effectively for them. "This is a frightening disease, and women do not want to be told that there is nothing they can do to protect themselves," Allina says. "We have to demand that a new tool be developed."

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