Female Radiologist's View: Get Mammograms at 40

Friday, 04 Dec 2009 10:28 AM

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Amid the confusion and controversy after a federal task force suggests that women don't have to get mammograms until they are 50, my doctor/niece begs to differ.

The U.S. Preventive Services Task Force, a federal scientific advisory panel, rocked the medical world with its recent report recommending that women in their 40s with an average risk for breast cancer — no special factors being present — do not need annual mammograms.

The House Energy and Commerce Committee convened a hearing on the issue Wednesday and took testimony from task force members.

CBS News reported, “Sticking carefully to the script, the lead doctors behind the controversial new mammogram recommendations issued a mea culpa, saying they ‘communicated very poorly.’. . . Still, the government-appointed task force is holding firm on its recommendation that most women should not get regular mammograms until age 50.”

CBS correspondent Nancy Cordes continued, “Lawmakers and doctors worry that insurance companies will use the guidelines to justify reductions in mammogram coverage. . . The task force insists its guidelines have been misconstrued to mean that women under 50 should forgo mammograms altogether. They say they meant to convey that women under 50 should consult with their doctor to make the choice that’s right for them.”

I thought my readers would benefit from the comments of Dr. Marjorie Rosenblatt, who happens to be my niece. She is brilliant and has the credentials needed to comment on this issue. She is a radiologist who specializes in women's imaging, with more than half of her office time spent providing breast imaging services. That translates into reading several thousand mammograms annually.

She is a member of the Radiologic Society of North America and the Institute of Ultrasound In Medicine, among other radiologic organizations. The statistics for her office indicate that for the year 2008, 34.53 percent of new breast cancers and atypia (pre-cancerous lesions) they diagnosed were in women under 50 years old, and in 2007, 37.80 percent. As such, she strongly opposes the new suggested guidelines for mammography.

Here are Rosenblatt’s thoughts:

“As a breast imager, how do I feel about the new mammography guidelines? This is a question I have been asked by dozens of my patients . . . since the revised guidelines of the Preventive Services Task Force of the Department of Health and Human Services were made public.

"Quite simply, I am confident that the changes will lead to great morbidity and eventual mortality. In my practice in the suburbs of NYC, more than one-fourth of our new cancers in the past year occurred in women under the age of 50. Tumors in younger patients tend generally to be more aggressive than those in the elderly.

"While I don't have a formula to translate treatment of incident malignancies into lives saved, it is incomprehensible to me that the diagnosis of scores of cancers in women in their 40s does not translate into significant lives saved. Additionally, a smaller cancer may result in lumpectomy rather than mastectomy and the need to treat distant metastases, and may avoid radiation and chemotherapy, significantly decreasing the overall cost to the system.

"For an examination to be appropriate to serve as a screen, it must be cost effective, and therefore we are, unfortunately effectively left determining the financial value of a life; the task force concluded that saving one out of 1,339 lives of those 50-59 was cost effective, but not one out of 1,904 lives of women 39-49; again, these numbers seem abnormally low to me, as we, in my office, identify a new malignancy in every few hundred mammograms interpreted.

"As striking to me when I consider that concept is the idea equating the value of a life of a 40-year-old with that of an older patient; are the implications of illness the same for each? Is a 40-year-old not much more likely to have small children who rely on her, or more likely to be contributing to the workforce?

"Who were the people making up the government's task force proposing the new recommendations, which were disputed by the American Cancer Society within hours? The 16-member team consisted of an epidemiologist, a professor of biomedical informatics, a geriatrician, a pediatrician, and a nurse, amongst others. Not a single ob/gyn, breast surgeon, oncologist or radiologist was to be found — not one person who deals with breast cancer on a daily basis.

"As one who is in the battlefield with the patients every day, I am concerned that the insurance companies will inevitably use/misuse these disputed suggestions to reject claims for indicated mammograms, as I see them do on a daily basis with breast MRI. I also worry that less-educated patients, as a result of the imbalanced press, will not recognize that there is vehement opposition to the proposed changes and will simply welcome justification to delay an unpleasant examination.

"It is clear that false positive breast examinations result in great patient anxiety, and mammography is, at best, an imperfect science. Breast cancer is, as a result of its prevalence, very frightening to most women; it will directly affect approximately 1 in 8 American women, and is the second-leading cause of cancer deaths in American females.

"Poll your female friends, and I guarantee that the majority would gladly risk a false positive study to find a cancer while it is small. I also feel confident that almost all of them have a sister, mother or friend diagnosed with breast cancer prior to the age of 50. I know that these are truths in my patient population. So . . . how do I feel about the new guidelines?

"My friends, my patients and I will unequivocally continue yearly mammographic screening over the age of 40 until there is a significantly more compelling argument to do otherwise.”

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