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After the mammogram storm, what should women do?

By Lisa O'Neil Hill, Special to CNN
Nancy G. Brinker, founder and CEO of Susan G. Komen for the Cure, said the confusion about screening kept women away.
Nancy G. Brinker, founder and CEO of Susan G. Komen for the Cure, said the confusion about screening kept women away.
  • Experts say the benefits of getting a mammogram far outweigh any potential harm
  • The majority of women who develop breast cancer do not have an identifiable risk factor
  • Doctors agree that it's something that needs to be discussed on an individual basis

(CNN) -- Christie Hall began putting off mammograms long before debate about appropriate screening became a hot-button issue.

Hall, a 52-year-old yoga instructor who lives in Southern California, has had two or three mammograms, far fewer than experts recommend. She has a doctor's order for the screening but has put it off, noting conflicting reports and concerns about radiation exposure. Hall said there is no history of any kind of cancer in her family, but her physician has been persistent.

"There are so many unneeded biopsies and so much unneeded testing because of false positives," said Hall, who has studied the issue and who has a master's in kinesiology. "I don't see a point to exposing myself to this process."

While breast care experts acknowledge that mammography is imprecise and can lead to false positives, undue anxiety and overtreatment, they say it is the best tool they have for detecting breast cancer and that the benefits far outweigh any potential harms. Mammography has helped reduce breast cancer mortality in the United States by nearly one-third since 1990, according to the American College of Radiology.

Last month, the American College of Obstetricians and Gynecologists (ACOG) issued new breast cancer screening guidelines, recommending that mammography screening be offered annually to women beginning at age 40.

Screening guidelines have been controversial for decades, but the issue exploded nearly two years ago when the U.S. Preventive Services Task Force recommended against routinely providing the screening for women in their 40s. The task force said the decision should be based on individual considerations and said overscreening caused stress, unnecessary testing and other negatives outcomes.

Dr. Virginia A. Moyer, chair of the task force and professor of pediatrics at Baylor College of Medicine, said the recommendation was based on a recognized modest benefit shown by studies in human subjects. Recommendations from other organizations are based on evidence of lower quality, and the task force is extremely strict about the level of evidence it can accept, she said.

"There are also risks, and the benefits and the risks are closely balanced," Moyer said. "It doesn't mean that there is no net benefit."

The American Cancer Society, the American College of Radiology and Society of Breast Imaging as well as Susan G. Komen for the Cure, which is the world's largest breast cancer organization, condemned the task force's recommendation and have been united in their message that women can decrease their chances of dying from the disease by beginning annual mammograms at 40.

"The initial recommendation from the task force caused a great deal of confusion, which was unfortunate because what I think they were trying to say is, I think, something very reasonable. The way they said it and the way it came out was very unreasonable," said Dr. Otis W. Brawley, chief medical officer of the American Cancer Society.

"What the task force was trying to say is mammography is an imperfect screening tool and there are some harms associated with it, but there are also some benefits associated with it," he said. "They were trying to say the benefits are not nearly as good as we would all like."

Moyer said Brawley is on target.

"In many, many instances, our recommendation has been interpreted as a 'don't do it.' That is incorrect," she said. "It's something that needs to be discussed on an individual basis. For some women, it will be consistent with their values to choose to have a mammogram between 40 and 50. For other women, they will choose not to, and those are both reasonable decisions."

The benefits of mammography increase as women age. The task force said that 1,904 women in their 40s need to be screened to save one life. For women in their 50s, one life would be saved for every 1,340 women screened and for women in their 60s, it is one life per 370 women.

Brawley noted at the time that the task force was essentially telling women that mammography at ages 40 to 49 saves lives -- just not enough of them to recommend annual screening.

Women should begin getting annual high-quality screenings at 40 at the same place so physicians have access to previous mammograms, Brawley said.

It is unclear whether the task force's recommendations turned women in their 40s away from mammography, although some facilities reported a decrease in screening in the wake of the controversy.

Nancy G. Brinker, founder and CEO of Susan G. Komen for the Cure, said the confusion about screening undoubtedly kept women away.

"We know today that only 50% of women with health care benefits are getting screened," said Brinker, who said the task force was clumsy in the delivery of its message.

"Every five years, this discussion erupts and people spend a lot of money and time and come to the same conclusion," she said.

Susan Pisano, a spokeswoman for America's Health Insurance Plans, whose members cover more than 200 million Americans, said she did not know of any companies that changed their policies after the task force's recommendations.

"Our members are concerned that all the discussion may result in women getting the wrong message," she said. "We think mammography is important."

Under the Affordable Care Act, signed into law last year, insurance companies will be prohibited from charging deductibles, co-payments or co-insurance on preventive services, including mammograms for patients who bought or joined a new health plan on or after September 23, 2010.

Breast cancer is the second leading cause of all cancer-related deaths among American women and one in six breast cancers occur in women 40 to 49.

However, the number of breast cancer cases diagnosed in the U.S. declined 2% each year between 1999 and 2006, and deaths from breast cancer have also decreased steadily over the past two decades.

Although women in their 40s have a lower incidence of breast cancer compared with older women, the window to detect tumors before they become symptomatic is shorter (2 to 2.4 years) compared with women ages 70 to 74 (4 to 4.1 years), the authors of the ACOG guidelines said. The five-year survival rate is 98% for women whose breast cancer tumors are discovered at their earliest stage.

Debate about appropriate screening continues, however. A study published in the Annals of Internal Medicine in July advocates a more nuanced approach to mammography, taking personal risk factors such as age, family history of breast cancer, breast density and personal preference into consideration.

Dr. Carol H. Lee, chair of the American College of Radiology Breast Imaging Communications Committee, said straightforward guidelines for screening mammography are necessary because leaving it up to a woman and her doctor is impractical.

"How many women in their 40s -- busy with families, jobs, life -- will take the time to have that discussion?" she said. "Where in those seven minutes is there time to go in-depth?"

The majority of women who develop breast cancer do not have an identifiable risk factor, Lee said.

"Conflicting recommendations create a lot of confusion and angst," Lee said. "I just wish the conversation would stop. I'm not sure why there is so much attention paid to this particular topic. We know it works. Maybe because it involves a lot of money, a lot of health care costs in order to screen, but to my mind that's what health care dollars are for."

For Brenda De Armond, a retired sheriff's department communications supervisor, the issue has always been cut and dried. De Armond, 50, gets annual mammograms and has been doing so for years.

"It just relieves me from any worry," said De Armond, who also examines her breasts. "It just absolutely frees me. When it comes to breast cancer, we do have the advantage of getting that information."

The bottom line, according to Lee, is that mammography is a public health measure that works.

"I'm tired of this debate, and it saddens me knowing the strides we have made," she said. "When I started my career 30 years ago, it was not uncommon to see women presenting with very advanced breast cancer, and now it's very uncommon."

Brawley said people believe mammography is better than it is.

"I think that the belief is actually hindering our ability to find something better, and we desperately need to find something better," he said.