Mammogram still the best test.

Byline: TIM CHRISTIE The Register-Guard

For years, physicians and cancer organizations have urged women, starting at age 40, to get mammograms every year or two so that cancerous tumors could be caught early and treated.

But now this crystal-clear tenet of women's health has suddenly gotten a lot murkier.

Research by two Danish scientists has sparked a contentious, confusing debate about the effectiveness of mammography screening.

The question is, do mammograms reduce deaths caused by breast cancer?

The short answer is, there is no definitive answer. And until there is, most major cancer organizations and agencies, including the American Cancer Society and the National Cancer Institute, as well as cancer doctors, are standing by the recommendation that women should get mammograms every one to two years, starting at age 40.

Debra Troutman, a 44-year-old insurance claims adjuster from Springfield, got her annual mammogram Friday at Oregon Imaging Center in Eugene. Her grandmother had breast cancer, and she doesn't think twice about getting screened.

"The key still is early detection," she said. "The earlier the better; that's what saves lives."

That's been the accepted medical wisdom, and the mammogram has become an uncomfortable annual rite practiced by health-conscious women. The fact that breast cancer deaths in the United States and Canada have declined nearly 30 percent since 1990 would seem to bear out the benefits of early screening. But experts aren't sure whether early detection or better treatment is responsible for more women surviving.

And a study published in the British medical journal The Lancet has cast doubt on what has been a doctrine of women's health.

Danish researchers Dr. Peter Gotzsche and Ole Olsen analyzed seven mammography clinical trials that provided the scientific basis for the recommendation that women get regular mammograms.

They contended that five of the seven studies were so flawed that there was simply insufficient evidence to show that mammography screening prevents cancer deaths in any age group of women.

That analysis prompted an independent panel of experts at the National Cancer Institute, part of the federal National Institutes of Health, to conduct their own analysis of the original clinical trials. The panel, led by Dr. Donald Berry of Houston, reached the same conclusion.

Annual screening appears to add 36 hours to the lives of women who start mammography in their 40s, Berry said. Berry is chairman of the biostatistics department at the M.D. Anderson Cancer Center in Houston.

"You would get better benefit from walking to the doctor's office than getting those mammograms," he said.

Other researchers have criticized the findings of the Danish researchers and the NCI panel. And a more recent study, published last month in The Lancet, concluded that routine screening reduces breast cancer deaths, though not as much as previously believed.

News stories about the conflicting findings have left some women in a quandary about what to do.

Karen Leigh is executive director of Hopeline Women's Cancer Resource Center, a Eugene group that connects women with the support and resources they need when they get cancer. Leigh is not an expert on cancer, and she found herself unsure how to respond when women call and ask for advice. She can only tell what she would do, which is continue annual screenings, self exams and physician exams.

"It's challenging. It's frightening," she said. "It's Greek. You read the reports, and it's all so conflicting."

But local health providers said they haven't wavered from recommending mammograms to their patients.

"Most physicians are still recommending women still undergo mammography," said Dr. Tina Schnapper, a Eugene obstetrician and gynecologist. "Most physicians would agree that we don't base our practice on one or two studies.

"We feel the risks of a mammography are low and the benefits are potentially very great."

Likewise, Dr. Kristian Ferry, a Eugene surgical oncologist, said he tells his patients that mammography is a useful tool for screening for cancer in women age 40 and older.

"I don't think there's any doubt in clinicians' minds that mammograms work for what they're designed to do: detect cancers and detect cancers early," he said.

Oregon Imaging Center has been inundated with questions from patients, said Dr. Cathy Chicola, the clinic's lead mammographer.

"What I tell patients is that I see cancers every day," she said. "I see cancers in young women and in old women. The best screening tool we have with today's technology is mammography and ultrasound."

Other groups are taking a more skeptical view of mammograms, notably the National Breast Cancer Coalition, a grass-roots group that lobbies Congress to spend more on breast cancer research. The coalition contends that there is insufficient evidence to recommend for or against screening mammography for any age group.

"What we're advising women to do is look at the information that's out there and have a conversation with their own physician about what's best for them," said Jan Platner, the coalition's director of programs and administration.

The issue is not whether mammograms catch cancers, but whether they save lives. It's difficult to know because there are so many kinds of breast cancers, Platner said.

"Some women have cancer so aggressive, it doesn't matter how it's found, it's going to kill them," she said. "Some have cancer that would probably never kill them." Other women get cancer that responds to treatment.

"The problem is we don't have any way of sorting who's who," she said.

Mammography is notorious for producing false positives and false negatives, Platner said. These inaccurate readings cause a lot of unnecessary anxiety for women and lead to "many, many needless biopsies," a procedure in which a surgeon removes a suspicious lump, she said.

"Fewer than 20 percent of women who have biopsies have breast cancer," she said. "Some people might think it's worth it, but it's not nothing to go through a biopsy."

Many women take comfort in getting annual mammograms, thinking they're protecting themselves, she said.

"One of the things that makes it appealing to women - as unappealing as it is to have one - is it gives you a feeling of control," she said.

But the reality is something else, and the benefits of mammography have been "oversold" to women, she said.

One problem with mammography is that it's become a multibillion-dollar industry, Platner said.

`If people continue to believe, `If I have my mammogram, I will be fine,' it's a disincentive to be looking for something much better,' she said. "We need to find other ways to detect cancer besides mammography. We need to find something that finds it much easier."

The Danish analysis isn't the only research that questions the benefits of mammograms.

Dr. Rodney Pommier, a surgical oncologist and associate surgery professor at Oregon Health & Science University in Portland, has just completed research that led him to conclude mammography doesn't save lives.

His research showed that women who have mammograms that detect tumors have better survival rates than women with "palpable" tumors - lumps detected by manual exams conducted by women or their doctors.

But the survival rates for women with tumors caught by mammograms are higher "not because they're caught earlier, but because they're better tumors," he said.

The types of tumors detected by manual exams tend to be more aggressive and more lethal than tumors caught by mammograms, he said.

"Therefore, you can do all the mammograms you want, and it's not going to change the survival rate of women," he said.

Still, Pommier said he's telling his patients to follow the existing recommendations for mammo- grams.

"I say, we'll follow the recommendations, but if you're expecting mammography is going to find your cancer earlier and prevent you from having the worst cancer, I don't think that's realistic," he said. "Doing mammograms does not defend you from bad cancer.

"The bottom line is, to treat cancers, you've got to find them. Whether that changes survival, which is what the public has been led to believe, that's a completely separate issue."

MAMMOGRAM CONTROVERSY

Researchers have raised new questions and sparked a contentious debate about the effectiveness of regular mammograms in saving women's lives.

Should I still get a mammogram? Most cancer groups and doctors still are advising women to get screening mammograms every one to two years, starting at age 40. There's less controversy about annual screenings for women 50 and older, and for women with risk factors for cancer, such as a family history.

Everyone knows mammograms detect tumors every day, so what's the controversy? The question is whether mammography prevents deaths from breast cancer. Researchers who analyzed the original clinical trials that provided the scientific basis for regular mammograms contend that there's not enough evidence to determine whether mammograms save lives.

Even if scientists aren't sure, what's wrong with getting regular mammograms, just to be on the safe side? Mammograms can produce false positives, which can cause unnecessary anxiety for women and unnecessary procedures, such as biopsies.

Where can I find more information? On the Web, go to: the National Cancer Institute, www.cancer.gov; the American Cancer Society, www.cancer.org; the National Breast Cancer Coalition,www.natlbcc.org.

- The Register-Guard

CAPTION(S):

Oregon Imaging Center radiologic technologist Jean Allen (left) gets Debra Troutman positioned for a mammogram - still the best test despite questions of its ultimate value.