Statistics and lives.
Public outrage over a federal task force recommendation that women ages 40 to 49 years no longer have regular mammograms highlights the bugaboo of applying statistics to lifesaving medical screening: Even if cancer shows up in only one woman out of every 1,900 screened, who's to say saving that one life is not worth the price of all those other OK results?
It is to 41-year-old Lisa Lawton, who's undergoing chemotherapy after being diagnosed in July with a fairly aggressive breast tumor about 2 centimeters in size.
"I'm right in the age bracket where they're recommending that women don't have regular mammograms," Lawton said. "I did a self-exam early in July, and something just didn't seem normal, so I knew I should get it done. If I'd had a mammogram the year before, when I was 40, it might have been even easier to treat.
"But if I had just followed these new guidelines - or if I hadn't done the self-exam last summer - my chances of survival would be much worse than they are now. And if I'd waited another year, or even six months, it could have grown and spread to the lymph nodes or other parts of the body, and that could have been fatal."
Eugene oncologist John Caton said he's not surprised by the task force's recommendation about curtailing routine mammograms for women in their 40s, nor - in the context of the report - by another of its recommendations "against clinicians teaching women how to perform breast self-examination."
However, a third recommendation, that women ages 50 to 74 years have mammograms only every two years instead of annually, gives him pause.
"The 40 to 49 issue doesn't surprise me because it's not really new at all. That issue has been revisited two or three times through the years, based on the statistics that mammography detects cancer in only one of 1,900 women in that age group," Caton said. "But these recommendations are purely a matter of numbers. This task force is a bunch of epidemiologists sitting in a room looking at data. They're in a box. There's no policy, no costs, no politics in what they're doing. We need to view the data for what it is."
One reason for the task force recommendation is the negative aspects of undergoing mammography. According to the report, those include anxiety leading up to the procedure, the chance of "false positives" that lead to additional procedures such as biopsies and "overdiagnosis" of some forms of breast cancer that never would progress to an invasive state but once detected, are treated nonetheless.
Oncologists spend "a tremendous amount of time and energy to increase breast cancer awareness," he said. "I do worry that the report will sway women away from seeking mammograms."
Women with any family history of breast cancer "should start mammograms at age 40," Caton contends. "These new guidelines would not change the recommendations that I would have, although in my field we see people at the end of the process, after the cancer has been diagnosed. But I would bet that most physicians won't want to change their screening practices for their patients."
As far as breast self-examination goes, he agrees that formalized instruction by physicians may not be effective, "but that doesn't mean women shouldn't examine themselves and know their bodies and the changes that occur."
It's "almost heresy" to admit that a structured program of teaching breast self-examination doesn't produce results, Caton said. But according to the data going back at least to the mid-1990s, it appears to be true.
"Breast self-examination is most effective when it's done in a common sense approach, when women do it occasionally" and act on changes that they notice, he said. "That's the biggest thing: to be aware."
When it comes to doubling mammogram intervals for women ages 50 to 74 years to two years from one, the task force's analysis concludes that biennial screening is from 70 percent to 90 percent as effective as annual screening, but Caton says he's not comfortable with that.
"That's a real change. I'm not in favor of that without seeing more data," he said. "What we know now is the percentage of breast cancers detected with annual mammograms and breast examination is in the high 90s, and with mammogram alone it's 85 percent. That's why we have had the annual guideline for so long."
As far as radiologist Cathryn Chicola is concerned, if something isn't broken, don't fix it.
"This new guideline is scary to me because before the 1990s, the death rate from breast cancer had been high, and it had been unchanged for 50 years," Chicola said. "That's when we started doing mammograms in earnest, and since then the death rate has declined by 30 percent. This (task force) report tells me that annual mammograms save lives, but in their eyes it's not enough to justify the cost.
"I think if the Food and Drug Administration accepts these guidelines - they're the ones that make the rules, and clinics like ours have to follow them - mortality rates will climb."
She's particularly concerned about changing the frequency of mammograms for women in Oregon and Washington, because both states are in "a cluster" where the incidence of breast cancer is much greater than average.
"I don't know why it is. It's probably partly genetic and partly environmental. But I think we need the more frequent screening," Chicola said, "My personal feeling is that the (additional) detection we have with the guidelines we have now justifies the cost."
A mammogram conducted through her medical group, Radiology Associates, costs about $300, Chicola said.
At that rate, testing 1,900 women to find the one that has breast cancer costs about $570,000. However, at a conservative estimate of $60,000 for treating a woman whose cancer is diagnosed at a more advanced stage that requires not only surgery and radiation but also chemotherapy, $570,000 would pay for only 9.5 cases.
In contrast, $570,000 would pay for about 23 cases detected earlier and requiring only surgery and radiation to treat.
"The task force talks about more frequent mammograms being more `anxiety provoking,' but they don't talk about the `anxiety' of having a far worse case of breast cancer later," Chicola said. "On my end, sure, that would make the cancer bigger and easier to find, but is that what we really want? I want to find cancers when they're millimeters, not centimeters."
Both Chicola and Caton say they're concerned about the effect the recently released report could have on coverage of mammograms by insurance companies.
"That's the big question: How will the insurance companies react?" Caton said. "Right now, with annual mammogram coverage, many won't pay if someone has a mammogram 364 days from the last one. It's hard to say what effect, if any, this will have."
From Chicola's point of view, "This is a case of putting cost before benefit. Mammograms are inexpensive, available and save lives," she said. "If the insurance companies want to cut costs, they shouldn't start at the bottom with the least expensive procedures. They should start at the top with the most expensive ones that are (elective) and don't save lives."
As far as Lawton is concerned, women such as her, diagnosed with cancer, need to have "the best tools and techniques at our disposal."
"Why take a chance?" she said. "If you can attack breast cancer early, you can live a long and happy life. If you can't, wella..."
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|Title Annotation:||Health and Fitness|
|Publication:||The Register-Guard (Eugene, OR)|
|Date:||Nov 30, 2009|
|Previous Article:||LETTERS IN THE EDITOR'S MAILBAG.|