Educational Information: Mammography

Annual mammograms may reduce mastectomy risk for women in their 40s.

The Los Angeles Times (12/3, Forgione) "Booster Shots" blog reported, "For women in their 40s, a new study suggests that annual mammograms may reduce the risk of having a mastectomy." The subject has generated considerable "controversy over the past few years," with the US Preventive Services Task Force and the American Cancer Society making their separate recommendations. This latest recommendation is based on "a British study of 971 women between 40 and 50 years old who had been diagnosed with breast cancer."

Investigators eventually discovered "that among the women who had a mammogram in the preceding year, only 22% needed a mastectomy, compared with 52% who had mammographies done more than a year before," MedPage Today (12/3, Fiore) reported. "Women who'd been screened in the preceding year also had smaller tumors -- 17.8 mm, on average, compared with 24 mm for those who'd had mammography more than a year before and 29 mm for those who'd never had one. They also had less multifocal disease -- 12% versus 36% for those never screened (P=0.003) -- and less high-grade disease (31% versus 46%, P=0.03)."

Anger lingers over mammogram recommendations.

CNN (12/3, Landau) reported, "If you're a woman in your 40s, you probably remember how checking the health of your breasts became a point of national contention last year." Many "fought back...when the United States Preventive Services Task Force recommended that women with average breast cancer risk begin biannual mammograms at 50." The "American Cancer Society, the American College of Radiology...and other organizations have continued to support women getting yearly mammograms from 40 onward," and recent research "has continued to suggest that women in their 40s need annual mammograms." Although "the situation has calmed down," many remain angry about the revised recommendations.

Study suggests mammograms may benefit women in their 40s.

ABC World News (9/29, lead story, 2:30, Sawyer) reported that there is more "big news for American women who are so confused and maddened by all of those conflicting instructions on mammograms." Nearly a year ago, "a government panel said women do not need regular mammograms until the age of 50" and just last week, Norwegian researchers attributed modest reductions in the breast cancer mortality rate mostly to better treatments and increased awareness. Now, however, "a major new study says mammograms in your 40s can dramatically save lives from breast cancer."

Indeed, the "new study has major limitations, and cannot account for possibly big differences in the groups of women it compares," the AP (9/30, Marchione) points out. "Nor does it consider the harm -- such as unnecessary stress, unwarranted biopsies and overtreatment -- of screening women in their 40s." But the "Swedish study appears to be the largest of this age group -- about 1 million women" -- and "'it captures the real-world experience' they have from regular mammograms, said Dr. Jennifer Obel, a spokeswoman for the American Society of Clinical Oncology." Similarly, Harvard's Dr. Daniel Kopans, "an American College of Radiology spokesman, said the study 'should end any debate and end the use of age 50 as a threshold for screening.'"

The "study's authors include Dr. Stephen Duffy, an epidemiologist at the University of London, and Dr. Laszlo Tabar, professor of radiology at the University of Uppsala School of Medicine in Sweden, who have long been advocates of mammography screening," the New York Times (9/30, A24, Kolata) notes. According to the paper published online in Cancer, investigators "took advantage of circumstances in Sweden, where since 1986 some counties have offered mammograms to women in their 40s and others have not." Specifically, they "compared breast cancer deaths in women who had a breast cancer diagnosis in counties that had screening with deaths in counties that did not," eventually finding that the "rate was 26 percent lower in counties with screening."

Thus, the authors concluded, "screening mammography saves lives in the controversial 40 to 49 age group but with a relatively high number-needed-to-screen compared with older groups," MedPage Today (9/29, Phend) reported. In other words, "to save one life, 1,250 women would have to be screened every other year from age 40 to 49." The "number-needed-to-screen is the critical issue, according to Jennifer Obel," MD, who speaking in "advance of presentation at the American Society of Clinical Oncology Breast Cancer Symposium." But "mammography has been shown in study after study to reduce the risk of breast cancer in women 40 to 49," she added. What's more, opined "Carol Lee, MD, chair of the American College of Radiology's Breast Imaging Commission," the "benefits far outweigh the potential harms."

Still, according to HealthDay (9/29, Gardner), "the findings will no doubt do little to quell a controversy that has existed since the 1980s over the value of mammography screenings for women in their 40s."

And. "critics...noted that the researchers did not provide mortality rates, which made it difficult to compare the results in the two groups of counties," the Los Angeles Times (9/29, Maugh) "Booster Shots" blog reported.

Mammography appears to be associated with modest reduction in mortality rate.

In a front-page article, the New York Times (9/23, A1, Kolata) reports, "Previous studies of mammograms, done decades ago, found they reduced the breast cancer death rate by 15 to 25 percent, a meaningful amount" that may have influenced "most women in" the US, "starting in their 40s or 50s," to "faithfully get a mammogram every year." Now, however, a paper written by Harvard and Norwegian researchers "suggests that increased awareness and improved treatments rather than mammograms are the main force in reducing the breast cancer death rate." While those assertions are "unlikely to settle the debate over mammograms," they seem to "wash out most of mammography's benefits by making it less important to find cancers when they are too small to feel."

Even Georgetown's Dr. Jeanne Mandelblatt, who "headed six teams that helped shape the new mammogram guidelines issued last year by an influential government task force," told the AP (9/23, Chang), "It's not the great lifesaver that people think it is. It's not a magic bullet." Notably, the US "Preventive Services Task Force concluded that women at average risk for breast cancer don't need mammograms in their 40s and should get one just every two years starting at 50."

But, "some cancer organizations reject the panel's advice," according to HealthDay (9/22, Pallarito). For instance, the "American Cancer Society still recommends annual mammograms starting at age 40, as long as a woman is still in good health," and "on Tuesday, the American College of Radiology (ACR)" and two other groups "launched 'Mammography Saves Lives,' a campaign designed to encourage women to have an annual mammogram starting at age 40." Indeed, "mammography is not perfect," says Harvard's Dr. Daniel B. Kopans, "a member of the ACR Commission on Breast Imaging," but "since the advent of routine mammograms in the 1990s, the rate of death from breast cancer has dropped 30 percent." That is "'a huge achievement,' Kopans noted."

So, WebMD (9/22, DeNoon) asked, "should US women continue to get routine mammograms?" The author of an editorial accompanying the study says that "it's a 'close call.'" H. Gilbert Welch, MD, MPH, of the Dartmouth Institute, "notes that many women may find that the benefits of routine mammograms outweigh the" risk of undergoing "needless surgery, radiation, or chemotherapy." Nevertheless, the "very fact that the American Cancer Society recommendations are so hotly debated, Welch says, means that doctors remain divided."

As for the team at the Oslo University Hospital, they "still emphasized that mammography screening is effective in reducing breast cancer mortality," MedPage Today (9/22, Gever) reported. But, "to maximize that benefit, screening must be part of an integrated healthcare system covering the entire population." Before reaching those conclusions, the group conducted a study that "had a unique design, exploiting the staggered rollout of nationwide mammography screening in Norway starting in 1996." Investigators "compared outcomes in two groups of women -- those living in counties where the screening was provided during this period and those in areas where the program had not yet been introduced."

They eventually discovered that "participation in the Norwegian breast cancer screening program was associated with a 10% reduction in the rate of death from breast cancer among women 50 to 69 years of age," Medscape (9/22, Nelson) reported. "However, only part of this reduction can be attributed to the screening program...because during the period that the study was conducted, Norway built multidisciplinary teams to treat breast cancer, which also had an impact." In other words, "one third of the mortality reduction...observed in the 20-year period -- 1986 to 2005 -- can be associated with the screening program, while two thirds can be attributed to enhanced breast cancer awareness and improved diagnosis and treatment for breast cancer."

Those findings, according to Welch, "raise questions about using mammography screening rates to measure healthcare quality," the Boston Globe (9/22, Cooney) "White Coat Notes" reported. "But no one can argue that screening mammography is one of the most important services we provide in medicine," he wrote in the New England Journal of Medicine. However, "the time has come for it to stop being used as an indicator of the quality of our healthcare system."

Meanwhile, City of Hope's Dr. Joanne Mortimer "noted that the United States does not -- except in rare instances -- have the same sort of multidisciplinary teams to treat breast cancer that are common in Norway and the rest of Europe," the Los Angeles Times (9/22, Maugh) reported. "Given that difference, she added, mammography is likely to make a larger contribution to preventing deaths here." Still, "if the results from the Norwegian study are confirmed, mammography could soon be viewed more like PSA screening." Although "major health groups no longer recommend routine PSA screening," they say that the "decision to screen should be made after a consultation between physician and patient in which they discuss the benefits and the risks," and "that could become the routine procedure for breast cancer as well, experts said."

Few options for pain reduction during mammograms.

Reporter Nara Schoenberg writes in the Chicago Tribune (9/22) about her experience with painful mammograms and says she could discover few answers for "pain-reduction options." She adds, however, that "one of the few bright spots I could find was a 2008 study published in Radiology, in which researchers at St. Luke's Mountain States Tumor Institute in Boise, Idaho, managed to cobble together a solution using the topical over-the-counter pain relief gel Topicaine and plastic wrap (to cover the gel after application)." That provided about a 20 percent reduction in pain, or "from 5 to 4 on a 10-point pain scale," but concern about side effects has been expressed by the FDA.