Panel Offers Mixed Mammogram Message

WASHINGTON — Although two recent studies showed reduced breast cancer death rates among women 40 to 49 who get regular mammograms, a federal advisory panel convened by the National Cancer Institute on Thursday declined to recommend routine screenings for women in that age group.

The panel’s conclusion was challenged immediately by the institute’s director.

The advisory panel declared that overall research still does not support recommending “across-the-board” screening for these women and said that the decision should be made by each woman in consultation with her physician.

In explaining its decision, the panel said that, despite “new pieces of evidence” from two new studies in Sweden, scientific evaluation of all available data does “not warrant a single recommendation for mammography for all women in their 40s.”

“We are dealing with a changing situation, but at this point the best recommendation is to provide women [in the 40-49 age group] with the best information about the risks and the benefits” and allow them to decide for themselves about mammogram tests, said Dr. Leon Gordis, a professor of epidemiology at the Johns Hopkins University School of Medicine who chaired the panel. “For each woman, it may be a unique decision-making process.”

The panel also said that women under 50 who take the tests have an increased risk of false results.

The issue of whether women in their 40s should have regular mammograms has been the subject of an intense national debate within the health community since 1993 after a series of studies indicated no decrease in mortality rates among women of those ages who received them. The latest chapter almost certainly will confuse women in their 40s further about what to do.

The scientific community agrees that women 50 and older should have annual mammograms.

NCI Director Richard Klausner, asked at a news conference about the panel’s findings, said he disagreed with them.

“It’s not something I feel comfortable with,” he said. “I am concerned that women [in the 40-49 age group] are not being given all the evidence that they actually need. There is evidence we didn’t have previously that there is a benefit” to the mammograms.

Calling the new study results “statistically significant,” he added: “And women need to know that.” Members of numerous patient and medical organizations in the audience burst into applause.

The advisory panel’s decision also was criticized by the American Cancer Society. “We find it especially troubling that the panel would issue a pessimistic statement and conclude once again that the burden of decision [about mammograms] for a woman in her 40s is hers alone,” the group said in a statement.

The panel urged all health insurers to cover the cost of the test, which typically costs from $100 to $200, if a woman in this age group decides to have it. But the impact of that recommendation is unclear.

Currently, coverage decisions depend on individual insurers, who typically will pay for a mammogram among women in their 40s if a symptom, such as a lump, is present, but not always if a patient has no symptoms. Most insurers cover routine tests for older women, however.

Breast cancer is the most common cancer in women and the second-leading cancer killer among them after lung cancer. It is the leading cause of death for 40- to 49-year-old women.

In the wake of the studies questioning the usefulness of mammograms for women 40 to 49, the NCI dropped its recommendation that they routinely undergo the tests. That action provoked heavy criticism and deep divisions within the cancer community. The ACS is among numerous organizations that have continued to urge women in their 40s to be screened, and the organization reiterated those recommendations Thursday.

The NCI convened 13 cancer experts to weigh the issue again in light of new mammography research that included the two Swedish studies.

One of those studies, conducted among women 39 to 49 years old, showed a 44% reduction in deaths among those having mammograms compared to the control group, which did not have them.

But the NCI’s advisory panel--made up of medical and scientific experts as well as breast cancer survivors--noted that the body of research, including the new studies, showed that the differences in the breast-cancer death rate among those who did and did not receive screening only became apparent after at least seven years, rather than early in the screening process.

“We are not saying there is no benefit, just that it is small and may not occur until quite late,” said Dr. Leslie R. Laufman, a hematologist from Columbus, Ohio.

Constance A. Rufenbarger, a breast cancer survivor and the consumer representative on the panel, defended the group’s conclusions, saying that it was not charged with “choosing one set of data over another” but “with looking at all the data.”

“It would have been nice to say that all of the data [bore out the 44% reduction in mortality] but you cannot pick just those [studies] that you want,” she said.

Panel members also said that, for women under 50, there are additional risks of false-positive results, which could result in unnecessary biopsies and anxiety, and false-negative readings, which could render a false sense of reassurance. But Dr. Edward Sickles, a professor of radiology at UC San Francisco and a member of the American College of Radiology, called it “unfortunate that the panel chose to ignore the new information.”

Sickles added: “We’ve been telling women for years that they should begin screening at 40--and do it every year.”

This year, an estimated 180,200 new cases of breast cancer will be diagnosed and there will be 43,900 deaths. Breast cancer risk increases with age, particularly after 60.