Hospitals favor mammograms at 40, despite new study

OUT IN FRONT: Dr. Jennifer Gass, an oncology surgeon at the Breast Health Center at Women & Infants’ Program in Women’s Oncology, reviews medical images with Dr. Robert D. Legare, medical director for the Breast Health Center. / PBN PHOTO/DAVID LEVESQUE
OUT IN FRONT: Dr. Jennifer Gass, an oncology surgeon at the Breast Health Center at Women & Infants’ Program in Women’s Oncology, reviews medical images with Dr. Robert D. Legare, medical director for the Breast Health Center. / PBN PHOTO/DAVID LEVESQUE

Findings from a new national study has widened the clinical – and emotional – divide over the use of mammography in diagnosing breast cancer and its value in reducing the rate of death from the disease.
The observational study, published in Nov. 22 issue of the New England Journal of Medicine, examined more than 30 years of mammography and found its use has resulted in “a substantial over-diagnosis” of breast cancer. Further, the study found that mammography screening “is having, at best, only a small effect on the rate of death from breast cancer.”
Conducted by Dr. Archie Blyer of the St. Charles Health System in Oregon and Dr. H. Gilbert Welch of the Dartmouth Institute for Health Policy & Clinical Practice in New Hampshire, the study used 32 years, from 1976 to 2008, of breast-cancer data from the National Cancer Institute’s Surveillance, Epidemiology and End Results program to evaluate the efficacy of breast mammograms.
What these data findings suggest about the benefit of mammography screening is damaging, according to Welch. “If it does not advance the time of diagnosis of late-state cancer, it won’t reduce mortality,” Welch wrote in a New York Times opinion piece on Nov. 21. “In fact, we found no change in the number of women with life-threatening, metastatic breast cancer.”
The study’s findings are in concert with controversial guidelines issued by the U.S. Preventive Services Task Force in 2009 that recommended women over the age of 50 have mammograms every other year, instead of annual screenings starting at the age 40.
Those controversial guidelines, however, have not been adopted by Rhode Island’s two largest hospital systems, Lifespan and Care New England. Instead, both hospital networks have adhered to the guideline recommendations that women have yearly breast-cancer screenings with mammography beginning at age 40, as recommended by the American Cancer Society. Dr. Martha Mainiero, director of the Anne C. Pappas Center for Breast Imaging at Rhode Island Hospital, said the hospital conducts a total of about 20,000 mammograms a year. She does not agree with the task force’s guidelines, saying that women should be offered breast-cancer mammography screening beginning at age 40. “The benefit for women between the ages of 40-49 is greater,” Mainiero said.
Mainiero said her fellow surgeons and oncologists who treat breast cancer all support the policy of beginning breast-cancer screening at age 40. “They feel that finding cancers earlier and at a small stage provide better treatment options,” she said.
Mainiero acknowledged the incidence of breast cancer is increasing and that more research is needed into the causes, looking at lifestyle and environmental factors. “Breast cancer is not all one disease; it’s very biologically heterogeneous.” About one in eight women, nationally, will have breast cancer, if every woman lives to be 80, Mainiero continued. “What we want to find out are ways to stop it and prevent it, not just diagnose it.”
On its website, Women & Infants Hospital’s director of the Breast Health Center, Dr. Robert Legare, also defended the guidelines to begin breast-cancer mammography screening at age 40, in response to the 2009 task force guidelines. “We acknowledge the limitations of mammography, but it remains our best tool for early detection and successful treatment of breast cancer,” Legare wrote. “Since 1990, the breast cancer mortality rate in the United States has been steadily declining” from breast cancer in women aged 40 to 49 years screened with annual mammography.”
Dr. Jennifer Gass, assistant director and chief of surgery at the Breast Health Center, also endorsed annual breast-cancer screening with mammography as an important and effective diagnostic tool. “At Women & Infants, we’re still adhering to the American Cancer Society guidelines,” Gass said, pointing to data from the Rhode Island Cancer Registry. “Rhode Island [has] the highest percentage of screening-eligible women,” Gass said. In the data from 1991 to 2005, “the average size of the breast cancer has dropped by 12 percent, and the number of women who present with breast cancer that has already traveled to the lymph nodes has dropped by 23 percent.”
As a result, Gass continued, “we’re finding breast cancer earlier, cancer that is less developed.” She pointed to the registry results that showed more women had a lumpectomy rather than a mastectomy. “In the 1990s, there was a 50 percent rate of mastectomies; in 2005 that rate was down to 30 percent.”
According to Gass, most women ask when diagnosed: why did I get breast cancer? “We really don’t know what causes breast cancer,” she said, pointing out factors that include age, heredity, environment and lifestyle. In the future, Gass is looking for better diagnostic tools that can detect causes of breast-cancer metastases that currently go undetected, but are present when the breast cancer is first diagnosed and treated.
In terms of guidelines, Gass would like to see mammography guidelines that look at the value of annual mammography in women who are older than 75. “The challenge is to define what is older,” she said.
It’s a balance between life expectancy and the value of screening, Gass said. “It’s up to the patient and their primary-care provider to look at what the risks are for breast cancer. The potential risks for mammography are fairly low, and there is a risk of over-diagnosis,” she said. “There’s also a risk of missed and undetected cancer that progresses.” •

No posts to display