Breast cancer survivors, health care pros, pan new screening guidelines

By Malka Eisenberg

Breast cancer survivors, doctors and nurses — even the U.S. Department of Health — are criticizing the recommendation of a government task force to delay by 10 years the onset of routine breast cancer screening in women.

No radiologists or oncologists are on the United States Preventive Services Task Force, or any other specialists in breast health. Yet, the group, which is sponsored by the federal government's Agency for Healthcare Research and Quality, recommended mammography every other year for women beginning at age 50 and ending at 75, with routine mammography from age 40 only on an individual basis after consultation with a doctor.

The task force also recommended against teaching breast self-examination (BSE), questioned the benefit versus harm of clinical breast examination (CBE), and questioned the benefits of digital mammography over old-fashioned film mammography.

Current guidelines recommended by the American Cancer Society for women at average risk of breast cancer include yearly mammograms from age 40, a clinical breast examination every three years for women in their twenties, and yearly from age 40, and self-exams for women beginning in their twenties. There are more stringent guidelines for women considered to be at higher risk of breast cancer, either for genetic or familial reasons, to begin BSE between ages 18 and 21, yearly mammograms between age 25 and 35 and twice yearly ultrasound examinations.

Women - particularly breast cancer survivors - greeted the new guidelines with horror and dismay. Despite serious backpedaling by the USPSTF, cancer and other medical associations dug in their heels, calling for retention of the old recommendations. With the high cost of health care a current top priority on Capital Hill, there is great concern that Medicare, Medicaid, and private health insurance companies might adopt the new guidelines, creating new out-of-pocket expenses or other restrictions.

"Stick with the old guidelines," suggested Dr. Elisa Kadish, a mammography specialist at Sitron-Hammel Radiology in Bethpage, and a Woodmere resident. Mammography is the "gold standard" in breast cancer screening, she said. We "shouldn't backtrack from the current recommendations."

Kadish anticipates an increase in malpractice lawsuits if the new guidelines become standard policy, since cancers found after biennial screening would be larger than many tumors diagnosed under the current guidelines, having had time to grow.

The Society of Breast Imaging issued a letter to its members that they and other "respected professional organizations will voice strong opposition to the changes proposed" and that "adopting these guidelines would result in a major step backward in women's healthcare and increased deaths from breast cancer."

The American College of Radiology pointed out that mammography has reduced the breast cancer death rate by 30 percent since 1990.

Sharsheret, the support group for young Jewish women with breast cancer, held a teleconference to discuss the new recommendations. Niecee Singer Schonberger, a genetic counselor, pointed out that 25 percent of women who do not go for screening account for 75 percent of breast cancer deaths. Half of the breast cancer survivors in Sharsheret's database were diagnosed with mammograms or by self-exam, she said.

Mammograms are proven to save lives in studies, Dr. Thomas Kolb, a radiologist, told the teleconference participants. The task force used a "mathematical model to find the most efficient method to screen women," he said, and factored in costs to come to their conclusions. The task force conceded that "a significant percentage of women will die of breast cancer if they are not screened between the ages of 40 and 49," Kolb added. He called the panel's arguments against mammograms not "practical;" they said that some cancers found are noninvasive and may not progress to be threatening, and women may be over-treated, while in other cases testing is not down often enough to catch some lethal cancers. Kolb suggested that the correct analysis is "what can we do to diagnose...try to find methods to find tumors at the earliest and most treatable [stage]."

"It's the governments obligation to try to save lives," he said.

"Each case has to be individualized," said Dr. Barbara Mandell, an internist in Hewlett. "It shouldn't be mandatory that you can't have a mammogram," noting that patients often are called back for other views and further testing. She also said that BSE should be taught.

"It's horrible, absolutely horrible," said Ann, a nurse who lives in Woodmere. "They are finding breast cancer in younger women; more women are going to die. Someone I know in her 40s went for a mammogram every year. This year she found three spots; she's going for a double mastectomy."

Beth, a breast cancer survivor, was concerned about radiation from mammograms and felt that sonograms would be a better option. As for not teaching BSE, "That's ridiculous," she said, that's "keeping people ignorant."

Another breast cancer survivor called the guidelines "moronic." A third survivor, Rivka, said the "craziest" part was the task force's concern for causing women "anxiety." "Maybe they'll have a little bit of anxiety from a false positive when they have to go for a biopsy and it's negative, or is it better not to go for a mammogram and don't do BSE and then have serious anxiety for six months or more when she's going through surgery, chemotherapy and radiation. Anxiety is the original sin of Adam and Eve.  You're going to be anxious both ways."

"Economically it makes no sense either," Rivka added. "It still costs more to treat one woman with breast cancer than to have tested a thousand false positives."

"I waited too long," she said of her own experience after she detected a lump during a self-exam. "The doctor couldn't feel it but they found it with the mammogram. I was stage two. If I hadn't gone for the mammogram it would have been much worse."

"If you have a leak in the bathroom, you don't wait until the ceiling collapses in the dining room to take care of it," she said. "Check it out and fix it before your options become too narrow."

For further information contact www.sharsheret.org or www.cancer.org.