Breast-cancer guidelines touch off firestorm

SEATTLE -- To Gail DeGiulio, new breast-cancer guidelines from a national panel of medical experts saying most women in their 40s shouldn't bother with annual mammograms weren't merely startling news. They smacked of a potential death sentence.

The 51-year-old Bellevue resident has twice been diagnosed with breast cancer: the first case detected when she was 33 through mammography and the second in September when she found a lump in her other breast. DeGiulio had a mastectomy in October, started chemotherapy two weeks ago, and expects, once again, to fully recover.

"I am alive by mammograms and self examinations," DeGiulio said. "My mother died at 48 of breast cancer in 1985. She was not as lucky."

Around the nation, thousands of outraged women offered up similar testimonials upon hearing that an influential task force of preventive-health experts sponsored by the U.S. Department of Health & Human Services had concluded that annual mammograms for women in their 40s likely do more harm than good. The panel, instead, recommended routine mammograms only for women 50 to 74, and then only every other year. It also found that breast self-exams do not help in reducing death rates from breast cancer.

The findings, by the U.S. Preventive Services Task Force, add to a growing scientific debate about the wisdom of routinely screening millions of people for cancers, particularly prostate and breast cancer.

In a paper published in October in The Journal of American Medical Association, researchers from the University of California at San Francisco and elsewhere reported that screening for breast and prostate cancers has led to the detection of early-stage cancers in far greater numbers than to a drop in late-stage cases.

That, according to the authors, suggests that screening may be catching low-risk cases - including some that never would have turned lethal - without doing much to lower overall mortality rates.

In their own paper published Monday in The Annals of Internal Medicine, members of the preventive-services task force calculated that 1,904 women in their 40s would have to be screened for breast cancer to avert one death. That's not enough benefit, the panel argued, to justify the radiation exposure, unnecessary biopsies, emotional strain, chemotherapy and other treatments that some who are screened undergo.

Still, the newest recommendations that most women should put off regular mammograms for a decade until age 50 and drop their vigilance about checking themselves for lumps struck many as incomprehensible.

"This is absolutely asinine," said Janice Wherry of Kirkland, who caught an early-stage breast cancer in 1997 through mammography. "I would far rather have a false positive and biopsy than find myself in Stage 4 (cancer) with an uncertain future."

The American Cancer Society said it will continue to recommend annual mammograms for all women starting at age 40.

Dr. Otis Brawley, the group's chief medical officer, said in a statement that the conflicting mammography guidelines reflect judgments about the balance of risks and benefits.

Brawley noted that, according to the preventive-services task force, it would be worthwhile to screen 1,339 women in their 50s to save one life, but not to screen 1,904 women in their 40s to save the same number.

"The American Cancer Society feels that in both cases, the lifesaving benefits of screening outweigh any potential harms," Brawley said.

But other experts applauded the new guidelines.

Diana Miglioretti, a biostatistician at Group Health Research Institute and an expert on mammography, said she particularly welcomed the advice to space out breast-cancer screening to every other year.

Though mammography uses low-dose radiation, Miglioretti said that making the screening biennial would halve the exposure. That's the schedule followed by most European nations, including Denmark, France, Italy, Norway and Switzerland. Those countries also recommend routine mammograms starting at age 50, not 40.

An even bigger potential risk from mammograms, Miglioretti said, is overdiagnosis — treating cancers that don't require treatments. In 2008, for instance, nearly 68,000 American women were diagnosed with noninvasive breast cancer, cancer that hasn't spread out of the milk duct, according to the American Cancer Society.

But because doctors can't tell which of those cancers will become invasive, they treat all of them as if they might become lethal, Miglioretti said.

So among the breast-cancer patients who credit early detection for saving their lives are those who may have survived even without any treatment, Miglioretti said.

"What these women don't understand is that they never would have known that they had cancer in their lifetime," Miglioretti said. "The cancer would never have killed them. They would have died from something else."

Miglioretti, however, wasn't ready to accept that most women in their 40s should dispense with regular mammograms. Greater use of digital mammography, which is far more accurate than film mammography, could rebalance the risk-benefit calculation. That could make it advisable for women 40 to 49 to get screened every two years, Miglioretti said.

But any lines drawn will be arbitrary, she said. After all, women get breast cancer in their 20s and 30s, too.

"We could screen and biopsy all the women at all times," Miglioretti said. "But at what cost?"

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