New breast screening report met with dismay

Dr. Paul Stumpf, the graying 61-year-old chair of obstetrics and gynecology at the University of Nevada School of Medicine, admits some of his colleagues wonder where his head is at these days.

But as the bearded academician-clinician steered his well-dented Hyundai Elantra toward his office Thursday off West Charleston Boulevard, he said it really doesn't surprise him.

"Even if you say you find truth with a small 't' in a report suggesting most women don't need to get mammograms until they reach the age of 50, you have to expect people will be upset with you," he said. "There may be no more emotional medical issue than breast cancer."

He may well be right.

Just the statistics are frightening: Nearly 195,000 American women will develop breast cancer this year, and about 40,000 will die.

An uproar quickly followed the U.S. Preventive Services Task Force's Monday recommendation that women should now have mammograms beginning at age 50 rather than 40, reversing a position the same group had taken seven years earlier, one pounded home constantly through public service advertising.

By Wednesday -- following protests from women, lawmakers and many clinicians -- the Obama administration distanced itself from the new standards, declaring that government insurance programs would continue to cover routine mammograms for women starting at age 40.

The panel of medical experts, appointed by the federal Department of Health and Human Services, also recommended that women age 50 to 74 should be screened through mammography only every other year, not annually, as currently recommended.

The reaction to the recommendations, which also included advising doctors to stop teaching women self-examination, was swift and often angry.

"We would regress in saving women's lives." said Las Vegas breast surgeon Dr. Theodore Potruch.

He said in the past week he'd done three breast surgeries, two involving women in their 40s whose cancers were detected through mammograms.

"These new recommendations would be a huge step backward," he said. "Everything is based on early detection. If you're a practicing clinician and deal with this problem, you also know that just having a mammogram every two years is a crap shoot. You miss too much."

The task force report said the benefits of screening women in their 40s -- one life is saved for every 1,904 women screened for 10 years -- don't outweigh mammography's downsides. Those drawbacks include excess biopsies, needless anxiety from false positives and the discovery and treatment of tumors that, if left alone, would not cause difficulties.

According to the task force's new guidelines, one life would be saved for every 1,339 women age 50 to 74 screened for breast cancer.

Task force researchers also found that screening every other year would detect cancer 81 percent as often as would annual screening; and false positives would come back nearly half as often.

Potruch isn't overly concerned with anxiety caused by false positives.

"I think most women would tell you they'd rather be alive," he said.

Because he thinks the task force worked from sound data, including studies from Europe, and he's seen how women react to false positives, Stumpf said he finds persuasive the argument for healthy women starting mammograms later in life.

"When we order a mammogram for a screening test, everyone expects it to come back normal," he said. "But when you tell someone that she has an abnormal mammogram, that there is just a possibility of cancer, she doesn't hear you. There is such an emotional impact on people.

"When people say, 'Oh, a little anxiety is worth it if a test may save your life,' that kind of logic denigrates the emotional impact on women. It's always easy if you haven't gone through it. And when you have additional testing that proves that you were dealing with a false positive, that person and her friends lose confidence in testing forever."

He also said less frequent testing can mean medical resources can be spent in other ways, including finding a cause for breast cancer.

Stumpf said he thinks most physicians will use the data from the task force in a constructive way. They'll let their patients know what the latest science has found on the subject of breast cancer.

"I don't believe in physicians being authoritarian," he said. "I think patients want to know what the newest science is showing. I advise them to get second opinions, to use the Internet."

Dr. Karen Milligan, an oncologist at the Nevada Cancer Institute, said researchers there have not found the task force findings persuasive enough to change current screening standards.

But she did say they are worth discussing with women. She said that if women find a doctor who takes a position on testing they're not comfortable with "they should get a second or third opinion, if necessary."

She said she wasn't surprised that the task force advises doctors not to spend a lot of time teaching self examination to women, explaining that research hasn't found it is very helpful.

"You want to find it before you can feel it," Potruch said. "When you can feel it, too often that means it has spread well beyond the breast."

Milligan said the "jury is still out" as to whether private insurance companies will try to use the task force results to get out of paying for annual mammograms, a standard that the American Cancer Society still supports.

In a recent public statement, Susan Pisano, a spokeswoman for America's Health Insurance Plans, which represents 1,300 companies covering 200 million Americans, said no companies have decided at this time to change their coverage.

Members of the Obama administration, concerned that the task force's recommendations could be seen as rationing medical care, have repeatedly said the recommendations are not binding on private insurance companies or physicians.

Some women say they find the recommendations of the task force confusing.

"I was furious," said Caryn Goldsmith, a Las Vegas sales professional who was recently profiled in the Review-Journal when a bout with the H1N1 flu virus postponed a scheduled lumpectomy.

She now faces both radiation and chemotherapy for breast cancer.

"I'm only 39 with no risk factors," she said. "I wish mammograms had been recommended even earlier. I couldn't believe the task force was saying statistics showed that not that many women in the 40 to 50 range would be saved by mammograms. This is so confusing to think of lives this way. If you save any lives through mammograms, it's worth it."

As teachers finished their day recently at the West Preparatory School, two of them, Gloria Rankin and Patricia Hershwitcky, agreed to talk about the new screening recommendations.

Rankin, a 61-year-old science teacher who follows the issue closely, called the proposed guidelines "insane."

The statistical differences found in the 40-to-50 and 50-to-60 age brackets, she said, do not warrant a change in medical testing "when you're talking about lives."

"I'm afraid all this will do is drive male-dominated insurance companies to support less cancer testing for women," she said.

Hershwitcky, 59, an English teacher, believes her sister wouldn't be alive now if the task force recommendations were in place.

"She had breast cancer in her 40s," she said. "If they had not caught it with a mammogram, she'd be dead now."

Stumpf hopes people understand that his support for the task force report is a nuanced position.

"Listen, I think new scientific data is important," he said. "Look at the discussion Americans are having right now. That in itself is going to make people take breast cancer more seriously. I'm not saying that this report is the truth with a capital 'T.' We don't have that in science. But I am saying we should not dismiss scientific work because of emotions. That is dangerous.

"What women should do with this information is use it," he said. "And they should talk with their doctors and read the Internet until they're satisfied they can make an intelligent decision. We now have more information to use and that is a good thing. And we shouldn't be surprised if the guidelines change again."

Contact reporter Paul Harasim at pharasim@reviewjournal.com or 702-387-2908.