Local physicians take issue with new mammography guidelines

Local physicians take issue with new mammography guidelines
January 22, 2010

Emily Averbook, M.D.

Scott Hees, D.O.

Raymond Washington, M.D.

PINEHURST – Troy resident Beth Ferree was 43 with no risk factors or family history of breast cancer when a routine mammogram saved her life.

She was having her first screening in a couple of years, shamed into it by her gynecologist, when a mammogram detected the slightest hint of a problem so near the edge of the image that it was barely noticeable. A second mammogram, an ultrasound and a breast biopsy confirmed Stage II breast cancer with lymph node involvement.

An operating room nurse at FirstHealth Moore Regional Hospital, Ferree believes she might not be alive today if her gynecologist had been following mammography guidelines for women in their 40s like those recently recommended by the independent United States Preventive Services Task Force (PSTF). Convened by the Public Health Service, the PSTF evaluates clinical research to determine the impact of preventive screening tests, counseling, immunizations and medications.

“If I had waited until I was 50, I would have been in a mess of trouble,” Ferree says. “The cancer would have been all over my body in a short period of time.”

Citing the “risks” and “harms” of testing, the PSTF announced late last year that it was changing its long-standing guidelines for mammography and would no longer recommend annual screening for women between the ages of 40 and 49. The group claimed the benefits of mammography do not sufficiently outweigh the discomfort, anxiety, radiation exposure and possibility of over-treatment to warrant routine screenings in women of that age group.

However, numerous other organizations, including the American Cancer Society (ACS), National Cancer Institute, American College of Obstetricians and American College of Radiology (ACR) continue to recommend annual screenings, which include clinical breast examinations as well as mammography, for all women beginning at age 40. The ACR even called the PSTF recommendations “a step backward” that could “have deadly effects” for American women.

Local physicians also take issue with the PSTF findings. One is Emily Averbook, M.D., a radiologist with Pinehurst Radiology Associates and Moore Regional Hospital, who reads and interprets mammograms every day.

Dr. Averbook says the possibility of early breast cancer detection is the only reason that a woman would choose to endure the relative discomfort of a mammogram and that should outweigh every other concern. Even the possibility of a false positive is a small price for early detection, she points out.

“Women are generally accepting of that, because that’s the price you pay for early detection of breast cancer,” she says. “You don’t put yourself through this if you’re not motivated.”

Noting that the PSTF panel didn’t include a single representative from the diagnostic imaging field, Dr. Averbook says early detection is especially important for women in the pre-menopausal 40-to-49 age group. Because their cancers tend to be more aggressive, they must be found early in order to save lives, she says.

“The older age group is less likely to have aggressive cancers,” Dr. Averbook says. “Something that’s growing very rapidly, you wait two years and you’ve lost your chance.”

According to Dr. Averbook, the use of digital mammography has had an especially significant impact on the effectiveness of routine screenings in younger women. Citing the 2005 Digital Mammographic Imaging Screening Trial (DMIST), she says, “In the general population, no significant difference was found in digital vs. film mammography. But in women 50 or less, digital mammography can make a difference in cancer detection.”

Scott Hees, D.O., a radiologist at FirstHealth Richmond Memorial Hospital, agrees. “From what I have read, the task force used older data and did not take into account the advantages of digital mammography,” he says. “The DMIST study included about 50,000 patients and showed an increased sensitivity of about 8 percent for diagnosis of breast cancer for women under age 50.”

Although the risk of breast cancer increases as women age, Dr. Hees says, the kind of cancers older women typically develop tend to be less deadly. “If a woman lives to be 85, she has a one in eight chance of having breast cancer during her lifetime,” he says. “But the cancers in older women tend to be relatively indolent (inactive). However, the cancers found in younger patients tend to be more aggressive and associated with metastatic (spreading) disease at the time of discovery.”

Because of the mortality risks associated with cancer in younger women, both Dr. Averbook and Dr. Hees agree, routine screening actually makes more sense in the 40-to-49 age group.

“I live by the credo I was taught in residency, that early detection saves lives, especially in younger patients,” says Dr. Hees. “Breast cancers detected in women younger than 50 tend to be more aggressive so, as far as saving lives, this would be the last group of patients based on the current recommendations that I would scale back.”

“The motivation should be to find more cancers that affect mortality,” Dr. Averbook says.

For confirmation, Dr. Hees points to a Swedish study that indicated mammography has reduced breast cancer mortality by 40 percent in women ages 40 to 49 and by 44 percent in women ages 40 to 69.  

“Multiple studies since mammography utilization began increasing in the late 1980s have shown that, since 1990, the mortality rate due to breast cancer has decreased by 30 percent,” he says.

Raymond Washington, M.D., a general surgeon with Pinehurst Surgical, says the PSTF findings “put a price on what we want to pay for health care and in the number of lives saved in this age group.”

“The goal for mammography is early detection,” he says. “That’s what we preach. It’s really hard to put a price on early detection and preventive medicine. I still recommend having annual mammograms.”

According to Dr. Washington, who operates on women who have been diagnosed with breast cancer, early detection also plays an important role in determining how the disease can be treated.

“The key with not having a mastectomy is really early detection,” he says. “If we can catch things early on, before they get really big, a lot of times they can be cured with radiation and a lumpectomy. The sooner we detect it, the better chance we have with breast-conserving surgery.”

In a statement released in response to the PSTF recommendations, the American Cancer Society acknowledged the limitations of mammography but said even that doesn’t change the fact that mammography beginning at age 40 saves lives. The ACS also took issue with the PSTF’s interpretation of numbers indicating that it takes 1,904 routine screenings to save the life of one woman age 40 to 49 as opposed to 1,339 screenings to save the life of one woman in her 50s.

In each set of circumstances, the lifesaving benefits of screening outweigh any potential harm, the ACS statement said.

Dr. Hees ascribes to the same interpretation. “If we have to screen 1,900 patients to save one 40-something-year-old’s life, who is in the prime of her life with a family, a career, an important part of the community who can survive into her 80s or 90s,” he says, “I’m good with that.”

Beth Ferree enthusiastically agrees. “I thought that’s not going to happen to me,” she says. “But it did.”

As of April, Ferree will have been cancer-free for five years.

Digital mammography is available to all three FirstHealth hospitals (Moore Regional in Pinehurst, Richmond Memorial in Rockingham and Montgomery Memorial in Troy). For more information, call (800) 213-3284.