Nov. 20, 2009 -- The new guidelines on breast cancer screening have instantly ignited an emotionally charged firestorm among doctors across the country.
“Physicians are quite divided about this," says Joseph Stubbs, MD, an Albany, Ga., internist and president of the American College of Physicians.
David Mutch, MD, a St. Louis ob-gyn, says the recommendations from the U.S. Preventive Services Task Force will not change his practice in any way. “It’s clearly economically driven and not patient care driven."
Other doctors have taken a step back to study the science. Julie Wood, MD, a Kansas City, Mo., family physician, says the new guidelines have led her to re-evaluate her practice patterns. She’s also looking for guidance from the American Academy of Family Physicians on the screening issue.
There’s one thing, though, that doctors agree on: The new mammography advice will spark more discussions between women and their doctors about the benefits and risks of these screenings for the early detection of breast cancer.
Those talks have already begun, Wood says. “Patients have discussed it. They’re responding OK, but they’ve had a lot of questions.’’
Stubbs, meanwhile, predicts that the mammography advice will lead to an "evolutionary change" in medical practice. “I think there will be a decrease in the number of mammograms," he says. “But we won’t see a sharp drop-off."
Debate Over Screening Mammograms
The federally appointed task force released the new guidelines Monday. It recommends that women at average risk should wait to get routine screening mammograms until they’re age 50, instead of the current standard of 40. It also advises that women ages 50 to 74 get them every two years and discourages doctors from advising women to examine their own breasts regularly.
The guidelines, which are nonbinding, seek to reduce overtreatment. The downsides to screening include false-positives, radiation exposure, and psychological harm, the task force says.
“The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms," the task force says.
Leading medical groups, though, immediately announced their own guidelines had not changed. The American Cancer Society reiterated its guideline for annual screening mammography for all women beginning at age 40. The organization says it reviewed "virtually all the same data" that the task force scrutinized. “The lifesaving benefits of screening outweigh any potential harms,’’ says Otis Brawley, MD, chief medical officer for the American Cancer Society.
And the American College of Obstetricians and Gynecologists (ACOG) says it continues to recommend regular screening mammograms every one to two years for women in their 40s, annual screening for women 50 and older, and self-examination for breast cancer.
No Changes in Insurance Coverage
With health care reform percolating in the background, the mammography discussion immediately shifted to how the new advice would affect insurance coverage.
The leading health insurance trade group says insurers would maintain the status quo on mammograms. “Our interpretation is that women should be talking to their doctors, and if their doctor orders the test, then it would be covered,’’ says Susan Pisano, a spokeswoman for America’s Health Insurance Plans. “We’ve advocated for women to get screened. That hasn’t changed. Doctors and patients should be talking about benefits and harms.’’
Secretary of Health and Human Services Department Kathleen Sebelius admits the recommendations "caused a great deal of confusion and worry among women and their families," and emphasizes that the department's policies remain unchanged.
Women who are currently getting mammograms under Medicare will continue to be able to get them, says a spokesman for the Centers for Medicare and Medicaid Services. Medicare is the federal health insurance program for people 65 and older and the disabled.
How the new guidelines will affect private employer coverage is unclear, according to benefits consulting firm Mercer. “It is too soon to tell," says Mercer spokeswoman Stephanie Poe, adding that there is "too much conflicting advice" for employers to know if or how they would change their benefits plans.
Guidelines Often Change
The task force advice, meanwhile, offers an example of how the practice of medicine is not set in stone, doctors say.
Much of medicine "is a work in progress," says Peter McGough, MD, a family physician who practices in a Seattle outpatient clinic connected with University of Washington Medicine. Doctors, he says, "are always thrilled when the guidelines are well established and clear."
McGough likens the mammogram debate to disagreements over guidelines for prostate cancer screenings. “We’ve always had to discuss it with patients - the benefits and risks - having them working with us to make the call."
He says he already has changed his practice on breast self-examination because recent scientific evidence shows it does not increase early detections.
“A couple of years ago, I stopped reinforcing it," he says.
Still, he notes it’s a highly emotional topic. “My opinion is that breast cancer, for women, is close to being No. 1 among their health concerns," McGough says.
Talk to Your Doctor
Stubbs says the task force guidelines are not much different from those created by the American College of Physicians two years ago. Doctors now will "be entering into more discussions with their patients," he says, and will focus more on treating them as individuals.
Tom Bader, MD, chief of general obstetrics and gynecology at the University of Pennsylvania, says the task force advice may change some doctors' practices, but not his.
Meanwhile, Judi Chervenak, MD, an ob-gyn and associate clinical professor at Montefiore Medical Center in New York, defends current ACOG recommendations for routine mammography for women in their 40s.
“Catching something early may mean a woman may not need as aggressive a therapy," she says. “If we have a modality that can pick up the disease early, why can’t women have it?"
The risk of false-positives that the task force points out, Chervenak says, "is insulting to a woman’s intelligence."
“It’s assuming that women can’t take the news that they have a false-positive,’’ she says. “Women know there can be a false-positive."