When, under intense political pressure, the National Cancer Institute changed its position on mammograms in 1997, recommending the screens every other year for women in their 40s, the primacy of politics over science in this matter was firmly established.
In the future, if a conclusion based on scientific data was politically untenable, it would simply be overruled by political leaders.
Thus, in the fall of 2009, when mammography for women younger than 50 again became embroiled in controversy, the federal government swiftly resolved the matter by taking the “pro” side. I predict this will turn out to have been our last heated national debate on mammography screening.
A very curious thing happened that October. In a moment of unprecedented candor for an official of the normally message- disciplined American Cancer Society, Otis Brawley, its chief medical officer, made a startling admission. In a New York Times interview, he said, “I’m admitting that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated.” He went on to say that even though mammography can save lives, “if a woman says, ‘I don’t want it,’ I would not think badly of her, but I’d like her to get it.”
Brawley was responding to an article that had just been published in the Journal of the American Medical Association, in which researchers argued that 20 years of widespread breast and prostate cancer screening had failed to deliver the promised health benefits. In both cases, screening had led to a huge increase in the incidence of early-stage disease, with only a very slight decrease in late-stage disease. This is significant because the basic rationale for screening has always been that identifying and treating more early-stage cancers will lower the number of late-stage cancers. That this has not happened suggests that screening detects many nonaggressive cancers that would not have progressed if left undetected. The practical result of large-scale screening, in other words, was overdiagnosis and overtreatment.
Then, on Nov. 16, 2009, in a move that seemed to shock everyone, the U.S. Preventive Services Task Force, a group of experts that periodically reviews the scientific justification for clinical preventive services, rescinded its 2002 recommendation that women younger than 50 should have screening mammography. Analyzing the data, the task force found that screening mammography in women under 50 resulted in a 15 percent reduction in breast cancer mortality. Although this was the same reduction seen in women 50 to 59, it was significantly smaller than the 32 percent reduction in women 60 to 69.
Furthermore, because breast cancer is less common in women under 50, the task force found that in order to avert one death, 1,904 women in their 40s would have to be screened -- compared with 1,339 women in their 50s and 377 women in their 60s.
The task force also considered the possible harms of screening mammography, including radiation exposure, pain, anxiety and false positive or false negative results. Women under 50, the panel found, were much more likely than older women to receive a false positive mammogram -- an abnormal report that requires additional imaging or biopsy but turns out to indicate nothing serious. With this in mind, the task force recommended against routine screening mammography in women 40 to 49, giving this activity a grade of C.
The panel’s timing, dictated by the publishing schedule of the medical journal in which the recommendation was announced, could not have been worse. During the last half of 2009, Congress was debating President Barack Obama’s health-care- reform legislation, and, over the summer, members of Congress had faced loud and hostile constituents in town-hall meetings. The conversation had devolved into ominous warnings about “death panels” and “pulling the plug on Granny.” So it was no surprise that the new mammography guidelines were denounced as an ominous instance of health-care rationing to come.
“This is how rationing begins. This is the little toe in the edge of the water. This is when you start getting a bureaucrat between you and your physician,” Representative Marsha Blackburn, a Tennessee Republican, said. Other critics of the health-care-reform bill pointed to language in the Senate version that required health plans to cover only those preventive services that received an A or B grade from the task force.
A news release from the American College of Radiology characterized the new guidelines as “a step backward,” posing “significant harm to women’s health.” Brawley of the American Cancer Society, despite his public mea culpa a month earlier, asked in an op-ed article, “How many mothers, sisters, aunts, grandmothers, daughters and friends are we willing to lose to breast cancer while the debate goes on about the limitations of mammography?”
The community of advocates for breast cancer research and treatment was divided. Nancy G. Brinker, founder of Susan G. Komen for the Cure, predicted “mass confusion and justifiable outrage.” But Fran Visco, president of the National Breast Cancer Coalition, welcomed the change, arguing that there had been too much emphasis on giving women an unambiguous message on screening. “While messages need to be simple, they need to be truthful,” she said.
Susan Love, the renowned breast surgeon and founder of the Susan Love Research Foundation, strongly supported the task force, both on her blog and in a round of news media interviews. On ABC’s “Good Morning America,” she stated categorically that mammography had “never been shown to work in women under 50” and said, “We’ve sort of oversold the notion of early detection.”
In response, Love’s blog was flooded with angry messages, including one that screamed, “Have you lost your freakin’ mind?” In her next post, Love found it necessary to declare, “I had nothing to do with formulating these guidelines” and “I have not been influenced or received any donations from any insurance companies, nor have I been bought off by our federal government.”
These few voices of support notwithstanding, public opinion ran overwhelmingly against the guidelines. Seventy-six percent of women 35 to 75 disagreed with them, a USA Today-Gallup poll found in the days after their release. Eighty-four percent of women 35 to 49 said they would ignore them. Most significantly, 76 percent of them believed that the new protocol had been proposed as a way to save money. Thus, even though the task force review of mammography guidelines had been completed during the George W. Bush administration, a line was drawn in the public’s mind to health-care rationing proposed under “Obamacare.”
The Obama administration, which had come to power stressing a new respect for science, found itself in a quandary: accept the scientific panel’s advice and watch health-care reform go down in defeat, or reject the advice and risk comparisons to the Bush administration in its controversial handling of stem cell research. Within 48 hours of the task force’s announcement, Health and Human Services Secretary Kathleen Sebelius disavowed the guidelines. “Mammograms have always been an important life- saving tool in the fight against breast cancer, and they still are today,” she said. “Keep doing what you have been doing for years.”
The controversy died quickly. In July 2010, after the Affordable Care Act had been passed, Health and Human Services announced that insurers would be required to cover mammography in accordance with the 2002 guidelines, which recommended routine screening beginning at age 40. In October 2010, in his annual Breast Cancer Awareness Month proclamation, Obama reiterated this message: In women 40 and older, he said, regular mammograms and clinical breast exams every year or two are “the most effective way to find breast cancer early, when it may be easier to treat.”
It is unlikely we will ever have another major national controversy on screening mammography in women younger than 50. After all, it has already been studied in excruciating detail. In any case, the debate has always been about access. Political leaders have now decided that American women have a right to screening mammography starting at age 40, so its status is secure -- at least until a replacement technology comes along.
(Handel Reynolds is a breast radiologist at Piedmont Hospital in Atlanta. This is the first of three excerpts from his new book, “The Big Squeeze: A Social and Political History of the Controversial Mammogram,” which will be published on Aug. 7 by Cornell University Press. The opinions expressed are his own. Read Part 2 and Part 3.)
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