Ann Kelsall is a medical writer who reported on the NIH Consensus
Development Panel meeting for Oncology News International. Here she considers,
from the woman's perspective, the panel's arguments against mammography
screening for women ages 40 to 49.
LANDOVER HILLS, Md--The NIH Consensus Development Panel evaluating the
value of mammography screening for women ages 40 to 49, concluded their
report with a recommendation that women "should have access to the
best possible information in an understandable and usable form," so
that they can make their own decisions in collaboration with their physician.
Having listened for two days to the debate among experts who agree on
little beyond the need for further research, I have to wonder where that
crucial information is going to come from for women making decisions here
I am not a physician. My comments on the ongoing debate are personal,
based on my own experience as a woman (well beyond my 40s), who has had
quite a few mammograms, including two false positives. Suppose I were 40
again. What would I make of the current confusion?
The results of recent randomized controlled trials related to mammography
for women between 40 and 49 years old are extremely difficult for the layperson
to decipher. All parties do seem to agree, however, that there is some
reduction in breast cancer deaths among the women in that age group who
are screened. But there is an acerbic parting of the ways when those benefits
are evaluated and weighed against the perceived risks.
The Possible Risks
The risks or "harms" to which the panel addressed itself include
the inappropriate sense of security that could come with a false-negative
reading; the difficulties associated with additional diagnostic testing
in the wake of a false positive; the potential risk of overtreatment of
low-risk ductal carcinoma in situ (DCIS); and the danger that accompanies
exposure to radiation.
The first two issues go to the point that mammography is not perfect.
The results can be flat wrong. Not all cancers are detectable by mammography,
especially in younger women. It is also true that false positives are not
Neither of these possible outcomes seems a valid reason to avoid being
tested. Rather they are signals that good advice and follow-up from the
physician are crucial. To paraphrase one of the speakers at the panel discussion,
should we avoid doing good because we know we cannot achieve perfection?
To be sure, it would be a grave mistake to be lulled into a false sense
of security by a favorable test result. And false-positive readings do
cause distress. In my own case, the worry occasioned by an abnormal result
was ameliorated by my physician's sensitive behavior.
I was notified of the potential problem early in the morning and advised
to come for further analysis that same day. On both occasions, the matter
was clarified within hours, and I was relieved to hear that all was well.
Neither time did it occur to me to stop having mammograms because mine
was a little hard to read.
The arguments about inconvenience or "psychosocial consequences"
puzzle me greatly. There is about as much inconvenience associated with
a mammo-gram as for any physical examination--hardly an argument for avoiding
I do understand that early discovery and appropriate treatment of DCIS
are matters of much uncertainty. Clearly, more needs to be known about
the history of this disease and its treatment.
But if I had the condition myself, the panel's statement that "some
cases of DCIS may not progress to invasive cancer," would not comfort
me. I would not wish to be ignorant of my condition simply because it might
not kill me. For me, the problem would be deciding on appropriate treatment,
not on whether I should have had the mammogram.
Radiation exposure is an understandable concern, but, if I am to believe
the evidence presented, it is nowhere shown that for the general population
or for women of the age in question, that theoretical radiation risk from
screening mammography in any way outweighs the known benefit. It has not
been shown that any woman has developed breast cancer as a result of mammography.
So, assuming that I am dealing with a competent radiologist, the theoretical
risk is one I am willing to take.
The panel did recommend that for women in their 40s who choose to have
mammography, the costs should be reimbursed by third party payers or HMOs.
It is hard to say just how seriously that recommendation will be taken,
given the unwillingness of the panel to recommend the test.
A woman in her 40s today does not have that "best possible information"
called for by the panel. She has to make the best decision she can based
on the wild assortment of guidance that is available to her.
In my own case, assuming I were free of symptoms, I suspect my decision
could well be based partly on cost. If I were 40 and not sure of coverage,
I might well wait, at least until I was 45. After that, I am quite sure
that I would be tested, and hope that I was among the great majority for
whom age 45 is not too late.