When Vesta Ray heard the new recommendations for breast cancer screening, she had two words"It's ridiculous."
Ray, 33, recently had a bilateral mastectomy after being diagnosed with breast cancer. She found a lump through a breast self-examination, went to her doctor for a clinical exam, then had a diagnostic mammogram that confirmed her fears.
Because her mother had breast cancer, Ray had asked for a screening mammogram nine months earlier, but her gynecologist advised against it -- she believes it was out of concern that her insurance company would not cover it.
The new guidelines released by the U.S. Preventative Services Task Force recommend against teaching women breast self-examination, say there is insufficient evidence that a clinic exam is beneficial, and would not give a woman a mammogram until they are at least 50 years old.
Ray said she hopes her 36-year-old sister will ignore that recommendation and get a mammogram as soon as possible.
"I truly think that being proactive with your health is important," the Rogersville resident said.
False positives
The government's task force released the new recommendation statement in mid-November, updating a 2002 recommendation that women do self-exams, get clinical exams and get their first mammogram at age 40.
The panel found that all those methods held a risk of false positives.
"The harms resulting from screening for breast cancer include psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results," the report read.
In 16 years working as a general surgeon at St. John's Hospital in Springfield, Dr. John Bumberry has seen a "fair amount of breast cancer," and has noted that those cases were far more advanced 16 years ago than today. He attributes that to "a dramatic change in the care and diagnosis."
He also has seen more women successfully treated for breast cancer. In large part, he says, that is attributable to the widespread acceptance of mammography."I'm concerned if the guidelines proposed become the standard for care, we will see a significant increase in more advanced breast cancer," he saidThat, Bumberry adds, is a more significant risk than a false positive that would lead to further testing. While no screening is perfect, he said, that does not outweigh the benefits.
Fear that insurance will not cover screening mammograms for women under 50 is legitimate, said Bumberry, who pointed out that legislation currently in the U.S. Senate states that government health insurance would guarantee coverage of services with a recommendation grading of A or B, but this latest recommendation regarding mammograms is a Grade C.
"Clearly, the groundwork has been set, intentionally or unintentionally, for mammograms to not be covered in the government health care plan," he said. "If government doesn't cover it, you can be sure the insurance companies won't be far behind."
The Missouri Department of Insurance recently announced that the latest guidelines have no effect on state consumer protection laws, which require insurance coverage for mammograms -- once from age 35-39, every two years between 40 and 49, and annually from 50 up.
The Breast Cancer Foundation of the Ozarks also will continue to fund annual screening mammograms on women 40 and older, and as otherwise recommended by their care provider, says Crystal Webster, executive director of the foundation.
Despite the new guidelines, Bumberry intends to continue ordering mammograms for his patients in their 40s, including his wife.
"In my opinion, the only reason not to get a mammogram is if you don't have breasts," he said.
Biopsies
Dr. Bruce Hedgepeth, a radiologist with St. John's Breast Center, pointed out that false positives are possible, and biopsies are sometimes done only to find that the suspicious area is benign.
That, however, is true of any diagnostic method. "You have to look under a lot of rocks to find the worm," he said.
Maureen Callaghan is only 30, but she had her first mammogram this year. Her mother is a breast cancer survivor, and her father and grandmother had colorectal cancer, so her doctor recommended the procedure.The first test came back positive, so Callaghan went to CoxHealth's Hulston Cancer Center for a second mammogram and an ultrasound. Within a few hours she was relieved to get the news that she did not have cancer. The same thing happened to her sister at age 32"I was told I can wait five years before I get another mammogram," said Callaghan, an employee of the News-Leader. "That was a big relief."
While Callaghan says she will return at 35 to get tested again, she finds the new guidelines on mammograms to be appropriate for women without a family history of cancer.
"I honestly think it makes sense," she said. "Not everyone needs to have a mammogram at 30."
But the recommendation that doctors not teach women to do a breast self-exam got a different reaction from Callaghan, whose mother discovered her own cancer through that method.
"I think that's stupid," she said. "I'm going to continue to do them."
Many tools
No matter what screening tests are recommended, the most important thing any woman can do to protect her health is to visit her doctor at least once a year, said Dr. Dave Redfern, an obstetrician/gynecologist and chairman of the Missouri section of the American College of Obstetricians and Gynecologists.
Redfern disagrees with the new breast cancer screening guidelines, but he agrees with a new recommendation on another women's health screening procedure.
The ACOG recently announced new guidelines for Pap smears, a test for cervical cancer and sexually transmitted diseases. The group said screening should start at 21, instead of 18, and that women could wait longer between screenings.
Neither of the new guidelines should stop young women from getting an annual exam, he said.
Like mammograms, "Pap is just one tool that we use," Redfern said. "But we have many things to talk about -- sexual activity, birth control, breast health and other things."
Both ACOG and the American Cancer Society have released statements disagreeing with the task force's recommendations on mammograms.I think there was some flaw in (the task force's) research," says Redfern, who will continue to recommend breast self-exams to all women and a mammogram at 40 --"until there is good hard science" against it.Hedgepeth agrees. He said the "real experts in data" have pointed to a decrease in mortality because of screening mammography.
Even the government's task force acknowledges that data. "There is convincing evidence that screening with film mammography reduces breast cancer mortality," the report reads.
But it focuses on the greater benefit to women aged 50-74, saying that it would take 1,904 screens to detect one case of cancer in a woman age 40-49, while 1,339 women age 50-59 would need to be screened to find one case of cancer.
Hedgepeth and Redfern question that rationale, suggesting that the lives of younger women hold a high value, even if fewer cases of cancer will be detected through screening.
"In my opinion," Redfern said, "the committee made the judgment that the lives of younger women aren't worth it."
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