Mammograms Should Be Covered by Insurance for Women of All Ages, but Research Shows Need for Better Technology

By Elizaveta G. Doubossarskaia, NOW Communications Intern

New guidelines from the U.S. Prevention Services Task Force (USPSTF) regarding mammogram screenings and breast self-exams have stirred up a storm of controversy. After decades of stressing that women should have routine mammograms and conduct frequent breast self-exams to promote early diagnosis, the USPSTF guidelines came as quite a surprise. Some have even speculated that changing the guidelines is just a governmental tactic designed to cut health care costs at the expense of women's well-being.

NOW believes that legitimate, relevant data prompted the revised guidelines, and that women should be better informed about the science behind the USPSTF's new recommendations. At the same time, NOW strongly asserts that health insurance should cover mammograms for women of all ages. We applaud the Senate for passing the Mikulski Amendment this week, guaranteeing women preventive health care screenings and care at no cost.

Routine Exams at 50 -- The task force recommends raising the age to begin breast cancer tests from 40 to 50, suggests that women in their 50s opt for biennial (every two years) mammograms instead of annual ones, and advises against breast self-exams. As with many health research findings, the story is complicated.

There is no evidence to suggest that the USPSTF guidelines were modified with ulterior political motives in mind. The USPSTF is an independent panel of medical experts, and the scientific data they presented has been published in the Annals of Internal Medicine, which is a peer-reviewed medical profession publication. The new guidelines are also in line with the guidelines used in Europe and international recommendations such as the ones issued by the World Health Organization.¹

Mammography Benefits Small -- Numerous women's health organizations, including the National Women's Health Network and Breast Cancer Action, have stated in the past that the benefits of mammogram screenings are exaggerated. The USPSTF found that the reduction in risk for women ages 40-49 was only "borderline statistically significant," and "the absolute benefit of mammography screening on mortality is very small, and that biases in the trials could either erase or create it."²

The Cochrane Collaboration review, a coalition of more than 11,000 contributors from more than 90 countries dedicated to evaluating the effects of health care interventions, has drawn similar conclusions. According to their 2006 systematic review, the screenings reduce the risk of death from breast cancer by a miniscule 0.05 percent in absolute terms. The reviews states that for every 2,000 women screened over a 10-year period, one death from breast cancer will be prevented, while 10 healthy women will undergo unnecessary diagnostic procedures and treatment with the associated toxic effects.³

These statistics are not meant to disregard those younger women whose life-threatening cancer was discovered by a timely mammogram, nor are they meant to underestimate the importance of saving lives. However, the new findings do prompt women to reevaluate their approach to cancer screenings and to take into consideration the fact that the risks associated with mammography frequently do outweigh the benefits.

False Positives a Problem -- One of the reasons the task force chose to change the existing guidelines is because mammogram tests of women under 50 result in a high number of false alarms. In fact, women who start getting mammograms at age 40 are estimated to receive 60 percent more false-positive results than women who start at age 50.⁴ Furthermore, The National Breast Cancer Coalition reports that in the United States, "it has been estimated that a woman's cumulative risk for a false-positive result after ten mammograms is almost 50 percent and the risk for undergoing an unnecessary biopsy is almost 20 percent."⁵

The high number of false-positive and false-negative results is partly due to the fact that younger women have denser breasts, which tend to show as white on the mammograms. Cancer also shows as white, which makes it extremely difficult to distinguish the difference between an image showing a cancerous tumor and a healthy mammogram.⁶ Mammograms can also miss life threatening cancers and identify benign growths as life threatening. False alarms lead to healthy women being treated with unnecessary medical procedures, such as exposure to x-ray radiation, which coincidently is one of the known causes of breast cancer, unnecessary biopsy and imaging tests, and in some cases unnecessary mastectomy, as well as psychological trauma and anxiety.⁷

Self-Exams Not Helpful -- The high number of false alarms is also the reason why USPSTF advocates against breast self-exams. By the time the cancer is big enough to be found in a self-exam, it is also big enough to be detected by a woman while dressing, showering, or to be found during the next medical check-up. No concrete research exists to support the idea that women benefit from breast self-exams.⁸

Cancers vary in type and speed with which they grow. Aggressive tumors undoubtedly pose a problem. On the other hand, slow growing tumors might never develop into a threat during a woman's lifetime. Mammogram screenings are more likely to discover a slower-growing cancer. The difference in time length might create an illusion that makes screening appear more beneficial then it actually is. For instance, if a lethal cancer is found early, it would seem that the patient lives longer because of the "lead time."⁹

Only One Group Benefits From Screening -- Additionally, finding breast cancer early does not guarantee survival. According to Breast Cancer Action, "women diagnosed with 'early' breast cancer fall into one of three groups, related to the biology of cancer." These groups include women with breast cancer that responds to early treatments, women with breast cancer that will never become life-threatening, and women with breast cancer for which there are currently no cures. The only people who would benefit from mammogram screenings are the ones in the first group.¹⁰

Some doctors suggest that a new method is needed for how we approach breast cancer diagnosis and treatment. Laura Esserman and Yewey Sheih of the University of Californian-San Francisco and Ian Thompson of the University of Texas Health Science Center propose "differentiating between low and high-risk tumors, reducing treatment for low-risk disease, developing decision-making tools, targeting prevention in highest-risk parties and launching demonstration projects" as innovative ways of combating cancer.¹¹

European Breast Exams Better? -- Another interesting fact to consider is that women in European countries are less likely to receive false-positive results.¹² The Lancet, one of the world's most-respected medical journals, suggests that the difference can be attributed to competency levels between American and European mammographers. According to the journal, "the European success is probably due to a combination of factors -- centralized screening and quality-assurance programmers, more standardized procedures, more reading experience required for mammographers, and lower malpractice rates of missed breast cancer."¹³ Clearly, this is an area in need of improvement in the U.S.

Preventative Health Services Assured -- The major area of concern for many women is whether or not insurance companies will be required under the new health care act to cover mammograms for women under 50. To ensure that women's health is effectively protected, Sen. Barbara Mikulski (D-Md.) introduced the Women's Health Amendment, which NOW supported and the Senate passed on Dec. 3. (Note: the overall health care bill must still pass in the Senate, and then this amendment must be retained when the House and Senate versions are merged into a final bill.)

"Without this amendment, there would be no guarantee that women under 50 would be covered for mammograms," Sen. Mikulski said. "Insurance companies have used every trick in the book to deny coverage to women. This amendment makes sure that the insurance companies must cover the basic care that women need at no cost."¹⁴

NOW's view is that until we improve our processes and have better diagnostic technology, we will have to rely on mammograms and breast self-exams. Obviously, the need for more effective diagnostic technology is great, as breast cancer continues to affect so many thousands of women. But, at the same time, we should be honest about what the data say on the limitations of the current methods of examination.

Our allies at Breast Cancer Action and the National Breast Cancer Coalition agree with the USPSTF recommendations, noting that these call for a more nuanced understanding of breast cancer. These and other groups committed to women's health agree that we need improved methods for detecting breast cancer.

For a thorough discussion of what women should be aware of in making a personal decision about whether and when to have a mammogram, go to "2009 Update: When Should Women Start Regular Mammograms? 40? 50? And How Often is Regular" on the website of the National Research Center for Women & Families.

Some of the best sources of information on this issue, including analysis of the new guidelines, can be found in the footnotes below.

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Footnotes:

¹ Our Bodies Ourselves, "New Mammogram Guidelines Are Causing Confusion, But Here's Why They Make Sense," November 2009

² National Breast Cancer Coalition, "NBCC Statement on Mammography Screening," 2009

³ The Cochrane Collaboration, "Screening for breast cancer with mammography," 2008

http://www.cochrane.org/reviews/en/ab001877.html

⁴ National Breast Cancer Coalition, "NBCC Statement on Mammography Screening," 2009

⁵ National Breast Cancer Coalition, "Mammography for Breast Cancer Screening: Harm/Benefit Analysis, Updated May 2007," 2009

⁶ NRC, "2009 Update: When Should Women Start Regular Mammograms? 40? 50? And How Often is "Regular"?," 2009

⁷ Breat Cancer Action, "Does Mammography Screening Save Lives? Let's Talk About It," 2009

⁸ National Breast Cancer Coalition, "Mammography for Breast Cancer Screening: Harm/Benefit Analysis, Updated May 2007," 2009

⁹ National Breast Cancer Coalition, "NBCC Statement on Mammography Screening," 2009

¹⁰ Breat Cancer Action, "Does Mammography Screening Save Lives? Let's Talk About It," 2009

¹¹ National Partnership for Women & Families, "Experts Recommends New Approaches to Breast Cancer Screening," November 2009

¹²Fletcher, Suzanne W and Joann G Elmore. The Lancet, Volume 365, Issue 9453, 1 January 2005, Pages 7-8

¹³Fletcher, Suzanne W and Joann G Elmore. The Lancet, Volume 365, Issue 9453, 1 January 2005, Pages 7-8

¹⁴ Senator Mikulski, "Senate Approves Mikulski Amendment Making Women's Preventive Care Affordable and Accessible ," December 2009