New Mammography Guidelines Jolt Medical Field
Doctors Predict By-product of Screening Debate: More Talk With Patients About Mammograms
By
Andy Miller
WebMD Health News
Reviewed By
Louise Chang, MD
Latest Womens Health News
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."
SOURCES: The New York Times: "Sebelius on Mammograms: Don't Change What You're Doing."
The New York Times: "Guidelines Push Back Age for Cervical Cancer Tests."
The New York Times: "Panel Urges Mammograms at 50, Not 40."
Julie Wood, MD, family practice physician, Kansas City, Mo.
Peter McGough, MD, family practice physician, Seattle.
David Mutch, MD, ob-gyn, Washington University, St. Louis.
Joseph Stubbs, MD, internist, Albany, Ga.; president, American College of Physicians.
Judi Chervenak, MD, ob-gyn, Montefiore Medical Center, New York.
Tom Bader, MD, chief of general obstetrics and gynecology, University of
Pennsylvania.
American Cancer Society.
American College of Obstetricians and Gynecologists.
U.S. Department of Health and Human Services.
Centers for Medicare and Medicaid Services.
CNN: "New cervical cancer screening guidelines released."
Susan Pisano, America's Health Insurance Plans.
Stephanie Poe, public relations, Mercer.
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