There has been a long-standing controversy around the benefits of screening mammography dating back to 1977 when the National Cancer Institute (NCI) first recommended annual mammography for women over 50. At the time, the NCI stated that women between the ages of 40 and 49 should have a mammogram only if they had a personal or family history of breast cancer. In 1983, the American Cancer Society declared its support for regular screening for women in their 40s, and the NCI followed suit in 1989.
However, in 1993, the NCI rescinded its guidelines, saying that there was not conclusive scientific evidence that women in their 40s should have regular mammograms. An independent consensus panel was convened by the NCI in 1996 to review the literature. The panel concluded in January 1997, that the existing data did not warrant a recommendation that all women in their 40s have regular mammograms. Shortly thereafter, the Senate unanimously approved a resolution urging the NCI to reissue its 1993 guidelines recommending regular mammograms for women in their 40s. Those guidelines were adopted by the NCI the same day.
More recently, an October 2001 Danish study published in Lancet found that screening mammography was not beneficial. Another study published in the same medical journal in February 2002 concluded that screening mammography was significantly beneficial over the long-term.
These conflicting findings led the Senate Health, Education, Labor, and Pensions Subcommittee on Public Health to hold a joint hearing with the Senate Appropriations Subcommittee on Labor, Health and Human Services, and Education on February 28 to examine the recent controversy.
Noting that the conflicting findings are “incredibly frustrating for American women,” Sen. Barbara Mikulski (D-MD), chair of the Subcommittee on Public Health, said, “Women don’t know who to believe or what to do.”
Sen. Kay Bailey Hutchison (R-TX) agreed. “I was just astonished that once again we could be mixing our messages….Here we are again,” she said.
The subcommittee heard varying opinions from a wide range of witnesses. Not only was there disagreement among the scientific community, but among advocates as well.
Dr. Andrew von Eschenbach of the NCI appeared before the subcommittees to clarify the NCI’s position with respect to screening mammography. “NCI continues to recommend mammography screening for women beginning in their forties,” he said, adding that the recommendation is consistent with the recently released report of the US. Preventive Services Task Force, which recommended screening mammography every one to two years for women in their 40s. Additionally, on February 21, Secretary of Health and Human Services Tommy Thompson issued the same recommendation.
“Everyone agrees that mammography detects early tumors when they are smaller, detects more tumors, and gives women more options for treatment. The benefits are substantial by themselves,” stated Dr. Eschenbach. “The controversial issue is whether it saves lives in the long run,” he added. Dr. Eschenbach noted that the current controversy stems from a “difference in statistical methodology,” saying that other statistician have looked at the Danish study and called into question their analysis.
Dr. Eschenbach stressed that women need to know that “while we are far from declaring victory, we are headed in the right direction,” in terms of eradicating breast cancer. He pointed to the declining mortality rates from breast cancer and stated that the NCI is undertaking “a broad range of research on promising new approaches to breast cancer screening and early detection,” including examining digital mammography, magnetic resonance imaging, positron emission tomography, computed tomography, optical imaging, and a host of other techniques.
The subcommittees also heard testimony from Dr. Donald Berry of the Physicians’ Data Query Screening and Prevention Editorial Board (PDQ). The PDQ is an independent group that reviews recently published literature and provides statements on such literature to physicians and the general public.
After reviewing the October 2001 article, which found that there was no benefit from screening mammography, the PDQ will revise its previous statement that “the estimates of the benefits of screening are uncertain” to say that “the existence of a benefit is itself uncertain.”
Dr. Berry stated that “women with breast cancer detected mammographically have extremely good prognoses in comparison with those having cancers detected in any other way. Since women whose breast cancers were found by mammogram do so much better, there is a tendency to attribute the benefit to mammography.” However, he noted, “This logic is wrong….Apparent survival from diagnosis may be longer, but life expectancy may not change at all.” He attributed this to biases in the study designs and the biology of breast cancer.
Dr. Berry told the subcommittee, “It is a mistake and it is patronizing to women to pretend that we know something we do not. Women have a right to hear about the risks of screening and about the uncertainties regarding the benefits.”
Representing the American Cancer Society, Dr. Harmon Eyre disagreed with the PDQ findings and reiterated the American Cancer Society’s support for screening mammography for women in their 40s. “We are confident that, armed with information, women and their health care providers will continue to see mammography as the best current strategy to reduce death from this disease, and that those whose confidence was shaken by the recent media attention will regain their confidence as the authoritative and credible interpretation of the scientific data on mammography prevails,” he said.
Fran Visco of the National Breast Cancer Coalition stated, “Mammography should be accepted for what it is: followed by treatment, it may extend the lives of some women who have breast cancer, but it does not prevent or cure breast cancer and it has many limitations,” adding: “For too long, mammography has been inextricably and erroneously linked with ‘prevention’ of breast cancer.”
Noting that mammography screening has become a “multi-billion dollar business,” Ms. Visco said, “We must ask ourselves whether this is the best expenditure of finite dollars?,” saying the “goal must be to focus research efforts on true prevention and on stopping breast cancer from occurring altogether.” She urged the subcommittees to fund health coverage for women and prescription drug coverage, as well as further research into the causes of breast cancer and better, more accurate ways to detect and treat the disease.
Dr. Carolyn Runowicz testified on behalf of the American College of Obstetricians and Gynecologists and presented a clinician’s point of view. “While the Lancet study has raised several important issues,…as a practicing physician, I have to look at this through the eyes of individual patients,” she said, adding that she believes that early detection can prolong women’s lives. “As a practicing physician, I would be derelict in my duties if I advised women to stop having mammograms,” she said.
Dr. LaSalle D. Leffall of the Susan G. Komen Breast Cancer Foundation agreed, saying the current controversy has “created a cloud of confusion and an atmosphere of suspicion” and has “done a true injustice to American women who understand that screening is not prevention.” Acknowledging that mammography is an “imperfect screening tool,” Dr. Leffall said that “while we are working to unlock the secrets of what causes breast cancer and eventually prevent the disease,” women should take advantage of regular screening.
During the question and answer period, several Senators raised additional issues. Sen. Patty Murray (D-WA) stressed that access to mammography has not increased across the board, noting that the screening rates for Asian American women and Native American women are “abysmally low.” She questioned whether the current controversy would further discourage minority women from seeking mammograms and urged the NCI to reach out to various communities with clear messages about the benefits of mammography.
Both Sens. Mikulski and Hillary Rodham Clinton (D-NY) expressed concern that the controversy may lead insurance companies to opt out of providing coverage for mammograms. Sen. Clinton noted that the reduced reimbursement rates for mammography are “becoming a real barrier to access” because radiologists and physicians are now opting not to offer mammograms because of the costs. Sen. Mikulski added that “new tools and treatment are a hollow opportunity if women don’t have access.”
