Dr. Catherine Buhler (left) discusses a breast ultrasound with Brianne Utt, RDMS, ultrasound supervisor. Breast ultrasounds help rule out cancer if a patient requires additional testing.
Multiple large, randomized, prospective studies – considered the gold standard of research – show that annual Affordable Care Act mandate coverage of yearly mammograms starting at age 40.
Yet women may be delaying their mammograms due to conflicting recommendations they are hearing in the news, according to breast imaging specialists with Radiologic Associates of Fredericksburg (RAF). The doctors are concerned about the potential impact on women’s health and the possibility that insurers may use confusion over mammogram guidelines to limit coverage, and thus limit access, for patients.
Catherine D. Buhler, MD, a board-certified, fellowship-trained breast imaging specialist with RAF who works at the Imaging Center for Women in Fredericksburg, said she is fielding more questions from patients and friends about when to start having mammograms and how often to have them. Friends are even posting questions on her Facebook page.
Some are reading articles quoting the U.S. Preventive Services Task Force, an advisory group to Congress. In 2009, the task force recommended that most women delay mammograms until age 50 and have them every other year versus annually. In a recent column for The Wall Street Journal, Daniel B. Kopans, MD, a professor of radiology at Harvard Medical School, said that the task force’s own computer models indicated that as many as 100,000 women mammograms starting at age 40 save women’s lives. The American Congress of Obstetricians and Gynecologists, the American Cancer Society, and other medical groups agree with these recommendations. Most insurers and even the could die from breast cancer if they waited until age 50 to start mammograms. Dr. Buhler noted that physicians who actually care for women with breast cancer were not even represented on the task force.
“People need to know that women in their 40s do get cancer, and that some of these cancers can be aggressive. They also need to know that the gold standard of research shows that mammography works,” Dr. Buhler said.
Large, randomized, prospective studies have found that breast cancer deaths dropped for the first time in 50 years after regular mammography screening programs started in the 1980s. Research also shows that 71% of women who die from breast cancer are those who have not had yearly mammograms starting at age 40, Dr. Buhler explained. That study, by Harvard University researchers, was published in the journal Cancer in September 2013.
Benefits outweigh anxieties
Compared with the benefits of breast cancer screening, Dr. Buhler felt the task force’s concerns about emotional “harms” to patients who are called back for more testing after an inconclusive mammogram were overemphasized. Most of the estimated 10% of patients who are called back require only an additional mammogram and ultrasound. An estimated 1–2% of patients will require a needle biopsy to examine a suspicious finding, according to the American College of Radiology (ACR). A study published earlier this year in the Journal of the American Medical Association found that short-term anxiety is real for many patients but diminishes quickly and has no measurable effects on health.
“We know that call-backs cause scares, and we are sensitive to this,” Dr. Buhler said. “The Imaging Center for Women offers same-day mammogram results for women who request it when they make their appointments. When women do have call-backs, we see them as soon as possible to minimize their anxiety, and always have a radiologist, specializing in women’s imaging needs, discuss the findings directly with the patient during the visit. Short-term anxiety is certainly preferable to the possibility of delaying a breast cancer diagnosis.”
A few recent studies have added to the mammogram guidelines controversy. Dr. Buhler criticized a paper published in the New England Journal of Medicine that concluded mammograms were leading to overdiagnosis and having only a minimal effect on breast cancer death rates. The findings were based on flawed data and assumptions, according to the ACR and Society of Breast Imaging (SBI) in a statement issued in November 2012. Another study earlier this year from Canada implied that physical exams were more effective than mammograms in reducing death rates. The study’s methods and data analysis have been criticized by groups including ACR and SBI and even the World Health Organization.
A mammogram can detect a non palpable 5 millimeter mass, smaller than the size of a pea. Mammograms can also detect cancers that are deeper in the breast, Dr. Buhler noted. “Why would you recommend that a woman wait until a cancer is palpable, when the mass is larger and possibly more advanced? The smaller the cancer, the better a patient’s treatment options and survival.”
At the other end of the spectrum, older women sometimes ask how old they should be when they stop getting regular mammograms. Dr. Buhler feels that the age 75 cutoff in the task force recommendations is too restrictive.
“I have had patients 90 years old and one treated for breast cancer at 87,” Dr. Buhler said. “It is not up to us to decide who deserves treatment. Our job is to diagnose cancer and let the patient and her doctor decide about treatment.”
Dr. Buhler is one of 10 breast imaging specialists at RAF who regularly interpret mammograms and care for patients at the Imaging Center for Women in Fredericksburg, designated by the American College of Radiology as a Women’s Imaging Center of Excellence. RAF physicians were trained at some of the most prestigious radiology programs in the country including Mallinckrodt, Johns Hopkins, Duke, Stanford, University of Virginia, Memorial Sloan-Kettering and M.D. Anderson Cancer Centers, among others.