Advocates slam proposals for later, fewer screenings
Kim Kozlowski / The Detroit News
After a decade of breast self-examinations, Cathy Sullivan discovered a lump at age 40. Tests later confirmed she had breast cancer.
Following surgery and treatment, Sullivan is now cancer-free. But she wonders what would have happened if she had followed a new federal recommendation that no longer recommends breast self-examinations.
“I may not be here today,” said Sullivan of Royal Oak.
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Sullivan is among many women, doctors and advocacy organizations objecting to narrower breast cancer screening guidelines recently issued by the U.S. Preventative Services Task Force, a government panel. The guidelines reversed those in place for years, igniting an outcry from some who fear diminished cancer screenings for women, confusion among patients and rationed care with the federal effort to overhaul health care.
The recommendations were followed by new cervical cancer screening guidelines and prompted some to draw parallels to other controversial recommendations, such as those for prostate cancer screening.
But researchers say the new recommendations are based on studies showing that some surveillance tools do not necessarily lead to better health outcomes.
“For years, we’ve been trying to evaluate the evidence on what’s most appropriate and what to do,” said Dr. Mack Ruffin, a University of Michigan family medicine professor and physician at the U-M Comprehensive Cancer Center. “Often the recommendations fly in the face of what people know. There is evidence, and what you believe. You are going to go with what you believe.”
Screening guidelines are outlined for patients by advocacy groups, professional organizations and the government. Not all are the same.
The U.S. Preventative Services Task Force, which bases its recommendations on scientific research, concluded last month that routine mammograms should begin at age 50, as opposed to 40, to screen for breast cancer, the most common cancer in women outside of some skin cancers.
The panel questioned the value of mammograms for those over age 75. It also recommended against monthly breast self-examination, and that women age 50 to 74 get mammograms every other year, rather than annually. The panel’s rationale for changing the guidelines is the risks outweigh the benefits: more women under age 50 have to be screened to save a life, and mammograms can lead to false positives.
Like many women, Royal Oak resident Nancy Piva was exasperated by the new recommendations.
“It’s amazing to me,” said Piva, who discovered cancer in her breast when she was 37. “The cancer cells can’t tell how old you are. They don’t just sit there waiting until your 50th birthday to show up.”
Since the guidelines were released, mammogram screening has been brought up by almost every patient seen by Dr. Richard E. Smith, a Henry Ford Hospital obstetrician/gynecologist.
“All of them prefer to have it done earlier than later,” said Smith.
Many local physicians and health organizations are not adopting the new recommendations and are continuing to conduct annual mammograms on women age 40 and older, such as Dr. Zeina Nahleh, an oncologist at the Barbara Ann Karmanos Cancer Institute. She said the report confused the public, and the panel should have left the discussion in the scientific community as to how to get better technology to screen for breast cancer to eliminate false positive reports.
“For now mammography is the best we have for breast cancer screening,” Nahleh said. “Until we find better technologies, we should stick to what we have because it works.”
After the new breast cancer recommendations were released, rationing of care was cited as a concern during health care reform efforts. This prompted an amendment to be passed by the U.S. Senate last week, ensuring that mammogram coverage and preventive screening for women would be part of any new health care legislation.
Michigan law also requires insurance companies to pay for one mammogram for women between the age of 35-40, and one mammogram every year for women age 40 and older.
Pap tests guides change too
Days after the new mammogram recommendations were released, the American College of Obstetricians and Gynecologists issued new pap test guidelines to screen for cervical cancer, which was diagnosed in 12,000 women nationally in 2005.
The new pap guidelines recommend that women begin the screening at age 21, changing the group’s recommendation from three years after the beginning of sexual activity.
These were not as controversial as the mammogram recommendations, perhaps because cervical cancer is not as common as breast cancer and there is a new vaccine, Gardasil, to prevent it in young girls by 70 percent, said Dr. Mark Werner, an obstetrician/gynecologist at Beaumont Hospital.
Even so, Werner still plans to do pap tests on his patients annually.
“Most patients want a yearly pap,” said Werner. “They are nervous to go two to three years between them. They want to make sure there is nothing serious in their body, and they would rather be checked.”
PSA test under scrutiny
The breast and cervical cancer recommendations are the latest in a string of other controversial recommendations, such as screening men for prostate cancer with the Prostate-Specific Antigen test, that suggest surveillance does not necessarily lead to better outcomes.
Experts disagree on the whether PSA test should be used to screen men for prostate cancer because the research is not clear on whether it saves lives. Prostate cancer, which was diagnosed in 186,000 men nationally in 2005, is typically slow-growing. Some say that most men will die from something else before succumbing to the cancer. Some prostate cancer treatments can also lead to incontinence and erectile dysfunction.
Sheldon Schwartz, a Novi resident, said all men should get the PSA test because it can detect more aggressive prostate cancers.
“It saved my life 18 years ago,” said Schwartz, 73.
Ruffin, the U-M physician whose work focuses on prevention, said there is not enough research to support use of the PSA test in men with an average risk of prostate cancer, and yearly pap tests to screen for cervical cancer in woman doesn’t improve mortality rates. Additional screening also has not impacted breast cancer mortality rates in women, probably because two-thirds of mammograms are done in women under age 40, when the cancer is less common. Women over 50 should be getting the bulk of the nation’s mammograms and in a more systematic way, as do women in European countries.
“We’re trying to look at what evidence we have and make recommendations for screening for these cancers that we know would make a difference,” Ruffin said.
Even so, some cancer survivors are skeptical of what has been told to them for years is now changing.
“It’s scary,” said Amy Noon, 39, of Auburn Hills, an ovarian cancer survivor. “Cancer can be very aggressive.”
kkozlowski@detnews.com< (313) 222-2024