Women in their 40s are on their own when it comes to deciding whether to have mammograms.
That was the surprising conclusion of a panel of experts convened by the National Institutes of Health last month to evaluate whether the latest scientific evidence supports mammography screening for women ages 40 to 49.
"At the present time, the available data do not warrant a single recommendation for mammography for all women in their 40s," the NIH panel found. "Each woman should decide for herself whether to undergo mammography."
Also on their own are healthcare executives, who must grapple with mammography policies without much guidance from government experts. Coverage is not as much the issue as emphasis. Health plans and insurers generally pay for mammograms a younger woman and her doctor decide are needed. At stake is whether the government will get behind aggressive screening of women in their 40s, as it already has for those 50 and older.
By failing to endorse expanded screening, the panel appeared to discount several recent reports that regular mammograms of women in their 40s reduce breast cancer death rates 16% to 44%, depending on the study, mammography supporters said.
In 1993, another NIH consensus panel balked at recommending mammograms beginning at age 40, citing a lack of clinical data. That this panel stood pat in the face of substantial new evidence puzzled many who thought previous doubts had been erased.
"I'm just incredulous that they could come to that viewpoint after hearing the data that were presented," said Stephen A. Feig, M.D., who testified before the panel and also chairs an American College of Radiology committee on mammography policy. "How much proof do they need?"
The panel's conclusion also surprised Richard D. Klausner, director of the National Cancer Institute, the NIH branch that originally sought the consensus panel to consider the merits of mammography for younger women.
"My own reading of the studies and information presented to the panel is that . . . there is a statistically significant benefit (for mammography) in terms of reduced cancer death from breast cancer for women in their 40s," Klausner said in a prepared statement.
Indeed, the American Cancer Society, long an advocate for starting screening at 40, called the panel's findings "troubling." For the American Cancer Society, the question is not whether women in their 40s should have mammograms but how often.
The group will convene its own expert panel in Chicago in March to consider whether to explicitly endorse yearly mammograms for women in their 40s. Currently, the American Cancer Society counsels those women to have mammograms every year or two.
NIH panel members defended their findings, contending the evidence in favor of extending mammographic screening to younger women remains far from conclusive.
Screening exposes a large population of healthy women to additional medical procedures when preliminary mammograms wrongly indicate cancer, the panel said. And for all women screened there is some incremental risk from radiation, albeit a minimal one. So the panel declined to recommend broad screening in the face of less than overwhelming data, said one participant.
"Before you institute a public policy for screening in healthy people, (the evidence) should be all thumbs up," said Susan Chu, a panel member and assistant director of the Center for Health Studies of Group Health Cooperative of Puget Sound, Seattle.
The NCI will revisit the issue later this month during a two-day meeting of the National Cancer Advisory Board, a panel of experts appointed by the president. So stay tuned.
In the meantime, what's a healthcare executive to do? The best advice seems to be stay the course with current mammography programs and, if anything, beef up education and outreach programs.
Providers' current mammography policies for women under 50 vary, reflecting in part the degree of uncertainty among medical experts about the benefit of such screening.
In line with the NIH panel's recommendations, Brookline, Mass.-based Harvard Pilgrim Health Care covers mammograms for women in their 40s but reserves screening for women over 50.
"I don't think the data are convincing in terms of a need to go forward with a massive program to screen our general population," said John Ludden, M.D., senior vice president for medical affairs at Harvard Pilgrim.
"In the absence of data that can really create a consensus, it comes back down to the patient and their doctor," he said.
By contrast, Allina Health System's Medica HMO aggressively encourages regular mammograms for women in their 40s. And that's been standard practice since the late 1980s, said Sara Stoesz, spokeswoman for the Minneapolis-based plan. In fact, upon enrollment, Medica sends all new women members, regardless of age, a letter encouraging them to arrange for a mammogram. Even women in their 20s can benefit by having a baseline study, Stoesz explained.
Although she could not quantify cost savings under Allina's policy, she said there is no doubt that earlier detection and treatment of breast cancer trims costs.
"The essence of managed care is prevention," Allina's Stoesz emphasized. "Now we find our major barrier is convincing people to consume these preventive healthcare services."
In the short term, at least, the NIH panel's highly publicized findings may discourage women on the fence from having mammograms.
"This will confuse many women about what they should do," said W. Phil Evans, M.D., medical director at Susan G. Komen Breast Center at Baylor University Medical Center, Dallas. Last year, more than 20,000 women had screening mammograms at the Komen center. More than a third of the mammograms were for women in their 40s.
"We're going to continue to recommend screening mammograms every year after age 40," Evans said. "In everyday practice, we see so many women who would not be alive if they had not received a screening mammogram."