Mammogram lacks better option

Many women, doctors not ready to abandon despite imperfections

February 28, 2002|By Jonathan Bor | Jonathan Bor,SUN STAFF

In the simmering debate over the value of regular mammograms, critics argue that they lead to unnecessary biopsies, treatments and anguish.

Barbara Olsen, 46, endured a cancer scare last year when a suspicious mammogram led to a biopsy that revealed nothing but a benign lump. Another woman, a research scientist in Washington, has endured three "false positives" that triggered biopsies and agonizing waits for results.

And Linda Osborne, 53, had surgery and radiation for a type of breast cancer that might never spread if left alone.

Although they may seem victims of needless tests and interventions, these women do not regret undergoing the mammograms and everything that followed.

That's one reason why the question of whether to recommend routine screening is so complicated and emotional. As imperfect as mammograms are, many women, doctors and professional organizations are not ready to abandon the tests until a better alternative comes along.

Not when the second-leading cause of cancer death among women - a disease responsible for 40,000 deaths annually - is at stake.

Today, the debate goes to Congress, where Sen. Barbara A. Mikulski will chair a hearing that she hopes will bring some clarity to a debate that she says has both confused and scared women.

"They are scared about what is the right thing to do, and are as apprehensive as I am that insurance companies will use the confusion to pull out of reimbursing for screening mammograms," Mikulski said.

Recommended for years by the major health organizations, mammograms came under renewed scrutiny in October when two Danish scientists questioned whether the tests protect women from dying of breast cancer.

The scientists, reporting in a British medical journal, reviewed seven studies long cited as evidence that routine screening lowers a woman's chance of dying of breast cancer by 30 percent.

Dr. Peter Gotzshe and Dr. Ole Olsen, both of the Nordic Cochrane Center in Copenhagen, said five of the studies were so flawed they should be discarded. As it happened, these were the very studies showing that mammograms were beneficial.

Two studies that they deemed statistically valid showed no benefit, prompting the scientists to conclude that there is no reliable evidence that the exams save lives.

Later, an independent panel appointed by the National Cancer Institute analyzed the same studies and found the evidence for mammography was so shaky that women ought to discuss the issue with their doctors and decide for themselves.

"Our best guess remains that mammography decreases the chances of dying of breast cancer, but the evidence is weaker than was previously appreciated," said Barnett Kramer, the panel chairman.

Last week, the Department of Health and Human Services weighed in - recommending that women 40 and older get screened every year or two. The guidelines were issued after an advisory panel, the U.S. Preventive Services Task Force, said women in the disputed studies were 23 percent less likely to die of breast cancer than women who were not screened.

"Our bottom line," said Dr. Janet Allan, vice chairwoman of the task force, "is that mammograms reduce deaths from breast cancer."

The debate hinges only partly on whether mammograms protect women from cancer. Critics also argue that screening is far more likely to turn up false positives than actual cancers. The result, they say, is unnecessary anguish along with biopsies and treatments that can include radiation, chemotherapy and mastectomies.

One study estimated that over the course of 10 mammograms, a woman stands almost a 50 percent chance of receiving a false positive result.

To some patients, receiving good news in the end is what really matters.

Barbara Olsen, who lives in Lutherville, received her scare last year when doctors noticed an irregularity on her annual screening and recommended a repeat test. The next mammogram didn't show concrete evidence of a tumor, so doctors suggested an ultrasound test, which can sometimes distinguish cancer from a harmless cyst.

Her ultrasound, however, was inconclusive.

Not wanting to miss anything, her doctor suggested that she receive a needle biopsy, a test in which tissue is withdrawn and analyzed under a microscope. To her great relief, her doctors found no cancer, just a benign fibrous mass.

"I'd rather have the scare and have it be nothing than to not have the scare and have it turn out to be cancer," Olsen said. "I think they need to improve the technology, but for now, what are you going to do? Nothing?"

Dr. Gina Sager, a breast cancer surgeon at Franklin Square Hospital, said she sees women who have grown so accustomed to false positives that they expect doctors to find nothing. But others can't sleep for weeks before their next mammogram, fearing that it will trigger a battery of new tests that turn up cancer.

"Sometimes, those patients are almost inconsolable when you tell them they don't have something because they're expecting cancer," Sager said.

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