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MU professor speaks on the science behind new mammogram recommendations

Thursday, January 21, 2010 | 12:01 a.m. CST

COLUMBIA — A University Hospital physician who served on the task force that issued new recommendations for mammograms last year said he regrets that many women under 50 concluded they should not be screened.

"Women should be aware of the risks of mammograms and consult with their physician before undergoing the procedure," said Michael LeFevre, one of 16 members of the U.S. Preventive Services Task Force and a professor of family and community medicine at MU.

“My recommendation: Discuss at age 40, encourage at age 50, strongly encourage at age 60,” LeFevre told an audience largely made up of medical students and professors Wednesday at MU's School of Medicine.

In his presentation, LeFevre explained the controversial new mammogram recommendations and the research behind two of the key conclusions:

  • Women over 50 should have mammograms every other year instead of annually.
    As a doctor, LeFevre said he would recommend biennial (every other year) screenings, “but I will not discourage annual.”
  •  Women under 50 should consult with their physician about benefits and harms of undergoing a mammogram. The investigation found that breast cancer risk is much higher in older women and that younger women are more likely to have a false positive result from a mammogram.

The task force, which began the project in 2006, examined the pros and cons of regular mammograms for women in different 10-year age groups.

The study looked at some of the harms of mammogram screening, including exposure to radiation, overdiagnosis, pain, anxiety and false positives and negatives.

"The goal was to balance benefits and harms and look at net benefit," LeFevre said.

The task force found relevant data to support its conclusion that it is statistically more efficient to screen older women than younger ones.

In one study, 556 women in the 40- to 49-year-old age bracket needed a mammogram to detect one case of invasive breast cancer.  Among 80- to 89-year-olds, 143 were screened to reach the same result.

The task force also looked at overexposure to radiation from frequent mammograms and concluded, though not conclusively, that it may increase the possibility of harm.

“At the end, radiation did not weigh heavily in the task force decision,” LeFevre said.

However, he emphasized that radiation is not benign and should be taken into consideration.

The issue of overdiagnosis is complicated because it is possible to identify and treat some cancers that ultimately would not have made the patient ill. In those cases, intervention may only have a negative effect, he said.

It may either subject a patient to unnecessary treatment or falsely persuade a woman that her life has been saved.

After reviewing all the data, the task force ultimately found that by screening women between 40 and 49, in addition to women over 50, just one more life out of 1,000 would be saved.

This led to the panel's recommendation that women under 50 should consult with a physician about the harms and benefits of a mammogram. Women over 50 should be screened every two years.

"I was waiting to hear this talk to adjust what I was going to do about advising patients about mammograms," said Anne Fitzsimmons, a physician at the Green Meadows Family Medicine Clinic who attended LeFevre’s lecture.

Fitzsimmons said she plans to keep lines of communication open with her patients.

“I want to have a discussion with them about the good and bad things…to discuss this particularly with women under 50,” she said. “Benefits are small, and risks are not negligible.”

But one member of the audience heatedly accused LeFevre of "throwing 40- to 49-year-old women under the bus" for the sake of cost savings on mammograms.

LeFevre responded with nearly equal fervor: “One sort of vicious thing I am not willing to accept is that this is a political, cost-conserving, rationing-motivated recommendation, which is absolutely, unequivocally false.”

Fitzsimmons said she doesn't believe the new recommendations are motivated by cost savings.

“Often, I don’t think we take the time to discuss the risk-benefit ratio,” she said.

LeFevre explained that women have the same option to have a mammogram at age 40 that they did before, but “the benefit is small and there are harms.

"Women are entitled to this information.” 


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