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Panel Fails To Advise Early Mammograms Decision Met With Instant And Ardent Criticism

An independent panel of experts convened by the National Institutes of Health said Thursday it cannot recommend routine mammograms for women in their 40s - a decision that seemed to stun many there, including the head of the National Cancer Institute.

After listening to 32 presentations over a day and a half, the panel told a packed crowd of researchers, doctors and activists that “at the present time, the available data do not warrant a single recommendation for mammography for all women in their 40s. Each woman should decide for herself whether to undergo mammography.”

But in a highly unusual move, Dr. Richard Klausner, head of the National Cancer Institute, which was one of the sponsors of the conference, said he disagrees. “My own evaluation is that the data do support” regular mammograms for women in their 40s, Klausner said at a news conference later. “Yes, I am disagreeing with the balance of benefits-to-risk ratio expressed in the report.”

Klausner said the cancer institute will meet within several months to discuss the panel’s finding and its own recommendations on breast cancer screening for younger women. The agency already has recommended that women over the age of 50 get regular mammograms.

Three years ago, when the cancer institute was headed by Samuel Broder, it rescinded its previous recommendation that women ages 40-49 routinely have mammograms. The reason, the NCI said then, was that while studies clearly showed mammograms saved lives for women age 50-69, they did not show that younger women received the same benefit.

That 1993 decision set off a firestorm of protests from groups such as the American Cancer Society, which continues to recommend screening for women 40-49 every one to two years, and from radiologists.

Thursday’s decision set off similar waves of concern and even anger.

Amy Langer, head of the National Alliance of Breast Cancer Organizations, said she was “hoping for much more direction from the panel. I think women will remain just as confused as before.”

Dr. Michael Livner, a radiologist from New Mexico, said, “I do fear this document is a death sentence for thousands of women.”

Dr. Daniel Kopans, head of radiologists at Massachusetts General Hospital in Boston and an outspoken critic of the cancer institute’s mammography recommendation three years ago, challenged the integrity of the panel, saying, “it sounds like the statement was written before the meeting.”

The panel urged all health insurers to cover the cost of the test if a woman in this age group decides to have it. But the impact of that recommendation was unclear.

Currently, coverage decisions depend on individual insurers, who typically will pay for a mammogram among women in their 40s if a symptom, such as a lump, is present but not always if a patient has no symptoms. Most insurers cover routine tests for older women, however.

Not everybody was unhappy with the panel’s recommendation. Cindy Pearson of the National Women’s Health Network praised the panel, saying it was “way past time giving women simple recommendations.”

The current panel was assembled after new evidence was presented at a meeting in Sweden last March from two Swedish studies that showed mammograms provided a clear reduction in breast cancer mortality. One study showed a 44 percent reduction in mortality after 11 years of follow-up and another showed a 36 percent reduction after 14 years of follow-up.

But the panel apparently didn’t find the data ultimately convincing, despite long years of followup. It focused on the fact that none of the trials showed a decrease in mortality within seven years of follow-up.

Dr. Donald Berry, of Duke University, who was one of the panel members, said the data from all the studies were simply not strong enough to warrant a recommendation for routine mammography under age 50.

The panel said that some studies show a decrease in breast cancer mortality among young women, but said, “This may be due to other factors, including clinical breast exams given to women and mammograms after age 49.”