St. Louis Globe-Democrat

Deborah Denson, of St. Louis, thought about postponing her first mammogram.

She had no family history of breast cancer. She took care of herself. She didn’t drink and didn’t feel unhealthy.

But she decided to get it over with and made the appointment for January 2010.

Her screening showed a small lump.

At age 40, Denson was diagnosed with breast cancer after her first mammogram.

Denson was shocked.

“I was going to wait,” she said. “Had I waited--I think it would have been devastating to not only me but my family members.”

Denson has already undergone one surgery and will go through another before the tumor is removed - but says the treatment is not as invasive as it could have been if she’d waited.

“The difference in catching something early is you have more options available to you - that’s a huge advantage.” she said. “I think it is important every woman knows and hopefully their doctors would advise them to be screened at 40.”

But according to a survey published in a medical journal last week, many doctors may start advising women to wait until their 50s to be screened.

Last November the U.S. Preventative Services Task Force (USPSTF) changed its recommendation that most women start mammography screenings from once a year at age 40, to once every two years at age 50.

According to the task force, mammography is more successful at reducing breast cancer mortality in women aged 50 to 74 than women in their 40s.

The USPSTF suggests women in their 40s were more likely to result in a false positive screenings which would cause more stress, unnecessary biopsies and over treatment.

But women like Denson, who was diagnosed at age 40 with her first screening, disagree.

“It would have been devastating to catch it later on if my doctor had followed those guidelines,” she said. “Cancer is cancer--it doesn’t matter what age you are. I think honestly they should open up the age limit to younger than 40.”

Last week, the Annals of Internal Medicine, published an editorial in support of the USPSTF recommendations along with a survey suggesting doctors and patients may be at opposite ends of the debate over what age breast cancer screening should start.

According to the survey, 71 percent of the women surveyed said even if their doctors advised against it, they would continue their annual mammograms throughout their 40s.

Local breast cancer survivors say this is a wise choice.

Cherie Maassen, of St. Peters, was 39-years-old and had never had a mammogram when she was diagnosed with breast cancer in 1987.

She said women should most definitely receive screenings before they are 50.

“If I’d waited until 50, I don’t think I’d be here today,” she said.

When Maassen found a lump in her breast she went to the doctor and found out the cancer had already spread to her lymph nodes.

She had surgery to remove the cancer in her breast and lymph nodes.

She said maybe if she’d had a mammogram, her cancer would have been detected before it spread and her treatment wouldn’t have been so extensive.

Maassen said her family has a history of breast cancer. Her aunt died at age 58 and her sister was diagnosed at age 45 before dying at age 52.

“I think all women should be aware and start check-ups earlier,” she said. “If you find the least little thing - don’t wait.”

In their recommendation, the task force also advised against self breast exams--suggesting this too can lead to false positive results and anxiety while it does not decrease breast cancer mortality.

Mary George, of Maryland Heights, says she is proof this is false.

She felt a lump during a self-exam and was diagnosed with breast cancer at age 40 last January.

“If I had done regular self-exams, I would have found mine earlier,” she said. “Mine was so fast growing had I not found it on my own, it could have been very hazardous.”

But the survey in the medical journal also showed more than half of the doctors who responded were likely to stop advising women in their 40s have mammograms and start suggesting women in their 50s to screen every two years.

Dr. Sara Beth Snell, a breast surgeon at St. Anthony’s Medical Center in St. Louis, is one physician who does not agree with these recommendations.

She said there are several things that disturb her about the recommendation and she fears it will set back 20 years of major progress in women’s health.

“Since 1990 when mammography became widely used in screening, breast cancer death rate has decreased 30 percent,” she said. “We finally reduced mortality rate, now this comes out and sends us back to the drawing board.”

Snell said she thinks the USPSTF’s recommendations are confusing women and mistakenly suggest mammography doesn’t save the lives of women under 50, when it clearly does.

“That’s worrisome to me,” Snell said. “That’s diagnosing at a later state and losing all the ground we’ve gained.”

She said mortality reduction is 15 percent for both the 40 to 49 and 50 and up age group.

“So how can you say ones important and one’s not?” she said.

Snell said mammography often detects small masses early on in women in their 40s - but waiting until 50 to be screened will be too late for some of these women.

“We know when we find it earlier and smaller the survival chances are greater,” she said.

Snell said one thing the recommendation doesn’t show is that several of the studies used to support the research are 10 to 15 years old and from different countries that use single -view film screening instead of the two-view digital screening used in the United States.

“Their argument is it’s not finding anything important, but digital mammography should change that,” she said. “The data that was used was not accurate data to the United States.”

She said a study from Sweden was the only one that used the same screening technology as the U.S. and it showed decreased mortality by 40 percent in the 40 to 49 age group.

Snell also disagrees with the task force suggesting the stress and anxiety of false positive results and unnecessary biopsies compares to the stress of not being screened and being left to wonder.

“I’m not sure how the task force can quantify the anxiety of coming in to get a biopsy and waiting for results, to the anxiety patients would have over not being screened at all,” she said.

Snell said she saw a patient last week who was in her 50s and had never had a mammogram--a situation she fears the recent recommendations will encourage.

“This reinforces her decision that its OK to wait - its not OK,” she said.

Snell said suggesting women avoid mammograms in their 40s, is taking away the option of finding tumors when they are small enough to be palpable and there is less risk.

Dr. Melissa Murray, family practice physician at St. Anthony’s is another who disagrees with the recommendations.

“What concerns me most is no where in there does it say that mammography saves lives of women between the ages of 40-49 - it’s more along the lines of it doesn’t save enough lives,” she said. “Well what is enough lives?”

Murray said she is still recommending patients under 50 receive screenings.

“There are several expert panels and the USPSTF are the only ones who’ve changed their recommendation,” she said.

Murray said she thinks the recommendation is unclear and may lead women to believe mammograms are more likely to result in a false diagnosis and unnecessary treatment.

She said it is actually much more common for screenings to find something that never manifests in the 74 and up age group than the 40 to 49.

Like Snell, Murray said the task force is comparing the incomparable--false positive results verse taking the risk of not knowing.

“I haven’t had a patient tell me they’d rather take the risk,” she said.

Murray also agreed that advising younger women to put off their mammograms would lead to more women dying of breast cancer.

“If we stop screening, we’re going to lose that improved mortality,” she said.

Murray suggests patients compare guidelines from other expert groups before jumping on the bandwagon.

Some women have said they think the recommendations are about saving money and worry that insurance companies will stop covering mammograms for women in their 40s.

With the future of the nation’s healthcare uncertain, it is unclear whether federal guidelines would limit mammography insurance coverage in the future.

But some local lawmakers say they are already taking steps to ensure that doesn’t happen.

Illinois Representative Eddie L. Jackson is supporting legislation to protect mammogram coverage if the federal government scales back Medicare.

According to House Bill 4817, if the federal government scales back scheduled mammogram coverage as recommended by the U.S. Preventative Services Task Force, Illinois residents with supplemental policies would not lose coverage.

Missouri Senator Jane Cunningham introduced SJR 25, an amendment to the state constitution, that if passed will shield Missourians from federal healthcare mandates by allowing them to choose their own medical and insurance options.

Cunningham said this would give women the freedom to choose medical providers who would provide mammogram screenings for women under 50.

The senator said she receives her mammograms every year and thinks the new recommendations proposed by the task force are dangerous.

Her grandmother was diagnosed with breast cancer at age 45.

“Being diagnosed at 50 wouldn’t have done her much good,” she said. “Breast cancer is so common these days, that to wait until 50 is really late.”

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