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Fiddling While Rome Burns: The Latest Mammogram Controversy
By Barbara A. Brenner, Breast Cancer Action
Unless you were in a media blackout, you could hardly miss it. The National Institutes of Health (NIH) held a consensus development conference in January on mammography screening for women aged 40 to 49. The conclusions reached by the panel have generated extensive comment. The general impression conveyed by the press is that women are outraged by the failure of the conference to recommend regular mammograms for women in their 40s.1 The debate raises a number of issues.
First, why were people expecting the panel to make a recommendation for regular screening? The media strongly indicated before the conference began that the only reasonable conclusion would be a renewed recommendation 2 that women begin regular screening at age 40.3 This press view almost certainly reflects the influence of the National Cancer Institute (NCI) and the American Cancer Society (ACS) on how the media covers and how the public perceives cancer issues. Dr. Richard Klausner, director of the NCI, who convened the conference, said afterwards that his own view is that there is a net benefit from screening of women 40 to 49. 4
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Mammograms have been the centerpiece of the ACS's campaign against breast cancer since 1983.5 As part of that campaign, the ACS has been advising women aged 40 to 49 to have regular mammograms, despite the lack of agreement on the benefits of the procedure. Following the NIH conference, the ACS restated its support of mainmograms every one to two years for women 40 to 49.6 The ACS is so locked into the "mammograms are your best protection" message of "breast health" that, by the time you read this column, it will have held its own conference in March to consider whether to recommend annual mammograms for women in this age group. (Dollars to donuts, I'm betting they answer the question with a resounding "yes.")
Despite the pressure to find clear benefits justifying a recommendation of regular screening mammograms for women 40 to 49, the NIH panel concluded that the scientific evidence does not support such a recommendation. Instead, the panel stated: "At the present time, the available data do not warrant a single recommendation for mammography for all women in their forties. Each woman should decide for herself whether to undergo mammography. [A] woman should have access to the best possible information in an understandable and usable form. Her health care provider must be equipped with sufficient information to facilitate her decision-making process. Costs of mammograms should be reimbursed by third-party payors or covered by health maintenance organizations." 7
By itself, this statement is hardly controversial. After all, it argues-as does BCA's policy on mammograms for informed decision making by women faced with conflicting data about the benefits of the technology. Which brings me to the second issue that the debate highlights: why all the outrage about the recommendations?
The short answer to this question lies in the way the media likes to cover stories. Personal testimonials by women who believe their lives have been saved by mammograms make much better and more compelling reading than the text of the consensus conference's report. Controversy also makes better press. In The New York Times, the story was presented as a conflict pitting radiologists and breast cancer patients against public health specialists and some feminists! 8
Then, of course, there are those whose vested interests impassion their arguments. Dr. Michael Linver, director of mammography at X-Ray Associates of New Mexico and a presenter at the conference commented on the findings: "I do fear that this is tantamount to a death sentence [for women in their 40s]. I grieve for them." 9 The American College of Radiology, whose members make part of their livings by doing mammograms, not only criticized the consensus statement, but recommended that the screening interval for women 40 to 49 be shortened to once a year. Let's see, now, that's twice as many mammograms, which means twice as much income, right?
And there is the ACS, which found it "especially troubling that the panel would issue a pessimistic statement, and conclude once again that the burden of decision for a woman in her 40s is hers alone." 10 Of course, none of the conclusions would trouble the ACS if the organization had been more forthcoming in the first instance about the risks and benefits of mammographic screening. By promoting mammograms as an unqualified good, the ACS has helped to mislead American women about the value of the technology.11
The debate ignores the third and most fundamental problem. If there is any reason for outrage, it is this: as long as we are spending our time, energy and money on the mammogram debate, we are distracted from finding a nonradiation-based detection method that works, discovering effective treatments and offering primary prevention. Just as Nero fiddled while Rome burned, we are spending enormous resources on an aspect of breast cancer that ultimately does very little, if anything, to save lives.
Reverberations from the recommendations demonstrate this misguided effort. Dr. Klausner was so unhappy with the conclusion of the consensus panel that he spent more taxpayer money to convene the National Cancer Advisory Board (NCAB) in February 1997 to review the decision. What we might expect from those deliberations is revealed by the comments of one member of the NCAB who has publicly stated that Klausner's actions constitute "a moral stand and a courageous stand" and prove that Klausner "cares about the health of American women."12
The panel's report itself includes some of the same misguided research recommendations that keep us from learning what causes and how to prevent breast cancer. As to directions for future study, the panel identifies 18 research questions that need to be answered. All them concern the utility and value of mammograms. When will we stop spending money on a technology that gains us so little in terms of reducing the death rate from breast cancer? Take the call for a study of the effectiveness of mammography for African American women. It's a waste of valuable resources unless it helps resolve more important questions, such as why African American women, who develop the disease less often, die more often and sooner than white women.
Too much attention is being focused on the mammography debate and away from the real questions that need to be answered. The interests that benefit while our efforts are diverted from the hard issues of the breast cancer epidemic are legion. None of us can afford to allow them to prevail. After all, Rome is burning.
Breast Cancer FactsBreast Self Exam
1. See "Mammogram Panel Only Adds to Furor," USA Today, 1/24-26/97; "Stand on Mammograms Greeted by Outrage," The New York Times, 1/28/97.
2. Since 1983, the American Cancer Society (ACS) has recommended that women 40 to 49 have screening mammograms every one to two years. The National Cancer Institute (NCI) began making the same recommendation in 1987. In 1993, the NCI decided that the scientific evidence did not support this recommendation, and withdrew it. The ACS and many other cancer organizations disagreed and continued to urge regular screening mammograms for women in this age group.
3. See "Personal Health: New Studies Indicate That Women in Their 40's Benefit from Annual Mammograms," The New York Times, 12/4/96; "News You Can Use: The Great Mammogram Debate," U.S. News & World Report, 1/27/97.
4. "Mammogram Talks Prove Indefinite," The New York Times, 1/24/97.
5. Batt, S., Patient No More: The Politics of Breast Cancer, p. 41 (Gynergy Books, 1994.)
6. "NIH Statement Doesn't Resolve Mammography Controversy," The Cancer Letter, Vol. 23, No. 4,1/31/97.
7. National Institutes of Health Consensus Development Conference Statement: Breast Cancer Screening for Women Ages 40-49, 1/21-23/97. Copies of the statement are available from the BCA Office, from the NIH by calling (toll free)1-888-644-2667; or on-line at http://consensus.nih.gov.
8. "Mammograms for Women in 40's Debated by Experts," The New York Times, 1/22/97.
9. "Mammogram Talks Prove Indefinite," The New York Times, 1/24/97.
10. "NIH Statement Doesn't Resolve Mammography Controversy," The Cancer Letter, Vol. 23, No. 4,1/31/97.
11. See "Mammography Under Fire," BCA Newsletter, October/November 1996, #38. See also Batt, Patient No More, supra, at p. 243.
12. Ellen Sigal, member of NCAB, quoted in "Mammography Screening for Ages 40-49 Not Supported by Data, NIH Panel Says," The Cancer Letter, Vol. 23, No. 4, 1/31/97. The implication that the consensus panel is indifferent to the health of American women is bad enough. What is worse is Ms. Sigal's suggestion that continuing to focus on the issue of mammograms for 40- to 49-year olds somehow puts the NCI director on the cutting edge of the efforts to end the breast cancer epidemic.
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