March 2010

Patient Backlash
By Beth W. Orenstein

Radiology Today
Vol. 11 No. 3 P. 30

Breast imagers report that women have joined the attack on the USPSTF mammography guidelines.


In November 2009, when the U.S. Preventive Services Task Force (USPSTF) recommended that most women start routine mammography screenings at the age of 50 rather than 40, it caused an uproar in the medical community. Radiologists, oncologists, and breast specialists were quick to condemn the recommendation. And apparently their patients were, too. Radiologists who have direct patient contact and their radiologic and technologists who perform mammograms say many patients they have seen since the news broke are appalled by the new suggested guidelines.

“It appears our patients are smarter than the ones who put out the recommendation,” says Carl D’Orsi, MD, FACR, cochair of the ACR Breast Imaging Commission. “They were questioning what the panel was talking about. They were asking, ‘Where did this come from?’ Our patients said not only would they not follow the new recommendation, but they also were criticizing it.”

D’Orsi, director of breast imaging at Emory University’s Winship Cancer Institute in Atlanta, says his patients’ reaction was “very rewarding” because it shows they were paying attention to earlier recommendations from groups such as the ACR and the American Cancer Society that advise annual screenings for breast cancer starting at the age of 40.

Like D’Orsi, Ellen B. Mendelson, MD, FACR, chief of the breast and women’s imaging section at Northwestern Memorial Hospital in Chicago, found that her patients were not only questioning the panel’s recommendation but also were indignant about it. “They were all asking, ‘How could this happen in this country?’” she says. The most vociferous, she says, were cancer patients in her office for follow-up screenings. Fortunately, she says, no patient indicated she would follow the new recommendations. “They said they wouldn’t listen because they know someone who has breast cancer or because they’ve been compliant with the current guidelines and they believe in them,” Mendelson says.

Upset Patients
Lawrence W. Bassett, MD, FACR, another member of the ACR’s Breast Imaging Commission and the Iris Cantor Professor of Breast Imaging at UCLA, says quite a few patients discussed the panel’s recommendations with him and seemed upset by them. He says most of the women who consulted with him or his office about the recommendations were concerned because they personally knew someone who had breast cancer in her 40s and that it had been discovered during an annual mammogram.

All but two of the patients said they would continue with their annual screenings and not heed the task force’s new recommendation, Bassett says. After the panel’s recommendation garnered front-page headlines and top billing on the evening news, Bassett checked with the staff member who keeps track of patient mammography appointments to see whether the news had affected volume. “And there hasn’t been,” he says. However, Bassett says he last checked in December 2009, and that December is “a strange month” because many people schedule appointments if they have met their annual deductibles so they don’t have to pay them again in the new year and to use up their health savings accounts if they have money left in them.

Mendelson says her patient volume for mammography appears not to have been affected either—so far. “For the most part, it’s been business as usual,” she says. However, she adds, it is impossible to say whether women may feel differently if their annual screening mammograms are no longer covered by insurance. Shortly after the panel’s recommendation was made public, several private insurers  announced that they would continue to pay for mammography screenings for women starting in their 40s. However, it’s not yet known what all private insurers will do; the task force is considered to have considerable influence on what procedures and tests insurers cover.

Bassett says he was concerned about one woman in his practice who said she would heed the new recommendations and not have screenings until she is in her 50s, and another patient who said that she may not continue with annual mammography if her insurance company would no longer cover it.

The radiologists also say that if more women choose to follow the new recommendation, they may not know the effect for years. “It takes a long time to see the impact of changes in these kinds of protocols,”  D’Orsi says. “When they do studies on the effectiveness of screening, you have to wait 10 to15 years to get accurate results.”

Mendelson says she wouldn’t be surprised if some women choose not to have screening mammography starting at age 40 because they are looking for any excuse and the panel’s recommendation provides one. Women often complain that it hurts when the breast is compressed during mammography, even if only for a few seconds, she says, “and they could say, ‘Oh, isn’t this marvelous? See I don’t have to do it.’”

Excuse to Skip Mammo
Rexine Hamill, RDMS, a certified breast navigator for Adventist Midwest Health DuPage Imaging Center in Hinsdale, Ill., expects women who complain that getting a mammogram hurts “are going to grab onto the panel’s recommendation because it’s backing what they don’t want to do.” Fortunately, she says, the women she has seen aren’t among them. Many of the women Hamill deals with came in for mammography screening in their 40s and ended up having a biopsy. “We found ductal carcinoma in situ, an early stage breast cancer, and when they heard the panel’s recommendation, they said, ‘Where would we be if we had waited until we were 50? It could have developed into something much worse.’”

Hamill was somewhat surprised that the mammography center phones weren’t ringing off the hook when the news broke. “Usually when something like this comes out, our phones will ring,” she says, “but we didn’t get many calls,” perhaps because most people weren’t worried about it, she says.

Stephen Feig, MD, FACR, a professor of clinical radiology at the University of California Irvine Breast Health Center and director of breast imaging and medical director of Aurora Breast MRI of Orange County, says most of his patients told him they would continue their annual screenings just as they have in the past. “A USA Today poll, taken shortly after the panel’s recommendation was made public, shows that most women are not listening to the new recommendation, and what I’m hearing from my patients is consistent with that poll,” he says. However, like Mendelson, Feig says he worries some women, such as those who don’t want to be screened perhaps for fear her doctors may find cancer, will point to the recommendation and fail to start screening when she should.

Feig also worries that the new recommendation will cause confusion because it differs from what women have been told for years. It creates confusion and women can’t remember which groups recommended what, he says. Many women also may think the latest recommendation is the best because it’s the newest. That’s why it’s extremely important for the ACS to continue to reiterate its stance that women of average risk begin screenings for breast cancer at the age of 40, he says. The Society of Breast Imaging and the ACR’s Breast Imaging Commission reiterated their positions that women who are at average risk for breast cancer begin screening with mammography at age 40, he says. Feig helped draft their recommendations that were published in the January issue of the Journal of the American College of Radiology. The society and the commission also said screening should start earlier—between the ages of 25 and 30—for those at high risk for the disease. The ACR says widespread mammography screening has helped reduce mortality from breast cancer in this country by 30%.

In talking with his patients, Feig says he found that many of them are politically aware and, like him, they see the USPSTF panel’s recommendation as economically motivated. The panel said many women undergo unnecessary follow-up treatment, including biopsies, because of findings on routine mammograms. The panel said the cost and anxiety associated with those false-positives may not outweigh the benefits of screening more women. The task force concluded that one breast cancer death is prevented for every 1,904 women aged 40 to 49 who are screened for 10 years compared with one death for every 1,339 women aged 50 to 59 and one death for every 377 women aged 60 to 69. Mammograms produce false-positive results in about 10% of cases.

Rationing Concerns
About 39 million women undergo mammograms each year in the United States, costing the healthcare system more than $5 billion. Feig says some of his patients echoed his sentiments when they said the panel’s recommendation could be an attempt to ration healthcare. “This could be an indication of what healthcare rationing will be in the future,” he says. “This might be the first item.”

Bassett says this isn’t the first time a controversy has erupted over cancer screening and likely won’t be the last. “I’ve seen all these things come and go,” he says. “When I started in radiology, we didn’t even train residents in breast imaging, so it’s relatively new and it’s always controversial.”

The radiologists say the controversy seems to have   diminished in recent weeks because the task force backtracked some. Also, the ACS, the National Cancer Institute, and the American College of Obstetricians and Gynecologists said they will not change their guidelines and will continue to urge women to undergo the screenings for breast cancer as previously indicated. Many physicians and their staff members are hoping that as the talk about the new guidelines dies down, little will change in the end.

— Beth W. Orenstein is a freelance medical writer and regular contributor to Radiology Today. She writes from her home in Northampton, Pa.