Hutch News

Breast screening backlash

Expert who helped set the controversial new guidelines responds to confusion, criticism, questions

Oct. 22, 2015
Dr. Ruth Etzioni

Fred Hutch's Dr. Ruth Etzioni who served on the American Cancer Society's breast screening guidelines committee said the new guidelines are designed to allow women to "tailor their screening."

Photo by Robert B. Hood / Fred Hutch News Service

Editor's note: The American Cancer Society’s new breast screening guidelines, released earlier this week, raised many questions (and criticisms). Fred Hutch public health researcher Dr. Ruth Etzioni, a member of the ACS guidelines committee, joined us for a tweetchat to respond to the confusion, the criticism and the many, many questions. View transcript

The American Cancer Society earlier this week released new breast screening guidelines for average risk women – their first in 12 years – unleashing an immediate firestorm of criticism and questions.

“I am so disappointed in the American Cancer Society and this announcement,” wrote one of nearly 600 people who took to the ACS Facebook page to express their dismay – or, in some cases, disgust. “It will just encourage insurance companies to opt out of paying for the test.”

Elaine Schattner, who covers cancer for Forbes, referred to the new recommendation that women start screening for breast cancer at age 45, a “huge mistake.” Others, like TV personality and breast cancer survivor Giuliana Rancic, were just plain confused. “This news … is making my head spin,” the celebrity posted on Instagram.  As Newsweek put it in their headline, “No One Agrees on Mammography Guidelines.”

The backlash came as no surprise to Dr. Ruth Etzioni, a biostatistician with Fred Hutchinson Cancer Research Center and a member of the ACS’s guidelines committee.

People tend to read headlines, she said, and headlines don’t leave much room for nuance.

“I imagined that the media would paint this as a pulling back and it’s always big news when an organization ‘pulls back’ on its breast screening guidelines,” she said. “But I think that’s a rather shallow interpretation.”

In a nutshell, the new guidelines recommend average risk women start getting annual mammograms at age 45 (instead of 40) and continue to do so until they’re 54. At age 55, they suggest women get screened every other year – after menopause, breasts are less dense making them easier to read and tumors tend to be slower growing – and continue to do so as long as they’re healthy. They also no longer recommend clinical breast exams. Read full coverage of the new guidelines here.

Fred Hutch News Service tapped Etzioni and other experts to delve into a few of the questions and criticisms raised by these new guidelines. 

Dr. Scott Ramsey

Dr. Scott Ramsey of the Hutchinson Institute for Cancer Outcomes Research said that it's unlikely the new ACS guidelines will affect insurance coverage. "The Affordable Care Act mandates screening," he said.

Photo by Robert Hood / Fred Hutch News Service

Can women still get mammograms at 40 if they want?

“Absolutely,” said Etzioni. “If they think they can’t then they’re not reading the guidelines which say women who want to be screened at age 40 should have the opportunity to do so.”

Etzioni said the new guidelines are meant to both empower women and provide them with flexibility. 

“That’s how I wish women would interpret it,” she said. “It’s really where we want to go. It allows women to decide if they feel they need screening and allows them to tailor their screening. It gives them control while giving them guidance.”

According to the ACS, evidence from national cancer statistics shows that the risk of cancer is lower for women ages 40-44 than for women aged 45-49 and the risk of cancer among women aged 45-49 is similar to that among women 50-54. The new screening guidelines are meant to reflect the arc of risk in the average woman’s life. 

But screening is not a perfect medium.

“Screening is really a blunt tool,” said Etzioni. “We have to screen everybody to catch and save the relative few that can be helped by early detection. The guidelines are an attempt to use this tool wisely. We want to preserve as much of the benefit of screening as possible while being sensitive to its adverse effects like unnecessary biopsies and overtreatment which have received a great deal of attention in recent years.”

The more women are exposed to screening, the more likely they’ll have an adverse experience such as unnecessary biopsies, false-positive findings, overdiagnosis or even invasive surgeries and therapies – termed overtreatment – for cancers that would never cause them harm.

“The sheer numbers are staggering and the starting age of 45 is designed to protect the healthy population while bringing them into screening as they reach the age at which risk begins to rise,” she said.

Etzioni said she totally understands breast cancer survivors who were diagnosed at a young age and feel the guidelines are some kind of betrayal. But said the new flexible guidelines are a step towards much more tailored care.

“What we want ultimately is to figure out who needs screening and who doesn’t,” she said. “We need to know if you are at a higher risk so we can watch you and the people like you. And maybe screening isn’t the tool. Better screening tests will help, but better understanding of who is most at risk will help even more.” 

What about insurance coverage?  Will annual mammograms be covered for women under 45?  

Etzioni said she doesn’t believe the change will impact insurance coverage at all.

“The American Cancer Society’s wording said that women should have the opportunity to be screened at age 40 if their tailored approach is to begin at 40,” she said.

Dr. Scott Ramsey, a health economist, internist and director of the Hutchinson Institute for Cancer Outcomes Research (HICOR), agreed that it’s unlikely the new guidelines will affect insurance coverage.

“I would be very, very surprised if there were any restrictions in mammography access based on these new guidelines,” he said. “Think about it from a health insurance perspective. Do they want to restrict this when it’s such a politically sensitive issue? I doubt it. Particularly when there’s conflicting evidence, harms and benefits that are hard to balance and patients with very different preferences. Some don’t want mammograms very often; others are adamant about getting them.

“Insurers have to take into account all of these factors when they make a decision,” he said. “And the Affordable Care Act mandates screening.”

At Kaiser Permanente, which provides both insurance and medical care to more than 9.6 million members in eight states, the revised guidelines are expected to have minimal impact.

“At Kaiser, medical decisions are made by a patient and her doctor,” said Mike Foley, a Northwest spokesman based in Portland. ”If someone is concerned and wants to get a mammogram, the health plan will cover the mammogram.”

As for the ACS itself, their website said insurance coverage is usually linked to the U.S. Preventive Services Task Force screening recommendations, not the ACS guidelines and added that it was too soon to tell if the new guidelines (or the draft recommendations issues by the task force in April 2015) will impact insurance coverage.

What about dense breasts? How will women even know they have dense breasts – and an increased risk for breast cancer – if they don’t start getting mammograms early?

Etzioni said issues like breast density are just one reason why the guidelines were created with more flexibility.

“A woman who’s concerned about breast density could come in at age 40, and say, ‘I want to have a baseline,’” she said. “That could be part of her approach, tailoring her screening practices to her breast density. If she doesn’t have dense breasts, she might elect to wait and come back later [for more screenings]. Or she might elect to come every year. It’s all part of the tailoring and it’s all acceptable within the flexibility provided by these new guidelines.”

 What about other types of screening, like ultrasound or 3-D mammography (tomosynthesis)?

Etzioni said ultrasounds are not considered a first-line screening option but encouraged women to ask their doctor about alternate screening methods, using her own choices as an example.

“I don’t have dense breasts but have an area of fibrous tissue that’s hard to see on mammograms,” she said. “So I always go to the same person for my mammograms and she always does an ultrasound, as well. It’s a second-line test that women should feel free to ask their providers about. Mine is covered by my insurance because it’s recommended by my doctor.”

As for 3-D mammography, also referred to as digital breast tomosynthesis, the ACS said that this more sensitive type of mammography is “steadily being introduced” into breast screening clinics but that evidence comparing it to 2-D mammography was not available in time for the guidelines review. As evidence emerges, they will revisit the issue and update as necessary.

What about women with breast cancer in their family? Or an Ashkenazi Jewish background that could put them at a higher risk? Shouldn’t they be screened more often?

Etzioni stressed that the new guidelines are for average risk women.

Women who’ve had a personal history of breast cancer, a confirmed or suspected genetic mutation like BRCA1 or BRCA2 (many women of Ashkenazi Jewish ancestry fall into this category) or a history of radiation to the chest are considered high risk.

Women who have a family history of cancer but don’t carry a BRCA or other recognized mutation; women with a prior diagnosis of benign proliferative breast disease and women with dense breasts are considered intermediate risk.

The American Cancer Society plans to issue breast screening guidelines for intermediate and high risk women in several months. Look for them in 2016, a representative of the Washington state ACS told Fred Hutch News Service.

Until then, talk to your doctor about what type of screening is right for you or contact the SCCA’s Reduce Your Risk Clinic.

The new guidelines suggest women start screening at 45, but aren’t invasive breast cancers increasing in younger women?

Etzioni, a biostatistician with 25 years’ experience under her belt, examined SEER data (data on cancer diagnoses from the Surveillance, Epidemiology, and End Results program of the National Cancer Institute) and found that this is not true.

“I looked at SEER data for the last decade and found no evidence of an increase in the age-adjusted [breast cancer] incidence for women ages 30 to 44,” she said.

Etzioni said that it’s true that the number of invasive breast cancers is rising in this age group, but that is mostly because the population is growing.

“The numbers can certainly give you the impression that [cancer] is blowing up, but the whole population is increasing,” she said. “As the population grows, the numbers grow.”

Transcript of Dr. Ruth Etzioni's TweetChat on Oct. 22.

Solid tumors, such as those of the breast, are the focus of Solid Tumor Translational Research, a network comprised of Fred Hutchinson Cancer Research Center, UW Medicine and Seattle Cancer Care Alliance. STTR is bridging laboratory sciences and patient care to provide the most precise treatment options for patients with solid tumor cancers.

Diane Mapes is a staff writer at Fred Hutchinson Cancer Research Center. She has written extensively about health issues for NBC News, TODAY, CNN, MSN, Seattle Magazine and other publications. A breast cancer survivor, she also writes the breast cancer blog doublewhammied.com. Reach her at dmapes@fredhutch.org.

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