Mixed Messages on Mammograms

By Denise Grady

More than any other disease of women, breast cancer symbolizes pain, mutilation and death. The disease strikes 1 woman in 10 and is the second leading cause of cancer deaths among females in the U.S., where it has the highest incidence in the world. This year 135,000 new cases will be diagnosed, and the disease will kill 42,000 women. Worse, its incidence is rising: last month the National Cancer Institute reported significant increases during both 1984 and 1985, the most recent period for which figures are available. Equally troubling, deaths from breast cancer among young and middle-aged women are increasing. Despite those sobering realities, an estimated 70% of American women still fail to undergo regularly scheduled mammograms, or breast X rays.

There are several reasons for their reluctance. Many women fear that the radiation itself will cause tumors, a risk that researchers consider negligible, since radiation doses are far lower today than they once were. Other women simply find the cost -- an average mammogram is $100 -- prohibitive. Most to blame, however, may be doctors themselves: for several years, the medical establishment has been sharply divided over whether younger women will benefit from mammograms. The debate was rekindled earlier this month by a report published in the Journal of the American Medical Association. In the study, Dr. David Eddy of Duke University and several colleagues found routine mammograms in women under 50 to be of so little benefit that women may not consider the screening worth the trouble. An accompanying editorial took the findings even further. Declared Dr. John Bailar III, a physician and medical statistician at McGill University in Montreal: "The evidence . . . does not demonstrate any clear health benefit from mammographic screening for breast cancer in women younger than 50 years . . . Routine screening of this age group should be discontinued."

The J.A.M.A. report, which was an analysis of five major studies of mammography, found that for every 10,000 women between 40 and 49 who have yearly mammograms for ten years, only 22 lives would be saved. The overall price tag would be considerable. Screening even a quarter of the 14 million women in the U.S. between 40 and 49 would cost $350 million. The practical result: few poor women are tested for breast cancer at all; middle-class women, too, balk at the cost, which many health-insurance plans still refuse to reimburse (though four states require insurers to cover at least some routine screenings).

Eddy's findings tend to undermine the recommendations of both the American Cancer Society and the American College of Radiology, which have suggested since 1983 that women undergo the procedure at least once between ages 35 and 40 as a basis for comparison with later mammograms, and then every year or two * between 40 and 49. But several other professional groups, including the American College of Physicians, have long chosen not to recommend screening by X rays for women under 50 except for those considered at high risk: women who have had breast cancer already or whose mothers or sisters have had the disease.

The result has been confusion about the value of mammograms among both doctors and their women patients. Janet Gay Hamby of Thousand Oaks, Calif., was 44 and the mother of two teenagers when she discovered a lump in her breast two years ago. Two mammograms suggested that it was malignant, and when a biopsy confirmed the diagnosis, Hamby underwent surgery and radiation treatments. Because cancer cells had invaded a lymph node, six months of grueling chemotherapy followed. She knows that the chance of a recurrence will remain high for about another year. Says Hamby: "My prognosis is good, but it would have been better if the cancer had been found before it reached the lymph nodes. And it would have been discovered if I had had a mammogram earlier." Why didn't she? "Nobody told me to. I went to a doctor regularly, but nobody told me to."

Most physicians agree that yearly mammograms in addition to self-examination and regular physical exams can save lives in women over 50; X-ray screening can cut the death rate in this group by 30%. But the benefits of mammography for younger women are less clear. One reason is that younger women have a lower incidence of breast cancer than older women, so there is simply less cancer to detect. In addition, young breast tissue is denser and more likely to conceal tumors from X rays than the more fatty tissue of older women.

Whatever their age, women with small tumors that have not invaded the lymph nodes have a 90% chance of surviving at least five years. As the disease spreads, however, the odds of survival drop sharply. Thus cancer experts agree that a woman's best hope for a cure, whatever her age, lies in finding tumors early. Mammography can detect tumors as small as an eighth of an inch in diameter. By contrast, most cancers detected by patients themselves are at least half an inch in diameter, and have been growing for eight to ten years, says Dr. Ferris Hall of Boston's Beth Israel Hospital. The larger the tumor, the higher the probability that it has already spread to the lymph nodes -- and the lower the prospects for survival. Self-examination alone may give women false reassurance, says Dr. Melvin Silverstein, a breast-cancer specialist in Van Nuys, Calif. "It ignores the biggest breakthrough we've had: finding nonpalpable lumps with mammography."

But mammography is not infallible. There is a 1% chance of a false-positive result -- a mistaken diagnosis of a tumor -- and the anxiety, expense and pain associated with a biopsy. A graver problem is the risk of a false negative: about 20% of the time the X rays fail to detect cancers, which may be picked up by physical exam. "Is mammography worth it?" asks Eddy. Some women, he notes, upon hearing that ten years of screening will save 22 lives "will say, '22 out of 10,000, well, that'll be me.' Others will say, 'Take half a day off work for a 22-out-of-10,000 chance? You've got to be kidding.' Both responses are appropriate." Individual women may respond differently to the question than medical researchers do. Cost effectiveness is not something that most patients want to hear about, particularly when the money is being spent to prevent cancer. Ultimately, the responsibility for providing accurate information on breast cancer may lie with a woman's physician. And any doctor should be prepared to lay out the facts so that patients can decide for themselves about mammography.

With reporting by Elaine Lafferty/Los Angeles and Suzanne Wymelenberg/Boston