Karen Garloch

Meck health director agrees it’s OK for most to start mammograms later

Dr. Marcus Plescia, director of the Mecklenburg County Health Department, believes revisions in mammography recommendations should clear up confusion.
Dr. Marcus Plescia, director of the Mecklenburg County Health Department, believes revisions in mammography recommendations should clear up confusion. dlaird@charlotteobserver.com

A lot of people remain confused about the latest mammography recommendations. Should women start getting the annual screening tests at 40, or wait until 50?

For many years, the recommendation was to start at 40. But two major health organizations have revised their guidelines, suggesting a later start for healthy women who don’t have a family history or medical history of breast cancer.

Instead of being confused, Dr. Marcus Plescia, Mecklenburg County’s health director, thinks the question should be clearer now that two such respected groups have agreed the recommendation should be revised after three decades.

“I am less confused and more confident of how to advise the public,” Plescia said. “If you’re worried about breast cancer, then by all means get screened (at 40 or even earlier). But if you don’t have that same level of concern, it’s probably reasonable to start getting screened later. … I’d think the average consumer might start to think, ‘Maybe I’ll wait until my 50s.’ 

The debate started in 2009 when the U.S. Preventive Services Task Force, a panel of experts that advises the government on the value of screening tests, recommended raising the age for initial screening from 40 to 50, and specified every other year instead of annually.

This fall, after years of resisting such a change, the American Cancer Society also relaxed its guidelines, advising women to start mammograms at 45, and continuing once a year until 54, when the tests can be done every other year.

Many doctors – especially radiologists, whose offices provide mammography and interpretation – object to these changes. They argue that early detection is best and that “competing” recommendations just confuse patients.

But Plescia, who previously headed the cancer prevention division at the U.S. Centers for Disease Control and Prevention in Atlanta, said he’s surprised and disappointed to hear so many doctors resisting the changes. “It’s not just one lone voice,” he said of the task force and the cancer society. “And they’re pretty impartial voices.”

Of note, Plescia said, are the differences in breast cancer screening between the United States and Europe. U.S. doctors perform twice as many biopsies after mammograms than their counterparts in Europe. Yet, there’s no difference in mortality rates, Plescia said.

That means we’re detecting more “cancers” without saving more lives.

In relaxing their recommendations, both the task force and the cancer society concluded that the benefit of testing women starting at 40 was small and not without potential harm.

Part of the harm is emotional – the anxiety women feel when mammograms detect a problem and they’re called back for repeat mammograms and possibly biopsies that often turn out to be negative.

There’s also the harm in unnecessary treatment. Aggressive screening detects early cancers that might never become life threatening as well as DCIS (ductal carcinoma in situ), a potential precursor of cancer. Once it’s detected, the response has been to treat it.

“There is increased evidence that DCIS is over-treated, resulting in surgical procedures, such as lumpectomies and mastectomies, that may not be necessary,” Plescia said.

Plescia knows many cancer specialists will disagree with him. But he said they have a different perspective from that of primary care physicians and public health officials who care for a wider array of patients who don’t generally have cancer.

For now, the mammography recommendations are just that. No one is forced to follow them. And insurance still typically covers mammograms annually starting at 40.

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