Four years ago, Loraine Edwalds had just completed her routine, annual mammogram. Age 48 at the time, this "corporate worker," accomplished writer, singer and longtime member of Chicago's Artemis Singers learned that the test had detected a small but malignant spot in her breast. With early detection, surgeons were able to remove the spot and treat Edwalds with radiation. There was no lymph node involvement, no chemotherapy was required and she took only two days off of work. Had Edwalds not gotten that mammogram for several additional years, the treatment—and perhaps the outcome—would have been very different.
A primary rationale used by the government-sponsored U.S. Preventive Services Task Force ( USPSTF ) in new mammography guidelines issued last week—guidelines stating that screening should start at 50 rather than 40 and that women over 50 need only be screened every two years—was a concern regarding the high incidence of false alarms in screenings of women under 50 and the "anxiety" that these false alarms cause.
"I think the worry that too many women will be frightened by a biopsy or potential surgery is just bizarre," said Edwalds. "Do they know any women? Don't we worry as a routine course of living? I think what the study really demonstrates is that the labs doing the readings are overburdened. Judgment is the key factor in medical care and we should be encouraging more of it, not a 'just don't bother' recommendation."
"This was bad timing, bad judgment and a poorly stated change in policy on the part of the task force, and shame on them," said Chicago's Dr. Leigh Roberts of Hejira Healthcare. Roberts, whose Lakeview office provides primary health care to adults, will not change her practice of recommending annual mammography screenings for all women over 40. However, as a physician grounded in the hard sciences, she understands the recommendations, noting that "this is a good example of why it's very difficult to talk about medical issues in the public space.
"What the task force did was look at whether the mammogram fits into the technical definition of a screening test, which is a test that is very good at finding true disease, and whether that test is a cost effective one to administer to a given population," she explained.
"Based on those statistical criteria, they are saying that the data do not support mammography as a routine screening; that is the job of the task force. But a big part of the current problem is that no one understands what the task force is, what their job is, what 'screening' means or what 'recommendation' means. Meanwhile, all the medical colleges and organizations weigh in."
And they are. With breast cancer the leading cause of death in women 40-49, and more than 4,000 deaths expected in this age group this year, physicians and advocacy organizations are hurrying to decry the USPSTF and assert their support of the American Cancer Society's ( ACS ) 1983-established recommendations that all women 40 and over get annual mammograms.
"The task force says routine mammography would reduce deaths by about 15 percent," Otis W. Brawley, chief medical officer for the ACS, wrote in a forceful op-ed piece in the Nov. 19 Washington Post. "With its new recommendations the task force is essentially telling women that mammography at ages 40 to 49 saves lives—just not enough of them to recommend that all women get screened."
In what was awkwardly coincidental timing, The American College of Obstetricians and Gynecologists ( ACOG ) , on Nov. 20, issued new guidelines for testing for cervical cancer. The organization recommended that women not get their first pap smear until age 21 and that women 30 and older be tested every three years rather than annually, as long as test results have been normal to that point. The Nov. 20 New York Times quoted an ACOG spokeswoman assuring the public that the reports' timing was "uncanny," but that there was "no political agenda."
Locally, Howard Brown Health Center ( HBHC ) , which serves the LGBT community and is now home to the Lesbian Community Care Project program, issued a statement that the USPSTF guidelines are not supported by the ACS or the American College of Radiologists and that the recommendations "will not translate to immediate changes in the recommendations we make for the people we serve." Dr. Regina Kim of HBHC also pointed out that the USPSTF recommendations suggested women no longer be taught breast self-examination techniques.
"We view the recommendation to not teach women how to administer self breast exams as a huge disservice. Women should be experts in and advocates for their own health. Howard Brown Health Center embraces a policy of preventive care and therefore encourages women of all ages to continue administering self breast exams," said Kim.
" [ At Howard Brown ] we still encourage women to seek the advice of their health care provider to determine the best method of care. We recognize that LBTI and queer women experience health disparities and for some, getting to the healthcare provider's office for a breast exam and pap might be the only interaction during which other screenings can take place. Reducing the number of times and pushing back the age at which we start breast cancer screening may further increase the health disparity of LBTI and queer women," Kim concluded.
On Wed., Nov. 18, Health and Human Services Secretary Kathleen Sebelius issued a statement distancing Washington from the USPSTF recommendations, calling the task force an "outside, independent panel…who make recommendations [ and do ] not set federal policy." She recommended that women "keep doing what you have been doing for years," and asserted that "I would be very surprised if any insurance company changed its mammography coverage decisions as a result of this action."
This number-crunching game with women's health and lives naturally raises the specter of insurance coverage. Will insurance companies lower coverage standards based on the new guidelines? According to a Nov. 19 New York Times article, " [ h ] ealth insurers, including the federal Medicare program, have said this week they were unlikely to change coverage of mammograms in the immediate wake of the new guidelines…" Such qualified language is of little comfort to women and their families.
The USPSTF recommendations will not change my practice in recommending annual mammograms for women 40-75 and beyond," said Roberts. "But as far as insurers, who knows what they'll do when the dust settles. They are not about saving lives, they are about saving money."
The Association for the Advancement of Retired Persons ( AARP ) offers economically priced health insurance to its membership and has supported health care reform. At 50, members can choose from a variety of Aetna-sponsored policies; even the basic policy currently provides 100% coverage for an annual mammogram screening.
"This is particularly bad timing because it will be used as an excuse to not change health care for the better," said Roberts.
Wilbert Watkins, Ph.D., is the choir director at Pilgrim Congregational Church in Oak Park and director of the Lutheran Choir of Chicago. He is also the artistic director and conductor of Sing to Live, a community chorus founded in 2005 to "celebrate hope and survival for singers whose lives have been touched by breast cancer." The mixed choir is home to many lesbians and gay men who are, or are close to, breast-cancer survivors.
It is Watkins' twin sister, Candy, who is his connection to the survivor community. Ten years ago, Candy was just 40 when her cancer was discovered through a routine mammogram. "She came up from Texas this year to sing at our October concerts," Watkins said. "If it wasn't for early detection, she would not have been there with me. I don't have to tell you what early detection meant to our family.
"These guidelines are ridiculous, absurd," said Watkins, who is African-American and noted that mortality rates among African-American women ages 35-s often fall along racial lines. According to studies published by the National Institutes of Health and the Susan G. Komen for the Cure organization, these disparities are due in part to lack of routine screening and early detection among African-American women.
"My sister has been my best friend for all my life," said Watkins. "As far as I am concerned one life being saved is enough."
Visit www.WindyCityMediaGroup.com to see what else Dr. Roberts has to say about the controversial recommendations.
