2010-02-18 / Front Page
Mammogram frequency stirs debate
Radiologist reviews, contradicts findings of U.S. task force
Areport addressing routine mammogram screening for breast cancer detection that was released on Nov. 17, 2009, by the United States Preventative Services Task Force (USPSTF) has spurred much debate.
Dr. Kenneth Tomkovich, of Manalapan, director of breast imaging and intervention at CentraState Medical Center and Freehold Radiology Group, Freehold Township, recently presented a lecture titled “The Mammography Screening Debate: To Wait or Not to Wait,” at CentraState’s Star and Barry Tobias Health Awareness Center, Freehold Township. An audience of about 50 people, mostly women, filled the lecture room.
Tomkovich, who is an interventional radiologist, hopes to increase public awareness of the potentially dangerous consequences that could arise should the USPSTF recommendations be adopted by the government and insurance companies as a national standard.
Interventional radiologists are board-certified physicians who specialize in minimally invasive targeted treatments and diagnostic procedures. As radiologists, they use X-rays, CT scans, MRI, ultrasound and mammography to guide their procedures.
Tomkovich carefully reviewed the USPSTF’s recommendations and used the findings listed in the USPSTF’s own data to dispute the rationality of its proposals.
The USPSTF recommended against routine mammogram screening in women between the ages of 40 and 49, recommended screening for women between the ages of 50 and 74 every two years, and no screening at all for women above age 74.
Current standards call for a baseline mammogram for women between the ages of 35 and 40, and annual mammograms for women age 40 and up.
Tomkovich maintains that the current standards have been instrumental in saving many lives and that to decrease the frequency of mammogram screening would increase the number of lives lost.
The USPSTF warned against potential harm from mammograms, including fear of the test, pain and exposure to radiation.
Tomkovich asserted that those potential harms are merely situations of temporary stress and discomfort, much less severe and shorter in duration than the potential harm cancer can cause.
Those in attendance at the lecture agreed wholeheartedly with Tomkovich’s assertions.
As for radiation, Tomkovich said that no studies have ever been done to assess the impact of radiation in mammograms because doctors cannot use a control group that gets high doses of radiation.
He said most data on the effects of radiation comes from studies done on survivors of the atomic bombs that were dropped on the Japanese cities of Hiroshima and Nagasaki in 1945 and do not necessarily apply to low-dose mammograms. He also pointed out that digital mammograms use less radiation.
Tomkovich said the benefits of mammogram screening far outweighs the risks of radiation exposure. He also posed the question: “If there is truly a risk of cancer from radiation given off during mammograms, why is the breast cancer incidence decreasing under the current guidelines?” Overdiagnosis, false positives and unnecessary biopsies are also mentioned as reasons to avoid annual mammograms.
The USPSTF report cited statistics that included a 10 percent recall rate in mammograms, six-month follow-ups in 2 to 3 percent of the women screened, and biopsy recommendations in 1 to 2 percent of those screened. It stated that of those women who received biopsies, 20 to 40 percent were diagnosed with cancer. Since 60 to 80 percent of the women biopsied did not have cancer, the task force determined that the mammograms were unnecessary.
Tomkovich questioned how the task force could overlook the value of early detection through mammograms after 20 to 40 percent of women who had a biopsy were diagnosed with breast cancer that otherwise would have gone unnoticed until a lump was felt.
By the time a lump was detected, the cancer could have had a chance to wreak havoc on those women’s lives, the doctor said. He demonstrated how the latest digital mammogram technology can now detect a growth the size of a pea.
Tomkovich showed photos of celebrities Sheryl Crow, Olivia Newton-John, Edie Falco and Robin Roberts — all of whom are breast cancer survivors. He said they all would have been excluded from early detection of their cancer by mammography under the USPSTF’s new recommendations.
Tomkovich brought his point closer to home with statistics from his own experience. He said that at CentraState Medical Center and Freehold Radiology over the last 18 months, 19 women age 49 and under were found to have breast cancer through screening studies.
“Based on their [USPSTF’s] recommendations, it is OK to cut out people like these,” said Tomkovich. “It is not OK! I don’t understand this. Our goal is to find the smallest growths we can and get them out. It’s like putting your head in the sand. There is a cancer there and we won’t do anything about it. That’s what they want us to do.”
Tomkovich explained in detail about the methods used by physicians to further identify and, if necessary, remove even the smallest of cancers detected via routine mammogram screening, including ultrasound, MRI and image-guided breast biopsy.
He presented copies of two actual mammograms on which abnormal nodules were detected. Subsequent biopsies confirmed suspicions of a cancerous growth in one, which was removed. Without the biopsy that patient’s life would have been threatened. Without the mammogram, the nodules would not have been found at that point in the first place.
As for the task force’s recommendation that patients over age 74 not be screened at all, Tomkovich said no studies were included in the report to back up that claim.
Tomkovich found that no women over the age of 74 were studied in any of the control groups examined by the USPSTF, so the task force did not recommend screening women in that age group. He presented evidence quoted directly from the USPSTF that stated, “It is not feasible to conduct additional trials to get more precise estimates of the mortality benefits from extending screening to women younger than 50 years or older than 74 years or to test different screening schedules.”
He further stated that no data was included in the report describing age 50 as a threshold. In fact, the data suggests that the risk for breast cancer in those between the ages of 45 and 49 is the same as those between the ages of 50 and 54.
Tomkovich said that all of the studies and models used in the USPSTF report point to an increase in mortality as the screening interval increases and indicate a 19 percent increase in mortality if screening of women between the ages of 50 and 74 were to be done biennially (every two years). According to Tomkovich, this percentage reflects about 8,000 lives per year hanging in the balance.
In addition, Tomkovich questioned the structure of the USPSTF and those who serve on the committee.
The Internet website for the United States Department of Health and Human Services defines the USPSTF as “an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services.”
Tomkovich questioned why there are only preventative medicine and primary care physicians and no radiologists, oncologists or breast surgeons on a task force that is making decisions involving those areas of medicine.
He claims the USPSTF used randomized, controlled trials that were biased and used old studies from 1986 to 2006 and a database of people with breast cancer from 2000 to 2005 — before digital mammograms, which are much more sensitive, were commonly used, as they are now.
After taking a close look at the USPSTF’s data, Tomkovich summarized that the report could not prove any increased risk of cancer from mammography; it actually indicated that there is a 15 to 30 percent reduction in mortality with breast cancer screening — thus supporting the argument that breast cancer screening saves lives.
In addition, the USPSTF data indicated seeing a benefit for screening the older population as well as a benefit for annual screening and stated that years could be added to the lives of those who started screening at the age of 40.
Given all of that information and his review, Tomkovich concluded that he supports current recommendations for getting a baseline mammogram between the ages of 35 and 39, and annual mammograms starting at age 40 and continuing for as long as a person is physically able to do so; and in total contradiction to the final recommendations of the USPSTF, it could be argued that the data found within the task force report actually supports the current recommendations as well.
Dr. John Pellegrino, a breast surgeon at CentraState Medical Center, was present at the lecture. He called the USPSTF recommendations disturbing and said he totally agrees with Tomkovich.
“Their [the task force’s] main gripe is the false positive rate on mammograms that look suspicious but in the end are benign. We do find breast cancer in the 40-50 age group. The women I deal with say they would rather go through a biopsy and find out 100 percent that they have a benign lesion for peace of mind.”
Tomkovich implored those in attendance to embrace the current guidelines, apply them to their own lives and spread the word to others before insurance companies and the government put women in a position where they might have to choose between their health and affordability.
He warned that the potential lives lost could be 4,000 to 8,000 or more per year.
An article printed in the Dec. 11, 2009, edition of Medical News Today reported that California’s Health and Human Services Agency temporarily halted enrollment in a state breast cancer screening program for low-income women and raised the eligibility age from 40 to 50 in response to budget restrictions.
An agency spokesperson said the decision was motivated solely by fiscal concerns and has nothing to do with recent recommendations by the USPSTF stating that most women do not need an annual mammogram before age 50.
Congressman Frank Pallone Jr. is the chairman of the Health Subcommittee of the House Energy and Commerce Committee. The Subcommittee on Health held a hearing titled “Breast Cancer Screening Recommendations” on Dec. 2, 2009. To view the comments of those who spoke, visit the website at www.house.gov/Pallone and choose the link in the upper right corner that leads to the Health Subcommittee website.
Pallone said in a press release, “Breast cancer is a preventable and treatable disease if it is detected early, but we don’t want to cause other health problems in the process. Providers and patients need to understand the risks of both screening and not screening so that they can make a balanced decision.”
Contact Amy Rosen at email@example.com.