Accusations fly. Motives are impugned. Lifetimes of work are trashed.
Listen in as cool, objective scientists talk about each other:
“He has absolutely no proof of that.” “That’s an absurd argument.” “I’m tired of being attacked by people who didn’t do the work they should have.” “They did not have the best interests of women at heart.”
So much for dispassionate, neutral science.
The controversy: Does the evidence show that women between the ages of 40 and 50 benefit from having mammograms?
The spark: A recent Canadian study that concluded they don’t.
The resolution: Neither those who believe there is a benefit nor those who believe there isn’t can deliver a knockout scientific punch.
Who are the real losers? Women.
Camps are split along two major fault lines. One side, favoring mammograms for women in their 40s, includes mostly the radiologists who administer them and the American Cancer Society; call it the “pro” camp.
Among this group’s arguments is that the “anti” camp has a hidden agenda: advancing studies that cast doubt on mammograms for younger women, with an eye to finding a politically acceptable excuse to duck paying for them.
The anti camp is made up largely of epidemiologists and influential scientists in the government’s National Cancer Institute. Its chief line: The hidebound American Cancer Society and its supporters think with their emotions and can’t admit their longtime mantra of “early detection saves lives” might have been wrong for younger women.
To back up: Eleven major cancer organizations labored to reach consensus in 1988 on a mammogram recommendation. They agreed to recommend that women in their 40s receive mammograms every one to two years, and those 50 and older be screened once a year.
The American College of Physicians was the only large organization that stuck to recommending women wait until age 50.
Along came the Canadian study late last year.
The cancer institute and the cancer society sponsored international meetings on the subject in February. Each side accuses the other of rigging the results by the way they organized the meetings and by the speakers they invited.
The cancer institute says it is committed to reconsidering the guidelines, maybe by fall. But the cancer society, working with the same body of research, says there is no reason at this time to change the guidelines.
Meanwhile, both sides have been working behind the scenes to convince the other organization of its point of view.
The pro-mammogram society reminds the institute that differing guidelines will confuse women. The institute, in turn, pins its hopes on the fact that the society has a new medical director who maybe will have a different point of view (“Wishful thinking,” replies the society).
What’s going on, a number of “pro” scientists say, is health rationing. “Whether consciously or unconsciously, it’s an economic question,” says Dr. Daniel Kopans, Harvard Medical School radiology professor. “If mammograms were free, you and I wouldn’t be talking.”
Guidelines influence what private insurance and government entitlement programs, and possibly health-reform packages, pay for; if mammograms are not recommended, the cancer society says, it’s unlikely that they will be covered.
At a time when the women’s lobby is demanding more funding for women’s diseases, the pro camp says, it would be politically incorrect for the institute to say screening women from 40 to 50 is too expensive.
Instead, the institute puts the Canadian study “on a pedestal,” as one radiology physicist protests, to make a case there’s no proved benefit for screening women under 50.
Here’s where the collision between the institute and the society comes in.
The institute is a government entity focused on public health and concerned about government resources. The society, on the other hand, is focused on the health of individuals and concerned about the donors who support it.
It’s true, says society spokeswoman Joann Schellenbach, that screening all women from 40 to 49 is expensive, based on the numbers of lives saved. The society predicts 29,000 women in that age group will get breast cancer, or about 17 percent of those who will get breast cancer this year. But, she says, more important than cost-effectiveness is “the opportunity to save lives, whether 1, 2 or 29,000.”
The cancer institute denies any ulterior motives. Its official line is that there simply is a scientific disagreement over less-than-clear evidence, nothing more.
Arguing the institute’s case more persuasively is Sharyn Sutton, a psychologist in its information projects branch. She says it’s true what the pros claim-that the new regime at the institute is anti-mammogram, while the previous was pro.
“There’s a lot of politics in this stuff,” she concedes, adding: “I don’t think it’s nefarious.”
Institute scientists aren’t skewing things to save the government money, she says: “What they care about is science, cut and dry.”
The old regime, she says, consisted of family practitioners, using “best clinical judgment.” The new regime prides itself on being “objective” scientists.
Sutton says the issue she takes with the scientists is that they don’t realize that conflicting studies and changing recommendations end up befuddling women. “Scientists think the world is made up of scientists . . . .”
She notes that when the scientists say they have no data to prove benefit, women may not realize that doesn’t mean they have data to prove harm.
Sutton and her group did a study in the aftermath of the initial media coverage of the mammogram dispute, showing that the debate is more confusing to poorer, less educated women. It showed that better-educated, higher-income, younger women will continue to get mammograms.
“They said, `This is the only tool we have, and we’re still going to get it,”‘ Sutton said.
The confusion tended to make those already not following the guidelines-older, as well as poorer, less educated women-say they’ll be less likely to get as-frequent mammograms.
(As it happens, Sutton had breast cancer diagnosed at the age of 32, through a mammogram.)
In addition to the clash between organizations, there’s the division between scientific specialties.
Epidemiologists say radiologists are less than objective because they make lots of money on mammograms, and that radiologists’ anecdotal stories of lives saved aren’t borne out by the numbers.
Says Dr. Tony Miller, lead investigator of the Canadian study: “I call their views hope, not science.”
Radiologists say experts in their field are academic radiologists on salary and that epidemiologists are too focused on numbers, not people.
Dr. James Nelson, acting director of the mammography section at University of Washington Medical Center at Seattle, says: “They can talk cost-effectiveness ’til the cows come home, but in 10 years I’ve saved 40 lives of women aged 40 to 50; those lives are irreplaceable. And nobody paid me anything extra for that. . . . That’s not science, but neither is the Canadian study.”
Personalities are part of the picture too. The pro camp has turned with a vengeance on Miller, chairman of the Department of Preventive Medicine and Biostatistics at the University of Toronto.
They’ve trashed his study and accused him of refusing to see its problems because he can’t admit his life work is for naught.
Miller says he’s fed up with unrelenting attacks that he’s the one who did the necessary studies that U.S. scientists should have.
“They thought, `Why spend the money when we know the answer?’ . . . And now we’ve come up with answers they don’t like.”
The cancer society and its scientific supporters, he says, can’t back down after years of advocating mammograms as the answer.
Meanwhile, still another conference on this question is scheduled. This one, three days in late September in Geneva, is sponsored by the International Union Against Cancer, a worldwide group of cancer societies.
What are the odds that the Geneva conference will resolve the questions?
The anti camp already is skeptical because the cancer society is a major funder of the international union.
Says one “pro” radiologist, Dr. Edward Sickles, professor at the University of California, San Francisco Medical Center: “They can stack the deck, if they want. Or they could invite people from both camps. . . . If they stack the deck, it will be meaningless.”
For now, women are left waiting for answers. Even if new studies are funded, it would be years before there are results.
The anti camp says the real focus should be on getting the higher-risk age group, those 50 and older, to get mammograms; they have fewer mammograms than younger women.
But some from the pro camp says the answer must include making mammograms less expensive for everyone.
Schellenbach, of the cancer society, says efficiency would get mammograms down to $50 instead of an average of $150. This would mean eliminating mom-and-pop operations in favor of large centers where huge numbers can be screened.
She notes that the American College of Radiation itself has advocated a two-fee schedule: less for a screening mammogram, more for a diagnostic one (when something is suspicious and is being checked). Screening mammograms can be read when it s convenient for the radiologist and are much quicker than diagnostics. “But it’s hard to convince the physicians,” she says.
Another way to cut costs, says Kopans, the Harvard radiologist, is to get away from the trend of having radiologists read the mammogram before the patient leaves the office. That’s expensive, and the money could be better used to reduce mammogram costs, he says.
“Screening should almost be a service to society, not a way to make a lot of money,” he says.
While for now the controversy makes for confused women “and is no fun for scientists,” Fletcher, of the American College of Physicians, is one who sees a positive side.
“Ultimately,” she says, “the disagreement helps make medical progress.”
