MAMMOGRAM TWO-STEP

By Jeffrey Kluger

For women and their doctors, early detection of breast cancer has always had a crapshoot quality to it. Regular mammograms seem like a wise precaution, but the tests may be expensive and unreliable--and in a very small number of cases, may actually help stir up the very disease they're designed to spot. Neglecting mammography can be even riskier, giving an incipient tumor a chance to take hold and grow. This year the confusion only increased, with the medical community clamoring for clarity just as various cancer advisory groups issued conflicting guidelines.

Last week the National Cancer Institute--part of the far larger National Institutes of Health--finally moved to end the confusion, formally recommending that all women begin regular mammograms no later than age 40. While most experts applauded this ounce-of-prevention prescription, some questioned whether the decision might have been driven as much by political considerations as medical ones.

The good news about the mammography controversy has always been that in certain age groups at least, there is no controversy. Below 40, the incidence of breast cancer is low enough and the density of breast tissue may be great enough that annual mammograms are unlikely to spot anything suspicious. At 50 and above, as cancer rates rise and some breast tissue becomes more transparent to X rays, once-a-year exams are a good idea. Between the ages of 40 and 49, however, things have never been clear. Early this year the NCI convened a panel to resolve the question. But the group's findings, announced in late January, were more like nonfindings: the mammography decision, the panel said, was between a woman and her doctor.

Such a bureaucratic beats-me did not go down well. Says radiologist David Dershaw of Memorial Sloan-Kettering Cancer Center in New York City: "People were stunned by the NCI panel's action." Women's groups slammed it; NCI chief Richard Klausner admitted he was shocked by it; and the U.S. Senate, reading these hardly inscrutable tea leaves, voted 98 to 0 for a nonbinding resolution endorsing the value of regular mammography.

The backlash grew worse early last week when the privately funded American Cancer Society announced that it was tightening its own recommendations and calling for once-a-year mammograms for all women in their 40s. That announcement seemed to bring the matter to a head. On Thursday, Klausner convened a press conference to announce that his organization was retracting its panel's vague January recommendation and replacing it with a far more definitive one. Women between 40 and 49, the NCI announced, should undergo mammography every one to two years. Women at high risk for the disease--those with a family history of breast cancer, say--should consult their doctors about beginning the tests even earlier and undergoing them even more frequently.

No sooner had the press conference concluded than President Clinton made an announcement of his own, applauding the revised policy, ordering that future federal health-care programs pay for the tests and urging private insurers to do the same.

Medically, the decision seems sensible. Though only 15% of women in their 40s with mammogram spots worrisome enough to require a biopsy actually turn out to have cancer, tumors that do start so early may grow faster and become more deadly--largely because of higher premenopausal estrogen levels. Among women in the target age group who have regular mammograms, there are 17% fewer breast-cancer deaths. And as for the increased risk of cancer posed by exposure to mammographic X rays? "The danger is so small, it's not even calculable," says Dershaw.

What troubles some people is not the substance of the NCI's decision but how it was made. Changing medical policy because new data suggest it is one thing; changing because public pressure demands it is another. "The public and Congress spent months lobbying the NCI to issue a new statement," says epidemiologist Russell Harris of the University of North Carolina. "That's a pretty interesting way of doing science if you ask me."

NCI officials, however, insist that they never intended the January announcement to be taken as their final word on the matter and that the institute's position had always been a fluid one. Says Klausner: "More evidence from clinical trials led us, about a year ago, to begin a process of re-evaluating our recommendations."

Regardless of whether the new guidelines are a re-evaluation or a reversal, the reaction to them was mostly positive--and well it might be. Current studies show that at some point in her life, at least 1 out of every 8 women will learn she has breast cancer, and 25% of those who come down with the disease will die within five years of diagnosis. With stakes this high, last week's action appears to be one of those times when a politically expedient move turns out to be scientifically smart as well.