NCI moves to resolve controversy over mammography screening in 40s

Panel’s decision supports insurance reimbursement

The National Cancer Institute took decisive action last week to resolve the ongoing controversy over whether women aged 40 to 49 should receive regular screening mammograms. The NCI's National Cancer Advisory Board on March 27 issued an unambiguous recommendation that women in their 40s receive mammograms every one to two years if they are at average risk for breast cancer.

The advisory board's move should help resolve a dispute that has been simmering since 1993, when the NCI rescinded its recommendation that women in this age group receive screening. The NCI's support for the no-recommendation policy has slowly eroded since then in the face of withering criticism from mammography advocates.

The NCI tried to resolve the issue in January, when it asked the National Institutes of Health to convene a panel of experts to come up with a consensus on new guidelines. The NIH panel, however, declined to issue a recommendation, stating that there was too much uncertainty about the benefits of screening for women in their 40s (SCAN 2/5/97).

That prompted another round of criticism, not only from mammography proponents but also from the NCI itself, including director Dr. Richard Klausner, who said he was shocked by the panel's findings. The NCI then ordered its National Cancer Advisory Board to take up the issue at its meeting in February.

After several weeks of study, the NCAB came back with last week's recommendation. In issuing its advisory, the board said that it had considered updated findings from breast cancer screening studies presented at January's NIH consensus conference.

"The board concluded that there is enough evidence to support a woman's decision to begin screening in her 40s," said Dr. Barbara Rimer, board chair and director of cancer prevention, detection, and control research at Duke University in Durham, NC. "But the board also wanted women and their providers to be informed fully about both the benefits and limitations of mammography so they can make informed decisions."

The NCI's next move is unclear. Technically, the NCI itself has not yet issued a recommendation; only its advisory board has done so. Following the 1993 debacle, the NCI took the position that it was no longer in the business of making recommendations.

But given the change in temperament in NCI's leadership, it is possible that the agency will either issue a new recommendation, or let the panel's proclamation stand as a de facto recommendation. Adding support to the NCI panel's stance is the American Cancer Society, which also last month strengthened its position on screening for younger women by recommending that women aged 40 to 49 receive mammograms annually, rather than every one to two years, as the ACS had previously advised.

What impact will the new policies have on the mammography market? They could result in increased procedure volume as more women in their 40s begin getting screened more regularly. In addition, the new guidelines bolster efforts to persuade insurance companies to reimburse for screening of younger women. The NCI advisory board specifically recommended that insurance providers should reimburse for mammography for all women beginning at age 40.