Although controversy has erupted again over whether women should begin to have routine mammograms at age 40, most employers that provide this benefit likely will continue to offer coverage beginning at that age.

Employers and benefit consultants agree that the financial and medical advantages of conducting mammograms on women in their 40s to screen for breast cancer far outweigh the costs of the procedure.

However, quantifying the money saved through health screenings remains difficult, experts agree.

State laws require group health insurers in most states to cover screening mammograms, often beginning at age 40. Self-insured employers are exempt from state benefit mandates.

Federal legislation that was introduced earlier this month in the House would require all group health plans and health insurers that provide coverage for diagnostic mammography to cover annual mammograms for women ages 40 and older. The bill, H.R. 617, was introduced by Rep. Jerrold Nadler, D-N.Y.

Under the federal legislation, self-insured employers, group health insurers and public health care plans such as Medicare and Medicaid would not be able to impose deductibles, copayments or other cost-sharing measures for mammography screening that exceed those assessed for diagnostic mammography.

The current controversy over when a woman should begin receiving screening mammograms stems from a draft report that was issued late last month by a panel of experts on breast cancer and mammography.

The panel of independent experts, many of whom are academics, was convened by the National Cancer Institute and the National Institutes of Health but does not represent the views of the federal government.

According to the report, "the available data do not warrant a single recommendation for mammography for all women in their forties." The report also states that "each woman should decide for herself whether to undergo mammography."

However, "for women in their 40s who choose to have mammography performed, costs of the mammograms should be reimbursed by third-party payers or covered by health maintenance organizations."

The report said that though "the potential benefits of mammography for women in their 40s include earlier diagnosis and breast-conserving therapy. . .these benefits must be weighed against the risks or potential risks, including discomfort and inconvenience as well as potential risk from mammographic radiation. In addition, the impact of false reassurance given to women with false-negative screens must be considered, given the lower sensitivity of mammography in women in their 40s compared with women in their 50s."

Most breast cancer organizations and many breast cancer experts disagree with the panel's conclusions.

The New York-based American Cancer Society said the panel's conclusions "did not go far enough in support of mammography" for women age 40 and older. "In addition, the report places undue emphasis on issues such as radiation risk, anxiety caused by false positive findings and the fact that mammography will not detect 100% of cancers," according to an ACS statement.

Even Dr. Richard D. Klausner, director of the NCI, testified before Congress recently that "the draft report of the panel overly minimizes the benefits and overly emphasizes the risks" of mammography for women in their 40s.

The ACS recommends that women begin at age 40 a regular program of mammography screening, including mammograms every one to two years until age 50. Annual mammograms are recommended thereafter.

The National Alliance of Breast Cancer Organizations has supported the ACS' recommendations since 1993 and continues to do so, according to Kimberly Calder, associate executive director of the New York-based information and resource center.

A majority of large employers do pay for screening mammograms, according to a survey of 935 large employers conducted last year by Hewitt Associates L.L.C.

Hewitt found that 79% of employers that offer some type of health prevention, promotion or early intervention initiative cover screening mammograms through their medical plans.

Most large employers that cover screening mammograms follow the ACS' guidelines and are unlikely to alter their benefits based on the independent panel's report, experts agree.

"Most employers, if they are going to cover (screening) mammograms, will cover every other year between 40 and 49," stated Ca-mille Haltom, a consultant at Hewitt's Lincolnshire, Ill., headquarters.

Employers are unlikely to cut back the benefit because it would be perceived negatively by employees, she said. "Employers that are proactive enough to cover (screening mammograms) will continue to cover them" for women ages 40 to 49, she predicted.

Self-insured employers, though they are not required to, typically follow state benefit mandates, most of which adhere to the ACS guidelines, Ms. Calder added.

Most employers that cover mammography screening are "comfortable in following the ACS guidelines," agreed Larry Boress, vp at the Midwest Business Group on Health in Chicago. "No one's taking any action regarding this task force report."

First Chicago NBD Corp. offers screening mammograms through its medical plan-onsite in many locations-for women beginning at age 40, noted Dr. Wayne Burton, the bank's Chicago-based medical director. "I believe that the ACS is correct in their recommendations," he stated. "We're going to continue to follow" their guidelines.

First Chicago spends about $100,000 annually, including staff time, to do some 600 to 700 screening mammograms a year, Dr. Burton noted. One case of breast cancer is detected for every 500 mammograms, on average, Dr. Burton said.

The financial cost of treating breast cancer that is detected early can be dramatically less than the cost of treating more advanced breast cancer, he said. "Non-workplace detected breast cancer unfortunately tends to be more advanced" than cancers detected by the workplace program, he said.

For example, in the first four years of its mammography screening program, breast cancers detected through the program cost an average of $18,500 to treat and employees took an average of 34 disability days. Breast cancers detected outside the bank's screening programs cost an average of $35,000 to treat and involved about 75 disability days.

Stamford, Conn.-based Champion International Corp. covers mammography screening based on guidelines issued by the U.S. Preventive Services Task Force.

These guidelines suggest a baseline mammogram one time for women age 35 to 39, if recommended by a physician; screening mammograms once every two years, beginning at age 40; and annual mammograms for women age 50 and older, according to Howard Kraft, manager of corporate health services for the forest products company.

"I do not think we will change our guidelines based on the information now presented," Mr. Kraft stated. "We feel that our recommendation is one that makes sense economically and from a health and productivity perspective."

Mr. Kraft did not have information on how much Champion has spent on its screening mammography program, which includes onsite mammography at some locations, or how much the company has saved by detecting breast cancers earlier than they might otherwise have been detected.

Conducting a cost/benefit analysis of screening mammography generally is difficult for employers to do.

"It's very difficult to do cost/

benefit analyses around preventive screenings," said NABCO's Ms. Calder.

Expenses that are associated with screening mammography can be "difficult to justify" because "it's difficult to measure claim avoidance," agreed Hewitt's Ms. Haltom.