Beyond the Debate: Making an Informed Decision about Mammograms

While research is informative and instructive, it is not always the final word because so many factors go into clinical studies.

(WASHINGTON D.C.) - According to an updated recommendation from the U.S. Preventive Services Task Force, an expert government panel, routine screening mammography is advisable every two years for women ages 50 to 74 with average risk for breast cancer. The Task Force recommends against routine screening mammography for women ages 40 to 49.

According to the panel, the decision to start screening before the age of 50 should be an individual one and should take into account a woman’s age, general health, hormone level, family history, and how these factor into specific benefits and harms.

The Task Force found insufficient evidence to assess the benefits and harms of screening mammography for women older than 75 because of the lack of studies for this age group. The task force also recommends against breast self-examinations, stating that teaching women how to perform them doesn't save lives. According to experts, women should instead make a point of noticing any changes in their breasts in the course of daily activities.

It is understandable that women are confused with the differing opinions from experts on annual mammograms. What is important, however, is that women keep the recommendations in perspective, understand the facts behind the debate and make an informed decision with their doctor’s input.

The first issue to keep in mind is that the U.S. Preventive Services Task Force bases its decisions on research that addresses screening from a public health perspective, based on the impact to the general public rather than on each individual. This means that, regardless of the task force position, women and their doctors need to make the decision that is most appropriate on an individual level.

The second thing to remember is that the task force is not suggesting that women should not get screened for breast cancer. Rather, it advises against a particular level of routine screening. Again, women should talk to their doctors and determine the best course of action based on family history and other risks, as well as personal circumstances, including any related anxiety from not being screened.

The recommendation shouldn’t be used by women to disregard getting mammograms altogether in their 40s but should be used to reiterate the need to have a regular Primary Care Physician with whom a woman can make an informed decision. For example, a doctor may recommend women with a strong family history or a genetic risk to start screenings even earlier than 40. We need to recognize the complexity of the issues involved and make sure women have access to easily understood information on their own risk factors as well as the benefits and risks of mammograms.

The task force’s stand on women not performing regular breast self-examinations is questionable. These are simple exams women can do on a regular basis to detect any changes in their breasts, so doctors can Beyond the Debate: Making an Informed Decision about Mammograms Page 2 of 2 evaluate further. While there are some negatives, such as increased anxiety for women who do find a lump, there are no real risks to doing self-exams and they can actually empower women in their own care.

Clinical breast exam needs to be a part of annual health exam at a doctor’s office. The third issue to understand is that mammograms aren’t without risk. The medical community increasingly recognizes that more tests and treatment may actually harm patients. The first risk with mammograms is radiation, which has a cumulative effect. By starting screening annually at age 40 we are exposing women to radiation possibly ten years earlier than the age where the screening has been shown to be most useful.

Other problems relate to screening mammograms returning false-positive results (results that indicate disease, when there really isn’t any). This is more common in women in their 40s because younger women have dense breast tissue, which not only means mammograms may miss some cancers because it can’t see them, but that the normal lumps may be mistaken for cancer, prompting more unnecessary testing.

This can lead to associated potential side effects not to mention additional costs. A small percent of women may even undergo further treatment, including surgery, radiation and chemotherapy when it isn’t needed. MRI and ultrasound isn’t any better for detection in this age group. Starting too early may also lead to treatment for lesions that would not have become clinically significant.

According to the National Institutes of Health, about 50 percent of women with mammography-detected breast cancer would not have died from breast cancer even if they had waited until a palpable lump appeared, because their tumors are slow growing and more treatable.

To put the screening in perspective, it is important to note that some modeling by experts suggest that for every 1,000 women screened starting at age 40, just about 0.7 deaths from breast cancer would be prevented, while at the same time approximately 470 additional women would receive a false-positive result and about 33 more would undergo unnecessary biopsies.

Put differently, the data USPSTF used to make the decision showed that screening reduced the breast cancer death rate by approximately 15 percent, or that, one cancer death is prevented for every 1,900 women aged 40 to 49 who are screened for 10 years.

While statistics make no difference if that one person is you, your mother, wife or daughter, they are important to note since mammograms deliver x-rays that, over extended periods, can damage cells and are their own risk factor for cancer, including breast cancer. Although there are no convincing data to support the hypothesis that annual mammography may cause cumulative-radiation-induced breast cancer, the risk is real, particularly in women who are genetically susceptible to radiation exposure.

While research is informative and instructive, it is not always the final word because so many factors go into clinical studies. Just like experts who have performed the research that led the task force to create new guidelines, there are often experts to show different studies that would lead to different conclusions, and vice versa. In fact, The American College of Physicians, which represents internal medicine doctors across the U.S. and is the largest medical specialty, actually has been making similar recommendations to the current USPSTF guidelines.

The World Health Organization also recommends mammograms every one to two years for women starting at age 50. Many other developed countries, including Britain and our neighbors up north, do not start screening until age 50. Beyond the Debate: Making an Informed Decision about Mammograms.