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Mammograms: To Screen or Not to Screen?

Text by Tracey Gaudet, M.D.

Having counseled countless patients about mammograms, I know that women have wildly varying feelings about them. 

Not surprisingly, then, there was a range of reactions last year when the United States Preventive Services Task Force (USPSTF) issued new screening guidelines, the most controversial of which contradicted the recommendations from the American Cancer Society and other health groups to start screening at age 40. The USPSTF advised against the annual test for low-risk women in their forties.

According to recent estimates, nearly one in eight U.S. women may develop breast cancer, and despite advances in treatment, about 40,000 will die from it this year. So why would the USPSTF, an independent group of experts that issues (and reviews) screening guidelines, change its advice? And what should women do now?

I can tell you that for a woman in her forties, there's data to support continuing screenings and forgoing them; both are reasonable choices. One thing the data shows clearly: The benefit-risk equation improves with age. (In other words, the advantages of screening increase as you get older.) 

The USPSTF concluded that the benefit-risk ratio wasn't strong enough to recommend across-the-board screening, based on several factors: First, compared with women in their sixties, fortysomethings are much less likely to get breast cancer. They're also less likely to have their lives saved by a mammogram and more likely to have false positives. 

Many European countries have long recommended a schedule similar to what the USPSTF advises, based on data suggesting that the net benefit for women in their forties is small. This doesn't mean that mammograms don't save lives among younger women -- they do. They just save fewer lives compared with older populations.

The Science of Screening
The task force's job is to determine whether to recommend screenings for an entire population, so health experts weigh data comparing the benefits of the test with the risks. In reviewing the guidelines last year, the task force took into account new studies and used new statistical models. The ultimate benefit -- preventing deaths -- was broken down by age group. For women in their sixties, screening 344 women saves one life. For women in their fifties, screening 1,330 women saves one life. For women in their forties, it's one in 1,904 women.

As for the risks of mammograms, the USPSTF found several, including what are known as false-positive results. In these cases, a woman is told she has an abnormality and undergoes more intensive mammograms and, potentially, a biopsy -- only to find out that she doesn't have cancer. False positives can bring stress and anxiety, as well as unnecessary procedures.

The task force also looked at the risks of radiation, a common worry, and concluded that for most women, the low levels that accompany mammography pose little danger. (Women who have been exposed to a lot of radiation from other tests, however, should mention it to their doctors when discussing mammograms or any other routine X-rays.)

Statistics aren't meant to take into account individual experiences, which leads me to another important point. If you're that one in 1,904, the big-picture data doesn't matter -- the mammogram saved your life. Since the USPSTF released its new guidelines, we've all heard dozens of such powerful stories. 

One of the misperceptions is that the USPSTF made a blanket recommendation for all women in their forties to stop screening. It didn't. The recommendations apply to low-risk women -- not, for instance, those with genetic mutations that greatly increase risk (BRCA-1 and BRCA-2). Every low-risk woman in her forties should make a decision about screening with her doctor. 

While I can't tell you what to do personally, I can help guide you to make a conscious choice. Think of it as a personal risk-benefit analysis, and follow these five steps before deciding.

1. Do Some Inner Detective Work
Consider how you feel about breast cancer and mammograms. Have you always avoided or postponed mammograms? Did a specific experience contribute to the aversion? Do you live with the constant fear that you may get breast cancer? Exploring these feelings will help you learn important information about the underlying emotions that may be influencing your actions.

2. Talk to Your Doctor
Discuss your risk factors and the latest recommendations with your doctor. If you have concerns about a specific screening issue, such as false-positive results or radiation exposure, voice them. Sharing your thoughts will help you get a personalized, professional opinion about when and how often you should be screened.

3. Know Your Risk Factors
The biggest breast cancer risk factor is aging itself: Most cases occur in women over 50. Other risk factors include having a strong family history, starting your period at a early age, not having children or having them later in life, not breast-feeding, the use of hormone replacement therapy and birth control pills, moderate to heavy alcohol use, and obesity. To learn more about risk factors, visit the American Cancer Society at cancer.org.

4. Make a Decision, Then Sit with It
Based on the information you've gathered, determine a course of action. Put it on the back burner for a few weeks, then reconsider. If you're unsettled, revisit your decision.

5. Stay Informed and Be Flexible
Medicine is dynamic, and so is your health. New studies emerge, and expert opinions change. Monitor the latest information, keep a dialogue going with your doctor, and allow your screening plan to evolve.

+ For more tips on breast health, inside and out, read How to Take Care of Your Breasts

+ For more cancer-prevention tips, read Breast Defense.

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Comments

Comments (1)

  • 27 Oct, 2010

    I was diagnosed with breast cancer at age 46. Mammogram and ultrasound tests were both "inconclusive". I did have a biopsy, but only upon getting a thermogram was I able to see the cancer on a test result. Google thermography. I don't know why main stream medicine is not using this technology. It is non-toxic, relatively inexpensive (compared with mammography), completely painless and very conclusive.

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