Why breast screening is still important
Today is International Women’s Day, a great time to remind everyone to take care of their “girls.” A recent study carried out by the Mayo Clinic showed that, in the year following a federal task force’s (U.S. Preventative Services Task Force) revised breast screening recommendations, the number of women in their 40s undergoing mammograms declined slightly — by approximately 6 percent — a change researchers call modest but still significant. I recently interviewed Dr. Stacey Vitello, a fellowship-trained radiologist with Montclair Breast Center, in Montclair, N.J., about this trend. Dr. Vitiello is a leading voice on breast density and blogs about breast health at her blog, The Breast Diaries, and TheAtlantic.com.
Why do you think the recommendations are a setback?
The United States Preventive Services Task Force (USPSTF), a panel appointed during the George W. Bush Administration and supported by the federal Agency for Healthcare Research and Quality, issued recommendations regarding breast cancer screening in 2009. This panel consisted of physicians in primary care (internists, pediatricians, Ob/Gyns), nurses, epidemiologists, biostatisticians, and public policy officials. Not one single breast cancer expert (breast surgeon, oncologist, radiologist, radiation oncologist) was included at the table.
The panel recommended screening mammograms every other year, beginning at age 50. This was a significant departure from the 2002 USPSTF recommendations, which called for annual screening commencing at age 40. Incredibly, the panel also recommended that women should not be taught or encouraged to do breast self-examination, and that physicians should not perform clinical breast exams on their patients to check for cancer.
To support its proclamations, the panel used a computer model to create new, non-peer-reviewed data extrapolated from previously published studies on mammography screening. Some of these papers were decades old. The USPSTF used the lowest estimate of mortality reduction attributed to mammography (15%) among the various numbers that exist in the literature (as high as 54%). Even with their selective use of a low mortality reduction figure to create their new numbers, the USPSTF’s own “data” confirmed that significantly more women would survive if mammography screening began at age 40.
But they ignored their own data, and they claimed that the supposed “harms” of screening (discomfort, anxiety of additional testing, and the risk of diagnosing cancers that wouldn’t necessarily kill the woman — though no one can tell us which cancers those are) outweigh the benefit of lives being saved. This was clearly not an objective, impartial scientific judgment; this was a value judgment, made with the over-arching goal of creating cost-saving public-policy recommendations for a broken healthcare system.
Why do you think women in their 40s should continue to get mammograms?
Breast cancer is the leading cause of death in women age 35-50. Screening for breast cancer in women in their 40s saves lives. There is no legitimate reason not to offer screening, unless cost-saving for the healthcare system is the only goal.
Radiation: Some women are concerned about the amount given in mammograms. Can you address that?
For digital mammography, the average radiation dose from a standard four-view mammogram of both breasts is 3.7mGy; for film-screen mammography (not digital), the average dose is 4.7mGy. Data suggests that if there is any risk for developing breast cancer because of screening mammography, it is extremely small. In the Swedish Two County Trial, over 100,000 women have had repeated mammograms since the 1970s, and the screened group has no more cancers than the group who has not had mammograms. It has been estimated that the theoretical risk of mammography causing a breast cancer is one in one million. That being said, we are quite aware that younger breast tissue is much more sensitive to the effects of ionizing radiation, due to more active cell division. Therefore, we use mammography very carefully in women younger than 35 years old.
I understand that mammograms may not be the best tool for detecting cancer in women with dense breast tissue. Is ultrasound or MRI better?
If you have “heterogeneously dense” or “extremely dense” breasts, your doctor should send you for an additional screening test each year in addition to a mammogram. If you are at high risk for breast cancer, that test should be an MRI. If you are of average risk, you should be having an ultrasound and a mammogram every year. Don’t rely on a mammogram alone, which will only find half of cancers for you.
Why is doing breast self exams so important for this age group?
Breast self-examination (BSE) is one of our key weapons in the arsenal to detect breast cancer as early as possible. It only takes a few minutes a month, yet a woman can potentially save her own life by taking the time to do it. BSE is especially important if you are younger than 40, since you are not yet in the group of women having yearly screening mammograms. Many young women with breast cancer find their own cancers.
Self-examination is also important if you are older than 40, and you are diligent about having your yearly mammogram. This is because mammography does not find all cancers and it is especially limited if you have dense breasts (up to half of cancers in women with dense breasts will not be seen on the mammogram (See What Breast Density Means to You). See useful instructional videos from HealthiNation. Your gynecologist can show you how to do a good self-exam as well.
If you ever detect something abnormal on your examination you need to see your doctor right away. Very often (eight times out of 10), the lump that you feel turns out to be something benign (not cancer), such as a cyst or a common benign tumor called a fibroadenoma. You should consider getting a second opinion if you feel something abnormal in your breast, but your doctor doesn’t feel anything and tells you everything is fine. You know your body better than anyone.