Sally Herschorn, MD, is Director of the Breast Imaging Division at Fletcher Allen Health Care.
“Mammography saves lives.”
“Wait, mammography doesn’t save so many lives.”
“You should get screened annually from age 40 on.”
“No. Screening should be a part of your routine every two years, from ages 50 to75.”
Talk about confusing information. What’s a woman to think?
As a breast imager for the last 20 years, as a 50-something woman who is at risk of breast cancer herself, and as a daughter of a wonderful mom who succumbed to breast cancer at age 52, I am here to try and help you sort through the confounding, often mixed messages about mammography and breast cancer screening.
The impact of mammography on breast cancer mortality has been studied more than any other medical intervention. There is overwhelming proof that mammography has had a tremendous influence on breast cancer mortality. Yet, every few years over the span of my career, studies have attempted to prove it is not worthwhile.
Here are the facts: Mammography saves lives. No, it is not perfect. Mammography does not find all cancers, and in particular, has greater difficulty detecting cancers in women with dense breasts. Detecting disease before it causes symptoms in a population at relatively low risk of disease involves selecting women whose mammograms show they might have the disease. Most of them don’t.
For every 1,000 women who have a screening mammogram:
- 100 are recalled to get more mammography or ultrasound images
- 20 are recommended for a needle biopsy
- 5 are diagnosed with breast cancer
These 95 out of the original 1,000 women screened are called “false positives”, as they do not have breast cancer.
Is it stressful to be called back? Yes. Is it a relief to be told everything is normal? Yes. Does the biopsy hurt? A little bit, but not nearly as much as some dental work. Is it worth it to diagnose a cancer earlier than when a lump is present? Yes, absolutely. Studies show that death from breast cancer has dropped 30 percent since we started screening most women.
What you can do:
- Have an annual mammogram beginning at age 40 and continue to do so as long as you remain in good health.
- Have a conversation with your physician regarding the pros and cons of mammography. All women are at risk for breast cancer, even those with no family history. If we screened only those women with a positive family history, we would miss detecting 75 percent of breast cancers!
- Find out from your health care provider whether you are at increased risk, based on family history or other factors. If so, you may need additional screening – possibly including an MRI in addition to mammography. If that’s the case, you may also wish to consider genetic testing and counseling.
For more information about the value of mammography, please visit the following links:
http://www.mammographysaveslives.org/
http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-detection
It’s October. It’s breast cancer awareness month. But for the Fletcher Allen staff and physicians in the Breast Imaging Division, breast cancer awareness goes on all year long. I would love to answer your questions regarding mammography and breast cancer screening. We’re all here to help.
Sally Herschorn, MD, is Director of the Breast Imaging Division at Fletcher Allen Health Care
Nice to see some common sense recommendations from an expert!
I appreciate the point of view, and it’s definitely a matter that deserves full discussion. However: If an annual mammogram is recommended because it catches more cases of cancer sooner, wouldn’t a semi-annual mammogram catch still more, still sooner?
How about monthly? Daily?
Eventually, the cost-benefit drops off sharply. But where? I think it’s unscientific to approach this in such an unquantitative way as the “annually-from-40-as-gospel” camp seems to do. Why is that the magic number?
I don’t think there are any studies “attempting to prove” it’s not worthwhile, as you say–that clearly suggests bias, if not malice. I think there are studies that objectively disagree with your prejudiced conclusions, which don’t appear to be rooted in science so much as instinct (please forgive my assessment, and feel free to correct it). Now, these studies might be flawed, and there may in fact be good evidence for annual screenings from 40 onward–but where is it? Let the facts do the fighting.
Thank you for your thought provoking comments. Those are indeed insightful questions. Let me take a moment to address each one.
According to data analyzed by the USPSTF, and published in November 2009, screening women age 50-75 every two years instead of every year would provide 70-99% of the benefit with less cost and fewer of the potential harms of mammography (mainly false positives). However, that is not the case with patients in the pre-menopausal age group; who tend to have more rapidly growing, more aggressive breast cancers.
Furthermore, there is no available evidence that screening more often than once a year; even in high risk patients, finds more cancers or decreases mortality. The logic here is based on the average time it takes a tumor to double in size (about 250 days). If you screen more often than the time it takes for a tumor to double in size, you are less likely to detect an interval change and therefore less likely to detect the tumor.
As we all have busy lives, I’m all for simplicity. It is much easier to remember annual screening; along with semi-annual dental cleaning and our other routine health maintenance measures. I am concerned about confusing messages which might lead women to skip screenings or forget them entirely.
It is important to note that the vast majority of deaths due to breast cancer occur in women who have never had mammographic screening. In a recent analysis of breast cancer deaths in Massachusetts, 75% of cancer deaths occurred in women who had not had regular mammography within the past two years.
You have found my weakness as a mammography advocate. I do take this often too personally; having devoted a good portion of my professional life to this. It just seems that the issue of mortality benefit from screening has been definitively scientifically proven. The controversy seems to be with the potential harms and whether they might outweigh the benefits. I believe these risks have been overemphasized by some. Studies show that most women would rather deal with the anxiety, cost and inconvenience of being called back for additional views or ultrasound, than risk a delay in diagnosis of their breast cancer.
Mammography is far from perfect; but it is certainly well studied. It will be interesting to see how this debate evolves as data become available from digital mammography; which detects more cancers in younger women and those with dense breasts; and as new and improved technologies, such as tomosynthesis become available.
Here are some links to some mammography screening articles.
http://www.sbi-online.org/associations/8199/files/Mammography%20Screening%20References.pdf
http://www.sbi-online.org/displaycommon.cfm?an=1&subarticlenbr=42
I really appreciate the response, and I think I understand now. I’m not in the industry at all (and I don’t actually have breasts, fair disclosure), so my interest is solely from the perspective of a layperson who followed the heated battles over comparative effectiveness research in ’09. I came away from those confrontations with the impression that some–including some who represent the Komen Foundation–had arrived at a mentality that could manifest itself as destructively anti-scientific with respect to breast cancer screening (though, I understood, through the best of motivations). I see that impression was probably in error.
I can agree completely that the “false positives cause unreasonable anxiety” argument falls way short, I’ve never understood the prevalence of that concern. I have to wonder if it’s not supposed to be a way of avoiding the discussion of financial expense, which is an unpleasant but a necessary factor in the debate.
Your point about the 250-day tumor doubling interval pretty much closes the book for me. That’s a very strong argument for the effectiveness of annual screenings.
(I’d also like to say my original comment was *way* too confrontational, I’m not sure how that got past my internal filter. Thanks again for the thoughtful response.)
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I am 52, healthy, and with no history of breast cancer in my family. I had been wondering if I really needed to get a mammogram every year. Thank you for the excellent facts. As far as I’m concerned, if having a mammogram every year saves even one life, that benefit is priceless. I’m scheduling my appointment!
I’d like to know more about the comparative risk of increased exposure to ionizing radiation – with a demonstrated link to cellular changes and cancer – vs screening benefits…
I’ve been told by practitioners that the radiation risk is minimal but have not seen a clear comparison – perhaps that something you could discuss?
Also – have you seen this screening bra concept? really interesting in terms of continuous monitoring – without continuous radiation exposure…http://www.smartplanet.com/blog/bulletin/a-bra-that-detects-breast-cancer/2431?tag=nl.e660&s_cid=e660
Coming very late into this discussion from 2010, but I would like to remind Gareth that he probably DOES have breasts, and that males can get breast cancer too.