What the heck are the new guidelines for mammograms?

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Mammograms save lives, right? Or is it just a great business model, as some have suggested?

Most women know the statistic: 1 in 8 women will develop breast cancer. All of us know a handful or more of friends and family who have gotten "the call" from their doctor breaking the frightening news. Despite that, you may be surprised to learn the incidence of breast cancer has actually been dropping over the past 10 years. Some believe it's as a result of postmenopausal women using less hormone replacement therapy. Whatever the cause, women are more aware than ever about the need for breast cancer screening - but the issue is also more complicated than ever.

Where is the confusion coming from?

Conflicting studies coming out recently from a variety of sources have added to statements from patients highlighting a litany of concerns: the suggestion that mammograms lead to over-diagnosis, create false-positive results, require unnecessary exposure to low dose radiation, cause unnecessary workups, lead to needless surgeries, chemotherapy, radiation and cost. The stress and potential health implication of getting a mammogram is clearly a charged and anxiety-inducing topic for women today. Women and (some) physicians are confused about whose recommendations to follow.

What do the experts say?

The leading medical organizations making official screening recommendations for women with an average risk of breast cancer are now divided:

The current guidelines by the American College of Obstetricians/Gynecologists recommend starting mammogram screening at age 40 and continuing every 1 to 2 years until age 50, after which they should be done yearly. Self-breast exams and physician breast exams are recommended yearly.

The American Cancer Society (ACS) recently veered from the pack suggesting annual mammograms starting at age 45, and every other year after age 55. In fact, the ACS also said doctors should stop doing physical breast exams altogether.

Finally, to further complicate these medical organizations' recommendations, the US Preventive Services Task Force (USPSTF), an independent government panel, recommends mammogram screening every 2 years in women aged 50 to 74 years.

All these organizations agree on one thing: Evaluating each individual woman’s risk factors and discussing benefits and overall risks must be considered when making screening guidelines.

We know breast cancer risk increases with age, which makes recommending mammograms over the age of 50 years less contentious. The controversy lies within the group aged  40-49 years. Women in this age group who are diagnosed with breast cancer typically have the more aggressive and deadly form of cancer that may be more difficult to detect on mammogram. "About 85% of women in their 40s and 50s who die of breast cancer would have died regardless of mammography screening," Dr. Nancy Keating, a Harvard Medical school professor, explains. Some suggest mammogram screening falls short in detecting these more aggressive breast cancers and MRI testing may be more beneficial in this group of women who are considered high risk. The question is therefore, "Is mammogram screening the most effective way to detect breast cancer in this age group?"

As the conflicting recommendations indicate, many don't believe so. Individualizing who should be screened and how often is left to the discretion of the health care provider depending on the women’s risks factors. Certain factors will make women more high risk than others and this must be looked at on an individual basis when making mammogram recommendations.

Risk factors for breast cancer include:

  • Number of first-degree relatives with breast cancer
  • Women who had their first menstrual period before age 12
  • Women who had their first pregnancy after age 30 or women who have never had a full-term pregnancy
  • Number of previous breast biopsies
  • Previous history of breast cancer
  • Presence of atypical hyperplasia
  • Mammographic breast density
  • Excessive alcohol consumption
  • BMI> 30
  • Physical inactivity

It is also important to note that 60 percent of breast cancers occur in women without any known risk factors.

What’s the significance of "dense" breasts? The 40 percent of women with dense breasts have twice the risk of the average woman of developing breast cancer. Dense breasts makes it harder for radiologists to find suspicious lesions on mammogram, making early detection of breast cancer difficult. More and more states are mandating physicians to notify women whose breasts appear "dense" (mild, moderate or severe) on mammogram and counseling them on other imaging tests including ultrasound, MRI and 3-Dimensional Mammography that could be more valuable in diagnosing breast abnormalities and reducing false-positive results. The bottom line is a women's degree of breast density on mammogram combined with her breast cancer risk factors are now taken into consideration to know what additional tests should be done routinely.

Considering all the information, it can be said regular mammogram screening has increased the diagnosis of breast cancer in women, but the sad fact is it hasn't reduced the number of women who die from breast cancer each year. Early detection is the key. As a woman, it is clearly better to receive a breast cancer diagnosis as early as possible in order to have the chance to be treated and reduce the likelihood of dying from a disease that affects 1 in 8 women. Mammograms are currently the only cost effective screening tests available for women for early detection and for reducing the risk of death from breast cancer.

So what doe this mean for me?

If there is a takeaway from the recent confusion on this issue, it's that it is more important than ever before for all women to become actively involved in their breast health. Age is no longer the only factor to take into account for when and how often to perform breast cancer screenings. Women need to become educated about their personal risk factors in order to be their own best advocate in making informed decisions and becoming the champions of their breasts. 

References:

Gawande A. Overkill: An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it? The New Yorker. May 11, 2015. http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande Accessed September 23, 2015.

Lin, Kenneth W. Lin. Screening Mammography Guidelines: The Change Clinicians Should Know.

Løberg, M., Lousdal, M. L., Bretthauer, M., & Kalager, M. Benefits and Harms of Mammography Screening. Breast Cancer Res. 2015;17(63) 

Orvos, J. Do dense breasts mean more imaging? May 27, 2015.

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