Breast Cancer Screening

AIR DATE: Wednesday, November 18th 2009
POSTED BY: JULIE SABATIER
Photo credit: bookgrl / Creative Commons

For years, annual breast cancer screening has been standard for women starting at age 40. Now, a government task force made up of primary care doctors is saying most women can wait until they're 50 to start regular screenings and, even then, they only need to do it every two years. The U.S. Preventative Services Task Force released their new recommendations Monday, adding that doctors should no longer instruct women on how to do breast self-exams because these personal inspections have not been linked to any mortality benefit. Not surprisingly, the new guidelines have been the subject of intense discussions among women, physicians and advocacy groups. This issue is of particular concern to residents of the Pacific Northwest, where breast cancer rates are the highest in the country.

The current discussion is somewhat remeniscent of one set off earlier this year when a study of risks and benefits of prostate cancer screenings came out, showing that routine screening often leads to  unnecessary treatment.

How old were you when your doctor first talked to you about screening for breast or prostate cancer? What's your personal experience with the risks and benefits of screening? Did screening help you catch cancer in the early stages? Have you ever had a false positive? What happened?

Tagged as: cancer · doctor · women

Photo credit: bookgrl / Creative Commons

I was 38 when my doctor suggested I have a mammogram.  There was enough fibrous breast tissue he wasn't confident with his palpation.  That mammogram found a small intraductal calcification that my doctor wasn't able to palpate even knowing it was there.  The biopsy found it was malignant.  After a lumpectomy and radiation, I was considered "cured."  This event put me in the catagory of annual mammograms.  Eight years later (I was 46) a 2 cm mass was found in the other breast.  Again it was malignant.  I wonder if I would be healthy and cancer-free today if that initial mammogram wasn't done.  If there are better screenings, use those.  If not, are we to let statistics doom the few that the screenings would help?

Bett —

I think you overlook the fact that the diagnosis started with the physician who felt something abnormal on palpation and sought confirmation with mammography. The mammogram helped to sort out what he already suspected was problematic.

Laurel —

I was 40 years old when I found a lump.  I had not had a mammogram because I was pregnant, and then breast feeding.  It was a stage 2 cancer, and I had a lumpectomy, radiation and chemotherapy.  I am lucky that I had insurance coverage, and could afford the best care.  5 years later I have been diagnosed with metastatic breast cancer and I am dying.  This is an extremely rare outcome when the breast cancer is diagnosed early, as happens when it is found by mammogram.  While it wouldn't have changed my story, how many more women will die if they wait to get their mammograms?  Only 1 in 2000 say the researchers, but do you want to be that 1?  Do you want your friend, or your sister, to be that 1?   DON'T FOLLOW THESE GUIDELINES!  And we have to find a way to keep the insurance companies from adopting them as well.

dbrandtx —

I'm so sorry about what has happened to you.

Jackiesh3 —

I am 55 years old, with no family history of breast cancer.  I do monthly self breast exams and have yearly mammograms. I also have fibrocystic breast disease.   I was three months over due for my mammogram in January of this year when my PCP found a lump deep against the chest wall.  The mammogram barely picked it up because it was so deep and on US the doctor had difficulty locating it.  The biopsy was positive and I was node negative as well as no metastasis.   I have just completed all the recommended chemotherapy.  In three weeks I will begin six weeks of daily radiation.

I intensely disagree with the new recommendations to start screening mammograms at a later age and then do them every two years.  If I had waited two years my cancer being aggressive would most likely have invaded the lymph nodes and then my outcome would not be as positive.  It is a sure death sentence to many women if breast cancer is not found in the early stages.

I also feel the medical community has a long way to go in improving their mammogram technique to get better views of tissue deep against the chest wall as in my case.

Dori54w —

I am 54 years old, worked in cancer care for many years (as an R.N.) and had annual mammograms between 40 and 50. Then I began to question their value as I was concerned about radiation exposure. I had no family history of breast cancer and aside from age and no children, had no risk factors for breast cancer. I decided on my own to reduce the frequency of mammograms to every two years. What if somehow a cancer crops up in that two years that was there a year ago? I reason that it's probably aggressive and likely would not be as amenable to cure. That happens even with annual mammography.

With regard to the outrage and skepticism about this new finding, I recall in the 1980s when French researchers suggested that early stage breast cancer could be effectively treated with lumpectomy, radiation, and chemo. Surgeons and many of their patients adamantly refused to believe that anything less than radical and modified radical mastectomies were sufficient treatment for ANY breast cancer. Curiously, many women continued to opt for the disfiguring surgery many years after it was proven that it wasn't necessary.

Rather than quibble about these findings, women should take an open mind. Medical care will constantly evolve. Just as we recently learned that estrogens may offer no benefit to women, it may be true that our obsession with cancer screening may offer no benefit.

WRT arguments that this is a cost-saving effort, perhaps all the angry women should consider the extent to which profit motives figure in frequent mammography. Medical device manufactureres are making money on all those mammograms, and to what extent have they figured in the recommendations for more frequent mammography?

Laurel —

I'm 57 years old and my breast cancer was diagnosed at an early, treatable stage by an annual mammogram when I was 44.  The cancer was stage 1 and hadn't spread to my lymph nodes. I have no family history. I'm fortunate to have health insurance; and assumel that the new recommendations are driven more by  economics than science. Breast cancer is less common in women under 50, but often is more aggressive.  The recommendations are irresponsible and will reverse the gains that have been made in reducing deaths from breast cancer that began in the 1990's when more women followed the annual screening guidelines .  Until the cures are found, early detection is  the key to survival.

The paternalistic tone of the recommendations is also troublesome--that  women can't handle the "anxiety" of  being called for additional tests when something abnormal shows on the mammogram, so instead we will avoid scaring them by not screening them..

mas —

I can't agree more with your last paragraph - is it really better to not "scare" 20-50 women out of 2000, and have 1 woman die?  I think not!

dbrandtx —

This topic certainly resonates with those of us who have been diagnosed with breast cancer, reading all the comments thus far.  I am one of those who would probably be dead if it had not been for early detection.  I was 40 at first mammo, which showed nothing.  By nearly 41, I found a lump, which turned out to be cancerous.  Without that base mammo, it would have been hard to know how fast the cancer's growth rate was.  Fortunately after a lumpectomy, radiation and chemo, 13 years later I am still cancer free after being stage 2.  At what percentage of detection does it become worth suggesting mammos in 40's?  I find it interesting that this task force was made up of primary care doctors.  What about breast cancer doctors?  They have to deal with the aftermath if insurance companies decide not to cover early screening.  Them, and the families of those who will surely die.  At what cost does life become worth it?  

marygold —

I am 65 but I had two sisters who got breast cancer in their early 40's and thanks to a mammogram, they bought many more years with their nine children.  There was no history of breast cancer in our family.  I have spent the last 14 years in breast cancer prevention studies (BCPT, STAR, and Sister's Study) for my sisters and our children.  So much progress has been made in research that I feel both of my sisters would be alive today with treatments available now.  Why would we now go backwards and not do mammograms after all the hard work and time and money spent on research??  We can make a difference if we make a stand against this recommendation.  Mammograms cost much less than cancer treatment and insurance will not cover them if the government gets their way in starting them at age 50!!!!  Very concerned, Carolyn

eleanor —

I believe that much of the controversy around screening tests are based on an inability to intuitively understand statistics.  A great article in Scientific American Mind earlier this year awakened me to this fact. (http://www.scientificamerican.com/article.cfm?id=knowing-your-chances)  

When given the stats for breast cancer frequency and the false-positive rate for mammograms, 160 gynecologists were asked "What is the chance that a woman with a positive result on a mammogram actually has breast cancer?" 

From four choices, 60 percent of the gynecologists answered that there was a 81 or 90 percent chance the woman has breast cancer.  Only 20 percent of the gynecologists did the math correctly, yielding the correct answer that the woman has only a 10 percent chance of having cancer.  9 out of 10 women, in this hypothetical example based on real statistics, would be unnecessarily alarmed, and their alarm would  would be compounded by their physician's lack of proper statistical perspective.  Not to blame physicians (I am one who would have answered wrong before I read the article), but rather to point out the dearth of statistical literacy that is present in our society.

drtraviselliott —

I believe my doctor gave me the right statistic when I was called in for a repeat mammogram a year ago, at age 42.  I knew the chances were small, and I was alarmed, but not freaked out. Had I later learned there was no cancer, I would have been immensely relieved...and grateful I had a cautious physician.  I would gladly put up with "unnecessary alarm."  

It did turn out to be cancer. Because it was caught so early, I have to believe we saved $$ on health insurance payouts because my treatment plan was less extensive than it would have been had I walked in after it had advanced.

Hale Goodfellow —

I have a family history of breast cancer so when my doctor found a lump, she sent me in for my first mammogram at age 23.  First they did an ultrasound on the lump and, even though the technician said it was nothing to be concerned about, she sent me in for a mammogram and also did a needle biopsy on the lump "just to be sure." 

Since then, I have heard (from someone who practices Chinese medicine) that mammograms can cause as much cancer as it finds (because of the radiation) and that often it finds tiny bits of cancer that our bodies could naturally weed out, but removing this tiny cancer medically is like using a backhoe to pull a tiny weed out of your yard. 

What I don't understand is why the study recommends that women don't do self exams.  What is the harm in that?

christy —

I don't understand how something like this becomes a public debate? Not that it shouldn't be, but I thought science should be, well, scientific. Is this simply bad science? Or is the topic actually inherently controversial or up in the air? Is there really so much lack of certainty with this report? Do cancer organizations simply not want to hear it, because they don't like the change? Do they have a legitimate objection? Do we need higher standards for government task forces? Were cancer organizations not included in this process?

It should concern us that on a larger level this lessens our faith in science, because everything seems to be up for debate in this country and everyone seems to be an expert. Swine flu vaccines? Climate change? And when the media disseminates the information, and then the controversy, while they are doing their job, it can kind of get out of hand. 

scottmil —

Your guest (Dr. Nelson) keeps incorrectly referring to call-back mammograms as false positives.

Call-back mammograms do NOT represent false positives.  They are incomplete examinations that require additional films for completion.  These are more common in dense breasts.  However, a relatively small percentage go on to biopsy.

False positives results actually call a "cancer" or "suspicious abnormality" (ACR category 4 or 5) that is proven not to be there (typically by biopsy).

jjjhhh —

I had a mammogram 3 years ago at the age of thirty-four after finding a painful lump in my right breast. After clearing up it was most likely fibrous breast tissue, my mind was put at ease. Yet, since then I've asked my female friends at my age to at least a get a baseline mammogram, even as a birthday gift for herself.

These new recommendations leave me to wonder how many women will wait until even later to get their first mammogram.

I'm even more concerned how these recommendations will affect health coverage for so many women.

What would Susan G. Komen think of this?

mamablack —

What is the age of the data used for this study?  Have methodologies gotten better currently to alleviate the unnecessary treatment for false positives?

aengle —

I'm 51 and have had an annual mammogram since I was 40. I've never had a problem and have no risk factors and am fine with holding it to every other year. I do, however have several friends who have had breast cancer, one whose cancer has metasticized to her bones (and now other organs) after 10 years. She had a variety of symptoms that, in retrospect, were indicators that the disease had  spread. But her oncologists had never warned her of these symptoms or what to look for. Neither of these friends were given any regular kind of screening (other than mammograms) after their cancer or a list of symptoms to look for that would indicate the cancer had spread.  It has been hard for my friend, and those of us around her, to know that the symptoms were there and she didn't know what they meant.

Jackiesh3 —

What are the recommendations for self breast exams?

depmd —

The doctor's who's concerned that she'll see people with larger tumors said that somewhere around 25% of people with breast cancer are under 50.  How many of those people were diagnosed via screening mammograms? Aren't there other, cheaper ways to screen people in lower-risk groups?

I remember hearing on NPR that screening hasn't really decreased the number of cancer deaths.  What research supports that screening actually decreases the number of cancer deaths?

kgodwin —

The primary principle I taught my 7th and 8th grade health students was to PLAN to position themselves to take the percentage shot in life.  What were those attitudes, basic scientific knowledge, self-understanding insights, and the literacy skills needed to recognize the heads-up/pay attention cues that would come from new research that might suggest needed change in their health game plan.

 

These new studies are a perfect example.  Evidence bases research findings are important to include in all those factors affecting one’s health care choices.  If it is already known that you have a low breast cancer risk then this information will be helpful in scheduling a regime that would be effective in personal health management which does include co$t considerations.  If on the other hand your family has a history of cancer then your health care planning should be tweaked to cover the increased risk.  

 

One thing to note is that these new findings are RECOMMENDATIONS.  I do realize that nothing remains pure science for long.  Insurance companies might see these recommendations as a way to trim costs.  Mammogram suppliers will see their business and bottom lines affected.  Some may grasp a false security.  One thing that will result from the pull and tug caused by these recommendations will be a broader conversation. Hopefully this will mean that more women will rethink the way they approach their health care.  

 

As in any sport, strategy is important. A personal health care strategy is crucial.  

Cheryl from Bend —

There is something about the recent recommendations that is not at all clear to me. What is the matrix that is used to determine value of harm factors to value of benefit factors?

mclennan —

Our family has no other incidence of breast cancer.  My daughter is 39 years old and was diagnosed with metastic breast cancer last February (2009).... she had never had a mammogram but found the lump herself.  The prognosis after biopsy and scans was that the type is slow growing so she probably had it progressing through her body for around 8 years.  (through 3 pregnancies and breast feeding).   OK - so there are a lot of false positives but maybe we should do earlier baseline mammograms, like starting at age 25 and do them every 5 years, then switch to every 2 years at age 40 or whatever.  ANY check would have found this one sooner, when it was still at the lump stage, before it began to move to her lungs and liver and lymph. The treatment would have been cheaper, easier to her insurance, to her, her family, and to society.  Doing less is not better. 

diggerodell —

These recommendations presume that the "harms" of screening (none of which are life-threatening) outway the benefit of lives saved.

The task force does not look at the benefit of less invasive and less disfiguring therapy that be achieved with early diagnosis.

These recommendations are dangerous and ill-advised.  Please refer to the ACR statement regarding these recommendations.

jjjhhh —

The old age guidlines leant to a false sense of security.  E.g., my then 42? year-old daughter was taking a leave of absence from her job and would have no medical insurance during that year.  To be sure she was reasonably OK she had a physical exam late in the year, along with a mammogram which was reported negative.  Within a few months she sought a medical exam, now covered by insurance through a new marriage, wherein the physician detected a breast mass (which was painful), but recommended waiting 6 months for a re-exam.  

My daughter insisted on a biopsy which was positive for breast CA, as advanced a Stage II as possible, for which she has gone through breast and axillary node removal, and radiation and chemotherapy.  She is doing well, no thanks to that negative breast MRI.  

My Point?: a medical colleague and I reviewed that MRI, agreeing it was negative.  Apparently breast MRI's are not as reliable in women whose breast tissue has not yet shut down, probably explaining my daughter's negative breast MRI.  But it led to a false sense of security. 

Dave Huffman, 

Longview, WA 

huffmandi —

Hi,
I would be interested in knowing statistically how many false negatives occur when screened at age 40. I was diagnosed with BC when I was 39 years old a year after I was told by my physician that the lump I felt was a result of "lumpy breasts," and because  the mammogram did not detect anything suspicious,,,the flip side of the problem with dense breast tissue. I was deemed cancer free. After a second opinion a year later, I was diagnosed with BC, along with 6 out of 16 lymph nodes with microscopic cancer cells.  I followed in short order with a left breast mastectomy and 6 rounds of chemotherapy.  I remained in remission (no evidence of disease--NED) for 11 years until 2006 when I was diagnosed with metastatic cancer to my bones. So much is now available in the way of treatment and I am very encouraged by my progress...but there will always be a haunting question in the back of my mind if I had been more proactive a year sooner. 
Thank youDiana 

ptconception —

I think every healthy person should read the book Should I Be Tested for Cancer?: Maybe Not and Here's Why by H. Gilbert Welch before getting screened for any kind of cancer. He looks at the risks and benefits of routine screening and explains them in a very straightforward way. It's definitely worth reading.

inquisitu —

At age 46 I was diagnosed with breast cancer that was not detected by mammography.  With a 2 cm lump, it was a self exam and nagging by my doctor to keep up with the self exams that saved my life.  We had had this mammography and self exam discussion 2 year ago.  If you recommend less screening, you have to keep the self exam in the fore front of women's minds.

Notthenorm —

As a radiologist, I regret Dr. Johnson's comment that the ACR has a potential conflict of interest in opposing these recommendations.  Unfortunately, this represents one of the highest area litigation within the specialty of radiology and mammography does not reimburse well.  Were it not for the beneficial service it provides, I'm sure many radiologists would love to drop it from their practice.   While not a perfect test, it is the best screening tool we have for breast cancer and I trust in the credible, peer-reviewd scientific studies that show it's benefit. 

Oh, by the way, most of us do actually care about our patients.

jjjhhh —

First and foremost this is a womens issue, let women decide.

Second, the arguement that these are "just recommendations" is a red-herring... recommendations, if not stopped early, quickly become guidelines and then protocols.

Third, consider this in light of the health care debate, who do you want to make these decisions for you?

rethomas —

I have lost three cherished aunts on my mothers side. All had their breast cancers detected early through mammograms. Nevertheless, and despite assurances that treatment was progressing well because of the early detection their deaths followed roughly two years or less after diagnosis. I think the medical community hasn't a clue about diagnosis and care of any cancer and given that is hardly in a position to be relaxing standards for detection and care. SO WHAT if a biopsy is negative. Rather than be annoyed, the doctors and administrators should rejoice. An individual woman receiving false positives and repeat biopsies has to make some personal strategic policies on how to deal with that,  but for the HMO's or clinics that perform the procedures if they do 20, 30 or 50 thousand of them and many are negative that will have to be accepted as the price to be paid because of the inneficiencies of the front line diagnostic tools.

I don't know if it has been mentioned in this blog yet but there are thermal imaging mammograms that do not use radiation. My ex-GF was given a questionable standard mammogram and was due for a repeat in six months. I convinced her to get a thermal scan to reduce her radiation exposure. The thermal scan found two additional anomalies that the standard mammogram didin't even detect. It was $300 out of pocket for her but she could afford it. Why aren't HMO's buying these machines and thus bringing the prices for their use down??? Of course my ex needed biopsies done on the anomalies and they were negative. I don't think she is unhappy about that!

H

leisesturm —

Breast cancer is not analguous to prostate cancer. The female counterpart to the male prostate is the uterus. That said, IMO the fact that medical science eventually developed a screening tool for prostate cancer that involves a simple blood test should raise the bar at least that high for the detection of ALL cancers. I don't think it is an easy assignment but I see no evidence that Big Pharma is even trying out products that detect a variety of cancers non-invasively.

I also feel that rather than allow Big Pharma to continue raking in Billions doling out regimens of chemotherapy drugs that do not work, they should be directed towards CURES. Where is the incentive on the part of Roche or Pfizer or Warner-Lambert or any other pharmaceutical company to come up with effective cures for cancer when they are compenated so handsomely for drugs that add only months or weeks... years? Doubtful. IMO if someone does go years without a recurrence of their illness it wasn't due to the efficacy of their drug regimen but that they would have had this outcome regardless. Obviously this is America, we don't go around 'directing' corporations to do anything, so how about simply not rewarding them so handsomely for palliatives. How about notifying them that they will get the big money jackpots when and if they can deliver drugs that CURE. They can either supply the drugs they do make at steep discount or donate them: in direct proportion to their efficacy in patient outcomes. If they can't deliver a cure, nothing is lost, but I'm betting that they can. They just need some incentive.

H

leisesturm —

This seems so black and white to me. If we screen women in their 40s, the "risk" is anxiety and stress, while the "benefit" is possibly preventing death?  Who would rather risk death than deal with a little added anxiety?

PortlandGirl2008 —

I m a 60 year old woman and I started having mammograms around age 40. Getting a mammogram is a very difficult experience for me because I have very large breasts. I usually have a high tolerance for pain, but the mammogram seems like pure torture to me. Mammograms are so painful that I have put off getting a mammogram as frequently as recommended.

One time I had a false positive, and was sent for a breast ultrasound and I was amazed that it was completely pain-free. Ever since then I feel angry that I can't be screened with an ultrasound instead of the painful mammogram. I was told the cost would be prohibitive. But for people like me, couldn't they make an exception?

Yes this is a women's issue. Mammograms are primitive and brutal! Would there ever have been developed a screening for testicular cancer that involves compressing the scrotum as tightly and flat as possible between two heavy plates?

janni —

This article by a British breast cancer specialist explains the risk/ benefit analysis of cancer screening tests really well. There are real risks to routinely screening healthy people for cancer, not just "a little added anxiety" or increased health care costs.

http://www.spiked-online.com/index.php?/site/article/4272/

Americans need to have an honest conversation about routine cancer screening without overstating the benefits or underestimating the harms.

I hope the new recommendations for mammograms (and pap smears) will make a lot of people look at the evidence, not point to anecdotal stories about individual cancer patients (as sad as those stories are).

inquisitu —

Comments are now closed.

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