Tuesday, April 03, 2007
Making sense of mammograms
Doctors don't always agree on everything. Sometimes, one doctor might tell you to get a certain test and another will say don't bother. At times, you will find a doctor who will want to whisk you off to the operating room, while another will say "go home and rest." There are certain things, though, that patients count on being consistent. One of those things is a schedule as to when to get screened for cancer. For a long time, women heard they should get a mammogram every one to two years, beginning at age 40. Not so fast now says the American College of Physicians. (Full Story)

Based on looking at lots of different studies, they have concluded that the benefits of mammography in women aged 40 - 49 might be outweighed in some cases by certain risks. The risks include a concern about radiation exposure, findings on mammograms that might lead to unnecessary biopsies, worry and anxiety. The flip side is of course that you could find cancer early, which is so critical. By the way, all organizations seem to agree that women 50 and older should get a mammogram.

So, this really is a rub in the world of medicine. What might make sense for the public generally might not necessarily be a good idea for anyone in particular. Sometimes the public health recommendation is at odds with individual recommendations, as is the case here. Many doctors will continue to tell their individual patients to go ahead and get the test, even as recommendations reflect less benefit in women aged 40 - 49.

Keep in mind that many people will take solace in the fact they are not at "high risk." While factors such as family history, breast density and genetic mutations may qualify women as high risk, the majority of women found to have breast cancer never had any of these risk factors. In essence, they become the first person in a family history to have the disease. That was the case in my family, and I am delighted she did get the test. So, what do you do? Will this make you more or less likely to either get a mammogram or recommend it to a loved one?
I had my first mammogram when I was 40 and my second at 42 which discovered a Stage 1 fast growing breast cancer. The cancer was discovered at .8 of 1 centimeter which caught the cancer in it's very early stages before it could be felt. I am appauled that we would turn back the clock of progress made that is saving lives by pushing back mammograms into 50 year range and increase mortality rates again as we fight this disease. Early screening is key in fighting Breast Cancer and other cancers as well.
I, like too many Americans, have no health insurance. I cannot pay for a mammogram. Even if I could get tested, for any type of cancer, I could not afford to pay for treatment. What about addressing this? Recommending early testing is great, what about recommending how to pay for it?

Early screening is not the key in fighting cancer. Making ALL treatments available for ALL people equally, regardless of their ability to pay would save more lives.
As far as I'm concerned, it's better to be safe than sorry. It is like pulling out teeth to get my mother to a mammogram. Having it less often won't change that!
This won't make me change my ideas about mammograms. I've already known for some time that the research shows that mammograms are most cost-effective for women over age 50, but that doesn't mean they are not helpful for women between 40 and 49.

I personally think the American College of Physicians is being motivated by their bottom-line with this latest media release, more so than their concern over a woman's increased risk of excessive worry about a false positive. I'd rather have a false positive checked out with further testing, than a true positive not found until it is too late.

Lord help us all if insurance companies pick up on this and deny coverage for mammograms for women under 50.
Every woman I have ever known that has been diagnosed with breast cancer has either had yearly mammograms and/or hormone therapy. Do you think it may be something we are doing to ourselves...?
As a radiologist subspecialized in breast imaging, I can tell you that we do read a lot (approximately 200 screens of asymptomatic women 40 and over) of mammograms to find a single cancer. But if you were that one person who had a chance to catch a cancer early who missed that chance because of a difference in opinion that would be hard to justify. The idea behind yearly screening is to catch a cancer while it is growing, before it gets large. Although breast cancers grow at different rates, the AVERAGE growth rate is such that a growing cancer is best detected by looking at one year intervals. A woman's greatest risk factor is being female and getting older. We see cancers in people without family history in women in their 30's and up. Younger is more rare, but does occur. Every tool is important, including self-exam, doctor exam and mammography.
To the individual in Nashville who stated that she did not have health insurance and couldn't afford to get a mammogram, here is a link to the Centers for Disease Control and Prevention's site for the National Breast and Cervical Cancer Early Detection program that will help you identify a program in your state that may be able to provide a no or low cost mammogram and Pap test if you qualify: http://www.cdc.gov/cancer/nbccedp/. You'll see a link to the list of state programs on the right.

I am an employee of the CDC and a breast cancer survivor, diagnosed last May at the age of 39 (discovered through self breast exam, not by mammogram as I was not in the recommended age range). I understand some women's reluctance to have a mammogram, but I feel that early detection is so important. Self breast exams have been under the gun as well, but that's how I found my cancer. Both these methods of detection are important. It's what we have at our disposal at the moment; my hope is that we find better detection methods in the future that make it simple for younger women to have their cancers detected early as well.
My understanding is that the type of breast cancer found in younger women is different and often more aggressive than slower-growing tumors found in older women. This would seem to me to indicate the while the odds of finding anything in younger women might be smaller, the importance of finding it fast is much, much greater (and I say this as someone who has had several scares which thankfully have turned out to be benign.) Very stressful, yes, but wouldn't you hate to be on the wrong side of a doctor's best guess?
I'm not technically at the age yet where I should need to worry about it. I'm in my early 20s, have had at least once (benign) lump removed - which I found myself, much to my doctor's surprise, as it was apparently smaller than what most people notice. I had an ultrasound, but no mammogram. It was basically a case of "well, I think it's this, but better safe than sorry", so out it came. And it was exactly what the doctor had assumed.

But as for mammograms... I've heard from people who've had them. I've heard they're very uncomfortable. I think it was my mother who said something about the machine pressing down and feeling like it tore some muscle a bit. Which I suppose is silly to fuss about when it's cancer you're checking for, but I do hope by the time I start getting them, they will have improved the technology to be a bit less unpleasant (I already have one yearly exam that's quite uncomfortable... not looking forward to avng two).

Ironically, mammograms are something I know litle about. You'd think somebody would be flinging literature at me or advice at the very least before I reach the age where I'll need those yearly exams. So perhaps someone could answer me... why are they needed even when monthly self-exams and doctor exams have shown nothing? Is it a concern of catching something smaller than you can feel?

I'd be grateful for an informed answer. They say ignorance is bliss, but it's downright frustrating for me.
OK, I hope somebody can answer these questions. We've had 20 years of mammograms now, plenty of time to assess their real world effect. We've been told repeatedly that mammograms "are the best way to save women's lives." Well, have they done that? Has the mortality rate for breast cancer just plummeted over the past 20 years? Uh, no. Last year, for what appears to be the first time, breast cancer deaths dropped - by a measley couple hundred out of tens of thousands - not even one percent! And this is after 20 years of this "life saving" test. And what about all the DCIS that mammograms are so great at finding (a "disease" that was never even heard of before mammograms, by the way). Hundreds of thousands of women have had radical surgery and radiation over the past 20 years because of DCIS - has it likewise reduced the number of invasive breast cancer cases? Well folks, the correct answer would again be "nope".
Before I go for another mammogram (I'm 53 by the way), somebody is going to have to show me the statistics that prove that mammograms have had any major positive impact on women's health. The worst thing we can do is fool ourselves with hype and wishful thinking about mammography's "magical" abilities to "save" women. As for "everyone" agreeing that mammograms are the best thing since sliced bread - hey, DES, thalidomide and HRT were all once the doctors' best friends in treating women. I guess "everybody" can be wrong once in a while. Please ignore the hype and learn the facts.
Dear Dr. Gupta,
I was so surprised this morning that you are still promoting hormone replacement therapy for alleviating night sweats and hot flashes. All of my friends that did not have a history of cancer, and felt safe taking hrt drugs, now have breast cancer.
When are we going to start looking at and acknowledging the causes for the increased risk of breast cancer in this, the richest country in the world? Could it be linked to the use of growth hormons in our meats or all the chemicals used to bring our vegtables to market?
I'm upset when people say the DCIS I had a mastectomy for wasn't cancer. The surgery was all I had and I'm so grateful for the yearly mammogram at age 54 that found it so early that I needed nothing more. My testimony for early detection doesn't mean much if people don't think I really had "breast cancer."
I had no family history of breast cancer, and has my first baseline mammogram at 35. There was a small lump and a needle biopsy showed it not to be cancer. However, at 44, after a mammogram, i had a different lump, which turned out that it WAS cancer! If i had followed the recommendation of not getting my first mammogram until 45 or 50, I could have been dead by then! Ladies (and men get breast cancer too) listen to your body! If you think something feels wrong, and your doctor tells you that you are too young, get another doctor! Get the tests early and get them often!
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