To Mammogram or Not To Mammogram?

Is that really the question? Apparently, so. What are the current recommendations or guidelines for mammography? Who should have a mammogram? When should they have one? How often? At what age should mammographic screening begin? These are all straight-forward questions for which, one would think, we would have simple answers.

We should not have to stand for this, right? Let us simply ask the experts. “They” should know. There in lies the problem. These answers are dependent upon which experts constitute “they”.

Back in the stone age when I was a medical student and later an obstetric and gynecologic resident, the recommendations were simple and it seemed everyone was in agreement. Women should have a screening baseline mammogram between the ages of 35 and 40, mammograms every two years from 40 to 50 years of age and yearly thereafter. Life was so simple then. The recommendations showed a reasonable progression. Obtain that baseline picture-in-time from which all other future films would be compared and increase surveillance over time as a woman’s risk increased. Sounds reasonable, no?

It was reasonable until 2002 when the U.S. Preventive Services Task Force (more on these folks in a moment) decided, after reviewing all of the evidence, that the baseline screening mammogram was not all that useful and should be discarded. They further concluded that screening mammography should begin at age 40 and repeated at 1-2 year intervals. I do not recall many clinicians objecting much to these recommendations. Most reasoned, “OK, do away with the baseline, usually normal, mammogram but effectively increase our vigilance by beginning annual mammography at age 40 rather than 50. No problem.” However, in 2009, things changed AND many “experts” not only took notice, but raised a contrarian eyebrow at this task force.

So who is this, “U.S. Preventive Service Task Force”? By whom are they empowered and what is their purpose? Your good friends in congress established the Task Force and have directed it to review the, “scientific evidence related to the effectiveness, appropriateness and COST-EFFECTIVENESS of clinical preventive services for the purposes of developing recommendations for the health care community.” Although their recommendations are primarily directed at primary care physicians, do not think their recommendations do not influence those making important decisions about your health care benefits. Is there anyone more interested in cost containment (read stock dividends) than your caring insurance professional?

In 2009, those on the U.S. Preventive Service Task Force, changed their recommendation regarding mammography again. These new recommendations were based largely on the results of studies conducted by Heidi D. Nelson, M.D. and colleagues. They recommended AGAINST routine mammographic screening in women ages 40-49. Additionally, they recommended screening for women aged 50 to 74 every 2 years and stated that the evidence was insufficient to assess the benefit or harm of screening women aged 75 and older. They did not stop there, however. They also recommended AGAINST teaching patients self-breast examination and stated that the evidence was insufficient to be able to assess whether one’s physician doing a breast exam was of benefit or harm.

Now does that sound reasonable or even logical? What possibly could have been their reasoning? The task force concluded that despite the fact that women in their 40s experienced equal benefit from routine mammographic screening as women in their 50s, they experienced greater harms from the screening than did the women in their 50s. These increased harms were reported as radiation exposure (a low dose consistently shown to be safe), false-positive and false-negative results, over-diagnosis, pain during procedures, anxiety, distress and other psychological responses. Incredible!

And how about those pesky breast exams? Dr Nelson and the Task Force concluded that breast exams did not decrease breast cancer mortality but resulted in increased imaging and biopsies. Therefore, they recommended against teaching breast exams as they offered no benefit and placed women at risk for harm.

How many of you know someone, a friend or family member who found a lump on a self-breast exam that prompted them to seek evaluation and were found to have breast cancer? My grandmother is still alive today following just such a scenario.

Well, they are the experts, right? We, in the medical community, have all fallen in line with the current recommendations of the Task Force, correct? Not so fast my friends. Not this time. Remember the initial questions? Remember the answers to those questions were dependent upon who the experts were comprising the “they?” Fortunately, other experts outside of the Task Force or Dr. Nelson have a different view.

The American College of Obstetricians and Gynecologists still recommends screening mammography every 1-2 years for women aged 40-49 years, screening mammography yearly for women aged 50 years and older, patient self-breast examination and a clinical breast examination by a physician every year for women aged 19 and older.

Additionally, the American Medical Association, the Society of Breast Imaging, the American College of Radiology and the American Cancer Society all support screening mammography and clinical breast exams beginning at age 40.

So what is a girl to do? The information available and recommendations are varied and sometimes conflicting. Several studies around the world have since provided additional information on the subject including a Swedish study revealing that screening in this population of women in their 40s reduces cancer deaths by as much as 29%.

I believe, especially when faced with conflicting information, it is best to evaluate all of the variables and perhaps the motivation behind the various opinions and make a decision that is most appropriate for you as an individual.

For example, in this case, Dr. Nelson and the Task Force feel that the possibility of some additional anxiety or discomfort from a procedure outweigh the potential benefit one might obtain from a screening mammogram or breast biopsy. If it is me, I will trade a little anxiety or a little discomfort if it will increase my chance of avoiding death at the hands of a malignancy.

In terms of evaluating motivation behind these studies and opinions, one must keep in mind we live in a society where a growing number of individuals view medical care as an entitlement. Unfortunately, a disproportionately large number of those same individuals do not want to participate in funding this “entitlement.” As such, we have an ever-decreasing percentage of the population providing the financial support for a health care system that is, itself, on life support. Therefore, as fewer and fewer are paying in to this system, fewer and fewer dollars are available for services within the system like mammography. This is where cost analysis and cost-effectiveness come into play.

I am sure there would be a significant savings if we eliminated routine screening for women in their forties. And as I heard from one of the physicians involved in the studies and Task Force recommendations say, “We are only going to lose “x” number more women per year if we don’t screen that population.” No problem if you are not one of the women included in “x”. For the record, I believe the number reported by the Task Force is ONLY a savings of 1200 women per year. Yikes!

The American College of Obstetricians and Gynecologists reported that when looking at U.S. Census data in conjunction with epidemiologic data that screening women in their 40s would decrease the number of deaths expected from the 10-year death rate by 6,800 and stated, “The fewer deaths expected with screening compared to the predicted deaths demonstrates the significant benefit of screening on mortality in this age group.”

The question you must ask yourself is, “How much is your life worth?” Not only financially, but other factors, as well. Is it worth some additional anxiety or discomfort from screening or a procedure? Even if these services were not covered, I would still want to have the information and pay out-of-pocket. I am worth it, my family is worth it and my patients are worth it.

Mammogram or Not to Mammogram? MAMMOGRAM!