When Should Women Get Mammograms?
The latest thinking on who should get mammograms, and how often
Some diseases frighten us more than others. For many women, breast cancer tops the list. Perhaps we’ve witnessed the physical and emotional toll of the disease in a relative or friend, or have experienced cancer’s effects firsthand. Regardless, the last thing women need is conflicting advice about how to lower their risk of getting breast cancer. But a set of recommendations issued by the US Preventive Services Task Force provided just that when it sparked controversy over the value of breast-screening mammography.
Bucking the long-standing, prevailing advice that annual mammogram screening should begin at age 40 for women at normal risk of breast cancer, in 2009 the Task Force recommended that average-risk women hold off on screening until age 50, and then continue it every other year until age 74. The Task Force also advised normal-risk women not to bother with the monthly breast self-exams that the medical community has in the past strongly encouraged women to perform.
Soon after the Task Force’s announcement, the government issued an amendment requiring insurers to cover annual screening mammography for all women aged 40 to 49 — a move interpreted by many as a sort of rebuke to the Task Force’s recommendations. In the end, a national debate was ignited among medical providers, and many women were left wondering: what do we do now?
In some circles, at least, breast cancer screening has become a “controversial” topic, says Kari M. Rosenkranz, MD, medical director of Norris Cotton Cancer Center’s Comprehensive Breast Program at Dartmouth-Hitchcock Medical Center, and assistant professor of surgery at Dartmouth’s Geisel School of Medicine. “A lot of providers are concerned about screening less because they don’t want to take any chances with cancer, and the insurers right now actually penalize [doctors] if a certain percentage of patients don’t get screened every year,” Rosenkranz says.
Overwhelmingly, well-respected US medical organizations have remained steadfast in their support of the conventional advice of starting yearly mammograms at age 40. “Truly every national society, and I mean the American Cancer Society, the American College of Obstetricians and Gynecologists, the American College of Radiology — any society that you can think of — all still recommend 40” as the starting age for yearly mammograms in average-risk women, Rosenkranz says. But many women are peppering their doctors with questions, and “a lot of patients are hearing different things,” Rosenkranz says. “Their gynecologist is telling them one thing and their family practitioner something else.”
One point that every woman should be clear on, however, is this: The Task Force’s recommendations only concern women of average risk who show no symptoms of breast cancer. It’s well-established that women who face a higher-than-average risk of developing breast cancer have different screening needs. “It’s really important and very clearly stated [in the Task Force’s documentation] that the recommendations were for average-risk women, not all women — there’s a big difference,” Rosenkranz says.
Much of the thinking behind the Task Force’s recommendations hinges on the anxiety that is associated with false-positive diagnoses and call-backs for additional testing that turns out to be unnecessary and often accompanies screening of women in their 40s. And it’s true that many women approach their monthly self-exams with a touch of trepidation; as our fingers probe for abnormalities, we brace ourselves for the possibility that we might actually feel a lump.
Is the anxiety worth the potential benefit? Absolutely, says Marina I. Feldman, MD, director of Breast Imaging at the Elliot Breast Health Center in Manchester, and a diagnostic radiologist who specializes in breast imaging. Self-exams and mammogram screening improve the chance of early detection, Feldman says, and “one in 69 women in their 40s will develop breast cancer.” Without annual screening and self-exams, those cancers will still be detected, but later — when the physical, emotional and financial costs can be “tremendous,” she says.
The Task Force’s recommendations have led some women to skip their annual mammogram, Feldman says. When those women come in later and are questioned about why they aren’t maintaining an annual mammogram schedule, they say, “‘Oh, I thought it was every other year,’” or ‘I thought I was supposed to start at 50,’” Feldman says. “But from my point of view, it’s horrifying what could have happened over those years [that passed without screening], what could have gone undiagnosed.” Early identification of cancer often means that more — and more appealing — treatment options will be available to the patient. For instance, “maybe treatment can be a lumpectomy as opposed to a mastectomy,” Feldman says.
Ultimately, it’s every woman’s personal decision, Rosenkranz says. “There is risk to screening annually starting at 40,” she says, since the density of younger women’s breasts tends to make their mammograms more difficult to read. But “early detection can result in less therapy,” she says, so women should weigh the risks and benefits involved in screening and self-exams. “It needs to be an educated patient’s decision that each individual woman makes with her provider based on her perceptions of the risks and benefits and her risk factors,” Rosenkranz says. “Shared decision making with patients is really what needs to come out of this debate because it really involves individual patients’ risk factors and their priorities … It’s patient choice.”
What about radiation?
Imaging is a great tool for physicians, but it’s creepy knowing that every picture taken subjects us to radiation. Just how much are we getting? “It’s the same radiation that you’d get from atmospheric radiation if you fly from Manchester to Washington, DC,” says Kari M. Rosenkranz, MD, medical director of Norris Cotton Cancer Center’s Comprehensive Breast Program at Dartmouth-Hitchcock Medical Center, and assistant professor of surgery at Dartmouth’s Geisel School of Medicine.
Indeed, “the lifetime risk of breast cancer that is caused by radiation from mammography is really and truly minimal,” says Marina I. Feldman, MD, director of Breast Imaging at the Elliot Breast Health Center in Manchester, and a diagnostic radiologist who specializes in breast imaging. “The benefit of early detection of breast cancer significantly outweighs the risk of the minimal exposure from radiation of the examination,” she says.