Turning Forty? Do You Need a Mammogram?
Forty! Many people dread this birthday! It can signal the exit from youth in a youth-obsessed culture. For women, it also signals the first mammogram. Even though new equipment has reduced the compression needed for a good image, jokes and stories still abound about painful mammograms. These stories lead some women to decide they would rather avoid the ordeal. Just how risky is it to skip that mammogram? A study published in Cancer in August, 2017, is helping to answer that question.
For several years, women have had some support for foregoing an annual mammogram from respected public health organizations. In 2009 the U.S. Preventive Services Task Force, an independent panel of public health experts, said that routine mammography screening should start at age 50 and that every two years for a test was sufficient. Other organizations, such as the American Cancer Society (ACS), disagreed. The current ACS recommendations call for annual mammograms for all women between the ages of 45 and 54 with varying schedules for older or younger women. All of these recommendations are for healthy women at average risk for breast cancer with no symptoms. Everyone agrees that diagnostic mammograms and ultrasounds should be done at any age when lumps or other breast changes are noted.
The proponents of the less frequent schedule considered the financial costs to society of annual mammograms and the emotional toll on women for biopsies that turned out to be benign. Weighing all the factors, they decided that annual screening was not justified.
Objections to the recommendations for less frequent screening
Women whose cancers were discovered while they were in their early 40s by a routine mammogram were outraged when public health officials proclaimed that annual mammograms were not necessary. They felt their lives were saved by early detection. However, it turns out that early detection has not lived up to its promise. Many of those small cancers were not aggressive and might have never caused a problem, but the woman was put through surgery and radiation that might have been unnecessary. On the other hand, about a third of women whose cancers were caught early whether by mammogram or self-exam progress to have metastatic breast cancer. Early detection has not lived up to its life-saving claims, although certainly treatment is easier and there are fewer side effects from treating small tumors.
Radiologists and other medical professionals also protested the recommendations for fewer screening mammograms. Most patient expert writers like myself, caught in the middle of dueling experts, advised women in their 40s to talk to their doctors about whether their personal risk factors suggested that annual screening was the best for them.
Three screening schedules compared
Researchers at Weill Cornell Medicine and New York-Presbyterian Hospital are helping address this situation. Led by Elizabeth Kagan Arleo, M.D., they used six computer models to compare the expected lives saved by three different mammography screening schedules. They compared the recommendation of annual screening at ages 40 to 84 years with the second recommendation of screening annually at ages 45 to 54 years, then biennially at ages 55 to 79 years, and the third recommendation of biennial screening at ages 50 to 74 years.
They estimated that if a group of women aged 40 had annual screening over their lifetime, 29,369 deaths would be prevented. The second screening schedule would prevent 22,829 deaths. The biennial screening at ages 50 to 74 would prevent 15,599 to 17,153 deaths depending on which computer model was used. Multiply that by each year’s batch of women turning 40, and the number of lives potentially saved by annual mammograms is enormous.
What about mammograms for men at high risk of developing breast cancer? Because breast cancer in men is rare, so far no studies have been done on the efficacy of screening mammograms for men. Doctors use diagnostic mammograms for men with symptoms and as follow up for men diagnosed with breast cancer.
Don’t rely on mammograms alone
There are limits to what mammography can do. It may be difficult to find tumors in women with dense breast tissue. Aggressive tumors can grow between annual screenings. Some types of breast cancer, such as inflammatory breast cancer, are hard to detect on a mammogram. Women should not be so confident after a clear mammogram that they forget to notice breast changes and report them to the doctor between routine screenings.
It is still a good idea to talk to your doctor about the best mammography schedule for you. However, the data for now suggests that you need to schedule that first mammogram at age 40. Why not give yourself a birthday present of self-care and put it on the calendar for the week you turn that age? Then it will be easy to remember every year when you need to have your mammogram.
And those jokes you have heard about squish-o-grams? Ignore them. With the latest equipment and a good technician, you might experience some discomfort, but the days of painful mammograms are past.
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