I'm turning 40 next year and always figured that would be when I'd start having mammograms. Now I'm not so sure. New recommendations issued yesterday by the U.S. Preventive Services Task Force advise women against routine screening in their 40s, saying instead they should make individual decisions. The guidelines also now recommend mammograms every two years, instead of annually, for women ages 50 to 74 and make no recommendation for women 75 and over. They also call into question the usefulness of doctor-performed clinical breast exams and breast self-exams to check for suspicious lumps and thickenings. [Here's a full report on the new recommendations.]
These big changes have been greeted with dismay by several major medical organizations. In a press release issued Monday, the American Cancer Society stated emphatically that it "continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider." The American College of Obstetricians and Gynecologists said that it is maintaining its old recommendations until it can "evaluate both the data and the USPSTF's interpretations in greater detail." Of course, the imaging societies that represent health professionals who perform mammograms expressed the most displeasure. An E-mail from the Access to Medical Imaging Coalition warned that this will "turn back the clock on the war on breast cancer." And Daniel Kopans, a Harvard radiology professor, told the Washington Post that the task force members who made the recommendations are "idiots" and that the new advice is "crazy, unethical really."
I'm guessing that I'm not the only woman confused about what to do. I called Susan Love, a breast surgeon and clinical professor of surgery at the University of California-Los Angeles medical school who is trying to recruit a million women for research trials to find the cause of breast cancer. I asked her: Do you think I should skip a mammogram when I turn 40?
Yes, she tells me, provided I am not at a higher-than-average risk of getting the disease. Women who have a breast cancer gene mutation (namely, mutations in the BRCA1 or BRCA2 genes) or have immediate family members who were diagnosed with the disease before menopause should start screening at age 40 or sometimes even earlier. I don't fall into those categories, so I ask Love to make the case for why I should feel comfortable delaying mammograms until I'm 50. After all, I have several friends who were diagnosed with breast cancer before 50, many via screening mammography.
Love tells me I have to alter the preconceived notions about cancer that have been drummed into my head during 18 years as a health journalist. "One of the things that gets confused is that finding cancers isn't the same thing as changing the outcome," she says. "You can find cancer and not make a difference in whether a person is going to live or die." While studies show that breast cancer deaths can be reduced by 15 percent in women who have mammography screening in their 40s, the absolute number of deaths actually prevented, she says, is so small as to be greatly outweighed by the detriments of screening. About 1 in 10 younger women have false findings that turn out not to be cancer, causing needless worry, additional imaging, and unnecessary biopsies; some of the cancers diagnosed aren't life-threatening and might actually vanish on their own without treatment; younger women may be falsely reassured when a mammogram can't spot a tumor that's hidden by premenopausal breast tissue, which tends to be dense. "One study in Finland found that 29 percent of women who had a false negative finding on a mammogram delayed going to the doctor after they felt a suspicious lump," Love says. "They assumed everything was fine since their mammogram was normal."
Love says there's also some evidence that the accumulation of radiation from yearly mammograms may actually cause some breast cancers.
All in all, she says, mammography "isn't a good tool in young women. The risks don't outweigh the benefits, and the standard of care now isn't based on science." She also agrees that formal breast self-exams are a waste of time—though women should see their doctors if they suddenly feel a lump or thickening that wasn't there before while, say, soaping up in the shower or taking off their bra. And while clinical breast exams shouldn't fall by the wayside, she says the latest research on breast cancer suggests that the biology of the tumor, whether it's aggressive or mild, may be the most important factor in determining a woman's survival.
I wonder, though, whether gynecologists who do screening breast exams and refer women for mammograms feel the same way. After all, their medical society, ACOG, is sticking by its recommendations to screen women starting at age 40. "I'm going to tell my patients that I'm abiding by the old guidelines for now," says Isaac Schiff, chief of obstetrics and gynecology at Massachusetts General Hospital in Boston. He doesn't, though, recommend breast self-exams, since they lead to a lot of false positives. Apparently, we find a lot of normal "lumps" when we're actively looking for them; it's those we find accidentally that more often warrant a medical exam.
Schiff worries that the USPSTF recommendations are based on cost-effectiveness and the push to drive down healthcare costs. For instance, the new guidelines cite a study showing that 1,904 women would need to be screened with mammography every year for 10 years starting at age 40 in order to prevent one breast cancer death. That number drops to 1,339 for women who start at 50 and to 400 for women 60 to 69. Clearly, it's more cost-effective to screen women in their 60s. But Schiff says that's not a valid argument to make to the 40-something woman whose life would have been saved by screening.
"I think most doctors feel the way I do," Schiff says. "There's no motive here other than what we think is best for our patients. We're the ones who have to call the patient and tell them the diagnosis is cancer." He adds that it's not going to be easy to convince younger women to forgo mammograms. Surveys have shown that 64 percent of women in their 40s report having been screened during the previous two years. "For women who have been brought up with the idea that they need to have a mammogram every year and then be told that they don't—without really powerful data—that's not what I think they'd want to hear." And he says there's no evidence to suggest that the low doses of radiation from the newer mammography machines have the potential to trigger new cancers.
Getting diagnosed earlier, Schiff adds, simply makes sense, since a smaller tumor often means a smaller biopsy, lumpectomy instead of mastectomy, less aggressive chemotherapy. Love would argue that while that may be true in some cases, it's not true all the time. Clearly, there's still a lot to be learned about breast cancer. Even Schiff admits that "10 years from now, we're going to say this was really the Stone Age in terms of how we diagnosed and treated cancer." He expects rapid advances to make genetic mapping and personalized medicine more commonplace. Women may some day be offered a genetic test to determine the age at which it's best to begin screening.
Until then, we have a complex decision to make about when to start mammography—40 or 50? I'm still uncertain, though I'm leaning towards waiting. What do you think? Answer the poll below.