To Have a Mammogram or Not...?

New mammographic screening guidelines emerged today, this time from the American Cancer Society (ACS). They now recommend annual screening mammography to start at age 45, and to screen every other year after age 55. Also, they recommend against annual clinical breast exam by a doctor or healthcare provider. For many years the recommendations included screening mammography starting at age 40, and annual clinical breast exam starting at age 21. The changes reflect various studies indicating that many of the cancers found early in women age 40-44 won't be life-threatening, and thus, widespread screening may not be indicated. Also, there is a higher risk of false positive mammograms, leading to "unnecessary" biopsies. These are designated as "harms" for the patient. A few important points should be mentioned regarding these new recommendations. First, these recommendations are meant to include women of average risk, and not women deemed to be high risk based on family history, genetic mutation carrier, etc. Secondly, the recommendations are just that - recommendations. According to the chairman of the ACS panel, this is not meant to restrict women age 40-44 from having a screening mammogram, if they or their physician deem it necessary. They just feel that women in this age group should make an informed decision with their doctor about screening mammography. Next comes the matter of doing away with the clinical exam, which frankly I find insulting. This appears to imply that a clinical breast exam is useless, and can be eliminated from a well-woman visit. Why eliminate something that has no cost, is non-invasive, and carries no virtually no risk of harm for the patient, and can actually be helpful in identifying suspicious lumps in a breast? Many times I have seen patients who were sent because of a suspicious lump found by their doctor, which eventually turned out to be a cancer. Even more frequently, it led to a diagnosis of a high risk lesion, not necessarily cancer, but a finding that led to more frequent imaging, MRI, etc, due to its high risk nature. Lastly, the notion that an eventual negative biopsy would be considered a "harm" to the patient is frankly ridiculous. After years of performing needle biopsies to rule out a breast cancer, I have never had a patient complain that they were "harmed" by the testing when it returned benign, as if it was all for nothing. In fact, most if not all are extremely appreciative and relieved.

This is all meant to bring about "individualized care" for our patients. But for the physicians like myself who see patients in their early 40s or even 30s diagnosed with breast cancers, what do these new recommendations mean to them? Not much, since their cancers might have been missed or discovered late, possibly too late, under these new rules. Some of the most aggressive breast cancers we see are found in the younger population, so why limit the scope of screenings? For years we have known that early detection saves lives, and this is still true. Yes, the majority of early stage breast cancers likely won't be aggressive enough cause death. The hard part is, we can't truly predict which ones will behave well or which will behave badly. Will we start seeing more cancers discovered at a later stage? I fear that a sense of complacency may set in when we don't maintain a broad scope in regards to mammographic screenings, or even clinical breast exam.

My last point on this subject involves the narrow focus displayed by the ACS committee. They seem to dwell on whether or not a cancer caught early will actually be lethal or not, rather than the potential value in finding that cancer early, so that more aggressive therapies might be avoided, such as chemotherapy, or mastectomy. Dr. Marisa Weiss, a breast cancer survivor and president of Breastcancer.org., summed it up best: "The American Cancer Society made the value judgment that screening is only worth it if it improves survival. There's an arrogance to that. Let women decide what's meaningful to them." I agree completely.


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