When I was working as a physician in the US, our Federal clinic’s policy was to order mammograms on all women starting at age 4o.

Why was this important? Because there is some indications that mammogram and early diagnosis increases the cure rate for breast cancer in young women.

This statement is not as obvious as you think, because “pre-menopausal” breast cancer (women under age 45 or so) is a different disease in many ways than the slower growing tumor in older women. The difference is probably due to hormones.

Younger women have “dense” breasts, which make the smaller tumors harder to see on mammograms (false negatives) and make benign (not cancerous) changes to be read as being suspicious of cancer (false positive).

So every month, two weeks after our mammogram van came through, we’d have to notify half a dozen women to get either a close up mammogram or an ultrasound to check the suspicious spot. If we still weren’t sure, we had to order a biopsy: and in many cases, the spot was too small to feel, so it meant a “needle guided biopsy”.

Every month or two, we’d pick up a cancer. About half the breast cancer diagnosed at our clinic was diagnosed by mammograms: The other half were lumps found by women who came in to get them checked. Most of the cancers in younger women were found by the women themselves, but in middle aged women, finding a tiny cancer that could be removed by lumpectomy was satisfying, since most of these small cancers had a high cure rate.

Given that about ten percent of women get breast cancer at some point in their lives, I always felt doing mammograms starting at age 40 was worth it for my patients. T   he literature confirms this: this article in Medscape says that conventional mammography cuts the death rate down by 20 percent.

So why the buzz about not needing mammograms if you are between 40 and 50 years of age?

It has to do with cost.

Even though the number of women dying is going down, nevertheless, fewer women under age 50 get breast cancer, so to find each of those rare cancers you have to spend a lot more money to find each cancer.

Then you have another problem: All those hormones in younger women mean that the cancer grows faster. The more hormone, the faster the cancer grows, so if you were pregnant within a few years of your cancer, or you are obese (and obesity often is associated with higher hormone levels) the prognosis is worse.

So the cancers in younger women grow faster, and often have spread by the time they are picked up.

Indeed, doing a lot of mammograms in younger women makes us worry that 1) all that radiation will cause cancer in rare cases and 2) if a woman had her mammogram, she’ll ignore that lump growing in her bosom, and delay seeing the physician thinking; it can’t be cancer because my mammogram was normal…but the mammogram might have missed it because it was not there or too small to see.

The reason I am worried about the new “guidelines” is that the trends toward uniformity and cost control might mean pressure on physicians to eliminate or avoid ordering the mammograms. In other words, it might mean that I, as a physician, will have to get on the phone and beg some clerk with a high school diploma to pay for the test, and for people who actually do the tests, it means they might see my referral, notice that I forgot to cross a “t” or dot an “i” and tell the patient she either has to pay for the mammogram or go home without it.

Sigh.

Here are the USPSTF guidelines:

  • The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. Based on patient context, including patient values concerning specific benefits and harms, individual decisions should be made regarding starting regular, biennial screening mammography before age 50 years (grade C recommendation).
  • Women aged 50 to 74 years should undergo biennial screening mammography (grade B recommendation).
  • Current evidence is insufficient to determine additional benefits and harms of screening mammography in women 75 years or older (I statement).
  • In women 40 years or older, current evidence is insufficient to determine the additional benefits and harms of CBE beyond screening mammography (I statement).
  • The USPSTF recommends against clinicians teaching women the technique of BSE (grade D recommendation).
  • Current evidence is insufficient to determine additional benefits and harms of either digital mammography or MRI vs film mammography as screening modalities for breast cancer (I statement).

In contrast, the American Cancer society continues to support the traditional guidelines, and breast self examination (which also has never been proven to work).  It’s guidelines are:

  • Clinical breast examination should be done about every 3 years for women in their 20s and 30s and annually for women aged 40 years and older.
  • Women should promptly report to their healthcare providers any change they notice in their breasts. Breast self-examination is also an option beginning at age 20 years.
  • For women at more than 20% lifetime risk for breast cancer, magnetic resonance imaging (MRI) and mammography should be performed every year. Women at 15% to 20% lifetime risk should consult with their physicians about the benefits and limitations of adding MRI screening to their annual mammogram.
  • For women whose lifetime risk for breast cancer is less than 15%, annual MRI screening is not recommended.

Ironically, the cheapest method, breast self examination, is also not recommended by the USPSTF guidelines, since it is unproven to decrease mortality: this is probably because most lumps are picked up randomly by women rather than during the monthly self examination. Yet since women are now picking up small lumps (1 cm) (random or in BSE) whereas 40 years ago, the average lump was 2-3 cm diameter and less curable, I suspect that the simple awareness of one’s breast has increased the ability to find a lump and willingness for women to get the lumps they find checked.

Two more points to remember:

One: if the Health Care  bill goes through, the guidelines will become not suggestions but SUGGESTIONS backed by threats of non payment.

Two: If you read the end of the guidelines and compare them, you will notice a bit about MRI screening.

The cutting edge technique for high risk patients (i.e. with strong family histories) is to do an MRI.

The MRI is very expensive, and has a high “false positive” rate (meaning lots of scary spots that turn out to be nothing, but could need a biopsy).

The American Cancer Society recommends an MRI if you are high risk; the guidelines don’t recommend it at all.

Well, that will save a lot of money.

So what do I do?

I get a yearly mammogram. I have two close family members who died of breast cancer, so am aware of this terrible disease.

But if there is a strong breast history in the family, or your genetic testing shows that you carry a “breast cancer” gene, fight to get the MRI. It’s worth it.

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Nancy Reyes is a retired physician living in the rural Philippines. Her website is Finest Kind Clinic and Fishmarket, and she writes about medicine at HeyDoc Xanga blog.

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