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The Mammogram Dilemma

By Karen Asp
Posted On Jul 22, 2014

Recent research suggests that mammograms may not be as effective as we thought. Here’s what you need to know to become an empowered patient.

BY Karen Asp PHOTO-ILLUSTRATION by Katarina Kojic

Turning 40 has traditionally been considered a “coming of age,” a milestone that brings with it new health questions. It is the age at which most women, not at risk for breast cancer, have undergone their first mammogram.In recent years, however, the standard yearly mammogram has come under fire.
In 2009, the US Preventive Services Task Force issued new guidelines, advising that women who do not have an increased risk of breast cancer wait until age 50 to begin annual mammograms, then get screened every two years until age 74. A large percentage of physicians and leading cancer organizations have not endorsed these recommendations. The American Cancer Society, American College of Obstetricians and Gynecologists, and Susan?G. Komen still recommend yearly mammograms starting at age 40 for normal-risk women. (Note: Women who have a high risk of breast cancer are excluded from all of these recommendations, as their physician may recommend starting mammograms or other screenings earlier.)

So, what’s a normal-risk woman to do? Read about the issues behind this debate so you can determine what’s best for your breasts.

The Argument for Yearly Screenings
Mammograms—X-ray pictures of the breast—have been around for decades, yet they didn’t become the standard for breast cancer detection until the 1980s. The mammogram’s primary purpose? “Find breast cancer at the earliest possible stage, which then translates into a higher rate of cure,” says Stacey Vitiello,?MD, breast imaging and biopsy specialist at Montclair Breast Center in Montclair, New Jersey.

Weighing the Risks
Experts who support the 2009 guidelines don’t deny that mammograms for normal-risk women are effective. “Yet there’s no data to support the idea that annual mammograms are better, especially given the numerous risks,” says Karla Kerlikowske,?MD, and a professor at the University of California in San Francisco, who specializes in breast cancer.

One of such risks is overdiagnosis, which is the identification of non-invasive breast cancer. This common type of breast cancer would never become clinically apparent or impact a woman’s lifespan. In a recent study in The New England Journal of Medicine, researchers found that breast cancer was overdiagnosed in more than 70,000 women in 2008, about 31 percent of all breast cancers diagnosed.

“The big concern is overtreatment, which includes surgery, radiation, hormone therapy, and chemotherapy, not to mention the financial cost and psychological distress these women experience,” says Archie Bleyer, MD, clinical research professor at Knight Cancer Institute at the Oregon Health and Science University and lead author of the cancer study.

Bleyer concluded that mammography has had only a small effect on the decline in death rates from breast cancer. The real reason fewer women are dying? “More effective treatment,” Dr. Bleyer says, estimating that improved therapies may be responsible for as much as 80 to 90 percent of the drop. Another risk is false positives—undergoing screening and testing positive, but the final diagnosis is not cancer.“With false positives come biopsies and additional treatments,” Dr. Kerlikowske says.

According to her study in The Journal of the American Medical Association, women ages 50 to 74 with average breast density had a 50 percent chance of at least one false positive if screened annually for 10 years, versus 31 percent if screened biennially.

The above study tested one subset of women for whom annual mammograms make sense: women with extremely dense breasts. “Dense breast tissue and breast cancer both appear white on a mammogram,” explains Vitiello. “This means that women with dense breasts have a higher risk of receiving a false-negative result from their mammogram.”

Finally, there’s the issue of radiation exposure—a small dose in a mammogram. “Yet if you don’t need an annual mammogram, and because you’re already being exposed to radiation regularly in everyday life, why expose yourself more?” Kerlikowske says.

OPTIONS BEYOND MAMMOGRAMS

There is good news on the horizon. Other screening tools are available, and more are being developed . For instance, physicians do breast exams, part of the regular medical check-up, which Susan G. Komen recommends getting at least every three years between the ages of 20 and 39, and yearly after that. (Susan G. Komen, doesn’t recommend breast self-exam as a screening tool, as research has found that it doesn’t result in improved mortality rates, according to Brown.)

For women who have a high risk of developing breast cancer, breast ultrasound may be used as a diagnostic tool to further evaluate an abnormal finding from a clinical breast exam or screening mammography. High-risk women may also undergo a breast MRI. Breast tomosynthesis, also known as 3D digital mammography, may soon be another option.

“It’s expected to be more accurate and detect small breast cancers that may be hidden during conventional 2D mammography,” Bleyer says. It may also have a greater likelihood of detecting multiple breast tumors, which occur in 15 percent of breast cancer patients. Tomosynthesis does carry a higher radiation dose than 2D mammography. However, according to Bleyer, “If it could decrease over diagnosis by a greater degree than the increased risk of radiation, it will be advantageous.”

He adds that current research is determining who might benefit most from this. Women in the high-risk population may even consider being tested for the BRCA genes, specifically BRCA1 and BRCA2, which put a woman at higher risk of developing both breast and ovarian cancers. Estimates from the National Cancer Institute suggest that 55 to 65 percent of women who inherit a mutated BRCA1 gene—and around 45 percent who inherit a BRCA2 mutation—will develop breast cancer by the age of 70.

If you’re considering this option, work with a genetic counselor who will determine your candidacy for this test and educate you about your choices should the test come back positive. In the case of a positive finding, Vitiello says the choices may include intensive screening, taking appropriate anti-estrogen drugs, having your ovaries removed prophylactically, and undergoing bilateral prophylactic mastectomy—the option chosen in 2013 by Angelina Jolie.

How Dense Are Your Breasts?

In the future, experts are hopeful that breast cancer screenings won’t be a one-size-fits-all approach, but rather tailored to each woman’s risk factors and breast density. Until that day, it is strongly recommended to work with your physician to determine what’s best for you, keeping in mind that it’s ultimately your choice whether or not you get screened annually or less frequently.

If you don’t know your breast density, you’re not alone. “One survey found that 95 percent of women don’t know this fact,” says Dr. Vitiello. Mammography is the only way to determine breast density, he says, and your physician or radiologist can determine your breast density from your mammography results. If you do have dense breasts, request a digital mammogram, which is more accurate for these women. Vitiello suggests seeking a facility that offers tomosynthesis, and asking your physician to send you for additional screenings after the yearly mammogram—a breast ultrasound if you’re at normal risk or a breast MRI if you’re in the high-risk category.