I am 50 years of age and have a family history (my mother) of breast cancer. I live in a country that has mammography available as a test for breast cancer screening. I am distressed by the conflicting views regarding mammography for this purpose. What should I do regarding further mammogram tests?
First, we recommend that you discuss this issue with your physician. This is particularly important in view of your family history. There is a definite genetic component to certain breast cancers, and individuals who have a first-degree relative with breast cancer (mother, sister) should be especially conscientious regarding their screening schedule.
There is currently a debate in the United States related to the practice guidelines originally formulated by the American Cancer Society. The conversation has been influenced by the announcement of new guidelines on mammography screening by the U.S. Preventive Services Task Force (USPSTF) in November 2009. This followed the publication of an article in The Journal of the American Medical Association that raised probing questions about the value of mammography in saving women’s lives. While this was not news to many doctors and researchers, it has made news headlines and fueled public anxiety.
The USPSTF recommended against the commencement of routine mammograms for most women in their 40s as a screening procedure. They further recommended that women aged 50 to 74 should have mammograms every two years instead of annually. Those who are at high risk (e.g., carry a genetic mutation linked to breast cancer) should continue having annual screening or as frequently as advised by their caregivers. The taskforce made no recommendation concerning women over 75 years of age because of insufficient data. It further advised doctors not to teach women to do regular breast self-examinations because of lack of evidence that this procedure contributes to saving lives.
Confusion and disagreement grew when the American Cancer Society announced that it would stick to its original recommendations for annual mammography screening for women beginning at age 40. Various other opinions were then raised.
This whole discussion highlights the importance of transparent analysis and publication of the evidence in health-care practices, and what may appear to be a discouraging mess is in reality a process and not a crisis.
Two cancer screening tests have undoubtedly been shown to save lives: the Papanicolaou (Pap) test for cervical cancer, and a colonoscopy for colon cancer. There’s ongoing debate about the value of prostate-specific antigen (PSA) testing, as well as screening for lung cancer. Mammography, too, is an imperfect test, and although it has doubtlessly contributed to decreasing death rates in the United States over the past 20 years, the decrease has been gradual, very costly, and resulted in some unnecessary treatments. This latter problem is because some of the cancers identified by mammography are slow growing (indolent), and a proportion may even disappear without any treatment at all. The problem is that we do not know which cancers will be dangerous and life-threatening. It is clearly unsafe not to treat a diagnosed cancer.
The following suggestions are based on the fact that we believe mammography saves lives and women should continue to have the test:
♦Women known to be high risk because of family history, biopsy results, or known genetic status should have mammography as recommended by their caregivers.
♦Most women could safely switch to mammography every two years. This saves nearly as many lives as the annual screening but may be associated with less anxiety, pain, and expense of unneeded procedures. Again, consult with your doctor.
♦Although systematic self-examination is not an evidence-based recommendation, it is harmless. Be aware of any changes or lumps in the breasts and get medical advice early.
♦Screening for most women, unless advised otherwise, should start at 50 years and occur every 18 to 24 months.