Last month, the American Cancer Society (ACS)released a new set of guidelines for breast cancer screening. This left many of us with more questions â€“- now six different groups recommend three different ages to start screening. The choice of when to start is further encouraged to be a womanâ€™s personal decision with her doctor. However, the current guidelines are confusing at best (as a physician myself, I was certainly confused), and occasionally misleading.
Whatâ€™s in the guidelines? One change the ACS made was raising the starting age for mammograms in women of â€śaverage riskâ€ť (no family history, no prior chest radiation) to 45 years. However, the US Preventive Services Task Force (USPSTF) recommends starting at 50, while The American Society of Breast Surgeons starts at 45. The American College of Obstetricians and Gynecologists and American College of Radiology recommendÂ that screenings start at age 40.
Clear as mud, right? As April Speed, MD, a breast surgeon and spokesperson for Susan G. Komen Breast Cancer Foundation – Atlanta, told me, â€śPatients need to be empowered to know that they have a choice. These are guidelines, but not hard and fast rules.â€ť With that in mind, here is the information I didnâ€™t have when I had my biopsy this year. And itâ€™s what every woman needs to know when considering when to start mammograms:
1. Breast cancer is less common in younger women â€“ but not as low as some might imply. In fact, a woman at 40 has about half of the risk of a new breast cancer diagnosis as a 60 year old. That is indeed a smaller risk, but much higher than we often hear, and definitely significant.
2. You do risk getting a False Positive (FP). A false positive is a positive (abnormal) mammogram result, which a second test (ultrasound, MRI or even biopsy) shows to be negative (normal). The fact is, a false positive is a normal risk in any type of screening test. Denser breast tissue and lower rates of breast cancer in women under 50 means more false positives. But does that mean we should stop screening them? Consider the numbers.
If you screened 10,000 women in their 40s annually for ten years, youâ€™d find:
- 6,130 women called back for another imaging test (600 women/year)
- 900 women biopsied (90 women/year)
- 190 diagnosed with breast cancer
- 5-16 lives saved
With the current US population, that means that over ten years, almost 14 million women in their 40s would be called for further imaging and 1.52 million would get biopsies. That is indeed a lot of extra testing, which exposes many women to more radiation, a potentially painful (although usually fairly simple) biopsy procedure and financial costs. It also means saving the lives of 11,000 to 35,000 American women in their 40s alone.
3. Experts are factoring in â€śemotional distress. â€ť Another factor for the guidelines was that women with false positives might feel undue anxiety for being called back. Not only have studies shown that this has no prolonged impact, shouldnâ€™t we leave the decision of â€śemotional distressâ€ť to the woman who would experience it?
4. Overdiagnosis is possible â€“ but mammograms arenâ€™t the problem. Overdiagnosis, which can lead to unnecessary chemotherapy, surgery and radiation, is frequently used as an argument against mammogram. But itâ€™s really related to current limitations for biopsy results. Hereâ€™s what it means: There are many types of breast cancer, and while most are life threatening, some portion (itâ€™s heavily debated, potentially 15-20%) are not. The problem is, our current technology cannot fully differentiate which is which. So all abnormal cells tend to be treated as dangerous since most of them are, and the cost of betting incorrectly is someoneâ€™s life. Think of overdiagnosis like hurricane forecasts: We know that not every hurricane will hit land, but we donâ€™t know which will, and itâ€™s too dangerous to wait around without preparing. Avoiding mammograms would be like stopping weather forecasting because we occasionally over-prepare for storms that never hit. What we really need is better technology (scientists are researching this) to know which biopsy results need treatment.
Like forecasting, breast cancer screening and diagnosis arenâ€™t perfect â€“- especially in younger women. But that alone shouldnâ€™t lead us to stop using them. I, for one, would hate to get caught unaware in that storm.