Ask the Care Team
There is an ongoing debate over the value of routine mammograms, which women should have them, and at what ages. What is the best current advice?
Regular mammography along with breast exams is the best early detection method available. Few experts dispute that regular mammography can pick up some breast cancers when they are small enough to be curable. The argument is over the magnitude of the benefit and in which age groups. Studies concur that mammograms are most effective for women in their 50s and 60s, when the incidence of breast cancer rises.
The evidence is less clear for women in their 40s, when the risk of cancer is lower to begin with and less information can be gleaned from mammograms because the breast tissue is often denser. Some studies haven't shown a benefit in this age group, while others have, and critics on both sides have argued about how well the research has been carried out.
Even in the most positive studies, women who were not screened with mammograms had only a slightly higher death rate from breast cancer — about 16 percent — than those who were screened, according to a recent analysis. That's equivalent to one death being prevented in 14 years following screening of 1,224 healthy women.
But why not be on the safe side and get annual mammograms beginning at 40 anyway? At least you'd know you were doing everything you could to protect yourself.
It sounds reasonable, but be aware that there are some downside risks. Mammograms can be uncomfortable. At a few hundred dollars apiece, they amount to a considerable national health bill. A signficant number of suspicious lesions found by mammography turn out to be benign — but the woman has to deal with needless anxiety and an invasive biopsy that can have complications, though these are rare. In some cases, researchers say, mammograms lead to breast surgery and radiation for cancers that would never pose a danger to the patient's health.
Where do the majority of cancer and women's health organizations stand on the issue in 2003?
The National Cancer Institute and a federal task force on prevention guidelines both recommend routine mammography, with or without breast examination by a clinical provider, every one to two years for women age 40 and over.
J. Dirk Iglehart, MD, director of the Women's Cancers Program at Dana-Farber, points out that individual women may have higher-than-average risks of breast cancer, and thus might bene.t from a personalized screening schedule. Those risk factors include previous breast cancer, breast cancer in close relatives (mothers, daughters, and sisters) — particularly if they were diagnosed at young ages — and certain types of benign lesions found in breast biopsies.
"Women should ask their doctors if they have doubts about their own risks, and about when they should start having screening mammograms," adds Dr. Iglehart.
Aren't there some new imaging technologies that are more accurate than mammography?
Ultrasound and MRI scans are available at most major centers. In certain cases, they can be used following a mammogram to provide additional information or to help differentiate between normal and cancerous tissue in women with dense breasts. These tests are expensive, require highly experienced staff, and can sometimes provide misleading information. To date, their potential role in largescale screening hasn't been determined. When the American Cancer Society updated its screening guidelines in May 2003, it said that mammography remains the "gold standard" and that the newer methods, while useful in diagnosis, are not appropriate for breast cancer screening in the vast majority of women at the present time.
