News
Letter to the editor, Press gazette
Published 2009-12-01
Mammography-What’s a girl to do?
Mammograms save lives and money; somehow, this message is getting all mixed up. Mammography is not perfect, but it is the best tool to screen for breast cancer. Mammograms can be difficult to read, they are as unique as fingerprints, some abnormalities need further work up, and they find about 80% of breast cancers. Recently, the United States Preventative Task Force, USPTF, suggested no screening mammography for women ages of 40-49 and every 2 years instead of yearly for women over age 50, because these difficulties outweigh the benefits.
Mammographic changes can be difficult to detect because each breast is unique. As we age, the fat content of our breast changes. Young breast tissue is often dense and the mammograms show white shadows. An older breast is often fat replaced and the mammograms show a gray-black image with few white shadows. Cancer appears as white nodules or tiny white spots. Therefore, the radiologist may be looking for a white nodule in a snowstorm (dense breast), or a white nodule in a dark night sky (fat replaced breast). It is easier to find the white nodule in the dark night sky. By the time we reach 50 years of age, the majority of women have a fat replaced breast, and we can save one life by screening 1339 women with mammograms finding cancer early. For woman ages 40-49, 1904 mammograms would need to be done to save one life. It does not appear there is any new clinical information; however, the USPTF now suggests, 1904 is not a sufficient number to warrant routine screening mammograms for women ages 40-49. You could be a young woman with very little density in your breast and mammography could/should start at age 40, or someone over 50 with very dense breast tissue and mammography may not be the best tool or only tool to use for screening. What is a girl to do? Your best bet is to make sure you have a doctor who knows you, knows your mammogram, and knows the right information. What “number” of mammograms is sufficient to warrant routine screening is a policy decision, not a clinical decision.
Mammograms do not always show the whole story. A questionable area on a mammogram may require additional tests, and/or biopsies. Younger women have denser breast tissue and have more call backs when compared to older women. To eliminate the possibility of more call backs and confusion, the USPTF recommends no screening for this age group. It seems backwards, to disregard mammograms just because the findings might not be conclusive and may require judgment. This is precisely the time when a good doctor and good judgment is needed to find early cancers since early detection saves money in the end. Finding cancer early can be difficult since cancers start out as one cell that doubles into 2,4,16 cells… and so on, until a critical size allows detection (on average 18 months). The USPTF suggests a 2-year screening interval instead of 1 year. This may be an appropriate time interval since the critical interval is smack in the middle, but what was the motivation to change this recommendation?
It appears even the USPTF is not immune to the economic pressures of healthcare reform. These recommendations seem to be economically motivated more than clinically motivated. The discussion regarding how we want to spend our health care dollars for breast cancer screening is a great policy discussion, not a clinical discussion. A national dialogue by experts is needed before recommendations are released and adopted by insurance companies, and should not be disguised as something more.