Local doctor offers view on mammogram debate

Dr. John Harch

On Monday, Nov. 16, new guidelines for breast cancer screening were put out by the U.S. Preventive Services Task Force, a federally funded panel. The previous recommendations advised annual mammograms beginning at age 40. The new guidelines suggested no routine mammograms from age 40 to 49, mammograms every other year from age 50 to 74, and no clear advice for those women 75 and older.  Furthermore, the task force stated that physicians should stop teaching patients self-breast exam due to its lack of proven effectiveness.

This announcement has caused uproar, and physicians are being besieged with questions regarding what to do. I’d like to review the available data in an attempt to answer the common questions.

Guidelines for mammographic screening depend on large studies of patients.  Between 1963 and 1990, eight of these studies were done on nearly 500,000 women in the US, the United Kingdom, Sweden and Canada. Overall, these studies showed a 20% to 35% reduction in mortality (deaths resulting from breast cancer) due to mammograms in women between 50 and 69 years of age. In the 40-to-49-year-old group, the mortality reduction was about 18%, and these women had to be followed into their 50s to see the mortality reduction.

In the early part of this decade, other researchers began to dispute the above data. They pointed out numerous flaws in these studies (e.g., some patients never actually received their mammograms, some got only one view of their breasts rather than two, etc.).  Ultimately, these authors threw out the data from 5 of the 8 studies and, after reanalyzing the data, concluded that mammographic screening does not reduce mortality.

Many experts have since disagreed with this analysis, and continue to argue for mammographic screening.  Another study published in 2003 again demonstrated a 20% to 30% reduction in breast cancer mortality from screening women aged 40 to 69. 

Regarding self-breast exam, there is no information to show that it reduces breast cancer mortality, but most breast surgeons (including me) have seen many patients over the years who have found their cancers on their own.

Similarly, I can think of many patients (often less than 50 years old) whose very small cancers were found on screening mammogram.

What are the risks of mammography? There is a radiation risk, but a 1997 research paper estimated that mammography saves 48.5 lives for every life lost due to radiation exposure. Another risk is that a false-positive mammogram will lead to biopsy of a benign lesion. Less significant issues are discomfort during the mammogram and anxiety over the reports.

Cost is another major concern. It is widely feared that the recent task force recommendation is merely the first step down the slippery slope of government-run healthcare and rationing.  The task force members deny this, stating they are an independent group, they have no control over Medicare/Medicaid payment for mammograms, and their vote on this subject occurred in June 2008 – before the current administration was elected and before “healthcare reform” was underway.

Cost, however, does impact this debate. It is thought that up to 1,800 mammograms have to be done in the 40-to-50-year-old group to prevent one death due to breast cancer.  Some have questioned whether this (and other expenditures on cancer screening) is a wise use of our precious healthcare dollars.

So, what’s the bottom line? Everyone just wants to know what a doctor would do for his/her family. Since the data is somewhat subjective and not crystal clear, and because numerous other medical organizations haven’t altered their recommendations, I would suggest the following:

1. For patients aged 40-49: yearly mammograms (remember, these patients typically have the fastest-growing cancers and more years ahead to “save”).

2. For patients aged 50-74: yearly mammograms.  The data is the best for this group.

3. For patients aged 75 or greater: the data is unclear.  If a person is expected to live 10 or 20 more years, it may make sense to continue yearly or every other year mammograms. If not, the benefit of screening is probably low.

If cost is a serious issue, then it is reasonable to consider mammograms every other year. This is the standard in some countries.

Breast self-exam is easy, cheap and mostly harmless, unless there is a worry about adding unnecessary biopsies.  I recommend it.

Finally, the above considerations are directed to the average-risk patient. For those at increased risk, yearly mammography is generally advised.

• John Harch, MD, FACS, is a Mount Shasta general surgeon with an interest in breast cancer and breast problems who has been in private practice for 22 years.