If I could wave a magic wand over all midlife women, I would simply want us all to not be afraid.
Breast cancer is one of our biggest fears at this time of life, and with good reason. Even though over our lifetime, 87% of women will NOT get diagnosed with breast cancer, those who do get diagnosed want to catch it as early as possible when it is highly treatable. Mammograms do save lives, but when this benefit is optimized is controversial.
The announcement by the United States Preventive Services Task Force (USPSTF) in November 2009 caused controversy by recommending that doctors stop teaching women to do breast self-exam (BSE) and that mammograms no longer be recommended as routine screening for women under age 50.
This month, the USPSTF has updated their 2009 recommendations, saying again that women between the ages of 50 and 74 are the most likely to benefit from mammograms, and that even in this age group having a mammogram every other year is optimal.
Although their recommendations caused a very emotional reaction in me as well as the American public (back in 2009 and again this month), let me take a moment to discuss the data on which these conclusions were drawn.
In 1980, invasive breast cancer was diagnosed in 1 out of 12 women. Now this disease is diagnosed in 1 out of 8 women overall. Survival rates at 5 years are 98% for localized tumors and only 27% in women with advanced tumors. This makes the obvious case for the need for effective methods to detect breast cancer when it is localized. However, at this point large amounts of data show that screening mammograms have not decreased the number of cases diagnosed of invasive breast cancer. This is not the case for cervical Pap test screening and colonoscopy – these two tests have lowered the number of cases diagnosed of invasive cervical and colon cancer, respectively.
What widespread screening mammograms have done is increase the diagnosis of ductal carcinoma-in-situ (DCIS) of the breast, a pre-invasive state of breast cancer, in which cells have not spread from the ducts into the breast tissue. While DCIS used to be a rare diagnosis, it now constitutes one-fourth of all new breast cancer diagnoses. Some researchers think that some of these tumors would actually regress (and go away) if left alone. (This is based on European data.) They also conclude that only once a year mammogram screening would not be frequent enough to detect aggressive breast cancers in younger women early enough to improve survival rates.
As far as screening tests currently available, including breast self-exam, mammograms, ultrasounds, and MRIs, the researchers on the USPSTF estimated that for every one cancer death prevented by screening mammograms, 838 women need to be screened for 6 years, during which thousands of biopsies will be performed yielding benign results. These “abnormal” mammograms and benign biopsies result in tremendous costs, financial and emotional, to both the health system and to the screened women themselves.
The data reviewed by the USPSTF on breast self-exam shows that while biopsies have increased as a result of women doing BSE, there has been no increase in breast cancer survival as a result. The USPSTF recommendations are not meant for women with any risk factors for breast cancer, such as family history. They conclude that doctors are to continue to use their discretion for ordering breast testing when they feel it is indicated.
MY FEELING ABOUT IT AS A DOCTOR
My feeling as a doctor on these new recommendations echoes that of many of my colleagues. I continue to encourage women (starting in adolescence) to check their breasts, with the goal of women being familiar enough with their own bodies to know when there is a change during the year (between annual exams) that should be checked out by their doctors. After all, even a normal mammogram report always contains the disclaimer, “a normal mammogram should not prevent the evaluation of a palpable mass.”
I have long been aware of the data showing that monthly BSE does not lead to better breast health than doing the self-exam every 3 months. Based on this data, I teach my patients that occasional breast self-exams are better than no self-exams during the year.
However, a recommendation telling women not to do any breast self-exams and become more familiar with their bodies goes completely against the zeitgeist of today’s world – women want to be well-informed about their own health, and we want our doctors to help sift through the overwhelming amount of information on the internet and other media. A survey of doctors in December of 2009 showed that the USPTF recommendations will not change the plans of 75% of my colleagues to continue to teach women to check their own breasts on some kind of regular basis.
As far as screening mammograms are concerned (i.e. women without risk factors), I continue to recommend mammograms before age 50, although I am now less of a stickler for a woman to have a mammogram every single year between ages 40 and 50 (as the so-far unchanged American Cancer Society guidelines recommend). Also, newer modalities such as breast thermograms will hopefully now get more attention as ways to improve detection of breast cancer in the early and even pre-malignant stages.
THE PERFECT TEST FOR CANCER
The “holy grail” of a cancer-screening test is one that catches 100% of disease cases (i.e. if there is cancer the test is always positive) and is always negative if there is no cancer. Obviously, we don’t have this test yet in breast health (not even breast MRI). I am not a total cynic on the topic of cost-effectiveness in medicine. I don’t think cost-containment is the only goal of these new recommendations. We doctors want the tests we order to make a difference in the health of our patients. We need the data and discussion generated by the USPSTF to help move us forward toward the goal of spending money in the right places to improve health for all.