Category Archives: Mammography

Should You Get a Mammogram?

Leda Derderich wishes she had.

Dederich had stage IV breast cancer diagnosed at age 45, two years after she and her doctor discussed and dismissed the need for a routine screening mammogram while breastfeeding at age 43. That decision to delay screening mammograms may have meant that she lost the chance to find and treat her breast cancer before it had spread beyond the breast. It’s a decision she regrets now, and blames on the confusion around mammogram guidelines.

I have had a much harder time accepting that I was not screened for breast cancer before it was too late. Not because I couldn’t be bothered, was too anxious, or didn’t have health insurance, but because the guidelines for screening women in my age range are one hot mess of a controversy, and I fell through the cracks.

Two years before my diagnosis, when I was 43 years old, I asked my doctor if I should get a mammogram. I had a vague understanding that breast cancer screening protocols were in flux, but I wanted to be sure. My risk profile for the disease was very low. I was nursing my infant daughter, and I really did not want to stick my breasts in a vice grip (it’s not really that bad, but that’s how I was imagining it). My doctor told me that if I didn’t want a mammogram, I didn’t need to get one.

Her counsel was based on a set of widely used guidelines at the time that say having a mammogram is an “individual” decision for women under 50 at average risk for breast cancer. She had no reason to believe I was at risk, and I had no reason to believe I should question her judgement.

What I didn’t know, at the time, was that there are multiple and conflicting breast cancer screening guidelines for women between the ages of 40 to 49.

Dederich is right. There is controversy around what’s best for women in terms of screening mammograms, a controversy that began in 2009 when the US Preventive Services Taskforce rocked our world with their recommendation against knee-jerk, routine mammogram screening in all women between ages 40 and 49.

Now, almost a decade later, the guidelines for mammogram screening still vary, though not as much as you might think. With one notable exception. Allow me to summarize for you.

Screening Mammography Guidelines – Not as Out of Sync as You Think

With some minor differences in wording and nuance, the US Preventive Services Taskforce, American College of Physicians (ACP), American Academy of Family Physicians and 2017 ACOG guidelines in essence recommend that women at average risk for breast cancer be offered mammogram starting at age 40, but make informed, individualized decisions about having mammograms depending on their individual risk, personal values and concerns. The frequency of mammograms, if women choose to have them, varies between one and two years. The American Cancer Society guidelines recommends individualized choice between ages 40 and 45, with all women starting screening at age 45.

Wrapped into those guidelines is the fact that delaying mammograms to age 45 or age 50 accepts a small but real increase in breast cancer deaths – on the order of around 1-2 extra deaths per thousand women. In return for delaying mammograms, women get less false positives and less unnecessary biopsies. It’s estimated that if you have an annual mammogram starting at age 40, you have a 60% chance of a false positive and a 7% chance of having an unnecessary biopsy, compared with a 40% chance of false positive and 5% chance of biopsy if you wait to age 50 to start routine mammos.

Also considered in the guidelines are the fact that mammograms do not prevent breast cancer and do not find all breast cancers at an early, curable stage. They miss about 10% of cancers, and may not detect rapidly growing cancers that arise between routine mammograms and spread beyond the breast almost from the get go. In addition, the cancers mammograms do find may be the slow growing kind that would never kill you anyway, or are not really cancer (we’re talking DCIS), but can lead to surgery, radiation and even mastectomy.

The American College of Radiologists continues to recommend annual mammograms for all women starting at age 40

The one group still recommending routine annual mammograms for all women starting at age 40 (ie, no individual choice) is the American College of Radiology (ACR). The ACR is now on a campaign to re-inform women about mammogram screening, putting their own spin on the data to get their message out to the public that the everyone else’s guidelines are just plain wrong.

Is the ACR right? Should the US medical profession just go back to telling all women to have a mammogram starting at age 40 ? If so, we’d be at odds with most of Europe, where women at average risk of breast cancer are not invited to screening till age 50, and where breast cancer deaths are not higher than those in the United States.

As a compromise, the ACP and ACR in 2012 issued a joint statement on points of agreement designed to ensure that mammograms remain affordable and available to all women starting at 40 who want them regardless of risk. But the differences in recommendations between the ACR and other organizations remains.

Which brings us back to the fact that when it comes to mammograms, for now, women have a choice to make.

It doesn’t matter what the guidelines say if the decision you make about having a mammogram is the wrong decision for you.

Dederich regrets the decision that she and her doctor made, and feels that she did not have the information she needed to make the right choice for herself.  She feels that because the medical community is conflicted, our patients are confused and therefore misinformed.

Smart, dedicated people are deeply engaged in this issue. But while they compare data sets, grapple with the statistical significance of lives like mine, and churn out conflicting guidelines, far too many women are left confused and misinformed about what is best for our health and long-term survival.

This is exactly why my colleagues and I created Breast Screening Decisions*, a free website and Iphone App designed to help women make an informed decision about screening mammograms. Using BSD, a woman can determine her own risk of breast cancer (which, even among low risk women, is not zero), explore her own personal values around screening, learn about the benefits and harms of screening mammograms, and see for herself what the difference is between starting annual mammograms at 40 vs waiting till 50 or having them every other year vs. annually. There is a real difference in mortality, but it’s small, and we’ve created visuals to help you see it accurately.

Some women don’t care a hoot about false positives or unnecessary biopsies or the fact that their mammogram might detect a cancer that would never kill them but results in them undergoing surgery, even mastectomy. It will all have been worth it if they catch a cancer early. And even if they don’t catch it early, at least they feel they did everything they could have done to do so.

On the other hand, there are women who want to avoid mammograms at all cost. Perhaps they or a loved one had a bad experience with a false positive, or a biopsy that resulted in complications, or they just believe they will not get breast cancer and don’t want the harms of mammography.

What’s important is that women feel they’ve been given the information they need to make the choice that’s right for them.

Decisions are Not Easy

The hard thing about making decisions is that the decision we make today might be different than the one we’d make in hindsight, when we know how those odds we considered actually played out. I try when I can to tell my patients who are making choices to project themselves into future, having either a false positive, DCIS or a breast cancer diagnosis, and ask themselves if they would then regret the choice they are making today, whatever that may be. If their choice remains the same, it’s probably the right choice for them. If not, then they may want to rethink it.

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* Breast Screening Decisions (BSD) is completely free as well as ad-free, was built using funding from the NIH, and is maintained using private unrestricted institutional donations.  I have no financial interest in BSD. 

More from TBTAM on Mammograms

What Women Want – How and When to Deliver the News of a Breast Cancer Diagnosis

RAW1RLRTM7

If you’re going to have to tell a woman that she has breast cancer, she wants to hear the news as quickly as possible, preferably face to face, ideally within 1-2 days of the biopsy being done, and have an appointment set up to deal with the diagnosis either that day or the next.

That’s what Dr Deanna Attai and colleagues found out when they surveyed over 1000 women, including 784 breast cancer survivors, to find out how and how soon they wanted to get their breast biopsy results, and compared that to what actually happened when they got their results.

It’s no surprise that in almost all cases, when it comes to hearing results, what women got did not match what they wanted. For example, while 40% of women heard their diagnosis within 1-2 days of biopsy, 80% would have wanted their results within that time frame.  Fifty four percent heard their mammogram results within 2 days, but 84% wanted them the same or next day.

A few important nuances emerged from the data – given a choice between hearing results face-to-face and getting them faster over the phone, women opt for speed. If it’s a mammogram or blood test result rather than a biopsy, face-to-face is not as important.

Most interesting were the comments women made on their surveys, which should be required reading for anyone having to give bad news. Here are just a few –

  • “Use the same compassion and candor you would use if you had to give this info to your loved one”
  • “Nothing is worse than calling a patient and telling them to bring someone with them but not telling them why.”
  • “Please remember that a bad test result may throw a person off, so much so that they cannot really hear what you are saying. Be clear and be careful. Ask the person to reflect back what you have said, so you are sure they got it!”
  • “We were starving for reliable information when I was diagnosed. Wish there was information provided with the results that further explained everything.”
  • “Always present situation with hope.”
  • “My oncologist was exceptionally kind. He said ‘I’m sorry this is happening to you’. He was the only one of several doctors to do so’”

The study population by design sampled internet-saavy women, and Caucasian women were over-represented in the sample, so these results may not extrapolate to all women.

But the message is loud and clear – when it comes to breast cancer screening results, we are not meeting our patient’s desire for timeliness or preferred method of communication.

False Positive Mammograms & Subsequent Breast Cancer Risk

breast ca risk and false pos mammo
A recent study points to a higher risk of breast cancer in women with a history of a false positive mammogram.

Investigators examined the number of breast cancers occurring over 10 years with whose routine screening mammogram had resulted in either a “call back” normal mammogram or a benign breast biopsy (false positive mammograms), and compared it to the number of cancers in women whose mammogram was normal on the first go round (true negative mammogram.)

Women who had a false positive mammogram had a higher risk of breast cancer in the subsequent 10 years compared to women with a true negative mammogram. How much higher? As you can see in the graph above, for every 1/000 women with a true negative mammogram, 3.9 breast cancers occurred within the subsequent 10 years. This is in contrast to women with false positive mammograms who had 5.5 breast cancers for every 1,000 women, and women with a false positive biopsy who had 7 cancers per 1,000 women.

Thought the relative risks between groups is statistically significant, it’s extremely important to realize that ALL these risks are under 1%, so we are making distinctions between very small numbers.

Here’s what the study results looks like in an icon array, a useful tool for illustrating comparative risks that are under 1%. Among the 1,000 women pictured in each array below, the pink ladies are the ones who developed breast cancer within the 10 years, while the grey ladies remain cancer free.

true neg

False pos

biopsy

Further stratifying results by breast density, the researchers found that 10 year subsequent breast cancer risk was highest in women with extremely dense breasts and a false positive biopsy (9.01 per 1,000 women), and lowest in women with fatty breasts and true negative mammograms (2.22 per 1,000 women), with the rest scattered in between according to density.

breast ca risk by density

The investigators uses data from the Breast Cancer Surveillance Consortium (BCSC) from 1994 to 2009, studying over 2 million mammograms done in over 1 million women. It’s a robust database that the US Preventive Services Task Force used to advise their recommendations for mammogram screening. They adjusted risk data for age, race/ethnicity, menopausal status, history of breast biopsy, and family history of breast cancer, all factors that are associated with breast cancer risk.  The study results are consistent with those of other studies, adding to a growing body of literature linking false positive mammograms with breast cancer risk.

Now What?

A history of a prior breast biopsy is a known risk factor for subsequent breast cancer, and is already incorporated into the Gale Model and other breast cancer risks assessment tools. It may be time to consider incorporating a history of a prior false positive mammogram into these tools. At this point, breast density has not been incorporated into these risks assessment tools, primarily because it is such a subjective measure with not great reproducibility, and because it changes over time.

How to Use This Information

Women and their doctors may want to use this information to help them decide how often to have mammograms, or whether or not to begin to incorporate sonograms into their breast cancer screening regimen.

That said, it’s important to understand that although the risks for breast cancer are increased by a false positive mammogram, the absolute increase in risk is modest – still less than 1% in even the highest risk group.

More on Breast Density Notification Laws

mammo fatty and dense 2There’s a nice discussion of the practical considerations around breast density notification laws in this week’s NEJM.

The editorial and accompanying podcast summarize what we do and don’t know about breast density, and give practical suggestions for incorporating breast density into the discussion around mammography screening for individual patients.  Online access to both the editorial and podcast discussion is free, and I encourage you to read and listen.

Bottom line  

Most women under age 60 will have dense breasts on mammography. Breast density is subjective, and we do not as yet have a computerized way of standardizing breast density readings. Breast density can also vary in a given women across the menstrual cycle and with age.

Breast density may increase breast cancer risk from 1.2-2 times, but it is not clear if that increased risk is additive to other factors that already increase breast cancer risk – family history, lifestyle, reproductive history – or just a manifestation of that risk.  No current breast cancer risk model incorporates breast density.

At this point in time, mammography is the only breast cancer screening that has been shown to reduce breast cancer mortality. There is little evidence to support routine supplemental screening sonograms in women at average risk of breast cancer who have dense breasts.

In women at average risk for breast cancer with dense breasts, screening breast sonograms will detect less than 1 additional cancer per 1,000 women screened. In this group of women, supplemental sonography has not been shown to decrease breast cancer mortality and carries high rates of false positives. (Only 6% of biopsies will show cancer.)

In women at higher than average risk for breast cancer, sonograms in those with dense breasts pick up an additional 3.2 cancers per 1000 women screened.  How this may translate into reduce breast cancer mortality is not known. Women with a lifetime risk of breast cancer >20% are advised to consider breast MRI , which identifies an additional 8.5 cancers per 1000 women screened and has been shown to be cost effective in this population.

My take

Breast density notification laws, while well-intentioned, unnecessarily alarm women with normal mammograms by telling them they “may be at increased risk of breast cancer”.

A better approach would be to simply notify women that breast density may obscure masses that mammograms miss but sonograms may detect, albeit with higher rates of unnecessary biopsies and no proven efficacy in reducing breast cancer mortality in women at average risk for breast cancer.  Then let women make an informed choice about sonograms based on this information and their own risks.

One of the arguments made for screening sonograms  is that they allow for earlier diagnosis of masses that evade mammography, leading to less need for advanced treatments such as chemotherapy. Given that chemotherapy is now being targeted to tumor type and not just stage, this advantage of earlier stage diagnosis may not prove as large as some would hope.

The best approach to breast cancer screening at this time is to target it based on risk.

You can learn your breast cancer risk here.  Talk with your doctor about the benefits and harms of mammography, when to start screening, and how often to be screened. If your breasts are dense, and you are at increased risk for breast cancer, you  may consider additional screening with sonogram, although its benefits are not known. If your lifetime breast cancer risk is >20%, consider supplementing mammograms with breast MRI.

Age is one of the strongest risk factors for breast cancer, and it’s why mammograms are recommended every 1-2 years starting at 50 in all women, regardless of other risk factors.  Some groups, including the American College of Obstetricians & Gynecologists, recommend annual mammograms starting at age 40 for all women.  Others, including the US Preventive Services Task Force, recommend individualized screening schedules for women ages 40-49 based on risk and personal preference.   We’ve developed an online decision aid for women ages 40-49 that can help you and your doctor come to a screening decision that’s right for you.

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More info on mammograms and breast density

Breast Screening Decisions – A Mammogram Decision Aid

bsdsite2

I’m proud and excited to introduce you to Breast Screening Decisions, an online Mammogram Decision Aid designed to provide individualized, unbiased information that can help women ages 40-49 decide when to start and how often to have screening mammograms.

Breast Screening Decisions (BSD) was created in the wake of the 2009 US Preventive Services Task Force recommendations that every woman in her 40’s make an individual decision about when to start and how often to have mammograms. Not all medical groups agreed with the USPSTF recommendation, adding to the confusion many women feel about the mammogram decision and putting providers in the difficult position of having to steer each patient through the controversy to a decision that feels right for her.

Breast Screening Decisions is a support tool for shared mammogram decision making between women and their health care providers. Women ages 40-49 can access BSD online at their own convenience, then bring in the BSD summary to a preventive care visit, where an informed discussion can occur, leading to a decision about screening mammograms that both patient and her provider can feel good about.

Breast Screening Decision is not designed to influence mammogram decisions, but to inform and reduce anxiety around the decision-making process for both women and their providers. We want to help women make the decision that is right for them, whatever that decision may be.

Who Should Use Breast Screening Decisions?  

  • Breast Screening Decisions is for women ages 40-49. Women outside this age group should not use the site, as the data presented will not apply to them
  • Breast screening Decisions is for women at low to average risk of breast cancer. BSD starts with a breast cancer risk assessment – a series of questions to help women find out their own breast cancer risk. Women at higher than average breast cancer risk based on personal or family history are then advised NOT to use BSD, but instead to speak to their doctor about which breast cancer screening modalities are best for them – usually annual mammogram, but sometimes with the addition of sonogram or breast MRI.

A Tour of Breast Screening Decisions

Breast Screening Decision starts with a breast cancer risk assessment – a series of questions to help women find out their own breast cancer risk, which is then shown to her visually –

BSD YOUR RISK

The user then sees possible mammogram screening outcomes for women such as herself –

mammo bsd

including information about both the benefits as well as possible harms of screening mammogram. BSD also includes lots more info on breast cancer and mammograms that women can access through pop ups and link outs.

The heart of BSD is the option array – where BSD users can scroll through the various screening options available to them, using a a grid which displays the breast cancer mortality outcomes for each possible mammogram screening schedule – every year vs every other year or starting at age 40 vs  starting at age 50. (I love this page of the website…)

bsd mortality

The user then is shown a summary page of their breast cancer risk and possible outcomes –

bsd summaryBSD concludes with a series of questions to help women clarify their concerns and personal values around breast cancer screening.

bsd values

And finally, BSD users are given a summary to save or print out, and bring to their appointment with their health care provider.

bsd summary

An Invitation

If you are a woman ages 40-49 or her provider, we invite you to use Breast Screening Decisions, and hope it will prove to be a valuable resource in making individualized decisions about mammograms.

We welcome collaborators interested in studying the effectiveness and impact of BSD in clinical practice. If you’re interested in collaborating with us, please contact us – Margaret Polaneczky, MD (mpolanec@med.cornell.edu) or Elena Elkin, PhD (elkine@mskcc.org).

The BSD Back Story

It all started in December 2009 with a blog post I wrote explaining the United States Preventive Services Task Force Recommendations on Screening Mammograms. I was as confused as my patients were about the recommendation that the decision as to when to start and how often to have screening mammograms be an individualized one that takes into account a woman’s risk for breast cancer, as well as her personal values and concerns about breast cancer and mammography.

How the heck was I going to accomplish that in a 15 minute office visit, let alone be confident that the choice my patients made was indeed an informed one? My knee jerk response was just to ignore the recommendations and tell everyone to get an annual mammogram, regardless of who they were or what they may have wanted to do. I would certainly be supported in that tactic by my own ACOG, as well as the National Cancer Institute and of course the American College of Radiology.  Not to mention, it’s the fastest way to get off a controversial topic in the midst of busy office hours and the safest choice medio-legally.

But as I wrote that blog post and started to wrap my head around the facts about mammography as we know them today, I began to understand why some women might make a choice different that I would be recommending. In fact, I already had more than a few women in their 40’s ask me if they could skip their annual mammograms – healthy, low risk women, with no family history of breast or breast-linked cancers, some of whom had already had one or more false positive mammograms.  They wanted to back off the annual screening, and they wanted my support.  I stumbled through an office counseling session, doing what I could to confirm their low risk status, and we usually ended up compromising on an every other year schedule, while I remained worried that I was setting myself up for a lawsuit.

This was not going to work long term – not for me or for my patients. They deserved my support in making this choice, and I deserved some support in making sure their choice was an informed one, and in supporting them when they chose an option other than annual screening.

The blog post I wrote on the topic had received so much positive press (The Washington Post called it the “clearest assessment of the controversy you’re likely to find”) that I knew I was onto something. So I approached Al Mushlin, Chair of Public Health at Weill Medical College where I work, and told him I wanted to build a web-based mammogram decision aid. He hooked me up with Elena Elkin, brilliant outcomes researcher at Memorial Sloan Kettering and grant writer extraordinaire. We (well mostly Elena) wrote a grant and got funding from the Cornell CTSC. And together with our amazing research coordinators Paige Nobles and Val Pocus (both of whom unexpectedly turned out to also be web-savvy, graphically-minded visual artists), with input from Al and from experts in mammography and breast cancer, along with feedback from beta users in our target population, we build the first version of BSD (Thank you, Marwan Shouery) and piloted it with over 150 women and their providers at the primary care and Ob-Gyn practices at Weill Cornell Medical Center. We hope to publish the results of our pilot study soon, but suffice it to say that BSD was well received by women and providers alike.

For reasons related to firewalls and such (lessons learned), we had to rebuild BSD from scratch for public access (Thank you, Mohammad Mansour and colleagues), and that is the site we are releasing today.  Other than some new colors, prettier formatting and a new font or two, BSD is the same site as the one we researched. The research site will remain behind a very tight firewall for use in future research.

So now..

Almost four years, many many hours of collaborative work and thousands of dollars later, Breast Screening Decisions is finally live to the public.  

Just in time for the next USPSTF update on mammogram screening …

 

Dense Breasts on Mammogram – No Need to Be Afraid

Mammogram Fatty and Dense

Only in America can we find a way to scare the bejesus out of a woman with normal breasts and a normal mammogram. But that’s exactly what happened when NY Times reporter Roni Caryn Rabin read her normal mammogram results letter –

A sentence in the fourth paragraph grabbed me by the throat. “Your breast tissue is dense.”

I can’t really blame Rabin for being afraid. The information about breast density in her mammo letter was mandatory verbiage crafted by legislators as part of a law that all women be told if they have dense breasts on mammogram.

“Your mammogram shows that your breast tissue is dense. Dense breast tissue is very common and is not abnormal. However, dense breast tissue can make it harder to find cancer on a mammogram and may also be associated with an increased risk of breast cancer. This information about the result of your mammogram is given to you to raise your awareness. Use this information to talk to your doctor about your own risks for breast cancer. At that time, ask your doctor if more screening tests might be useful, based on your risk. A report of your results was sent to your physician.”

Raise awareness? More like raise the alarm. The information mandated by the law is just enough to scare any women who happens to have dense breasts, but not enough to help her understand what this really means.

If you’ve gotten a letter telling you your breasts are dense, don’t be afraid. Having dense breasts is entirely normal, especially if you are under age 60.  Here’s what you need to know –

What is Breast Density? 

Breast density is a radiologic assessment of how well x-rays pass through the breast tissue. It is a surrogate for how much of the breast is composed of glandular tissue and how much is fat. The radiologist reading the mammogram classifies the breast composition as one of the following –

  • Almost entirely fat (<25% glandular)
  • Scattered fibroglandular densities (25-50%)
  • Heterogeneously dense breast tissue (51-75% glandular)
  • Extremely dense (> 75% glandular)

Breast density is subjective.

Different radiologists may give the same mammogram different ratings. Use of computerized density measurement could alleviate inter-observer variability, but there is not yet a standardized computer rating system. For the purposes of the law, dense breasts are defined as those that are heterogeneously dense or extremely dense.

Breast density can vary across a woman’s menstrual cycle and over her lifetime.  

The same women being scanned at a different time of month or at a later year can land into a higher or lower breast density category, and may or may not get that extra statement in her mammogram letter. Recent research suggests that a single breast density reading may not be the best way to predict breast cancer risk, and that the risk may be confined to those women whose breast density does not decrease with age.

Dense breasts are extremely common, especially in younger women. 

According to a recent report of mammograms here in New York City, 74% of women in their 40s, 57% of women in their 50′s, 44% of women in their 60′s and 36% of women in their 70′s have dense breasts.

Increased breast density may be a risk factor for getting breast cancer. 

The mechanism is unknown, but it may be that breast density is just the end result of other factors that increase breast cell proliferation and activity – factors like genetics and postmenopausal hormone use.

How much of a risk? Well, it depends on what study you read and who you compare to whom. If you compare the two extremes of breast density in older women, those with extremely dense breasts have a three to five-fold higher cancer risk than those with mostly fatty breast. The risk is lower than that in those in the middle category of breast density and in younger women, though not well-defined.

The truth is, we really have no way to translate individual breast density into individual risk. Researchers are trying to see if breast density can be incorporated into current risks assessments such as the Gail Model, but at this point, breast density has not been shown to add much more than we already know about a woman’s risk from using these models.

The problem with breast density as a risk factor is that most women at some point in their lives have dense breasts. Should we really consider 75% of women in their 40’s to be at increased risk for breast cancer?

I don’t think so.

Dense breasts can obscure a cancer on mammogram.

This makes mammogram less reliable in women with dense breasts. Digital mammograms may be better at finding breast cancers in women with dense breasts who are also perimenopausal or < age 50, but it is not known if this translates into better outcomes. Additional testing with ultrasound and MRI can find cancers that mammograms miss in women with dense breasts. Unfortunately, breast ultrasound and MRI screening tests are less specific than mammograms – three times as many biopsies will be done, most of which will not be cancer.

Breast cancer patients with dense breasts are not at increased risk of death.

In a study of over 9,000 women with breast cancer, no association between increased density and death from cancer was found. In fact, it was obese women with lower breast density who had the higher risk of death, possibly because their fatty breasts may be a more favorable environment for tumor growth.

We do not know if additional breast cancer screening beyond mammograms saves lives.

Sonogram and/or MRI for breast cancer screening is currently not recommended based on breast density alone. Additional screening beyond mammography is only used in women at highest risk for breast cancer – those with cancer in a first degree relative with a high risk gene mutation, a family history suggesting one of these mutations, a Gail model or other combined lifetime breast cancer risk assessment >25% or a history of chest irradiation. Even in this group, declines in morality with the additional screening have not yet been shown, and the false positive rate of this additional testing is extremely high – only 20% of abnormals are cancer when biopsied.

There are no recommendations to use sonogram and MRI in otherwise low risk women, and none that have shown that using it based on breast density alone saves lives.

Additional screening beyond mammograms adds significant costs to breast cancer screening.

For some women, this additional cost may not be covered by insurance. While Connecticut has passed a law mandating that insurers cover additional sonograms, New York State has not.

What should you do if you’ve been told your breasts are dense on mammography? 

If you are at increased risk for breast cancer due to personal or family history, you may want to consider adding ultrasound or MRI screening.

Otherwise, at the point there is no recommendation that you do anything other than continue screening at whatever interval you and your doctor have decided is right for you. If you decide you want a sonogram, understand that you will need to accept the additional false positives and biopsies that may result and that the additional screening has not been shown to decrease deaths from breast cancer in women at average risk.

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More info on mammograms and breast density

Early Mammograms – New Study Misses the Mark

mammogram2A recent study has concluded that women with breast cancer who failed to get annual mammograms are more likely to die from their disease than those who had annual mammograms, and argues that more frequent mammograms are warranted in women under age 50. Unfortunately, despite all the media attention this study is getting, I don’t think the researcher’s conclusions are supported by the study results.

The researchers did a retrospective medical record review on deaths that occurred among breast cancer patients receiving care at Mass General or Brigham & Women’s Hospitals in Boston between 1990-1999 and followed until 2007. They call this a Failure Analysis.

Invasive breast cancer failure analysis defined 7301 patients between 1990 and 1999, with 1705 documented deaths from breast cancer (n = 609) or other causes (n = 905). Among 609 confirmed breast cancer deaths, 29% were among women who had been screened (19% screen-detected and 10% interval cancers), whereas 71% were among unscreened women, including > 2 years since last mammogram (6%), or never screened (65%). Overall, 29% of cancer deaths were screened, whereas 71% were unscreened. Median age at diagnosis of fatal cancers was 49 years; in deaths not from breast cancer, median age at diagnosis was 72 years

The authors concluded that because most deaths from breast cancer occur in un-screened women under age 50, initiation of regular mammograms before age 50 years should be encouraged.

Where this Failure Analysis Fails

Despite its strongly worded conclusions, the study raises more questions than it answers, and has a number of severe limitations.

  • The study fails to tell us what percent of women who did not die got annual vs not annual mammograms. This is akin to reporting that 80% of auto accident deaths occur among those who started their trip at home vs a public parking garage, without telling you what percentage of all car trips originate from home.
  • The study did not compare breast cancer treatments between women who died and those who did not die. The researchers just assumed that all women got standard of care at their medical center for their cancer. That’s a huge assumption to make without any proof.  It would have been actually quite easy to review a statistical sampling of charts to determine if this assumption was correct, but the researchers did not do this.
  • Women who don’t get regular mammograms may differ from those who do in other ways that increase the risk for death from breast cancer death, including low socioeconomic status, lack of health insurance, and distrust of medical treatments.
  • The researchers try to make the point that among those who died of their cancer, those who had not had mammograms prior to diagnosis had later stage cancers. Given that this analysis was confined to patients died of their cancer, I’m not sure stage at diagnosis mattered.
  • The entire analysis is conducted among women who died, either from breast cancer or from other causes. Since death from non-cancer causes is rare in women under age 50, breast cancer deaths will be over-represented in younger women in the sample. Older women not getting mammograms may be not getting screening because they are ill from other causes and are also more likely to die from these other causes during the follow up period, making breast cancer deaths less common in this group.  Who knows which way the data ultimately skewed as a result of these biases, but regardless, it is skewing every which way as far as I’m concerned. All of which muddies the conclusions.
  • The study was conducted at a Mass General and Brigham and Women’s Hospital using records from their breast cancer registry. Both these hospitals are referral centers likely to attract younger women with more aggressive cancers for treatment, who may not be representative of the general population of women presenting for mammogram screening or who are diagnosed with breast cancer. Indeed, the study population was over 90% white and of high socioeconomic status, pretty standard for a referral population if I ever saw one.

One thing that is evident is that breast cancers in younger women tend to be more aggressive than those in older women, an idea that would support more aggressive screening in younger women since each life saved carries more years of life saved. However, this is countermanded by the argument that breast cancer, despite being more aggressive, occurs much less frequently in younger than older women. Add in that mammograms are much better at detecting slower growing, less fatal breast cancers than the more aggressive cancers, and that screening is less effective in the denser breasts of younger women, and you have a sense of the screening conundrum we face for this cancer that claims so many women’s lives each year.

Unfortunately, this retrospective analysis is not going to solve the issue.

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Webb, M. L., Cady, B., Michaelson, J. S., Bush, D. M., Calvillo, K. Z., Kopans, D. B. and Smith, B. L. (2013), A failure analysis of invasive breast cancer. Cancer. doi: 10.1002/cncr.28199

More on mammograms –

The Truth About Mammograms

NYTImes cover

A  breast cancer survivor takes a long hard look at the myths and realities of mammography.

I used to believe that a mammogram saved my life.

Bottom line – Mammography is not perfect, and like all screening tests, has risks as well as benefits.  Mammograms lower breast cancer morality by 15%, but at a cost of over-diagnosis, and some believe, over treatment of cancers detected by screening that may never had caused death in the first place.  This is most evident in the increasing use of mastectomy to treat DCIS, a non-invasive form of breast cancer that is readily detected by mammography.

A must read for every woman considering having a mammogram.

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More on mammograms –

More on Mammogram Over-Diagnosis

Surgeon/scientist Orac has written a wonderful in-depth analysis of Bayer and Welch’s recent NEJM article on 30 years of mammography screening. I strongly recommend you read Orac’s post, entitled “Cracks  Spin vs Science on Mammography”,  if you are interested in exploring this topic further.

The post, like most of what Orac writes, is incredibly informative but very long (I thought I was verbose, but he beats me every time), so allow me to summarize the points I took home from reading it –

  • The NEJM study’s finding of over-diagnosis is in line with prior studies, strengthening it as a real possibility, but does not excluding the possibility that both studies have as yet unidentified biases that lead to the finding of over-diagnosis.

After reading this study, my first thought was: Here we go again. My second thought was: Wow. The result that one in three mammographically detected breast cancers might be overdiagnosed is eerily consistent with a study published three years ago that looked at mammography screening programs from locations as varied as the United Kingdom, Canada, Australia, Sweden, and Norway, which I discussed at the time it was released. The consistency could mean either convergence on a “true” estimate of overdiagnosis, or it might mean that both studies shared a bias, incorrect assumption, or methodological flaw. If they do, I couldn’t find it, but it’s still an intriguing similarity.

  • The study used SEER data, which is not perfect, and made some assumptions that could have over-estimated the rate of over-diagnosis, again not perfect and possibly over-estimating, but not eliminating, mammogram’s rate of over-diagnosis.
  • Using the rates of breast cancer in women under 40 as a surrogate for breast cancer mortality rates in un-screened women over age 40 may not be appropriate, as the biology of breast cancers in younger women is likely to be very different than those in women over 40. Unfortunately, there is not a better comparison group that could have been used instead.
  • The study ignores the possibility that stage creep could account for the lack of decline in later stage breast cancers of time. This is a phenomenon  in which previously so-called early cancers are more likely now to be classified as later stage due to better detection of tumor cells in axillary nodes using sentinal node biopsy. This is a concept of which I had not been aware.

One study suggested that the stage migration rate was as high as one in four; i.e., 40% of patients having “positive” axillary lymph nodes with SLN biopsy compared to 30% having positive nodes using axillary dissection. Another studyreported similar results. How this would affect Welch’s analysis is hard to tell, and correcting for it is probably not possible using the SEER database, particularly given that the extent of “up-staging” is not fully known yet. Be that as it may, an increase in the apparent incidence of patients with positive lymph nodes would increase the apparent incidence of advanced disease and decrease any decline in the incidence of advanced disease. How large this effect is, I don’t know, but it would suggest that the rate of over-diagnosis is lower than what Welch estimates. How much lower, or whether stage migration is even a significant factor, I don’t know, but I wish that Welch had at least mentioned it.

  • Could mammogram be victim of the so-called  “the decline effect”?

Basically, this is a term for a phenomenon in which initial results from experiments or studies of a scientific question are highly impressive, but, over time, become less so as the same investigators and other investigators try to replicate the results, usually as a means of building on them.

Orac also takes on the extremists on both sides of the issue – those that would use the study as fodder to paint mammograms as evil – or as he puts it,  “The cranks have had a chance to discover the study” – as well as those in the medical profession who refuse to accept any criticism of mammography – one actually calling it “malicious nonsense”.

…the Bleyer and Welch study is simply more evidence that the balance of risks and harms from mammography is far more complex than perhaps we have appreciated before. It’s very hard for people, even physicians, to accept that not all cancers need to be treated, and the simplicity of messaging needed to promote a public health initiative like mammography can sometimes lead advocacy groups astray from a strictly scientific standpoint.

It has weaknesses and might well overestimate the rate of overdiagnosis, but overdiagnosis is a real phenomenon….As I said, it’s hard for many physicians to accept that not all cancer necessarily needs treatment. Certainly this is likely to be true for ductal carcinoma in situ (DCIS), which consists of cancerous cells that have not yet invaded through the basement membrane of the ducts. Unfortunately, this is the predominant form of breast cancer that is detected by mammography.  Indeed, the authors even point out that their method didn’t allow them to disentangle the incidence of DCIS from that of invasive breast cancer, thanks to the way that the SEER database is setup. The problem, of course, is that we don’t know how to predict which cancers will progress and which cancers will not.

Finally, for all the confusion this study causes, there is one spot of good news, and that’s the observation that much of the decline in breast cancer mortality over the last 20 years—yes, contrary to what you might have heard, breast cancer mortality has actually been steadily decreasing—is likely due to improvements in treatment.

Finally, he reminds us that, for all its limitations, mammograms are not going anywhere anytime soon.

…right now reports of the death of mammography are very premature. To me, what is most important in breast cancer screening right now is to develop reliable predictive tests that tell us which mammographically detected breast cancers an be safely observed and which ones are likely to threaten women’s lives. We are currently at a point where imaging technology has outpaced our understanding of breast cancer biology, or, as Dr. Welch put it, “Our ability to detect things is far ahead of our wisdom of knowing what they really mean.” Until our understanding of biology catches up, the dilemma of overdiagnosis will continue to complicate decisions based on breast cancer screening.

Thanks, Orac. I always learn from reading your posts.

Increased Breast Density Does Not Increase Breast Cancer Mortality – One More Argument Against Mandatory Breast Density Laws.

On the heels on NY State’s Breast Density Notification Law, which mandates that women with dense breasts be told they may be at increased risk for breast cancer, comes the reassuring news that having increased breast density does NOT increase the risks of dying from breast cancer.

In order to determine if higher mammographic breast density is linked to a reduced survival in breast cancer patients, Gretchen L. Gierach, Ph.D., M.P.H., of the Division of Cancer Epidemiology and Genetics (DCEG) at the National Cancer Institute in Maryland, and colleagues looked at data from the U.S. Breast Cancer Surveillance Consortium and examined 9,232 women who were diagnosed with primary invasive breast carcinoma between 1996–2005 with an average follow-up of 6.6 years. The researchers studied the relationships between mammographic breast density and risk of death from breast cancer and all causes. Mammographic density was measured using the Breast Imaging Reporting and Data System (BI-RADS) density classification.

The researchers found that density does not influence the risk of death once the disease has developed. They write, “It is reassuring that elevated breast density, a prevalent and strong breast cancer risk factor, was not associated with risk of breast cancer death or death from any cause in this large, prospective study.”

Studies such as these are point out that the most important factor in breast cancer survival is the behavior of the the tumor itself, and not necessarily the risk factors that led to development of cancer in the first place. The analogy I like to use is that of traffic density and accident mortality. The chance of your being in a car accident is of course increased as population and number of drivers, automobiles and passengers in them increases. But your chance of dying in an individual car accident is related more to the circumstances of that accident – the drivers involved, the speed, the road conditions that day, etc – than to the fact that the accident occurred.

One more argument against mandatory breast density notification laws

Presuming that the woman in this study had their mammograms done long before any state passed a breast density law, this study further begs the question as to what benefit these laws will have for women, especially those under age 50, most of whom have dense breasts. (See my previous post on why these laws are misguided.)

At this point, breast density laws are simply legislation based on uncertain science advocated for by women desperate to eradicate breast cancer deaths and passed by legislators who refuse to accept the uncertain state of medical science.

In my opinion, it would be better to focus our legislative efforts on funding research in to the possible environmental causes of breast cancer, and on reducing the levels of known carcinogens in our environment.

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CBS News does a great job reporting on this issue

New York’s Breast Density Law – TMI with TLI for Too Many Women

MOST RECENT POST ON THIS ISSUE  Dense Breasts on Mammogram. No need to be Afraid.

Once again, legislators are meddling into healthcare. This time, it’s in my own home state, where Governor Cuomo has just signed a bill requiring radiologists to notify women when their normal mammogram also shows that they have dense breasts. In such cases, the following text must be included in the lay summary mammogram report given to the patient –

“Your mammogram shows that your breast tissue is dense. Dense breast tissue is very common and is not abnormal. However, dense breast tissue can make it harder to find cancer on a mammogram and may also be associated with an increased risk of breast cancer.

This information about the result of your mammogram is given to you to raise your awareness. Use this information to talk to your doctor about your own risks for breast cancer. At that time, ask your doctor if more screening tests might be useful, based on your risk. A report of your results was sent to your physician.”

New York is the fifth state to pass a mandatory breast density notification law. As of this writing, Connecticut, Virginia, California and Texas have similar laws.

What is Breast Density ? 

Breast density is a subjective radiologic assessment of how well x-rays pass through the breast tissue. It is a surrogate for how much of the breast is composed of glandular tissue and how much is fat. The radiologist reading the mammogram classifies the breast composition as one of the following  –

  1. Almost entirely fat (<25% glandular)
  2. Scattered fibroglandular densities (25-50%)
  3. Heterogeneously dense breast tissue (51-75% glandular)
  4. Extremely dense (> 75% glandular)

For the purposes of the law, dense breasts are defined as those that are heterogeneously dense or extremely dense.

Mammographically dense breasts are extremely common, especially in younger women. According to a recent report of mammograms here in New York City, 74% of women in their 40s, 57% of women in their 50’s, 44% of women in their 60’s and 36% of women in their 70’s had dense breasts.

What We Know (and Don’t Know) About Breast Density

Increased breast density can be a risk factor for breast cancer . 

The mechanism is unknown, but it may be that breast density is just the end result of other factors that increase breast cell proliferation and activity – factors like genetics and postmenopausal hormone use.

How much of a risk? Well, it depends on what study you read and who you compare to whom. If you compare the two extremes of breast density in older women, those with extremely dense breasts have a three to five-fold higher cancer risk than those with mostly fatty breast. The risk is lower than that in those in the middle category of breast density and in younger women, though not well-defined.

The truth is, we really have no way to translate individual breast density into individual risk. Researchers are trying to see if breast density can be incorporated into current risks assessments such as the Gail Model, but at this point, breast density has not been shown to add much more than we already know about a woman’s risk from using these models.

Dense breasts can obscure a cancer on mammogram.  

This makes mammogram less reliable in women with dense breasts. Digital mammograms may be better at finding breast cancers in women with dense breasts who are also peri-menopausal or < age 50, but it is not known if this translates into better outcomes.

Additional testing with ultrasound and MRI can find cancers that mammograms miss in women with dense breasts. Unfortunately, breast ultrasound and MRI screening tests are less specific than mammograms – three times as many biopsies will be done, most of which will not be cancer.

We do not know if additional screening beyond mammograms saves lives.

It might seem to makes sense that it would, but there are no randomized trials to show this. For now, this additional screening is only recommended in women at highest risk for breast cancer based on other factors such as genetic, family and personal health history.

Why the Breast Density Law is Misguided

Our legislators have women’s best interests at heart, but unfortunately, when it comes to the practice of medicine, they really don’t know what they are doing. Allow me to explain…

1.Most women under age 60 have dense breasts.  

Three quarters of New York women in their 40’s, all of whom have just had a normal mammogram, will now be told that they may be at increased risk for breast cancer.

2. Breast density measurement is subjective. Different radiologists may give the same mammogram different ratings. Use of computerized density measurement could alleviate inter-observer variability, but there is not yet a standardized computer rating system.

3. Breast density can vary across a woman’s menstrual cycle and over her own lifetime. The same women being scanned at a different time of month or at a later year can land into a higher or lower breast density category, and may or may not get that letter above. Recent research suggests that a single breast density reading may not be the best way to predict breast cancer risk, and that the risk may be confined to those women whose breast density does not decrease with age.

4. Sonogram and/or MRI for breast cancer screening is currently not recommended based on breast density alone. Additional screening beyond mammography is only used in women at highest risk for breast cancer  – those with cancer in a first degree relative with a high risk gene mutation, a family history suggesting one of these mutations, a Gail model or other combined lifetime breast cancer risk assessment >25% or a history of chest irradiation. Even in this group, declines in morality with the additional screening have not yet been shown, and the false positive rate of this additional testing is extremely high – only 20% of abnormals are cancer  when biopsied.

There are no recommendations to use sonogram and MRI in otherwise low risk women, and none that have shown that using it based on breast density alone saves lives.

5. Additional screening adds significant costs to breast cancer screening.  For some women, this additional cost may not be covered by insurance. While Connecticut has passed a law mandating that insurers cover additional sonograms, New York State has not.

6. The law is a medico-legal nightmare.  The legislators are creating a medical standard where there is none. That however, has never stopped the lawyers.

I would expect a lot more business for radiologists doing defensive breast ultrasounds ordered by referring docs who don’t want to get sued for a missed diagnosis by a woman with dense breasts. After the first breast density law passed in Connecticut, the use of ultrasound in that state skyrocketed.  (The American College of Radiology, by the way, urges caution on breast density legislation.)

I would also expect a lot more lawsuits for missed diagnosis aimed at the referring physicians whenever dense breasts are noted on a mammogram, even if that woman had no other risks factors for breast cancer.

7. The EMR Makes This Law Unnecessary. As EMR use expands, women will be able to read their actual radiology report online. Those who want to know their density will, and the rest will not be unnecessarily alarmed.

8. The law violates the free speech of physicians. This regulation did not originate from within the medical community or the department of health. It is a lay attempt to push screening beyond what the evidence supports at this point in time, and to set a medical standard (ultrasound for every woman with dense breasts) that does not exist.

At This Point, What Can be Done?  

Short of radiologists filing a lawsuit claiming free speech violation ? (Not a bad idea I think…)

We have 180 days before the law takes effect. In that interval, I would recommend that the New York State Health department come up with some educational materials on breast density that informs rather than frightens women. They could include information about breast cancer, mammograms in general, their limitations, benefits and harms. And tell women what to do and where to go if they feel a lump or have a breast symptom.  This additional material can be included with the report so that women actually get the information they need about breast cancer screening, rather than an unexpected scare when what they thought they had just gotten was a normal mammogram.

Hmmm, that’s actually not a bad idea…If someone wants to pass a law that Department of Health written breast cancer screening info be given out at the time of Mammography, I’d get behind it in a second.

But telling the majority of women in their 40’s who have just had a normal mammogram that they may be at increased risk for breast cancer? That’s just wrong.

Mammograms Decline in 40-49 year Old Age Group

Since the US Preventive Service Task Force published revised guidelines recommending individualized screening schedules rather than routine annual mammograms for low to average risk women in their 40’s, the number of mammograms being done in this age group has declined.

In the year after the guidelines were published, nearly 54,000 fewer mammograms were performed on women ages 40 to 49. That represented a 5.72 percent decrease from the previous period. The authors said that the modest reductions probably reflected some public resistance to the new recommendations, in part because of conflicting guidelines from other groups that urge more frequent routine screenings.

I’m not surprised.

The study reflects what I’ve been seeing in my own practice – women in their 40’s asking “Do I really need this test?”  and “Can I wait till I am 50?”. In most cases, after confirming that a patient is not an increased risk of having concerning symptoms or exam findings, we end up compromising on an every other year schedule. This seems to be something both they and I can feel comfortable with in light of the newness of the recommendations and the current medical legal climate in the United States.  The few who have chosen to wait till 50 tend to be those who come from Europe (where mammgrams are done later than in the US) and those with prior experience, either personal or familial, of harms from mammograms.

Mammograms – Reality Check

A well-written and balanced article on mammography from USA Today may help move the conversation about this screening test away from hype and a bit closer to reality. The title – “Mammogram is ‘terribly imperfect’, though recommended.”

For women in their 40s, mammograms reduce the risk of dying from breast cancer by about 15%… But mammograms miss some cancers and raise false alarms about others, causing women to go through unnecessary follow-up tests… “We’re saying, ‘Mammography is a terribly imperfect test, but we’re recommending women get it,'” Brawley says. “The task force was saying, ‘Mammography is a terribly imperfect test, and women have to make a decision about whether to get it in their 40s.'”

I encourage all women to read and share this article.

What I love about the article is how clearly written, non-inflammatory and concise it is, proving that the mainstream media can get it right when it comes to health information. The article also includes a fabulous summary graph that is simple to interpret and very clearly conveys just what it is mammograms can and cannot do when it comes to preventing deaths from breast cancer.
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More reading on mammograms from TBTAM and elsewhere

CNN Does a Nice Job Covering the Aftermath of the Mammogram Controversy

Kudos to CNN’s Lisa O’Neil Hill for a well-balanced and thoughtful article on the mammogram controversy. Absent from the article is hyperbole and stridency that make the medical community sound like a bunch of cats and dogs. Instead of “Them’s fightin’ words” soundbites, O’Neil Hill gives a well-written summary of all the major viewpoints on the issue.  She took the time to understand everyone’s point of view, and chose quotes that illustrate the fact that this is not a fight, but an intelligent discussion about how to maximize the benefits and diminish the harms of a less than perfect screening test for breast cancer.

“The initial recommendation from the task force caused a great deal of confusion, which was unfortunate because what I think they were trying to say is, I think, something very reasonable. The way they said it and the way it came out was very unreasonable,” said Dr. Otis W. Brawley, chief medical officer of the American Cancer Society.

“What the task force was trying to say is mammography is an imperfect screening tool and there are some harms associated with it, but there are also some benefits associated with it,” he said. “They were trying to say the benefits are not nearly as good as we would all like.”

Moyer said Brawley is on target.

“In many, many instances, our recommendation has been interpreted as a ‘don’t do it.’ That is incorrect,” she said. “It’s something that needs to be discussed on an individual basis. For some women, it will be consistent with their values to choose to have a mammogram between 40 and 50. For other women, they will choose not to, and those are both reasonable decisions.”

I strongly encourage you to read and share the article.

The Annual Mammogram – It’s What Women Want, But Is it For the Right Reasons?

Most women in their 40’s believe they should have annual mammograms, regardless of what screening regimen their doctor might recommend.

So say researchers in Massachusetts who surveyed women (primarily white, highly educated) ages 39-49 presenting for annual checkups. They gave the women a fact sheet about the new USPSTF guidelines on mammogram screening in their age group, and asked them to read one of two articles either supporting or opposing the guidelines. The researchers then asked women about their beliefs, concerns and attitudes about breast cancer and mammogram screening. Here’s what they found –

  • Women overwhelmingly want annual mammograms – Close to 90% of women surveyed felt they should have annual mammograms, regardless of what their doctor might recommend.
  • Women overestimate breast cancer risks – Eighty eight percent overestimated their lifetime risk for the disease, with the average estimate being 37%. (The correct lifetime risk for breast cancer is 12%). This is consistent with previous research on breast cancer beliefs.
  • The media may not influence women’s opinions about screening guidelines – No matter which article they read, close to 90% felt that that the (USPSTF) guideline changes were unsafe and 84% would not be comfortable delaying screening mammograms even if their doctor recommended it.
  • Friends and Family are a strong influence. Seventy six percent of women reported having a close friend or family member who had been diagnosed with breast cancer. Secondary analysis showed that 92% of those with a close friend or family member with breast cancer vs 77% of those without a close friend or family member with breast cancer felt women should continue to undergo routine mammography in their 40’s despite the new USPSTF guidelines.
  • The experience of false positive mammograms only reinforces women’s faith in mammogram screening. Ninety two percent of those with a prior false positive mammogram expressed discomfort with the USPSTF guidelines vs 79% of those who had not had a false positive mammogram.

This finding suggests that these patients were more likely to view the additional imaging and biopsies as a near miss rather than a false alarm. This is an important finding because it is in direct contrast to the conclusions drawn by the USPSTF, which cited psychological harm from false-positive results as one of the major risks of screening mammography in the fifth decade. Our findings are consistent with other research showing that women are very tolerant of false alarms if they perceive the issue being addressed as significant.

Breast cancer awareness or breast cancer misinformation?

Previous studies have shown that women not only over-estimate their personal risk for getting breast cancer, but also inflate their 10-year chances of dying from breast cancer by over 20-fold. They also wildly overestimate the efficacy of mammograms in lowering breast cancer mortality, believing it to be almost 100 times as effective as it actually is in reducing breast cancer deaths.

Who can blame women for believing they are at higher risks for breast cancer than they actually are? After all, breast cancer awareness campaigns have been among the most successful outreach programs ever created, with the pink ribbon being used at this point to market everything from jewelry to Kitchen Aid mixers. Whether these campaigns have actually had any impact in reducing deaths due to breast cancer remains a point of some debate, and there are those who credit the declines in breast cancer mortality more to new treatments than to increased uptake of mammography screening.

Have we lost women’s trust? 

With the disagreement among doctors about guidelines, the miscommunication of recommendations by the very folks writing the guidelines and the resulting confusion in the media attempting to report these guidelines, it’s no wonder women don’t trust their doctor’s recommendations and have made their own decisions about screening.

At this point, it’s probably easier to just write the mammo referrals once a year and move on. After all, the American College of Obs-Gyn agrees that women should be offered annual screening. And my medical-legal risks align nicely as well, since failure to diagnose breast cancer is one of the biggest reasons gynecologists get sued.

But it that the right thing to do?

Call me crazy, but I happen to think that an informed screening choice is still the best one.

I’m not giving up yet. My patients want to make their own decisions about mammograms, and that’s just fine with me. But I’m going to do my best to be sure that decision is not just a gut response to an inflated sense of risks, but a careful decision informed by risks as well as benefits of screening and realistic expectations about what mammograms can and can’t do to lower breast cancer mortality.

To that end, here are some great resources for getting better informed about breast cancer screening –

  • National Cancer Institute  mammogram information. NCI recommends having mammograms every 1-2 years starting at age 40
  • ACOG pamphlet on mammography – ACOG recommends that women be offered annual mammograms starting at age 40.
  • American Cancer Society information on breast cancer screening – ACS recommends having annual mammograms starting at age 40.
  • USPSTF guidelines on mammogram screening – USPSTF recommends having mammograms every 2 years from ages 50-74. The decision to start biennial screening in women under age 50 should be individualized.
  • Breast Cancer Coalition -31 myths and truths about breast cancer

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Davidson AS, Liao X, Magee BD. Attitudes of women in their forties toward the 2009 USPSTF mammogram guidelines: a randomized trial on the effects of media exposure. Am J Obstet Gynecol 2011;205:30.e1-7.