by Julie Goodale

Last month’s announcement of changes in mammography recommendations by the U.S. Preventive Services Task Force started an uproar. The task force suggested that mammograms should begin at 50, rather than age 40, and should only be done every other year. The report also recommended against doctors teaching women do Breast Self Exams.

 The USPS task force analyzed data from several US and international studies. They included only studies that used one strategy for all age groups. Studies with “mixed” strategies were excluded (such as yearly mammograms for younger women and every two years for women over 50). They judged that “mixed strategies are very difficult to communicate to consumers”.1.

 The task force did not find that there is no benefit to beginning mammograms at age 40. On the contrary, they say that, “if the goal of a screening program is to efficiently maximize the number of life-years gained, then the preferred strategy would be to screen biennially starting at age 40 years”.2. One to two breast cancer deaths would be averted annually per 1000 women screened if screening begins at age 40, compared with 50. 3 However, the task force concluded that, although benefit does exist from mammograms starting at age 40, that benefit is not worth the cost of additional screening, potential unnecessary biopsies, over-treatment, and the anxiety caused.

 This unleashed a firestorm. Disapproval of the findings was fast and furious. I, along with thousands of women across the country, raised our voices online, in our newspapers, in coffee houses and churches, to say, “I am the 1 in 1000, and my life is not an insignificant statistic!”

 Because this is such a personal issue for me, I took some time to gain a little perspective before writing about these recommendations for GalTime.com. I prepared a survivor’s view on the recommendations in which, surprisingly, I found some very real and valid arguments raised about the limitations of mammography – I just disagreed with the conclusions of the panel.

 But before my article could be posted, the fast pace of the health care debate overtook me. On December 2nd, the US Senate agreed to accept an amendment proposed by Senator David Vitter (R-La) to health care legislation that would prevent the new United States Preventive Services Task Force recommendations from restricting mammograms for women. And on December 3rd, an amendment by Senator Barbara Mikulski (D-Md) was introduced, which would, among other things, require insurance companies to cover mammograms that are determined to be necessary by physicians.

 These two amendments would take away the specter of younger women being denied screening that may save their lives. I am pleased that the fight is on to protect women’s rights to appropriate screenings. I just hope that this does not signal the end to the discussion.

 As discussed in the report, there has been growing concern over false positive or inconclusive mammogram results that can lead to anxiety and unnecessary follow-up procedures. Related to this is worry about potential over-treatment of non-invasive cancers that might never become a serious health threat. Many non-invasive, or in situ, cancers never progress to invasive cancer. In recent years, there has been much discussion of whether we are over-treating women with DCIS (ductal carcinoma in situ), putting them through difficult surgeries and treatments for a disease that would never threaten their lives.

 These are real concerns. Dollars spent on tests or treatments that are not necessary mean there are fewer dollars available for other medical concerns. Over-treatment is a serious issue. Cancer treatments are harsh; no one wants to undergo them unnecessarily.

 The anxiety caused is also real. I do not underestimate the anxiety of undergoing uncomfortable tests and dealing with scary biopsies. However, any cancer survivor with a later-stage diagnosis can assure you that the anxiety of a biopsy is nothing compared with the anxiety of facing long, difficult cancer treatments because the cancer has already spread.

 Bottom line: Mammograms are an imperfect tool. They are currently the best tool we have for detecting breast cancer, but they are not without flaws. They do sometimes detect abnormalities in the breast tissue that are harmless. Determining which abnormalities are cancer requires further tests, and being called back in for follow-up scans or biopsies causes understandable anxiety. Also, mammograms are less effective for younger women whose breast tissue may be quite dense.  Because of this, younger women tend to have more suspicious readings, which lead to more procedures.

 Once cancer is diagnosed, it can be hard to know what to do. It may be a cancer that, left alone, would never progress and threaten the woman’s life. But then again, it may be a cancer like mine – one that's very aggressive and spreads rapidly. The problem is, there is no way yet to tell.

 The report should signal a call to action. And that call to action should not be silenced whether or not our right to screening is protected. If there are limitations to mammograms, give us better tools for detection! Give us better tools to determine which cancers need to be aggressively treated! Give us better tools!

1. Mandelblatt J, Cronin K, Baily S, et al. Efects of Mammography Screening Under Defferent Screening Schedules: Model Estimates of Potential Benefits and Harms. Ann Intern Med. 2009; 151:738-747, p.745.

2. Ibid, p. 743.

3. Ibid, p.741.

Julie Goodale was diagnosed with breast cancer at age 37. She had a mastectomy and reconstruction.  Because of the high number of positive lymph nodes, she had chemo, radiation, and then more chemo. Always an avid hiker and rock climber, she discovered that exercising actually improved how she felt and helped manage the side effects of her treatment.

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