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Should You Get A Mammogram?

A recent mammogram study in the New England Journal of Medicine was so controversial that the authors (Drs. Welch and Bleyer) decided to make a YouTube video to defend and explain their conclusions. Now that’s a first, isn’t it? Well kudos to the study authors for their creative approach to getting ahead of a controversy. However, their video (created for the “general public”) is still a bit too technical in my opinion. I’d like to take a crack at distilling it further.

A question on most women’s minds (as they turn 40 and beyond) is whether or not they should get a screening mammogram (x-ray of the breasts). If you have found a lump in your breast or you have a family history of breast cancer the answer is yes. No need to read any further. However, for the majority of us lumpless, family-history-free women, a screening mammogram is far more likely to expose us to unnecessary follow up testing than it is to catch a tumor early.  Dr. Welch explains that screening mammograms aren’t very good at identifying aggressive breast cancer early enough to make a difference in whether one lives or dies anyway. That’s very disappointing news.

Dr. Welch goes on to explain that most of the gains we’ve made in breast cancer survival have been because of improved breast cancer treatments, not because of early detection with mammograms. He estimates that every year in the U.S. 1.3 million women are “over-diagnosed” with breast cancer because of screening mammograms, subjecting women to unnecessary biopsies, surgical procedures, and further follow up studies. In the video, Dr. Welch doesn’t explain exactly what these “over diagnosed” cancers end up being exactly (Cysts? Benign calcifications? Early non-aggressive cancers that the immune system kills on its own?) But suffice it to say that they don’t contribute to the cancer death rates.

So, given the fact that you are more likely to suffer through a false alarm than to discover a cancer early (and even if you do find it early, if it’s the “bad” kind you may not survive) are you willing to undergo a screening mammogram? That’s a personal question that we each have to answer for ourselves. As time goes on, however, I suspect that the answer will be made for us since health insurance companies (whether public or private) will begin to balk at paying for tests that do more harm than good overall. I think this issue is really at the heart of the controversy (the perception of rolling back a health benefit that women currently “enjoy”). Eventually screening mammograms may become an out-of-pocket expense for women who simply prefer the peace of mind that a normal test can give – even at the risk of going through a false alarm.

That being said, it sure would be great if we could find a screening test that identifies breast cancer early – especially the aggressive kind. Perhaps a blood test will do the trick one day? At least it is comforting to know that we have made great strides on the treatment side, so that fewer women than ever before die of breast cancer. More research is needed on both the screening and treatment sides of course.

As for me, I do regular breast self exams – though because I have no family history of breast cancer I’ve opted out of screening mammograms because I feel the cost/benefit ratio is not in my favor. I certainly hope that a better screening test is developed before I face a potential diagnosis. I respect that other women will disagree with me – and I think they have the right to be screened with the only option we currently have: the mammogram. I’m not sure how long it will continue to be covered by insurance, but at a price point of about $100, most of us could still afford to pay for it out-of-pocket if desired.

The bottom line of this controversial research study is that screening mammograms don’t actually catch death-causing breast cancers early enough to alter their course. Even though it makes intuitive sense to be screened, long term observations confirm that overall, mammograms do more harm than good. So now we wait for a better test – while some of us continue with the old one (as the National Cancer Institute recommends), and others (like me) don’t bother.

***

Thanks to ePatient Dave and Susannah Fox who brought the issue to my attention on Facebook. Isn’t social media grand?


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5 Responses to “Should You Get A Mammogram?”

  1. Carolyn Thomas says:

    Great job providing a clear overview of this complicated issue, Dr. Val. I am one of countless women (would be interesting to find out just how many of us are out there!) who underwent a disfiguring quadrant resection procedure on my right breast following the results of a mammogram that showed a ‘suspicious mass’. When the ‘all clear’ biopsy results came back, I was so relieved. There are few things more terrifying for women than the prospect of breast cancer – at the time, I never for one moment even considered that I’d undergone needless surgery. I just figured I’d somehow dodged a bullet, thanks to my miracle-working docs.

    For surgeons, there is no downside in doing unnecessary surgery based on mammogram results. If you find something serious, you are a hero. If you don’t, you have a patient who’s been out of her mind with worry who can now be reassured that it wasn’t cancer after all.

  2. John Lynch says:

    Congratulations on a well-reasoned and nicely presented analysis of an always controversial subject. There are literally millions of breast cancer “survivors” who attribute their survival to their mammogram when they’d likely still be alive if they’d never had one.

    My concern is with the “peace of mind” those receiving negative findings of no cancer enjoy. This can often be false peace of mind, and not simply because of the false negatives (not finding cancer that’s there) that plague every imaging test. There’s also the reality that, after breathing a sigh of relief that no cancer was found, many women resume dangerous, cancer-promoting behaviors thinking they’re free-and-clear of cancer risk until their next mammogram.

    Of course, an aggressive cancer could take hold a week after a negative mammogram and kill that woman before her next mammogram would even be scheduled, underlining the haphazard nature of such screenings. But more likely is that many women will resume negative diet and lifestyle behaviors that promote cancers of all types – adding or failing to reduce excess body fat, over-indulging in alcohol, smoking, or failing to get regular and (for breast cancer prevention) fairly intense exercise.

    A negative mammogram finding may inadvertently enable such counter-productive behaviors. If so, this could be a far bigger downside than the unnecessary over-treatment and anxiety that also ensue.

  3. @Carolyn Ugh – I’m so sorry to hear about your unnecessary surgery. How awful! A very large number of women have shared your fate, no doubt. More than we previously suspected. And @John you make an excellent point about false reassurance. A normal mammogram doesn’t prove you don’t have cancer – or that you won’t develop the aggressive kind the very next week. Thank you both for your comments. ;-)

  4. Alice says:

    I am another who is coming to the end of the diagnostic nightmare because of some “questionable areas” on my super-high resolution 3-D mammo. I, too, underwent numerous procedures, scans (u/s; mammo, MRI) needle-core biopsy, and ultimately a lumpectomy in 2 areas of my breast. Because of complications in my healing from surgery, I needed more surgery, and now at 10 weeks into this process am still in severe pain, albeit with (finally) a benign diagnosis. By the way, I am a survivor of a different rare cancer; I’ve been through it all with good reason. These past few months, however, have been lost for no good reason to the vagaries of a couple of tiny questionable areas. I think I’ll skip my mammo next year.

  5. Yikes, @Alice! I’m so sorry to hear about your story. I can see why you’d want to be extra diligent as a survivor of another cancer already… but having those surgeries was the last thing you needed added to your stressful life. I bet there are many other women out there (as many as 1.3 Million of them!) who were sent on a wild goose chase thanks to a mammogram. So sad.

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