When? Where? How often? What about Black women, who are not only more susceptible to developing breast cancer at earlier ages, but are also at a higher risk of having malignant tumors misdiagnosed…or diagnosed much later?
Especially if you’re a woman, you’ve probably been told to prepare for your first screening mammogram around the time of your 40th birthday and then to have one every year (in some cases, every other year) after that. Note: that’s just for routine mammograms; breast lumps always require a mammogram and/or other tests to start diagnosing whether it might be breast cancer.
The U.S. Preventive Services Task Force Controversy
But in November 2009, the U.S. Preventive Services Task Force (USPSTF) updated its screening recommendations and said that women of average risk for breast cancer could wait until age 50 to start getting mammograms and then follow up only every two years, rather than annually. The revised USPTF mammography screening guidelines marked a sea change
from the recommendations being made by nearly all major medical
associations, including the American Cancer Society, the American
Medical Association, and the American College of Obstetrics and
These new guidelines set off a heated debate within the medical community and don’t match up with most other mammogram recommendations from major medical organizations.
“We’re having the scientific arguments back and forth and in the meantime, women, in a sense, get caught in the middle,” says Len Lichtenfeld, MD, deputy chief medical officer of the American Cancer Society.
It was widely reported, however, that the USPSTF was against screening entirely for women with an average risk of breast cancer between the ages of 40 to 49. That wasn’t the case, says Diana Petitti, MD, professor of biomedical informatics at Arizona State University and vice chair of the 2009 USPSTF committee.
The actual recommendation was not communicated well, according to Petitti. “The decision about the age to start being screened at 40, 42, 44, 48, should be one that was more individualized,” she says, rather than a woman’s 40th birthday triggering an automatic authorization slip from her doctor to get a mammogram.
The Trouble With Statistics
The argument over when women should start breast cancer screening stems from a disagreement about the process the task force used to reach its conclusions. It relied on a sophisticated computer model rather than real-life, clinical, randomized studies to determine how many breast cancers are caught and treated in women ages 40-49.
Lichtenfeld says that the conclusions reached by multiple institutions using the same model were different. “So the reliability of that model to make a clinical decision, particularly when we have data from actual studies, we felt was not quite ready for prime time,” he says. “The task force did acknowledge at the time that mammography did reduce deaths for women between ages 40-49, Lichtenfeld says. “However, we said then, and I think it’s fair to repeat today, that the task force didn’t feel enough lives were saved for women in that age group, because breast cancer is more common as you get older.”
The American Cancer Society, Lichtenfeld says, disagrees and continues to recommend routine screening mammograms for women age 40 and older.
Is Too Much Testing A Bad Thing?
One of the central issues upon which the USPSTF based its recommendations had to do with the harm that can come from mammography testing: psychological harm, unnecessary imaging tests and biopsies, and false-positive mammogram results in which the patient is told there could be cancer, when in fact none exists. False-positive results are more common for women aged 40 to 49 than for older women.
“They were saying they felt the risk of harm of having extra procedures outweighed the benefit from saving lives, ” Lichtenfeld says of the Task Force’s reasoning to delay mammography.
The fact is that as women age, false positive mammography results decline. That’s mainly because the density of a woman’s breasts tends to decrease with age, making it easier to find cancer. But experts say that women understand mammography has limitations and still want to be screened for breast cancer.
“Most of the women you talk to would much rather go through that process and find something early than wait, ” Evans says. “No one likes to have a false positive about anything, but it’s part of what has to be done to find breast cancer early.”
Both Evans and Lichtenfeld say annual screenings, rather than biannual, are especially important for women in their 40s because cancer tends to grow faster and more aggressively in younger women. Lichtenfeld takes issue with the task force’s analysis because it only looks at the number of women that need to be screened in order to save a life, but not the number of years of life saved, he says. “If you find breast cancer in a young woman and save her life, she has more years of life ahead of her. Had they used that analysis, the [task force] may have come to a different conclusion,” he says.
The federal health reform law put mammograms on its list of preventive services, which mandate that insurance plans cover the test each year with no cost-sharing. The task force’s 2002 recommendations, which state that women should begin mammography at age 40 on an annual basis, were used by the government in writing the law.
Medical experts express concern that at some point these new recommendations will be adopted, threatening women’s ability to access and pay for annual breast cancer screening in their 40s. However, there is no indication that the government plans to stop requiring insurers to fully cover the cost of mammograms for women in this age group.
So What Should You Do?
At this point, the task force’s recommendations are in contrast with the majority of other major medical associations. Most of those groups recommend women begin getting routine screening mammograms at age 35 to 40 and to do so every year. Since African American women tend to have a higher breast cancer mortality rate, many experts agree that:
• All women should conduct consistent, monthly self-exams seven to ten days after the start of the menstrual cycle. For post-menopausal women, select one day of the month and consistently conduct a self-exam on that day.
• Women with no family history of breast cancer should have a baseline mammogram screening at 35, then regular mammogram screenings every year after 40.
• Women with a family history of breast cancer should have a baseline mammogram 10 years before youngest member diagnosed with breast cancer.
• African American women under the age of 40 with a palpable breast mass should insist on getting evaluated with a mammogram or ultrasound. Seek out a breast specialist if necessary.