Mammography Guidelines Revisited

 In 2009 the US Preventive Services Task Force made new recommendations about the use of mammography for general breast cancer screening. This government panel that seeks to set standards for preventative medicine and screenings. Their shift, both raising the age at which they recommend women begin getting screen mammograms and reducing the frequency, was met with fierce resistance in the community. Even Medicare announced that they would not follow the new guidelines, still covering the cost for annual screenings. The USPSTF is taking the matter up again and we should anticipate either new guidelines or more information for the basis of the current ones.

It is critical to note that these guidelines do not and never did pertain women at high risk, but rather are for women whose primary risk factor is being a woman. For others, it is critical to discuss the frequency and type of screening with your doctor.

Earlier this week, the American Cancer Society came out with their own recommendations which seem to strike somewhere in the between the old, annual screening guidelines beginning at age 40 and the new annual screening recommendation between 45-55, then biannual screenings after that. And so we are again abuzz with the concerns.

My recommendation, since I’m frequently asked: talk to your doctor!

But why the change?

Many people I’ve spoken to believe that this is the new managed care – less care. Others think it’s the “death panels” of the Affordable Care Act emerging. Personally, I think it’s neither – I think it’s a growing body of scientific evidence informing health care decision-making. For my money, I’d rather seen us follow the science.

Underlying the mammography debate is a critical question:
What difference does mammography actually make?
Is there more cancer? The more we look, the more cancer we find. Screenings at earlier ages combined with the technological capacity to identify ever-smaller evidence of cancer leads to more diagnoses. But that doesn’t mean we’re seeing more cancer – it means we’re detecting more cancer, especially more DCIS or “pre-cancer.”

How do we intervene? Knowing what to do with raw data can be a challenge, especially in the case of Stage 0 cancers. The truth is, we’re still learning how to advise them – the pendulum is swinging between the aggressive bilateral mastectomy for pre-cancer to “watchful waiting” to see if it beings to grow or spread.

When it comes to later stage cancers detected on mammography, here tend toward thinking more is better – aggressive surgeries and chemos, and radiation exposure that could cause other cancers later in life. Thirteen years ago, when I was first diagnosed, I was exactly there – let’s do “everything possible” to stop this from getting any worse. Famous last words…

What does the cell say? It is becoming increasingly clear that it is cell-biology, the inherent nature of the cell, that drives the progression of disease. If the cell has the capacity to migrate and can withstand dormancy until is it opportunistically “reawakened” you are at risk of metastatic spread. While a large tumor of Stage III cancer found in the breast might not ever metastasize, Stage 0 cells could have migrated elsewhere before it is even identifiable in the breast, sitting undetected. These answers will make a significant difference in how we treat cancers

Does it matter? Stage at diagnosis is but a small piece of the picture, and there is mounting evidence that it may not at all be the most important factor in spread. Beneath all of this lurks a modern “truism” that may not be true at all: that early detection saves lives. We’ve come to take this for granted, and for good reason. We want to believe that if we are vigilant we will be lucky.

Personally, I think the new guidelines are a compromise which seeks to identify the generally more aggressive cancers found in younger women, while being pragmatic about the slow-growing cancers that are typically found post-menopause. Further, we are coming into a fuller understanding of the very serious risks of over-treatment, recognizing that the risks and compromises made of treating cancer too aggressively is it’s own, legitimate concern. But there is no question that we need a fuller, better understanding of what mammography can and cannot do, accepting it’s limitations and shedding the myth that more – more screening, more surgery, more chemo, more radiation – is better.

Want to know more? I recommend Dr. Susan Love’s recent post on what mammograms do and don’t tell us.

2 Comments (+add yours?)

  1. tbtamMargaret Polaneczky, MD
    Oct 22, 2015 @ 19:05:41

    Came her via Diana Attai’s twitter feed. Great post, acknowledges the conundrum we face trying to find the aggressive cancers while minimizing the risks of overtreatment.

    We’ve developed a decision aid from women ages 40-49 at average risk of breast cancer to help them decide when to start and how often to have mammograms- it includes an individualized breast cancer risk assessment as well as a section fro women to clarify their values and concerns around screening.

    Thanks again for a great post.


  2. Trackback: American Cancer Society Screening Mammography Guidelines

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