Debate Over Mammograms
Breast cancer screening is a hot topic indeed. Whether you’re at work, the grocery store, the gym or your doctor’s office, the discussion is happening in our community and in communities across the country — and for good reason. Breast cancer is a very common disease. One in eight women will be diagnosed with breast cancer. In 2018, more than 266,000 women will be diagnosed with breast cancer. About 40,000 women will die from breast cancer in the U.S. this year. Despite these statistics, breast cancer is a disease that, especially if caught early, is very treatable. In fact, the five-year survival rate is almost 90 percent. That is, out of 100 women diagnosed with breast cancer, 90 of them will live at least five years — a prognosis that is far better than for other cancers. For example, the five-year survival rate for lung cancer is only 18 percent. So, why are the survival statistics for breast cancer so good? There are two reasons. First, doctors are very good at treating breast cancer. Advances in surgical techniques, radiation therapy and chemotherapy have resulted in highly effective therapies that are well tolerated by patients. Second, thanks to mammograms, doctors can detect cancers years before a woman would have a symptom such as a breast lump. Early detection plays a critical role in breast cancer care. Why the debate, then? Well, since breast cancer impacts so many lives, there are multiple different types of doctors who contribute to breast cancer screening and treatment. In addition to cancer doctors (oncologists) and surgeons, there are family practitioners, internists, radiologists and of course obstetricians and gynecologists. There are national societies that guide the practices of these medical specialties by issuing recommendations on topics such as breast cancer screening. The American Cancer Society and the U.S. Preventive Services Task Force publish screening recommendations for breast cancer and other cancers. It would be wonderful if there were a single, unified screening recommendation that could be applied to all women. Unfortunately, these professional societies’ guidelines do not always agree on important issues like the age at which a woman should get her first mammogram and how often she should get mammograms thereafter. This can lead to confusion both among patients and their doctors. As a radiologist, I too have societies in my specialty that issue screening guidelines. Both the American College of Radiology and the Society of Breast Imaging recommend that a woman of average risk for breast cancer should get a mammogram every year, starting at age 40. An average-risk woman doesn’t have a history of breast cancer herself, a family history of breast cancer or a genetic mutation that increases risk of breast cancer, and she has not had radiation treatment to the chest before age 30. These recommendations are from leading radiologists in the field who, like me, make their livings reading mammograms and other types of imaging studies. So, it may not be a surprise that these societies are pro-screening. However, it has been shown that annual screening beginning at age 40 saves the most lives and years of life for women. A mammogram is an excellent screening test, and it’s only getting better. The advent of digital breast tomosynthesis, also known as 3D mammography, has allowed doctors to detect cancers even earlier than conventional mammograms. But no screening test is perfect. It is possible to miss a cancer on a mammogram, and mammograms can detect breast lumps and calcifications that are not cancerous but require a biopsy to prove they are benign. There is a small dose of radiation from a mammogram, though the total dose is much less than a CT scan. It’s never too early to discuss breast cancer screening with your doctor. The discussion should include your family history of breast cancer, especially in immediate family members such as a parent, sibling or child. This information can impact the age you should start getting screenings and how often they should be performed. And of course, call your doctor if you have a breast lump, a lump under the arm, skin changes in your breast, nipple discharge, breast pain or any other concern regarding your breast health. JOHN FARRELL, MD, is a Geisinger radiologist.