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Paging Dr. Frischer - Mammograms
WRITTEN BY :   Dr. Alan Frischer

You are a woman who is over the age of 40, and your doctor recommends a routine mammogram. What do you do? Are mammograms helpful? Can they harm you in some way? And, why didn’t one catch the cancer that ultimately killed your aunt? Let’s explore.
One in eight women will be diagnosed with breast cancer at some point in her life, making breast cancer the most frequently diagnosed cancer among women. The American Cancer Society currently recommends that women over the age of 40 have an annual mammogram. The guidelines from the United States Preventive Services Task Force, however, suggest that women not be routinely screened in their 40s, but that they discuss the pros and cons of the test with their physician. Their new government guidelines suggest that women should get routine mammograms far less frequently: every other year between the ages of 50 and 75.
In fact, neither of these recommendations actually happens in the real world. In 2005, only 72% of women between ages 50 and 74 had received a mammogram within the past two years. The reasons varied, with the biggest one being limited access to doctors, followed by lack of healthcare coverage, the presence of co-pays, indirect costs such as transportation and lost wages, and most interestingly, myths, misconceptions, misinformation, and fear and distrust of the test. Advocates of the new and less frequent screening guidelines argue that women should be aware of the very real harm and limitations of mammography. The main argument against mammography is that cancer is over-diagnosed, leading to over-treatment.
Indeed, no test is perfect at finding everyone who may have a particular disease (the statistical term for this is “sensitivity”). If that were the case, then every woman who had breast cancer would have a positive mammogram result. Estimates of actual mammography sensitivity range from 75 to 90% (100% sensitivity would mean that every case of cancer was correctly found). Nor is every test perfect in showing that everyone who does not have a disease comes out negative (the statistical term for this is “specificity”). Estimates of actual mammography specificity range from 90% to 95% (correctly not finding cancer where none exists). If specificity were equal to 100%, then every woman who did not have breast cancer would have a negative mammogram.
In reality, many women who have mammograms are told to come back for follow-up mammograms, ultrasounds and even MRIs. In the end, they may be told that everything is OK. Others end up with biopsies that turn out fine. In addition, some women actually have breast cancer, but after all the additional tests and even biopsies, are still told that they are fine. Unfortunately, the cancer eventually makes itself apparent.
So, given the missed diagnoses, over-diagnoses and extra tests, biopsies, costs, etc, are mammograms worth it? Now that cutting health care costs is such a high priority, this question is being examined more vigorously. One study out of England concluded that women are not being properly informed of the harms of mammography. They claim that of 2,000 women screened regularly for 10 years, one will benefit and avoid dying from breast cancer, while 10 healthy women will be diagnosed with the disease, have part or all of their breasts removed, and may go through radiation and chemotherapy treatments. Another 200 women will receive false alarms and experience psychological stress until they eventually learn that they do not have breast cancer.
It is a reality that a patient’s experience will depend on where the test is being done, by the quality of the machine, the skill of the radiologist, and even more, on the aggressiveness of the surgeons and invasive radiologists who choose how to interpret and act on results. In our local community, we are blessed with high quality radiologists and surgeons.
Some woman are at heightened risk for breast cancer, including those who have a first-degree relative who has been diagnosed with the disease, a history of breast or other gynecological cancer, early menses, late menopause, no children or a late start on having children, and a host of other less significant factors. These women should have annual mammograms regardless of age.
Overall, however, data indicates that mammography is most valuable for those aged 50 – 69. For women under age 50 and over age 69, the data is still conflicting as to the benefit of routine mammograms.
My recommendations:
•Get the newer digital mammograms if possible.
•Don’t panic if there is a callback. This happens frequently and means that the radiologist is being cautious.
•Make sure that the mammography facility uses experienced radiologists, who read a lot of mammograms.
•Make an effort to frequent the same facility, so that previous films will be available for comparison.
•Get your mammograms routinely. Your personal physician can keep you up to date when recommendations change.
I wish you all the best of health!

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Published: May 28, 2010 – Volume 9 – Issue 6



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