Women, Breast Cancer and Diagnostic Mammograms

The Controversy

Controversy continues to surround the optimal time for women to get their initial screening mammogram,  Diagnostic mammograms (unlike screening mammograms) can be started at any age since they are used to “diagnose” palpable masses (lumps) or other abnormal masses or lesions discovered on an exam.  But true screening mammograms (in the absence of a visible or noticeable lump) continue to pose a particular dilemma.

When should women start getting mammograms?

The Reccomendation of Screening Mammograms

The United States Preventive Task Force (USPTS) recommends starting screening mammograms at age 50 while the American Cancer Society and some other organizations still recommend starting annual screening mammograms at age 45.

As a layperson, you might think the sooner the better, but, in fact, early screening mammograms may reveal lesions that, after further investigations (up to and including biopsy), are found to be false positives.

A false positive is when the screening mammogram shows an abnormal area that looks like cancer but turns out to be normal. False-positive test results are troublesome because of the added worry to the patient and the unnecessary costs. According to the USPTF, screenings that are done earlier than age 50 only result in rampant overdiagnosis, which may be from 14.7 to 25 percent of all screen-detected lesions.

Organizations such as the American Cancer Society that earlier annual screening mammograms, contend that earlier diagnosis does justify earlier screening and that women should have the right to request screening mammograms as early as 40.

Earlier diagnosis increases survival

Despite false positives (and the additional worry, side effects, and cost of additional tests), earlier diagnoses do increase survival for certain women with certain types of breast cancers, but not all.  The goal of screening, of course, is to save lives. The theory is that the earlier the diagnosis, the earlier the stage and the better the treatment options and survival. 

Unfortunately, other factors such as insurance status further complicate the issue of outcomes.  Women with private insurance demonstrate significantly higher five-year survival rates than women who are either uninsured or have Medicaid. Those issues mostly revolve around social determinants related to poverty, low education, and low social status.

Further complicating the question and the outcomes are the fact that breast cancer occurs in a host of variants related to cell type, hormone sensitivity, and other traits associated with their genetic map.

Genomics is bringing hope

Genetic mapping of breast cancers (genomics) has proven to be a boon to scientists and oncologists. Formerly, most breast cancers were treated in a similar way (with variations of surgical resection, radiation, and chemotherapy, depending on the type of cancer). With genomics, it has become possible to identify breast tumors that only require tumorectomy and no other complementary therapies.

Results for such tumors remain excellent and spare women from a needless expense and side effects. Genomics also helps identify tumors that will respond better to specific chemotherapy, which can be tailored more specifically to the type of tumor. Some tumors do not represent a clinical threat at all and can be safely observed.  

While breast cancer survival has improved over time, it remains a deadly foe, killing 40,000 U.S. women a year. Sadly, it can also sometimes recur 10, 15, or 20 years after an apparent cure, a demoralizing fact for patients and doctors alike.

Screening, treatment, and prognostic indicators do, however, continue to evolve. We now have breast CAT scans, 3-dimensional mammography, stereotactic biopsies, and genomics. But while scientific progress will surely to occur, we must also address the social determinants of poverty, poor education and low social status that have proven just as tenacious as breast cancer itself and just as deadly.

Whatever age you and your doctor decide to start screening, be sure, and get your mammogram. 

by David J. Holcombe, M.D., M.S.A., Regional Medical Director, Region 6 (Alexandria Region)

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