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Making Sense of the Mammography Debate

On November 16, 2009, the U.S. Preventive Services Task Force published new recommendations calling for reducing the use of mammography to screen for breast cancer. Since these differed from the existing recommendations of organizations, including The American Cancer Society and the American Medical Association, many women found these guidelines to be unsettling.

Fox Chase experts and others have been quick to note that mammography remains the best baseline screening tool currently available to detect breast cancer in early stages and to prevent mortality. The Secretary of Health and Human Services released a statement on November 18 assuring women that the government is not changing its guidelines at this point.

Following are the key recommendations from the report, published in the Annals of Internal Medicine:

  • The task force recommends against routine mammography screening for women under the age of 50 and over the age of 74
  • The panel advises against teaching breast self-exam
  • The group also suggests changing the screening interval for women ages 50-74 from once a year to every other year

(Above) Breast cancer specialist, Mary B. Daly, MD, PhD, FACP, explains the recommended guidelines for breast cancer screening mammography.

Director of mammography, Kathryn Evers, MD, also shares her thoughts on the mammography debate in the news. See the video here

Answers from Breast Cancer Specialists

Here, three Fox Chase Cancer Center breast cancer specialists answer some commonly asked questions to put the Task Force's guidelines into perspective. The specialists:

Mary B. Daly, MD, PhD, FACP,
Chair of the Department of Clinical Genetics

Kathryn Evers, MD, Director of Mammography

Lori J. Goldstein, MD, Director of the Breast Evaluation Center

Is mammography still the most effective and accurate tool for diagnosing breast cancer? While not perfect, mammography is the best screening tool for breast cancer that we have. The updated systematic review confirms that routine screening mammography decreases mortality from breast cancer at all age groups studied. The percent decrease in mortality rates is approximately 15 percent for all age groups studied. In addition to saving lives, mammography can identify breast cancer at an earlier stage, when less intense and invasive treatments can be offered.

Are there risks associated with diagnostic tests? The risks associated with screening mammography include additional breast imaging studies, the potential need for breast biopsies, and the anxiety associated with having to undergo additional tests. Most women have not found these risks to be a deterrent to having routine screening mammograms.

Are younger women (age 40 - 49) at risk for more aggressive disease? Although breast cancer is more common at older ages, women who develop breast cancer below the age of 50 years are more likely to have more aggressive disease and a higher mortality rate. This is particularly true for African American women who have the highest mortality rates from breast cancer in the 40-49 year age range.

What type of mammography equipment was used in the studies? The studies included in the systematic review are based on film screen mammography. Current practice in the US now uses digital mammography, which has been shown to be more sensitive for younger women and women with dense breasts. Therefore, it is likely that screening women in the 40-49 year age group with digital mammography will prove to be even more beneficial than the previous film screening.

Does breast self exam actually help detect cancer? The recommendation not to encourage women to perform breast self exam (BSE) is based on a study done in Shanghai, China, where cultural differences may play a role in women's desire to do BSE. No comparable prospective studies of the efficacy of BSE have been performed in the US. Both BSE and clinical breast exam (CBE) offer a low cost compliment to screening mammography.

Do the false positives picked up by mammography result in overtreatment? The concern about "overdiagnosis" of breast cancer refers to the potential to diagnose and treat a breast cancer that if, left alone, may not have caused symptoms or death from breast cancer. Currently there is no test which will tell us which breast cancers would have such a benign course, so the possibility of overdiagnosis cannot be used as a legitimate reason to withhold screening mammography.

In the studies (based on theoretic modeling rather than actual randomized clinical trials), the possibility of overdiagnosis was thought to be mainly confined to elderly women with other more immediate life threatening health problems.

Can our healthcare system afford to pay for additional screening and diagnostic tests? We do not feel that the savings incurred by reducing the number of mammograms performed each year justifies the additional morbidity and mortality from breast cancer that will occur if these recommendations are adopted.

What about women at high risk of breast cancer? Women with risk factors which put them at a higher risk for breast cancer should discuss additional screening options with their physicians.

For more information about breast cancer treatment and prevention at Fox Chase Cancer Center or to make an appointment, call 1-888-FOX CHASE (1-888-369-2427). The breast cancer scheduling department can be reached at 215-728-3001.