It’s October, the month that pink starts appearing everywhere including such incongruous places as NFL games. Yes, this means it’s breast cancer awareness month. I don’t know about you, but I’m pretty aware of breast cancer, without all the pink.
Of course I’m aware; I’m a breast cancer survivor. But I bet you’re aware too, without a personal history and all the pink.
What is awareness anyway?
Awareness highlights our risk of breast cancer and reminds us to get a mammogram. I have mixed feelings about mammograms. I had a 4.7 cm tumor, and my mammogram was read as normal dense breasts. But even before the less than stellar detection rate of my personal mammogram, I had mixed feelings about them. It turns out that despite all the pink promotion, mammograms have limitations.
You may remember that in 2009 and (again in 2015) the US Preventative Services Task Force (USPSTF), after reviewing all the available evidence released new and different guidelines on when to start and how often to obtain a mammogram. You also may remember the controversy surrounding these new guidelines.
According to the USPSTF, the benefits of routine, screening mammography for women aged 40-49 is unclear. Thus they could not recommend regular screening for women in this age range. Instead, they advise obtaining a mammogram for women in their 40s should be a personal decision depending on individual risks and preferences. You should be counseled regarding both the potential for harm and the ability to improve outcomes. Then decide for yourself. You are still at risk for breast cancer; but, a screening mammogram may not improve your outcome, and there is potential for harm.
For women ages 50-74 they recommend biennial (every other year) mammography. These guidelines are similar to the World Health Organization’s guidelines which are followed by most other countries around the world.
Before 2009 most US-based organizations like the American Cancer Society (ACS) and the American College of Obstetricians and Gynecologists (ACOG), recommended screening mammograms starting at age 40. All of these institutions ignored the USPSTF in 2009 and continued to support screening mammograms beginning at age 40.
All women, regardless of age, are at risk of breast cancer.
Women in their 40s and older than 75 are still at risk of breast cancer, so are women in their 20s and 30s. The incidence of breast cancer correlates directly with age. The older you are, the higher your risk. Women in their 40s and younger are at risk but much less so than older women.
For all screening tests, including mammography, the lower the incidence of the disease in question the less benefit the screening test provides. Additionally, breast tissue in premenopausal women is denser and harder to interpret further lowering the utility of mammography in this age group.
But perhaps the most significant problem with mammography is overdiagnosis and overtreatment. A notable number of lesions detected by mammography would never end up being clinically significant. Yet women end up getting treated like they have breast cancer. And let me tell you the treatment isn’t pleasant. Surgery, chemotherapy, and radiation have left a permanent mark on my body and my life.
It is these limitations that are reflected in the USPSTF guidelines. Since 2015, when the USPSTF reaffirmed their guidelines, more organizations and individual physicians are taking a closer look and at least considering this schedule. ACOG just recently changed their guidelines from recommending annual mammograms starting at age 40 to offering mammograms after consultation.
Conflicting opinions still exist.
The American Cancer Society updated their recommendations in 2015 as well. The ACS now recommends annual mammography from ages 45-54. At age 55 you can choose to continue with annual screening or go to every other year. Women should continue to be screened as long as you are in good health, meaning you have at least ten years of life expectancy. Screening between the ages of 40-44 is a personal decision.
Having a breast cancer detected by mammography does not mean that the mammogram saved your life. Most breast cancers are slow growing; you will do just as well if you find a lump on your own. It is only with aggressive breast cancers, sometimes known as triple negatives (because they lack hormone receptors or the growth factor receptor her2) that mammography and early detection make a difference.
Triple negative cancers are present in relatively small numbers, about 15 percent of diagnosed breast cancers. They are more common in younger women, African Americans, and women with the genetic predisposition, BRCA1 and 2. The incidence is low and the risks non-specific, yet everyone ends up getting screened.
When you break down the numbers for women in their 40s, 2000 women need to be screened for ten years to save one life. For that one life, at least 20 women will have to undergo unnecessary, life-altering breast cancer treatment and 1200 will have a false positive, need additional imaging and possibly a painful, invasive procedure.
If yours is that one life saved, clearly a mammogram is worth it.
But if you are one of those 20 who is getting miserable, life-altering treatment pointlessly, then not so much. Yes, mammograms do save even for women in their 40s. Not as many as you may have thought and for a price of the women who receive unnecessary treatment.
This fascinating study, published in the New England Journal of Medicine in November 2012, looks at the effect of mammography on breast cancer incidence. Figure 1A is especially telling. It presents the incidence of disease diagnosed at an early stage vs. late stage from 1976 through 2008.
Screening mammography began in the early 1980s. At that time, after the initiation of regular mammography, the incidence of early-stage disease explodes, more than doubling, while the amount of late-stage disease stays virtually the same. It has gone down slightly. According to their numbers, late-stage disease has decreased by a total of 8 cases/100,000 women. Late-stage disease is what kills you.
If mammography were a genuinely effective screening test, the enormous increase in early-stage disease would be reflected in a concomitant decrease in late-stage disease. Not the case.
Interestingly, the article points out that as treatment improves, screening becomes less useful. Breast cancer treatment has improved significantly. Treatment options are changing, evolving, and bettering on a monthly basis.
Oncologists and radiologists continue to support more frequent mammography. I can’t help but think that they are biased with a clear financial interest in more imaging and more treatment.
Again mammograms do save lives and those numbers add up.
But at what cost?
Finding the balance between the harms from unnecessary treatment and saving lives is hard to pinpoint. As with many things in medicine it is becoming more and more personalized. If you want to do everything you can to prevent dying from breast cancer even if that means undergoing unnecessary treatment than you should get more frequent mammograms.
If you do not want to receive surgery, chemotherapy, and radiation needlessly and are willing to accept a small, possibly very small, risk of dying from breast cancer than less frequent mammograms is probably best for you.
As I mentioned before, screening tests provide more benefit to those at higher risk. So consider your personal risk. Age is a risk as is family history, but there are more. A history of prior breast biopsies, dense breasts, older age at first pregnancy, obesity and sedentary lifestyle are also risks as are some types of hormone therapy use and alcohol intake. Look here for a more comprehensive list of risk factors.
The Gail model is a personal risk assessment tool. It includes various factors to help assess your risk although it is certainly not comprehensive, nevertheless it can give you some idea. My risk at the time of my diagnosis was 1.1% I had a 1.1% risk of developing cancer in the next five years. Sometimes you’re in the 1%. Not the 1% I want to be in.
When to start and how often to get a mammogram is ultimately your choice. I want that choice to be informed. Breast cancer, partly because of all the pink washed awareness campaigns, is a highly charged, emotional issue. It is so prevalent; everyone is affected in some way, either through personal history or that of a friend or family member. It’s scary, for sure.
Screening can be valuable, but prevention is even more so.
While you can’t change your family history, you can help to prevent breast cancer by reducing some of the other risks. In general, a healthy lifestyle which includes a diet of real food prepared at home, regular vigorous activity, maintaining a normal weight and getting 7-8 hours of sleep at night will reduce your risk.
Alcohol consumption is, unfortunately, another risk so limiting alcohol intake will also reduce your risk.
Finding cancer in its early stages can help, but preventing it from happening in the first place helps even more.
How do you feel about mammograms? When did you start? How often do you go? Are you more concerned about dying from breast cancer or receiving unnecessary treatment? Let me know in the comments.
I have a daily wellness checklist that I use to maintain my healthy habits, every day and hopefully prevent a recurrence. Click here for a copy.