It was hard to avoid hearing about the recent national debate regarding the timing of screening mammography. The brouhaha was in response to the very unpopular 2009 guidelines of the U.S. Preventive Task Force (USPTF), which recommended that women between the ages of 40 and 50 not obtain routine, annual screening mammograms and that women between ages 50 and 60 obtain screening mammograms every other year instead of annually. After meeting tremendous resistance, the USPTF later withdrew its controversial guidelines, replacing them with the recommendation that women ask their doctor about the appropriate timing of screening mammography. Unfortunately, the end result of the controversy was that most doctors were as bewildered as their patients regarding when and how often a woman should obtain screening mammograms.
Having rejected the USPTF’s original and revised guidelines, the American Cancer Society restored sanity to the discussion by reaffirming its original recommendations that average risk women begin obtaining screening mammograms at age 40 and continue yearly for as long as they have reasonable life expectancy. The guidelines are supported by a long list of professional medical societies and women’s advocacy groups as well as national health care law—the Affordable Care Act—which prohibits health plans from using the USPTF guidelines to deny access to annual mammography.
The mammogram controversy was driven in part by an ongoing national discussion about the potential over-diagnosis and over-treatment of breast cancers. While I do agree that many breast cancers diagnosed today are “indolent” cancers, meaning that they possess little ability to spread or cause death, especially among elderly women who are more likely to die of others causes, not all breast cancers are indolent cancers, and even indolent cancers may grow and become life threatening if given sufficient time to do so.
We must also acknowledge that premenopausal women, particularly those younger than 50, are more likely to develop aggressive cancers that grow and spread more rapidly and greatly increase the risk of breast-cancer related deaths. By the time these cancers are found by physical examination, most have already spread to and beyond the lymph glands. Given such high stakes, why would the USPTF reduce the opportunity for early detection by discouraging annual mammograms for women under 50 years of age?
There has been tremendous progress over the last decade in adapting breast cancer treatment to the behavior of the cancer. Women with aggressive cancers may be treated with surgery, radiotherapy, chemotherapy, and possibly anti-estrogen therapy, whereas those with less aggressive cancers may be managed with less invasive treatments. For example, in my practice, women with less aggressive cancers can be treated with less extensive breast and lymph node surgery, may receive intraoperative radiotherapy (radiation treatment given entirely during surgery) instead of the standard 6 week course of daily radiotherapy after surgery, and very soon may be offered tumor freezing instead of surgery and radiotherapy.
Presently, it is not possible to reliably predict which women will develop an indolent or aggressive breast cancer. That information is only revealed when a cancer has been detected and biopsied. Therefore, it is imperative that we continue to encourage annual screening mammography. We must preserve the opportunity for finding aggressive cancers early before they have had a chance to reach the point where they require the most intensive treatments.
I firmly believe that the practice of medicine should be headed in the direction of persistent screening, early diagnosis, and more individualized, patient-centered treatments that are appropriate for the behavior for the cancer, patient age, and to a certain degree, the personal wishes of the patient.
Besides skin cancer, breast cancer is the number one cancer in women and second only to lung cancer as a cause of cancer-related deaths. Annual mammography for the average risk woman, and even more intensive screening (see previous blog) for higher risk women, will go a long way to improving not only the lifespan but also the quality of life of women diagnosed with breast cancer.
Now that you know when to start obtaining mammograms, please join me in the next blog for a discussion of breast density and its impact on breast cancer detection.