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Discusses Women's Health

Before I address the debate about when to start, how often to get, and when to stop mammograms, I want to emphasize that mammography screening saves lives. As many of you read or heard on the news, the United States Preventative Task Force (USPTF), an independent board of physicians and experts appointed by the Department of Human Health Services, just issued new mammogram guidelines. They were published in the last issue of the Annals of Internal Medicine. (The journal also had four editorials and seven articles on the subject.) Basically, the panel continued their recommendation that women with average risk of
breast cancer should start screening at age 50, be tested every other year, and that after age 74 screening could be stopped.The recommendations that included “late start” screening caused a huge brouhaha when first announced in 2009.

Before I continue with the advice and subsequent comments I want to review “average risk”…This means that there is no significant family history of breast or ovarian cancer, no smoking, no obesity, no previous breast biopsies that demonstrated excess activity of breast tissue, no excess alcohol consumption and no use of hormone therapy. There are a lot of women who do not fall in a low risk category.

This time, the task force probably recognized that there could be problems with insurance reimbursement if their recommendations were to become the holy grail of breast cancer screening. So in the updated version they emphasize the fact that they’re not advising against screening for women under 44 or over 74 or against screening every year as opposed to every other year. They state that women should choose when and how often to be screened after they have been appropriately counseled. Counseling should include informing them about rates of false positive findings that mandate more extensive possibly expensive exams and even unnecessary biopsies. The task force relied in part on the study of 405,191 women who had digital mammograms from 2003 to 2011. Positives findings (i.e:something that seemed abnormal) were common, especially in younger women. Among those 40 to 49 who had regular screenings, for every 1000 women tested 121.2 had a false positive. But for every 10,000 women repeatedly screened the task force found that over 10 years, 4 lives are saved in women 40 to 49; eight in women 50 to 59; 21 in women 60 to 69; and 13 in women 78 to 74. Because the benefits of screening increase with age they felt that screening could be started at a later age.

Now here is where the confusion comes, and then I’ll add my two cents or two dollars (whichever you think it’s worth). The National Comprehensive Cancer Network, made up of multiple cancer centers, recommends mammograms every year starting at age 40. The American College of Obstetricians and Gynecologists (of which I am a fellow) recommends mammograms every year (or two) from ages 40 to 49 and every year after that. In October the American Cancer Society changed their recommendations from once a year starting at age 40 to a later start (age 45) and then continuing yearly through age 54. They recommend screening be done thereafter every other year.

When I council my patients I suggest they start screening at the age of 40. I agree that there may be more false positives in this younger group of women, but if breast cancer does develop in women in this age group it is often aggressive and I would hope not to miss it because of a two year delay in screening. And, like ACOG, I suggest my patients continue yearly especially if there is any risk. Statistically the older we get the higher our risk for breast cancer. There is not much data for women over 75, but if a patient is in good health and does not have other conditions that will limit her life span and health span for the next five years I feel that mammogram screening is appropriate.

Most of my patients will agree that missing a curable cancer is worse than the anxiety of dealing with a false positive. Actually, if after a work-up for a suspicious mammogram we find that there is no malignancy, most feel that congratulations are coming…

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