Mammogram recommendations

Posted by in Uncategorized on Apr 22, 2014

There are so many conflicting recommendations out there right now, it is hard to know what to do. I get a lot of questions about this and thought I’d review what information there is out there.
The most conservative recommendations out there are those from the American Cancer Society (2012) and the American College of Obstetrics and Gynecology
Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health
Clinical breast exam (CBE) about every 3 years for women in their 20s and 30s and every year for women 40 and over
Women should know how their breasts normally look and feel and report any breast change promptly to their health care provider. “Breast awareness” is encouraged at all ages. The idea is that younger women should be aware of what is normal for their breasts at any given point in their menstrual cycle, but rigorous monthly breast self exam (BSE) is not necessary.

Smith RA, et al. Cancer screening in the United States, 2012: A review of current American Cancer Society guidelines and current issues in cancer screening. CA: A Cancer Journal for Clinicians. 2012;62:129.

U.S. Preventive Services Task Force recommendations as of 2013
Routine screening of average-risk women should begin at age 50, (instead of age 40).
Routine screening should end at age 74.
Women should get screening mammograms every two years instead of every year.
Breast self-exams have little value, based on findings from several large studies.

Screening for breast cancer. Rockville, Md.: U.S. Preventive Services Task Force.

Then there was a huge and very significant study from the British Medical Journal in late 2013. This study followed over 89,000 women aged 40-59 for 25 years who had been randomized to yearly mammograms or no mammograms and routine care. in which researchers compared breast cancer incidence and mortality for upto 25 years in women 40-59. It was a massive randomized control study (the most rigorous design) and the results are disturbing. Mammogram screening had no effect on mortality among the women who were found to have breast cancer and 22% of women were over diagnosed, ie the cancer that was found would never have become clinically important in that woman’s lifetime if left untreated. This study has cause a lot of upset. It concludes that in countries with advanced treatment modalities, mammogram does not seem to make any difference in mortality despite earlier detection.
So, what are we to do with all of this conflicting information? I think about this a lot, not just as a physician caring for patients, but for myself (I am 49 years old) and for the women in my family. The days of me being able to provide a clear and concrete set of guidelines are gone. Each of us will need to make our own decision based on a personal cost benefit analysis on the issue of breast cancer screening. As with most medical decisions we make, it all comes down to what we fear most mixed in with family history. If you are a woman with a strong family history, of course yearly screening is appropriate. If you are one of the majority of women with no significant family history of breast cancer, the decisions are more nebulous. If your biggest fear is cancer then you are likely to opt for the more frequent screening schedules. If your fear is over intervention and potentially unnecessary treatment, you will go the other direction. I suspect most of us will tread the middle ground. So far I have had three mammograms in my forties….not quite as many as ACOG and ACS recommend, but more than USPFTF suggests. The new study from BMJ will probably make me err on the side of less than yearly mammograms as I enter my 50’s but I’m not sure I’m totally willing to give them up. As the evidence mounts, however, I may change my mind. Bottom line, there is no right answer here, and there may never be. Every woman will make a decision on this that takes into account a wide array of facts and fears unique to her.