First Alert

Basic questions about timing of mammograms trigger impassioned debate

December 29, 2008|By Kelly Brewington | Kelly Brewington,kelly.brewington@baltsun.com

Two-time breast cancer survivor Lillie Shockney knows mammograms save lives.

Her patients at Johns Hopkins Hospital heed her advice when she implores that screening can detect the disease early enough to fight it. And women all over the world e-mail her anxious questions about how to protect themselves from cancer at all costs.

When should they begin having breast X-rays and how often? Are mammograms sufficient or should they demand sophisticated MRI scans? What about their daughters - how soon should they have mammograms?

Shockney, who was 38 at her first diagnosis and 40 at her second, is an advocate for breast cancer survivors who has written several books on the subject. Women, she urges, should begin annual mammograms at age 40.

The American Cancer Society and the American College of Radiology recommend the same. But the advice is not widely accepted.

Last year, the nation's largest medical specialty organization challenged that standard. The American College of Physicians, which represents 126,000 internists, said breast X-rays should not be recommended for all women in their 40s. Instead, doctors and their patients should consider a woman's breast cancer risk and weigh the benefits of screening with such harms as false positives, radiation exposure and unnecessary biopsies.

Shockney dismisses the recommendation. At a time when breast cancer diagnoses are growing in younger women, such advice could discourage early detection and lose lives, she said.

"I have seen three women today with breast cancer. They are all in their 40s," said Shockney, the administrative director of the Johns Hopkins Avon Foundation Breast Cancer Center, on a recent afternoon. "What message does that send people?"

For years, medical experts have questioned the benefits of mammography for women in their 40s. In fact, in 2002, an article in the British journal The Lancet said the benefits of mammogram at any age are unclear, setting off an intense debate on the topic.

Even so, U.S. experts generally agree on most aspects of mammography. Women with breast cancer in their family or with genetic mutations that keep them at higher risk should be screened early. Mammograms are beneficial for women older than 50. And breast cancer is tougher to detect in younger women.

Women younger than 50 tend to have more dense breast tissue, making it difficult for mammograms to find tumors. As a result, they are more likely to have a false positive, which can lead to biopsies or surgery, not to mention the mental anguish of believing one has cancer, said the American College of Physicians.

Women in their 40s who have annual screens have a 30 percent chance of having a false-positive mammogram at some point over a decade and about a 7 percent to 8 percent chance of having a biopsy within the same period, according to the American College of Radiology.

The American College of Physicians, which based its recommendation on a review of nearly 120 articles, found that the benefits of mammograms are not the same for all women. One analysis found screening might reduce the cancer death rate for women in their 40s by 15 percent. Meanwhile, for women in their 50s, that reduction is 22 percent.

"I don't think you can determine that screening is the best decision without looking at a woman's risk factors and concerns," said Dr. Amir Qaseem, senior medical associate with the American College of Physicians. "Clinicians should inform women of the benefits and harms. Most importantly, women should be a part of making this decision."

Others note the disease can be especially deadly for women in their 40s. Breast cancer strikes about 200,000 women every year in the United States, killing some 40,000. The death rate has declined since the 1990s and experts maintain early detection through mammograms is a leading reason for the decrease.

Some doctors say they are concerned that not enough women are getting mammograms. Recent studies show a slight increase in the number of women who are waiting longer to have a first mammogram, skipping years and avoiding them entirely. About half of all women in their 40s have regular screens, according to the American Cancer Society. And rates tend to be lowest among low-income women, who are also more likely to have their cancers diagnosed at an advanced stage.

In the Baltimore region, primary care doctors say they spend more time urging women to seek mammograms rather than reconsider them.

"The data say in the 40s mammogram are not as good for the risk. In an ideal world that may be true," said Dr. Marc Leavey, internist at St. Joseph Medical Center in Towson. "But you are presuming that every woman does a thorough monthly self-examination. You are presuming every woman gets a mammogram every year or every other year. About half of women don't get one to begin with."

False positives, while frustrating and scary, are no comparison to false negatives, he said.

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