Mercy physician argues for mammograms

Expert advice

March 04, 2010

New recommendations about mammograms from the U.S. Preventive Services Task Force several months ago touched off confusion and debate about the breast cancer screening tool. The task force said the benefits of mammograms for most women in their 40s were small, and recommended mammograms only every two years beginning at age 50. But many doctors and patients disagreed, saying that while mammograms aren't a perfect method of detecting breast cancer, they can be lifesavers for women in their 40s.

Dr. Jean Warner, director of the Tyanna O'Brien Center for Women's Imaging at Mercy Medical Center, is one of those doctors who disagreed with the recommendations. She answered questions about mammograms in a live chat on The Baltimore Sun's Picture of Health blog.

Question: Given the recent panel recommendations on mammograms, what should women in their 40s do about mammograms if they don't have a family history of breast cancer?

Answer: I believe that women in that age group should still follow the recommendations of the American College of Radiology, the American Cancer Society and the Society of Breast Imaging to have an annual mammogram beginning at age 40, no matter what their family history or risk factors. The reason for that is that mammography has been proven in multiple studies and proven over time in our country to have decreased the mortality rates from breast cancer, even in this particular age group.

Q: Why are mammograms so painful? Are there efforts to design new technology that is gentler to patients?

A: Most women complain of the pain of a mammogram due to the compression of the breast. We have very good reasons for requiring that compression, including immobilizing the breast and decreasing the thickness of the breast tissue, which results in a lower dose of radiation to the breast. There really isn't a good way to take the compression part of mammography away. Researchers are looking into other types of imaging methods that don't involve compressing the breast, but none of these has been proven effective as a screening tool for detection of breast cancer in the general population.

Q: Why isn't ultrasound the standard for mammograms? Doesn't it do a better job of showing all areas?

A: Ultrasound is considered complementary to mammograms. Ultrasound aids in detection of cancer that may be missed on a mammogram, especially in women with dense breasts. But ultrasound has not been proven to be an effective screening tool for detection of breast cancer in the general population. It is used mainly to evaluate areas which are abnormal on physical exams or abnormal-appearing on the mammogram. It may also be used as an additional screening tool in particular subsets of patients who are at higher risk of breast cancer and who are unable to undergo MRI screening.

Q: How big does a tumor have to be to show up on a mammogram?

A: Cancers as small as even a few millimeters, in the range of 3 to 4 millimeters, may be detected by mammography. Of course this does not mean all cancers of that size would be detected by mammography.

Q: If something is found on my mammogram, what happens next?

A: If an abnormality is found on a screening mammogram, you should be notified by the facility. We would typically ask you to return to have additional diagnostic mammography views (this could include magnification and specialized compression views) and possibly ultrasound. In a majority of cases, this additional imaging is all that is required to rule out breast cancer. Sometimes after this evaluation you might be asked to return in six months to check an area that is thought to be very likely benign. Approximately 10 percent of patients who are called back after abnormal screening may require further evaluation with a biopsy. Most commonly a biopsy can be performed with a simple needle biopsy procedure using mammography or ultrasound guidance.

Q: I have not had any issues with breast implants but am now due to have my first mammogram ... could the compression lead to the breakage of the implant?

A: I would say yes, it is possible, but highly unlikely. We have special methods that we teach our technologists to utilize when performing mammography on patients with breast implants. You should always inform the facility that you have breast implants so that they are aware of this.

Q: I understand you don't support the task force's recommendations, but aren't there risks - such as false positives - associated with mammograms that outweigh the benefits for women in their 40s?

A: Yes, there are well-known limitations of mammography, including false positives, false negatives and the potential for over-diagnosis. Several studies have shown that when surveyed, women would prefer dealing with the false positive issues if it meant a higher ability to detect breast cancer early. Concerning false negatives, I believe that we should emphasize research to find additional potentially better methods for screening before abandoning the use of mammography, which has been proven to be effective at decreasing mortality.


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