Women are between a rock and a hard place, if you will excuse the expression, when trying to decide when, and how often, to have a screening mammogram.
Start at 40? Or 50? Once a year? Every two years?
Breast cancer strikes one in seven women. How do you know whether you are at risk?
And when did they take breast self-exams off the to-do list?
Do mammograms save lives? Or do they find tumors that would never have required treatment, putting women through the misery of surgery, chemotherapy or radiation?
What's a woman to do? Ask the experts. We turned to three local doctors to answer five questions about mammograms.
•Dr. Kathy Helzlsouer, an expert in breast cancer research and risk assessment and director of the Prevention and Research Center at Baltimore's Mercy Medical Center.
•Dr. Cecilia Brennecke, head of radiology at the Johns Hopkins Breast Center at American Radiology Services, Green Spring Station, who specializes in a variety of breast imaging techniques.
•Dr. Stacey Keen of Advanced Radiology of Maryland, a breast cancer survivor and radiologist who wrote a book about her experience and who focuses on breast imaging.
Question: Why did health officials stop recommending that women examine our own breasts for lumps or changes every month?
Helzlsouer: It is still true that some women find a breast lump that was not picked up on mammography or find it even before they start regular screening. However, several studies have looked at whether regular breast self-examination ultimately reduces death from breast cancer — and they have not found a benefit.
Women doing breast examination were able to detect more breast lumps than the women who were not taught careful breast self-examination. But for the most part, those breast lumps were not cancer. Indeed, many women find their breast lumps when showering and washing — not as part of a systematic breast examination. In addition, some women were not able to master the technique, or felt guilty if they failed to do it or anxious when they did.
Women can still do their own breast exams; it is always good to know your body. And you can ask your health care provider how to do it properly if you are unsure.
Q: When should I start getting mammograms? And where should I go? How do I know if a radiology center is good at breast cancer screenings?
Brennecke: Nothing has changed. Start at 40 and come back every year. You can consider stopping at the age of 80. A breast center is a good idea, and there are a lot of them in Baltimore. Radiologists are focused on breast imaging at these centers, and surgeons are focused on breast imaging.
All of the centers in the United States must now be accredited by the Food and Drug Administration, and they are very strictly controlled. But the one thing they don't assess is this: "Is the radiologist doing a good job interpreting the exams?"
The best way to determined this is to know whether the radiologist does a high number of readings. It does help to do a lot of something. The requirement is 960 over a two-year period. I think the FDA minimum is very low. [Brennecke reads about 7,000 images a year.]
Keen: People are going to accuse me of being prejudiced, but a screening mammogram picked up my cancer in my 40s, and it saved my life.
You can ask the facility how many readings their radiologists do each year. [Dr. Keen reads about 5,000 a year.] And if you need to find a center near you, you can go to mammographysaveslives.org. Just plug in your ZIP code.
You should also ask how many false negatives a facility has. We are obligated to give that information to the accrediting body, and facilities are often proud of that rate. [A false negative rate of 10 percent to 15 percent is considered normal.] Mammography is the best screening tool we have, but it is not perfect.
Q: Is it better to get a digital mammogram or does the old film screening do just as well? What about MRIs and ultrasounds?
Brennecke: Digital is best. To me, there is just no comparison. Digital equipment costs 10 times as much, but I don't see anyone hanging on to film screening anymore. It is particularly good for young women, who typically have dense breast material. If you are at high risk, you should be getting an MRI in addition to a mammogram, not instead of it. It does not take the place of a mammogram.
For those women who are at increased risk but who don't fall into the very high-risk category, we like ultrasound. We can pick up an additional three cancers a year in dense breasts.
Keen: You'd assume that digital would be better than film screening, but a study in the New England Journal of Medicine looked at that and found that digital was a little bit more sensitive in detecting breast cancer in women younger than 50 with dense breasts and who were pre- or peri- menopausal. But in women with fattier breasts, film screening did just as well.