The questions that all women consider when they think about mammography – should I get a mammogram, when and how often? – are always reliable front-page fodder, and this year has been no exception. There’s been a new mammography study, recommendation or opinion seemingly every month, fueling the confusion that many Americans feel about the test.
Unfortunately, there are no easy answers. Different organizations have different recommendations. For example, last week the U.S. Preventive Services Task Force released a draft proposal that women under 50 may not need regular mammograms, advising younger women to weigh the risks and benefits of the screening based on their cancer risk and overall health. The American Cancer Society, on the other hand, recommends annual mammograms starting at age 40.
Research clouds the picture even further. A Canadian study released last year found no difference in the death rates between women who got mammograms and those who got regular breast exams. What’s more, the researchers estimated that one in 424 women who received mammograms ended up with unnecessary treatment for cancers that would not be lethal or grow and progress. In short, these women were over-diagnosed, and may have undergone unnecessary surgery, radiation and chemotherapy—and suffered from a host of side effects—all for a cancer that would not have been a threat to their health.
In addition to the very real health risks associated with over-diagnosis, there are financial costs to consider as well. Another study, published in the Annals of Internal Medicine, projected that if all U.S. women were screened annually starting at age 40, it would cost $10 billion a year, $6.5 billion more than the cost of beginning screenings at 50. That is more than the National Cancer Institute’s entire annual budget.
So where do we go from here?
For a start, it’s time that all of us — clinicians, women and their families – stop thinking about mammography only in terms of age-based screening guidelines. Instead, everyone should work to better understand who is at risk for which type of cancer, and ultimately change guidelines to target those most likely to benefit from mammography.
Breast cancer is a complex disease and there isn’t a “one-size-fits-all” approach. Take, for example, the fact that there is compelling evidence to support annual screening for women in their 40s with extremely dense breasts. That is a very small population, but these critical distinctions underline the importance of moving toward more personalized screening guidelines.
We now have better screening techniques, therapies and an understanding of how to assign patients the treatments best for them. Using a risk-based screening approach works to improve detection of aggressive tumors while also minimizing screening risks.
It’s time to advance this discussion from what age women should begin screening to how to best identify the women most likely to benefit from mammograms. We must also move beyond the debate over whether screening is positive or negative, and instead focus on innovating and learning to make mammography better.
Laura J. Esserman, MD, MBA, is Director of the Carol Franc Buck Breast Care Center and a Professor of Surgery and Radiology at the University of California, San Francisco, School of Medicine.
Margaret E. O’Kane is President of the National Committee for Quality Assurance.