Mammography: Making Wise Choices for Your Health
Volume 6, Number 1 - January, 2002
Editors: Carol A. Rice, Ph.D., RN, Professor and Extension Health Specialist, and Janet M. Pollard, MPH, Extension Associate-Health
Download PDF version of this Newsletter [171K]
Inside HealthHints....
- Mammography: Making Wise Choices for Your Health
- Mammogram Facts
- Breast Cancer Facts
- Safety of Mammography is Not the Issue
- Women at Risk
- Mammography: Benefits vs. Limitations
- Current Controversies
- Current Recommendations
- Insurance Coverage Concerns
- Making a Decision
- Finding Better Ways to Prevent and Treat Breast Cancer
- Websites with Reliable Information
- References
Mammography: Making Wise Choices for Your Health
Recently news media highlighted findings published in the British medical journal, The Lancet, October 20, 2001, raising questions about when women should have mammograms and whether or not mammograms really prevent breast cancer deaths. A panel of experts recently concluded that while it was possible that mammograms were beneficial, it was also possible that they were not. This leaves many women over 40 wondering what they should do.
This issue of HealthHints will examine the current controversy, provide information about mammograms, and suggest important points for you to consider when trying to decide what is the best course of action for you.
Mammogram Facts
To take care of your health, it is important to get the facts about breast cancer and mammography.
A mammogram is an x-ray of the breast. There are basically two reasons a woman may have a mammogram, 1) for diagnostic purposes, or 2) for screening purposes.
- Diagnostic mammography -- is having a mammogram to diagnose breast disease in women who have a symptom such as a lump, dimpling, or other breast changes.
- Screening mammography -- is having a mammogram to look for breast disease in women with no symptoms.
Most mammograms are done for screening. The value of screening mammograms is the issue currently being discussed as a result of The Lancet article. The concern is that screening well women with no symptoms could lead to unwarranted treatments such as biopsies or other surgeries when there is no evidence that a woman will live longer or better.
Breast Cancer Facts
- After skin cancer, breast cancer is the most frequently diagnosed cancer among women in America.
- Breast cancer is second only to lung cancer in cancer-related deaths.
- In 1997, there were an estimated 180,000 cases of breast cancer with an estimated 44,000 deaths.
(National Cancer Institute, 2002)
Safety of Mammography is Not the Issue
"Strict guidelines are in place to assure mammography equipment is safe and uses the lowest dose of radiation possible. Many people are concerned about exposure to x-rays, and rightly so, but the levels of radiation in up-to-date mammograms does not significantly increase risk for breast cancer."
"To put dose into perspective, a woman who receives radiation as a treatment for breast cancer will receive several thousand rads. If a woman had yearly mammograms beginning at age 40 years and continuing until 90, she will have received 20 to 40 rads. As another example, one mammogram exposes a woman to roughly the same amount of radiation as flying from New York to California on a commercial jet."
(American Cancer Society, 2001)Women at Risk
The following conditions put women at higher risk for breast cancer:
- personal history of prior breast cancer
- family history of mother, daughter or two other close relatives (e.g., cousins) with breast cancer (especially if diagnosed at a young age)
- evidence of a specific genetic change that increases susceptibility to breast cancer (known as BRCA1 or BRCA2 mutations)
- diagnosis of a breast condition (e.g., atypical hyperplasia or lobular carcinoma in situ) that may predispose a woman to breast cancer
- history of 2 or more breast biopsies for benign breast disease
- giving birth to a first child at age 30 or older or never giving birth
- having had early onset of menstruation, before the age of 12, or late menopause, after the age of 50
- having received chest irradiation (for conditions such as Hodgkin's disease) at age 30 or younger
- long-term exposure (greater than 10 years) to hormone replacement therapy
- having at least 75% dense tissue on a mammogram at age 45 or older (not only because tumors are harder to detect in dense tissue, but because, in older women, dense tissue itself is related to increased risk) (National Cancer Institute, 1998; Orfilinda, Winter 2001/2002).
Note: Not having any of the above risk factors does not mean you will not develop breast cancer. The majority of women who develop breast cancer do not fall into any special high-risk category (National Cancer Institute, 2002), thus, the need to consider mammography, regardless of current risk factors.
Mammography: Benefits vs. Limitations
Benefits
- Saved Lives
- Several studies have documented that regular screening mammograms can help decrease the chance of dying from breast cancer.
- The benefits of screening mammograms are better for women age 50 to 69. Recent evidence shows that having mammograms on a regular basis reduces chances of dying 30% for women aged 50 to 69, while reducing chances of dying 17% for women aged 40 to 49.
- Estimates show that if 10,000 women age 40 were screened every year for 10 years, approximately 4 lives would be saved, while regular screening of 10,000 women aged 50 for 10 years would save 37 lives.
- More treatment options
- In some cases, finding a breast tumor early can allow a woman to choose surgery that saves her breast.
- Additionally, a woman whose breast cancer is detected early may not have to undergo chemotherapy.
Limitations
- Saved lives not always the case
- Even though mammography can often detect tumors 5mm (about 1/4 inch) in size and sometimes 1mm in size, mammography may not help women with fast-growing or aggressive cancer that has already spread to other parts of the body.
- False positives/False negatives
- As discussed earlier, younger women have denser breast tissue which makes it harder to detect abnormalities with a mammogram -- leading to possible false negatives (showing no cancer when cancer is present).
- False positives are also more common among younger women. For women of all ages, however, 5 to 10% show abnormalities, and are followed up with additional testing (e.g., a diagnostic mammogram, fine needle aspiration, ultrasound, or biopsy). About 97% of women ages 40 to 49 with abnormal mammograms turn out not to have cancer, compared with about 86% of women age 50+. Regardless, all women undergo follow-up procedures when they have an abnormal mammogram.
- Ductal carcinomas in situ (DCIS)
- Improvements in mammography have resulted in ability to detect a higher number of small tissue abnormalities known as ductal carcinomas in situ (DCIS), abnormal cells confined to the milk ducts. Some of these can go on to become cancer, but many do not. Since it is not possible to predict which ones will or will not become cancer, DCIS is often surgically removed -- sometimes treated with mastectomy, and sometimes with breast-saving surgery. There is disagreement among experts about the extent of surgery necessary for DCIS.
(Adapted from National Cancer Institute, 1998; WebMD, 2001.)
Current Controversies
There are currently two controversies surrounding mammograms that require consideration, whether or not you should have a mammogram, and if so, when you should have one.
Whether or Not to Have a Mammogram
The current controversy over whether or not to have a mammogram has been aroused by a study that reviewed 7 clinical trials on mammography and was published in the October 20, 2001 edition of The Lancet, a British medical journal. The authors of the study concluded that 5 of the clinical trials were flawed by biases (i.e., failure to ensure women were actually screened, failure to ensure that women in the control group were similar in age and other risk factors). Statements expressed by these authors also suggested that mammograms in these trials did not reduce mortality or prolong women's lives, and suggested that mammograms actually increased the number of mastectomies and lead to radiation treatments that cause an increase in cardiovascular deaths (Kolata, 2001; The New York Times Editorial, 2001).
This study suggests the very opposite of the conventional wisdom that early detection of small tumors allows more treatment options, less dramatic treatments, thus, prolonging life and reducing mortality. Other experts have found the study in The Lancet flawed, and guilty of its own share of biases (The New York Times Editorial, 2001).
In another recent study published in The Lancet, January, 2002, researchers from Cornell Medical Center concluded that screening mammography does not have an immediate effect on mortality, but rather has a benefit after about 7 years of screening. They found that breast cancer deaths are reduced by about 55% in women over 55 years old, and 30% for women 44 to 50 years old when they are screened for 7 years (Cable News Network, 2002).
Thus, though the earlier critique in The Lancet arouses questions, it is not sufficient reason by itself to abandon the screening recommendations of the American Cancer Society, the National Cancer Institute, and many top doctors and professional associations. The information presented needs to be further analyzed. Until that time, it is up to the individual to review the information, ask questions, and make decisions.
When to Have a Mammogram
The second controversy has to do with the age at which to have a first mammogram
- Since risk increases with age, both the American Cancer Society (ACS) and the American College of Obstetrics and Gynecology (ACOG) recommend beginning annual screening mammograms at age 40 (American Cancer Society, 2001).
- The National Cancer Institute (NCI) recommends annual or biannual screenings for women aged 40 to 49 and 50+, and recommends women at high risk start even earlier (Maginnis, 1997; National Cancer Institute, 2002).
- The American Academy of Family Physicians (AAFP) recommends beginning annual or biannual screening mammograms at age 50, suggesting women in their 40s have counsel regarding risks and benefits of mammography (American Academy of Family Physicians, 2001).
- The U.S. Preventive Service Task Force recommends women aged 50 to 69 have an annual or biannual mammogram. The Task Force, however, notes that there is insufficient evidence to recommend for or against routine mammography for women aged 40 to 49 as well as for women aged 70 and older (Moore, et. al., 2001). (For more information on this issue see The Department of Health and Human Services Guide to Clinical Preventive Services.)
So Why are the Professional Organizations and Institutes Not in Agreement?
The difference in recommendations stems from different interpretations of the research data.
- Some agencies assert that the data indicate that younger women who were screened more often did better, and that the disease can be more aggressive in younger women.
- Other agencies assert that the differences in mortality among women screened was not statistically significant, and that there is little or no reduction evident during the first 10 years after beginning screening for women in their 40s (WebMD, 1999).
- Still others, purport that current data provide statistically significant evidence that mammography screened women aged 40 to 49 can save lives (Doctor's Guide, 1997).
- While others express little doubt that mammography screenings have the potential of reducing mortality from breast cancer for women ages 50 to about 70, but suggest no clear benefit for women ages 40 to 49 and 70+ (Moore, 2001).
So, Why Not Screen Earlier, Just to Be on the "Safe-side?"
Several reasons are argued:
- Younger women, before menopause, tend to have denser tissue, which makes finding tumors in a mammogram more difficult (it is hard to differentiate between normal and dense tissue when looking for small tumors in glandular tissue).
- Since mammograms are more difficult to read in younger women, there is a higher incidence of false positives, and thus, unnecessary biopsies.
- Since mammograms are more difficult to read in younger women, there is also a higher incidence of false negatives -- missing up to 25% of breast cancer in women in their 40s, compared to 10% in women in their 50s (WebMD, 1999).
- Still, others purport that having a mammogram has saved their lives in their 40s, leading to:
- early detection
- more treatment options, and sometimes,
- breast-saving surgery (Food and Drug Administration, 1999).
With all this information in hand, it is again the job of the individual to review the material, ask questions, and make a decision.
Knowing and considering individual risk factors and discussing the options with your health care provider is an excellent way to help make wise health decisions about mammography.
A Woman's Chances of Getting Breast Cancer Change with Age...
- By age 30 -- 1 out of 2,525
- By age 40 -- 1 out of 217
- By age 50 -- 1 out of 50
- By age 60 -- 1 out of 24
- By age 70 -- 1 out of 14
- By age 80 -- 1 out of 10
(National Cancer Institute, 2002)
Current Recommendations
The following are the guidelines set forth by the American Cancer Society and the American Academy of Family Physicians regarding early detection screenings for breast cancer.
American Cancer Society recommendations:
- Women aged 40 and older should have a screening mammogram every year.
- Between ages 20 to 39, women should have a clinical breast examination (CBE) by a health professional every 3 years, and every year after age 40.
- Women age 20 or older should perform breast self examination (BSE) every month. By doing a BSE every month, a woman gets to know the normal feeling and can more readily detect changes (American Cancer Society, 2001).
Note: If any changes are detected in the breast or underarm (e.g., a lump, dimpling, swelling, nipple pain or retraction [turning in], discharge other than breast milk, skin irritation, redness, or scaliness), it is important to see a health care provider as soon as possible. (Remember, most of the time these changes are not cancer.) (Adapted from American Cancer Society, 2001).
National Cancer Institute recommendations:
- Women in their 40s should be screened every one to two years with mammography.
- Women aged 50 and older should be screened every one to two years.
- Women who are at higher than average risk of breast cancer should seek expert medical advice about whether they should begin screening before age 40 and the frequency of screening (National Cancer Institute, 2002).
American Academy of Family Physicians recommendations:
- "Strongly recommend" women aged 50 to 69 should have annual or biannual mammography and clinical breast exam (CBE).
- "Recommend" women aged 40 to 49 seek counsel regarding potential risks and benefits of mammography (American Academy of Family Physicians, 2001).
Have a Question About Mammography or Breast Cancer?
The National Cancer Institute (NCI) Information Service can help. Call them at 1-800-4CANCER.
Insurance Coverage Concerns
With all this talk about recent controversy, there may be concerns about health insurance coverage of mammograms. According to Joseph Luchok, spokesperson for the Health Insurance Association of America,
"If a procedure is covered it would stay covered until the medical community came to the opinion that it is not a useful procedure (Kolata, 2001)."
Most screening mammograms cost $50 to $100, and are covered in full or in part by health insurance (often outlined by state law). As of January 1, 1998, Medicare has helped to pay for one screening mammogram every year for women eligible for Medicare benefits. Information on coverage is available through the Medicare hotline at 1-800-638-6833. Some state and local health programs provide free or low cost mammograms. Information on free or low cost mammography screening programs is available through the National Cancer Institute (NCI) Information Service at 1-800-4CANCER (National Cancer Institute, 1998).
Making a Decision
What should you do in view of The Lancet study results? Continue having your screening mammograms and talk with your health care provider about any concerns you have. The National Cancer Institute is not changing their recommendations because of the Danish study. No single study, no matter how well it is done, should change practice recommendations regarding mammography. Dr. Peter Greenwald, head of the NCI's cancer prevention division said, "everyone agrees that mammography detects breast cancer when it's smaller and when it's earlier. Women in their 40s should get mammograms every one to two years" (Cable News Network, 2002).
Because you cannot call to make an appointment for a mammogram in a radiology department without first seeing your primary care physician, you will have an opportunity to discuss your concerns about mammography with your primary care physician. Come prepared and knowledgeable to your doctor's visit, but listen to what your doctor adds to any information you have found -- your doctor is the expert. To be a better health consumer regarding this important issue, here are some suggestions for learning more.
- Learn the basics about mammograms. Be an informed consumer. Many important facts are presented in this issue.
- Do your own research on the Internet, reading updates on current recommendations listed on reliable websites suggested in this issue.
- Visit medical libraries if possible.
- Call 1-800-4CANCER for further information.
- Realize you will find conflicting information wherever you look.
- Come prepared and knowledgeable to your doctor's visit, but listen to what your doctor adds to the information you have found -- they are the experts.
- Know your risks and note these to your doctor (i.e., How many of the noted risk factors do you have? Let your doctor know you have these risk factors.)
Finding Better Ways to Prevent and Treat Breast Cancer
Many efforts are underway to improve mammography and prevent and treat breast cancer. These efforts are underway in the areas of technology, research, prevention, and treatment.
- Technology -- Studies are aimed at the development of digital mammography, where a computer assists in the interpretation of the x-ray; teleradiology, where x-rays can be seen for long-distance consultations; and non-x-ray based technology, such as magnetic resonance imaging (MRI).
- Research -- Research efforts are aiming at identifying causes of breast cancer, including an analysis of the role BRCA1 and BRCA2 genes play, as well as how these genes interact with other genes, and with hormonal, dietary, and environmental factors.
- Prevention -- Studies are currently underway involving diet and nutrition in hopes of finding new preventative strategies.
- Treatment -- Studies continue to aim at more effective and less toxic treatment methods.
(Adapted from National Cancer Institute, 1998; WebMD, 2001).
Websites with Reliable Information
- Can Breast Cancer Be Found Early? (ACS)
[http://www.cancer.org/docroot/cri/content/cri_2_4_3x_
can_breast_cancer_be_found_early_5.asp?sitearea=cri] - Mammography Today: Questions and Answers for Patients on Being Informed Consumers (FDA)
[http://www.fda.gov/cdrh/mammography/
mmwebbro/mambrochure.html] - Screening for Breast Cancer (NCI)
[http://www.cancer.gov/cancer_information/doc_pdq.aspx?
version=patient&viewid=b906d0d0-63ac-4d55-ac29-2ae992440adf] - The Facts About Breast Cancer and Mammograms (NCI)
[http://www.cancer.gov/cancer_information/doc.aspx?
viewid=23C1D427-8DA7-42FF-A12B-78E276BF232D]
References
- American Academy of Family Physicians (2001). Periodic Health Examinations: Summary of AAFP policy recommendations and age charts [on-line]. Available: http://www.aafp.org/exam/.
- American Cancer Society (2001). Can breast cancer be found early? [on-line]. Available:
http://www.cancer.org/eprise/main/docroot/CRI/content/
CRI_2_4_3X_Can_breast_cancer_be_found_early_5?sitearea=CRI. - Cable News Network (2002). Conflicting studies cause breast cancer confusion [on-line]. Available:
http://www5.cnn.com/2002/HEALTH/conditions/
01/31/cover.story.your.health/index.html. - Doctor's Guide (1995). American Cancer Society statement on mammography guidelines [on-line].
Available: http://www.pslgroup.com/dg/196ba.htm. - Food and Drug Administration (1999). FDA sets higher standards for mammography [on-line].
Available: http://www.fda.gov/fdac/features/1999/199_mamm.html. - Gotzsche, PC and Olsen, O. Is screening for breast cancer with Mammography justifiable? The Lancet, October 20, 2001.
- Kemper, DW (1997). Healthwise Handbook: A Self-Care Manual for You. Healthwise Publications, Boise, ID; pp7-15.
- Kolata, G. Study sets off debate over mammograms' value. The New York Times, December 9, 2001.
- Maginnis, K. (1997). Two cancer agencies offer new mammography guidelines [on-line]. Available:
http://www.cnn.com/HEALTH/9705/27/mammograms/. - Moore, M. and DiGuiseppi, C. (2001). Department of Health and Human Services Guide to clinical preventive services, 2nd edition: Screening for breast cancer [draft update prepared for the U.S. Preventive Task Force, on-line]. Available: http://my.webmd.com/content/article/1680.50646.
- National Cancer Institute (2002). NCI Statement on mammography screening [on-line]. Available:
http://newscenter.cancer.gov/pressreleases/mammstatement31jan02.html. - National Cancer Institute (1998). Screening and prevention for health professionals: Screening mammograms [on-line]. Available: http://cancernet.nci.nih.gov/clinpdq/detection/Screening_Mammograms.html.
- National Cancer Institute (2002). The facts about breast cancer and mammograms [on-line]. Available:
http://www.cancer.gov/cancer_information/doc.aspx?
viewid=23C1D427-8DA7-42FF-A12B-78E276BF232D. - Orfilinda, L. What everyone needs to know about breast cancer. Scott & White Health Plan: Insights, Winter 2001/2002, p3.
- The New York Times Editorial. The latest mammography debate, The New York Times, December 10, 2001.
- WebMD (2001). Screening mammograms [on-line]. Available: http://my.webmd.com/content/article/1680.50708.
- WebMD (1999). The mammogram screening controversy [on-line]. Available:
http://my.webmd.com/content/article/1680.50647.
This issue of HealthHints has been funded by the Texas Cancer Council.
