When Pam Ladds, a retired nurse living in Newport, Vermont, was in her early 30s, she discovered a lump in her breast. So she went to the doctor to get it checked out. “He said, ‘you need a mammogram,’ so off I go and have one,” she says. The lump didn’t show up on the film, and in the end it turned out to be a fibroadenoma, a benign lesion that eventually went away on its own. But before they got to that diagnosis, Ladds had a negative interaction with a mammography technician that made her think twice about whether she should ever have another mammogram, a common screening and diagnostic procedure that uses radiation to create an image of the breast to detect cancer.
Ladds was living in Philadelphia at the time, having recently relocated to America from her native Britain, and says the mammogram took place at “one of the fancy hospitals that had this great big unit — the ones who were going to ‘take care of women.’ This young, very friendly radiology technician comes in and is squishing my breast tissue between two panels. She’s chatting along as she has a piece of me in that machine, and she deadly seriously asks, ‘did it take you long to learn the language?'” in reference to Ladds’ British accent. Exasperated, Ladds says, “this village idiot has me crushed in this machine, and it made me really question her and everyone else’s competence at that point.” Now 68 years old, Ladds still hasn’t had another mammogram. “I don’t think we should be nuking body parts,” she says adamantly.
[See: 7 Innovations in Cancer Therapy.]
Although Ladds’ experience may not be the norm, her distrust of the medical system (she questions who’s benefiting financially when “women are terrorized into thinking they have to have one every year”) is a sentiment that shows up frequently in discussions of how and when women should be screened for breast cancer. Alterations to screening guidelines issued in the past decade by both the U.S. Preventive Services Task Force and the American Cancer Society have added nuance to the discussion about who should get screened, how often and when those routine tests should commence. Where women were once admonished to get screened every year, now there’s more room in the guidelines for making a personal choice.
“It can be confusing,” says Dr. Mitva Patel, a radiologist at the Ohio State University Wexner Medical Center in Columbus, but she says every woman should discuss with her primary care physician whether and when to commence screening. Patel says being able to speak with a physician who knows you, your medial history and your risk for breast cancer can help you sort through the options and help you make a decision that’s right for you. “Start that conversation with your doctor.”
Dr. Otis Brawley, chief medical and scientific officer for the American Cancer Society, also encourages patients to communicate with their doctors. Although the organization revised its breast cancer screening guidelines for women with average risk of breast cancer as recently as 2015, “our recommendations are still that women aged 40 to 44 should have a discussion with their doctors about their concerns about risk for breast cancer and women aged 40 to 44 who want a mammogram should be able to get it,” he says. Once a woman is over the age of 44, Brawley says the ACS breast cancer screening guidelines encourage her to get annual screening. “We do see a benefit for annual mammography for women aged 45 to 54 and we recommend it. And then for women aged 55 and older, we say the woman needs to make a choice as to whether she wants it every year or every two years. We see very little difference between,” annual and biannual screening after age 55.
But the debate about when and how often to screen may be missing the bigger point, Brawley says, citing a modeling study done in 2013. This study showed that simply increasing screening doesn’t result in as many saved lives as better treatment after diagnosis can. He explains the study authors “modeled the increasing size of the population through 2025 and looked at raising the screening rate from what it is now — about 60 percent of women aged 40 and above are getting regular mammography — to 90 percent by the year 2025.” This model results in the prevention of between 5,100 and 6,100 deaths per year from breast cancer by 2025.
“If, on the other hand, all women received appropriate cancer treatment with no change in screening pattern,” meaning that the screening rate stayed at 60 percent, “in the year 2025, that would result in between 11,400 and 14,500 fewer deaths. And if all women in the United States received appropriate treatment and we raised the prevalence of screening to 90 percent, the combination of the two would save between 18,100 and 20,400 deaths,” he says. These figures underscore another figure that Brawley cites, which is that “studies have shown that 30 percent of women with breast cancer get lousy care.” So “instead of arguing about when to start administering regular mammograms,” we should focus on getting better care for the people who have been diagnosed with breast cancer.
[See: A Tour of Mammographic Screenings During Your Life.]
In addition to providing equal access to better care, Brawley says “we need to be admitting that we need a better test.” He says newer technologies such as 3-D mammography, also called digital breast tomosynthesis, are promising. Molecular breast imaging, which uses a small amount of radioactive dye to make cancerous cells more visible on film can result in more accurate diagnosis because it’s based on how the cells behave, not on how they look. “When I do a mammogram, I’m looking at the structure of the breast.” But molecular breast imaging “exploits the fact that the cancer is hyper-metabolizing versus the non-cancerous cells,” which makes them stand out against the rest of the breast tissue. “I really do think that is our future,” he says.
Another area of concern regarding regular screening mammograms is the question of whether they can actually elevate some women’s risk of developing the very thing the test is designed to detect. Because mammography uses radiation to create an image, there is a possibility that it can elevate risk of triggering breast cancer for some people. Patel says the radiation used to create mammogram images is minimal, measured at 4 millisieverts, which is about the same amount of background radiation you’d be exposed to if you were living in Ohio for three months. “It’s safe, but it’s not zero,” she says, noting that radiologists and radiation technicians administering mammograms need to “think about every exposure,” to get the best angle so that additional images are less likely to be needed later.
Still, because radiation exposure can have a cumulative effect, there is a slight risk. Brawley cites a modeling study done by the U.S. Preventive Services Task Force in 2016 that resulted in a projection of 125 mammography-induced breast cancers resulting in 16 deaths per 100,000 patients undergoing regular screening. The same study projects that regular mammography results in 968 averted breast cancer deaths per 100,000 patients undergoing regular screening.
This duality of results underscores the risk-versus-benefit discussion that surrounds virtually all forms of screening for cancer. “When I think of screening, I think of a double-edged sword, and I think of benefit and risk,” Brawley says.
Patel also acknowledges that “mammography isn’t perfect,” and that it has limitations. “Sometimes it doesn’t detect all breast cancers, and sometimes women have to come back for additional imaging and even biopsies that don’t end up being breast cancer.” But if the goal is to save lives, then she says it’s a good tool that’s been shown to reduce deaths from breast cancer.
[See: What Not to Say to a Breast Cancer Patient.]
Despite mammogram’s limitations and the risk of false positives and over-diagnosis, Patel says mammography does help achieve the goal of saving lives. “How do you determine whether something is overrated or underrated?,” she asks. “You’ve got to figure out what you’re placing the most value on.” For Patel — a radiologist who specializes in breast cancer — she puts “the most value on saving humans lives.” And with that as the goal, she says “it’s worth it to detect a breast cancer early to save a life,” and mammography is a good tool for doing that. “I get an annual mammogram. I get it for myself and I make sure my mother gets it.”
For Ladds, the projected benefits do not outweigh the perceived risks. The bottom line is, it’s an individual decision and ensuring that all women have access to high-quality screening and treatment should be the larger focus.
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Are Mammograms Overrated? originally appeared on usnews.com
