By Andy Oakes-Lottridge, MD, FAAFP, President of the Lee County Medical Society
Being 36 years old, and based on the current recommendations for breast cancer screening, Angela shouldn’t really have had to worry about mammograms for another few years. Unfortunately, she has a strong family history of breast cancer, since her mother had it at 38 years of age. Angela’s 1st mammogram was a few years ago and marked by an abnormal finding that was found to be benign, and fortunately the only major result was just adding a few gray hairs.
Our 2nd mammogram for Angela last month resulted in another abnormal finding. As one can imagine the report of an abnormal mammogram that is suspicious for cancer created an extraordinary amount of mental stress and anguish for her and her husband. The next step was to schedule a biopsy of the suspicious lesion. Even though the radiologist did an excellent job of describing the results for them, we still spoke on the phone and conversed through email many times over the next week. This just highlights the amount of natural worry and stress that comes with the potential diagnosis of cancer after having a screening test done. Fortunately, as a concierge medical practice we have the luxury of having more time to communicate and coordinate our patients’ care. After discussing her case with the radiologist myself, I was able to better reassure them that getting a biopsy was the right choice.
For those unfamiliar with the process, a mammogram is simply an x-ray of the breast tissue. To get a better image of the breasts, the tissue is gently squeezed between 2 plates to spread it out prior to the x-ray being taken. Several different views are typically done. What we are hoping to NOT find are changes in density that are consistent with a tumor and will show up on the x-ray. If a suspicious lesion is found then a biopsy may be recommended, which entails a follow-up mammogram where the radiologist carefully inserts a very thin and long needle into the suspected lesion to carefully remove samples of tissue to be examined in the laboratory for any abnormal or potentially cancerous cells. If the biopsy is positive (with the presence of abnormal cells), then a further surgical removal of the lesion may be recommended. This can include anything from the removal of the breast, lymph nodes, or perhaps just the removal of the suspicious lesion…also known as a lumpectomy. This last option was the recommendation made to Angela after her initial biopsy was negative (the absence of suspicious cells), however the x-ray presentation was still very suspicious appearing. She was taken to the operating room where the surgeon carefully removed the suspicious lesion as marked by the presence of a needle. There are usually follow-up mammograms to make sure that the entire lesion was removed.
With all the debate in the last few years on when women should start getting mammograms, and how frequently, perhaps it’s worth reviewing the recommendation. First of all, the confusion starts with different medical groups that have different recommendations. Breast cancer accounts for 23% of cancer cases, and 14% of cancer deaths, making it the leading cause of cancer death in women: an estimated 41,000 deaths in 2014. The good news is that breast cancer mortality has been declining consistently since 1990. Most physicians recommend screening mammograms starting at 40 years of age, usually once a year until age 50 and then extending the interval to every two years after that. Of course this applies to a woman without other risk factors.
Some do advocate more frequent mammograms at even younger ages, but we have to remember that there is a down side to every test, to which Angela can well attest. One way to think of it: 1000 women getting annual mammograms for 10 years starting at age 40…600 will have >1 false positive test, 80 will have >1 biopsy done, and 16 will get breast cancer. To contrast with another group of 1000 women over 10 years starting at age 60…400 will have >1 false positive test, 80 will have >1 biopsy, and 38 will develop cancer.
Editor’s note: The information in this column is meant to discuss medical issues in general. The reader should make individual decisions only after consultation with their physician.
Andy Oakes-Lottridge, MD, FAAFP, President of the Lee County Medical Society with Private Physicians of South-West Florida. The first concierge medicine practice in Florida, est. 1998. E-mail: DrAndy@PvtMD.com or call 239-415-1111.
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Gary M. Price, M.D., F.A.C.P.
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