By Mary Kay Peterson, M.D., Director of Women’s Imaging – Radiology Regional Center
As I recently attended the American College of Radiology’s Society of Breast Imaging conference in Austin, Texas, one of my main objectives was to gather information regarding the debate surrounding screening mammography. When to begin screening, what interval of screening, and how to sort out the various recommendations from multiple different medical and government organizations, were key topics to be addressed. In my practice, as a fellowship trained Women’s Imager, I am asked these questions almost daily.
The first few lectures of the conference addressed the screening debate. In the middle of the first lecture, it was clear that the literature and interested organizations are conflicting and confusing. The methodology and types of research to analyze data and formulate recommendations are varied, and may be misinterpreted to suit the needs or goals of individual organizations. However, and more importantly, by the end of the conference, it was clear that the complexity of the screening debate may be filtered out into basic conclusions that are practical and understandable for the patient, as well as the caregiver.
Dr. Robert Smith, Cancer Control Department, American Cancer Society, noted that “there are important differences in current guidelines, but also important similarities. All organizations emphasize that benefits outweigh harms at all ages. All organizations endorse informed decision making. All organizations endorse the importance of women being informed about benefits and limitations of screening.” These points validate mammography screening, when quite often, media sensationalism is used as an excuse to avoid mammography by women that are ill-informed, afraid, or have low tolerance of the temporary discomfort of having the exam. Key to his summary, Dr. Smith points out that “high adherence to even the least aggressive guideline (begin screening at age 50, biannual exam) would save more lives than the current weak adherence to the regular screening (begin screening at age 40, annual exam).”
Duke University’s Dr. Jay Baker pointed out that both the medical and government organizations “all agree most lives and years of life saved” result from starting screening at age 40, so most organizations agree to begin screening at age 40. “One third of all years of life lost to breast cancer, (are) from women diagnosed in (their) 40’s.” These premenopausal diagnoses are typically more aggressive and challenging to treat, therefore earlier diagnosis results in better survival, as well as less emotional, mental, and financial loss for the patient.
As far as annual versus biannual screening, for ages 40-74, the percent reduction in mortality, is significantly greater with annual (53.4%) versus biannual (38.5%), per Yaffee et al as reported in Health Reports 26(12); 2015. It is the annual screening that Dr. Baker indicates saves 25-40% more lives and saves approximately 40% more years of life.
Regarding mammography risks, Dr. Baker notes that “radiation exposure is a minor concern” per the U.S. Preventative Services Task Force, Annals of Internal Medicine, November 2009. The radiation from 3D mammography is comparable to living on earth for seven weeks. Overdiagnosis is relative when it is “impossible to differentiate ‘killer cancers’ from indolent cancers.” Minimally invasive breast biopsy allows for earlier diagnosis and treatment. Interestingly, Dr. Baker suggests that “(investigation of) ‘overtreatment’ rather than overdiagnosis” may prove more beneficial for the overall well being of the patient.
In summary, mammography’s benefits have been proven to outweigh harms (radiation, anxiety, overdiagnosis, etc) at all ages. The need and value of informed decision making by the patient cannot be overstated. As a caregiver, I welcome the screening debate and patient questions because it will only improve our health care system and those that provide it.
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