Routine Mammograms: Does harm outweigh benefits?

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New study results released today raise questions about routine breast cancer screening with mammography – do the harms outweigh the benefits? The findings may leave women confused.

It looks deep into breast tissue to spot suspicious areas that may be cancer. Modern digital mammography images help doctors find cancers very small in size and at an early stage. Still, like most medical tests, the technology is not perfect.

Dr Peter Jokich, director, Division of Breast Imaging, Rush University Medical Center: “You will miss breast cancers on mammograms. It’s estimated about 10 or 15 percent. Like anything else in life, it is not perfect, but it’s still really, really good.”

Concerns about false-positives have long fostered debate in the medical community. When a suspicious area is found – like this collection of micro-calcifications – patients typically undergo a needle biopsy.

Dr Jokich: “The counterpoint would say, you do too many biopsies. But whenever we see something that could be cancer, it is safest to do a biopsy and make sure it isn’t cancer. To have a minor outpatient needle biopsy is not a significant harm. It’s waiting until it’s too advanced and you can’t do anything about it. That’s really stressful.”

In 2009, the U.S. Preventive Services Task Force – an independent group made up of doctors, nurses and healthcare experts — reversed its previous recommendation of mammography every one to two years beginning at age 40, and recommended routine screening every two years starting at age 50. The recommendations sparked confusion and controversy among the general public as well as many physicians.

Dr Jokich: “We saw here at Rush a decline in volume because women were very confused.”

Today, researchers from Harvard Medical School’s Department of Health Care Policy and Brigham and Women’s Hospital spoke out about their recent findings. They conducted what’s called a comprehensive review – meaning they studied past studies — 50 years’ worth from all over the world.

Dr Nancy Keating, Professor of Medicine, Brigham and Women’s Hospital: “There is clearly evidence that there is a benefit to mammography screening, but that benefit is relatively modest and it’s smaller for younger women than it is for older women and women with more risk factors.”

Based on their review, the best estimate of the reduction in mortality from breast cancer due to annual screening is about 19 percent overall. For women in their 40’s, the reduction in risk of death was 15 percent. For women in their 60’s – it was 32 percent.

Dr Jokich: “I would argue that’s really, really, really low. We have had no modern studies looking at mortality reduction from modern digital mammography. It’s not been done, so we’re relying on these old studies from the 70s and 80s to rehash all this data, which I think is not relative today.”

Still, according to the Harvard researchers, the numbers raise the question – could patients benefit from a more individualized approach to screening? Meaning, mammography is not a one size fits all test.

Dr Jokich: “I think that’s a ridiculous statement, and the reason is based on facts.”

Rush University Medical Center radiologist Dr Peter Jokich – who has been screening patients for 30 years — has his own answer.

Dr Jokich: “The facts are 80 percent of women that develop breast cancer have no family history and no significant risk factors. So how do you individualize screening when 80 percent of the women who are going to get breast cancer have no significant risk factors? The only thing we can do to make a dent in this disease is screen every woman after 40. There’s just no other options. It’s the best we have right now.”

One issue both sides agree on – further debate is needed to determine how much treatment is too much when it comes to early, stage zero cancers.

It’s worth noting — the American Cancer Society still recommends yearly mammograms beginning at age 40 – they did not adopt the recommendations issued in 2009 by the U.S. Preventive Services Task Force.

If you’d like to read more about the Harvard mammography review, it’s published in this week’s Journal of the American Medical Association.

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