The Great Mammogram Debate | Another Year, Another Issue

Last fall when I sent the kids back to school, I took a little time to jump into the mammogram debate. A paper had just come out in the journal Cancer indicating that looking at a preponderance of data with the proper statistical analysis showed that mammograms do, in fact save lives. Worth reading if you’re new to RLC or just don’t remember, like me. I re-read it in preparation for writing this post. Loved the prophetic foreshadowing near the end: Somehow, I doubt this will be the last word in the great mammogram debate.

Not the last word, indeed. Just over a year later, the Journal of the American Medical Association published a new paper on mammograms, leading the American Cancer Society (who publishes the journal, Cancer, referenced in that last post, by the way) to change their recommendations for mammography. For a quick and easy overview, JAMA made this video. It is definitely worth the four and a half minutes it takes to watch it, and be sure to watch it with the narration, too.

This debate is a tough one, and I feel like everyone and their brother has already weighed in. The JAMA piece points out that the decision of who gets mammograms and how often involves the delicate balancing of benefits and harms, not unlike most medical diagnostics and treatments. They boiled down the significant potential harms to two categories: anxiety of false positives and overdiagnosis/overtreatment.

The Washington Post published an excellent opinion piece on the first issue. The title read simply: Don’t worry your pretty little head about breast cancer. That pretty much says it all– Marissa Bellack eloquently and with historical references pointed out the fallacy that has existed throughout time that women are too fragile to handle such anxiety and would somehow be better off not knowing about an actual life threatening diagnosis if it meant avoiding the anxiety of awaiting results that might come back with no evidence of cancer. The “don’t worry your pretty little head” line is perfect, exposing the ridiculous notion that avoiding worry is a valid reason to forgo screening that has been demonstrated to prolong life.

The second issue, overtreatment and overdiagnosis, is the only real consideration in my mind. It is the notion that mammography is so good that it finds tumors that are so slow growing and indolent that they would never spread to threaten the woman’s life. This is not a failure on the part of mammograms, rather, it is a failure on the part of research. Increasing research is focused on distinguishing which tumors will be the aggressive, progressive, life threatening tumors, and which would stay tiny and live happily contained to a woman’s breast until she dies of something else as a very old lady. The ACS conclusion is that biennial (every two years) screening after 55 will combat this problem, so that mammograms will note the difference in the fast growing tumors. Even though this recommendation is supported by data, it makes me pretty nervous. This is a place where I think bench and clinical research are going to need to step up, research is going to be our only way to really conquer the problem of overtreatment in early cancer or even pre-cancerous breast lesions like DCIS.

So what to do, my friends? To all my young friends who have asked, I refer you to my reflections from the Society of Women’s Health Research Meeting I attended where I learned so much about 3D mammography. I don’t disagree with the data presented by the JAMA paper (or the data collected by the USPTF, which doesn’t recommend mammography until age 50) that show little benefit in the youngest population of currently screened women. They have amassed and evaluated a huge collection of data to reach these conclusions. BUT this huge collection of data obviously took a lot of time to collect, which means that it is made up almost entirely of patients receiving traditional mammograms (and many of them even the old school film variety, at that).  What I learned at the SWHR meeting taught me that 3D mammograms do a much better job of finding tumors often missed by traditional mammography in women with dense breasts, which are more likely to be found in younger women. I think once there is a large data cohort of young women analyzed exclusively with 3D mammography, we will find benefit in screening that population as well. Incidentally, 3D mammography also reduced the call backs for additional diagnostics, thus reducing all the worry form those ladies’ pretty little heads about something that ends up not being cancer. So, young friends, I say pay your fifty bucks and keep on getting your 3D mammograms.

Yes, I think looking at the data is a good idea. But one must realize that the limitations of the data (not looking at 3D mammos in young women) and realizing that overly paternalistic (don’t worry your pretty little head) conclusions can not only lead to significant confusion, but also to the missed diagnosis of significant disease. Yes, I’ve had young friends– at least two just this month– who have gone through the stress of a false positive from a routine mammogram. But I also have young friends who are alive to raise their children because an aggressive tumor was treated after discovery on a routine mammogram. Anxiety while awaiting the results of what turns out to be nothing sucks. Know what sucks worse? Dying too young of something that could have been treated if anyone knew it was there in time.

*I forgot to even mention the clinical exam guideline. That got dropped from most recommendations a while ago because there was not clinical evidence to show its benefit. That said, I think most docs are still going to do it at your annual OB/GYN exam because they keep talking about the other stuff they’re supposed to cover while they’re doing it. I don’t consider it to be a big issue, except perhaps a sad commentary on the fact that doctors have so little time for patients that they can’t spend the extra 30 seconds on that kind of exam…