The Great Mammogram Debate | Another Year, Another Issue

Screenshot image from JAMA video.
Screenshot image from JAMA video.

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.

Screenshot images from JAMA video.
Screenshot images from JAMA video.

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 That pretty much says it all– Marissa Bellack eloquently and with historical references pointed out the fallacy that has existed throughout time that women are too fragile to handle such anxiety and would somehow be better off not knowing about an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…

Perky or Just Dense? | Breast Density and Breast Cancer

I really enjoyed attending the Society for Women’s Health Research meeting on mammography last fall.  Since I’m still not old enough to really need a mammogram, I never spent much time worrying about one, or wondering what it would be like or what the results might be.  Of course, women will always worry about the discomfort of the procedure.  And then there is the anxiety of awaiting the results.  My mom gets her mammogram done at a breast center where a radiologist reads the film while you get dressed and then discusses the results with you that day.  If there are any follow up procedures (ultrasound, biopsy, additional mammogram images) they’re done before you leave.  That is FABULOUS. And also super rare.  Usually, you get a letter in the mail a week later, and it’s not always all that easy to interpret.  Depending on your state, this letter might include details on your breast density, but it doesn’t tell you what breast density means to your health.  Information without context.  That seems useless and entirely unfair to me.

breast density mammos
Source: American Cancer Society

The above image shows what density looks like on a mammogram. While we think of younger women having denser (or at least perkier!) breasts, that’s only partially true.  You are more likely to have dense breasts if you’re younger, but there are plenty of old women who have dense breast tissue.  (Perky does not equal dense.) Breasts are made up of fatty tissue and the ducts and lobules that make milk– more ducts and lobules make a breast more dense. Normal fibrous tissue also contributes to  breast density. Just like an x-ray shows bones through the skin because they are so much more dense than muscle, etc., a mammogram film shows a tumor as a white mass because the tumor is more dense than the surrounding tissue.  In the fatty breast (medical term, no judgments here!) you could clearly discern the white mass of a tumor, right?  But on the far right in the dense breast? How can you tell what’s dense tissue and what’s a dense tumor?

The problem with dense breasts is not only that a tumor is harder to see with traditional mammography. The other problem– women with dense breasts are (very slightly, don’t panic) more likely to develop breast cancer. So, more likely to get cancer which is harder to identify with traditional screening.  Not so good.  Women with dense breasts are often called back after traditional mammography for an ultrasound, which is an effective way, together with the mammogram, to discern tumor from normal, dense tissue.  But as I learned at the Society for Women’s Health Research meeting, the use of 3-D mammography makes a huge difference to women with dense breasts.  Not only does it reduce the recall rate for additional testing, it finds more cancers.  If there is a tumor, it’s more likely to find it, but it’s not likely to send you for additional tests that you don’t need.  Win-win.

So the take home message? Pay attention to that line on your mammography report.  Don’t worry about it, but if you are in the “dense” category, consider the 3-D mammogram next year.   And if your doctor recommends that you come back for an ultrasound after a traditional mammogram because your breasts are dense, don’t worry too much about that either, it’s not likely to be anything, but will be able to tell you for sure.  Just don’t let the fact that traditional mammography isn’t as effective for women with dense breasts deter you from your annual mammogram.  They really do save lives, whether you are perky or not so perky, dense or fatty.

Society for Women’s Health Research | Expectations and Experiences in Breast Cancer Screening

society for womens health research mammography

Last week, I had the privilege of attending a forum of the Society for Women’s Health Research.  I’ve been on their email list since I was in graduate school, and when I received an invitation to hear the results of  a recent survey on women’s expectations in breast cancer screening, my interest was piqued. The panel, which included physicians and women’s health advocates, discussed the results of the findings, which were published in a special supplement issue of the Journal of Women’s Health.  Most striking were the findings that while most (nearly 80%) women agree that a mammogram is an important exam, almost half (46%) fail to schedule their own mammogram on an annual basis.  Most often, women cite high cost of care and inadequate insurance and the reasons they forgo screening. The panel also discussed the financial and emotional impacts of recall rate– women who are asked to come back after abnormal mammogram findings.

I love when I can be in a room of intelligent, passionate people– I always learn something new.  Not being a p0litical junkie, and having decent insurance, I have to admit that my knowledge of the Affordable Care Act is pretty limited. Apparently, I’m not alone, because I would have been in the 63% of women surveyed who didn’t know that the ACA mandates that preventative screenings like mammograms are to be covered with no cost sharing to patients. That means they are free, ladies. So cost/not great insurance coverage aren’t an excuse anymore- if you have insurance or medicare, they’re supposed to be free.  Because patient cost was such a deterrent, many speakers circled back to the importance of spreading the message that mammograms are now completely covered.

The second issue that really stuck out to me was the idea of patient recall.  I’m still not 40, so I never had to go in for my first screening mammogram. But I have a little secret to tell you– if you’re 40 and go in for your first mammogram, odds are good that you’ll be called back in. Why don’t they just tell women that from the start? I was chatting with a group of friends, and one mentioned how stressful it was being called in for further screening tests.  Then, one by one, each woman in the group admitted to going through the same thing. Of course, I’m sure that not every woman is recalled after her first mammogram, but with nothing to compare it to and the more dense breasts of a young woman, the odds are good that there will be something that they’ll want to look at a second time.  Not surprisingly, when this study asked women if they would prefer a screening test that could reduce unnecessary recall, the vast majority said yes. Also not a shocker, women said they’d rather use a screening method that found more cancer.  Um, yes. I want a test that does its job, and does it well.

Here’s where cost as a deterrent re-enters the picture…  If you’ve had a mammogram recently, you’ve probably been offered the option to pay an additional fee (from talking with my friends– I know, so scientific!– it’s usually $50) for a 3D mammogram.  It wasn’t until this meeting that I had really looked at the data on 3D mammography. Honestly, if offered that option, I think I might have felt like it was an up-sell– like when they constantly try to tack on services at Jiffy Lube when all you need is an oil change. And this is where I would have been very wrong, my friends.  It turns out that I think that $5o would be well spent– 3D mammography (officially called breast tomosynthesis) can reduce unnecessary recall and increases the diagnosis of invasive cancer.  It is especially effective in women with dense breasts, who are more likely to be recalled and whose cancers are more likely to be missed.  A study in the same supplement looks at the increased cost of the test vs. the cost of additional tests upon recall, and finds that the use of 3D mammography would save at least $50 per patient screened. (I read the study and still don’t understand all the financial details, but suffice it to say that additional imaging and biopsies are expensive, so not needing to do a bunch of them offsets the more expensive test.)  I think the aim of this analysis was to encourage insurance companies that by covering the more expensive test, they would actually save money,  but it emphasized to me that, saving money or not, this test is worth it.  There is a very real financial cost associated with recall– cost to your insurer, yes. But there is also the cost of the co-pay or percentage out of pocket that a patient pays. There is time off work, childcare, and even parking to consider.  (Seriously, why must it cost so much to park at the hospital, am I not giving them enough of my money already?) But on top of the financial burden, patient recall can take a pretty major emotional toll. While I don’t think that avoiding the anxiety that accompanies an abnormal finding is enough to avoid mammography altogether, quality of life should be  considered as we strive to improve screening methods.

I always love the opportunity to “dress like a grown up” and feel even just a little bit professional as I head to a meeting. But even more than that, I love it when I can say that a meeting was really worth my time. When I can leave with a few very solid and concise takeaways, it’s a win. So I’ll try to do the same for you. First, while not perfect, mammograms are important and FREE. Second, 3D mammography reduces the chance that a patient will be called back unnecessarily, and it reduces the chance that a cancer will be missed.  If there’s any way that you can swing it, and especially if you’re under 50, I think it’s worth your fifty dollars.

The Great Mammogram Debate | No More Excuses

mammogram debate helvie Today was back to school day at our house.  Thank goodness.  Those kids needed to go back to school.  For all of the learning, of course.  As it turns out, apparently I had a little learning to do myself.  (And yes, that’s the dog’s head. She’s missing her playmates. And driving me crazy.)

When we went around the circle of parents left at the bus stop discussing the glorious plans we all had for the day, they were about what you’d expect.  Jiffy Lube, Target, spider removal from a chandelier…  My goal for the day: make some lists.  You know I love me a good, long list with checkboxes. Got my list made. (Check.) Then I proceeded to start checking off the boxes.  Of course, I started with the easy ones.  Then I got down to a tougher one: the great mammogram debate. (Insert dramatic dun-dun-DUNNNNN music here.)  After hearing a lot about overdiagnosis and the inability of mammography to reduce the number of advanced cancers, I’d heard something about a new study that contradicted it, and decided I needed to clear it up.

Now hold on tight folks, it’s about to get a little science-y up in here.  But I think I can get you through it.  If a screening protocol is working, then one would expect to see more diagnosis of early stage disease and fewer cases of advanced disease.  If you’re “catching it early,” then it will be diagnosed before it advances.  Make sense?  A study published in the the New England Journal of Medicine (very reputable) by Bleyer and Welch in 2012 looked at deaths from breast cancer in a roughly thirty year period since the introduction of mammography, and found that while there was a significant increase in overall cases of breast cancer, there was only a marginal (read: tiny) decrease in advanced disease.  This led the authors to conclude that mammography was leading to a significant overdiagnosis of breast cancer (leading to the treatment of disease that would otherwise not kill the patient) without substantially decreasing the incidence of advanced disease.  Their takeaway: mammograms don’t catch advanced disease early and catch a lot of otherwise insignificant disease. (Their subtext: mammograms are more trouble than they’re worth.)

I have to be honest.  I didn’t like this.  This put mammography into the “non-evidence based” decisions in my mind, right up there with contralateral prohylactic mastectomy.  The evidence didn’t point to its benefit, but I just couldn’t imagine that mammography didn’t have a place in helping breast cancer patients.  Until today.

In today’s issue of Cancer (also reputable, published by the American Cancer Society), Helvie et al. (that’s scientist speak for “and others”– Helvie’s group) published another look at that same data set.  But they made one little tweak to their analysis that made a big difference.  They adjusted their data for “temporal trends,” the change in incidence of a disease over time independent of any screening.  (They looked at pre-mammography data and data from countries without widespread use of mammography to determine that each year, the number of breast cancer cases rises between one and three percent.) When they adjusted the data for this increase, they found that there was a marked increase in early stage breast cancer diagnoses, but a significant decrease in the number of advanced cases.  They mentioned that their data doesn’t take into account who had a mammogram and who didn’t– it’s just all of the breast cancer deaths in the mammogram era vs. the pre-mammogram era.  This would indicate that number of advanced cases would be even lower if they were looking only at a population of screened women.  Did you stick with me, folks? That’s huge! That means that mammograms are catching potentially deadly cancers while they are still treatable. This study validates mammography as a screening tool.  For years, studies showed the benefits of mammograms, but the Bleyer and Welch paper called that into serious question.  Fears of needless biopsies and unneeded chemo compounded with their data left many women encouraging others to skip the annual mammogram.  Somehow, I doubt this will be the last word in the great mammogram debate.  But it is a thoughtful review of an excellent data set that agrees with many other studies.  That’s enough for me.  I’ll climb back up onto the mammography soap box with confidence.  They do make a difference, ladies.  Stop making excuses.

And now that I’ve finished my homework for the day, I’ll climb down off my soapbox so that I can go pick up my kiddos.  I can’t wait to hear what they learned today at school.  Won’t they be surprised when I can tell them that I learned something, too?