Maybe a mammogram wasn’t really necessary this year.
Linda Ross pondered her options. The Greenwood resident had been receiving her yearly mammogram every year since she turned 40. After more than 20 years, doctors had never found even a hint of cancer in the scans. Her screening could probably wait another year, she thought.
But Ross eventually opted to go to the doctor, a decision for which she is still thankful. This mammogram showed a small mass in her breast, which ended up being cancer.
“We caught it quick enough that it was in Stage 1 and was still small. It had not spread,” she said. “If I had not have gone, I can’t say that the picture would have been as good next year.”
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Ross’ story shows how important regular mammograms can be. The scans have proven to be one of the most effective weapons in lowering the death rate from breast cancer.
But new recommendations regarding yearly mammograms and breast exams have women and doctors concerned about the effects the guidelines will have on women’s health.
The worry is that the gaps these new recommendations create, regardless of how small, will allow cancer to go undetected until it’s too late.
“There will be patients who end up dying of breast cancer because they waited to get a mammogram,” said Dr. Michael Fisher, a radiologist for Radiology Associates of Indianapolis. “There will be people who hear this and put off their mammograms, and they will have a worse cancer than they would have because they listened to this nonsense.
“This is doing a disservice to American women.”
The American Cancer Society unveiled its newest recommendations for breast cancer screenings in October. The findings were based on rigorous examination of scientific research that has emerged.
The new suggestions state that women don’t need to start receiving regular mammograms until age 45, and that both self-exams and breast exams conducted by a physician should no longer be an option at all for screening for cancer.
The new recommendations stem from a movement in medicine towards more personalized care, said Dr. Robert Goulet, breast surgical oncologist with Community Health Network and state spokesman for the American Cancer Society.
“It’s not just in breast cancers but in all areas of medicine, looking at the entire patient, providing the patient with the best care for their particular needs,” he said. “The guidelines that were given previously were more of a one-size-fits-all.”
Attacking the cancer
Breast cancer death rates have decreased by 36 percent since 1989, a fact that can be attributed to better treatment options and the use of mammography.Mammograms are the best screening tool that physicians have to detect breast cancer, Goulet said.Doctors were able to identify Ross’ cancerous mass before it had spread. The tumor was removed at the end of October, and Ross went through 20 sessions of radiation.
The 64-year-old has been cancer-free since ending treatment.
Ross was incredulous when she heard the new recommendations about mammograms.
“I don’t believe that’s right. I’ve known too many people who have found cancer by having a mammogram. That’s the only way I would have found mine, because you could not feel it,” she said. “If I had not regularly gone, I don’t know how bad it would have been.”
Despite stories such as Ross’, researchers examining how mammograms were used have noticed troubling findings, Goulet said. For women from ages 40 to 44, where breast tissue is more dense, the screenings were less accurate.
Discrepancies would show up, but doctors were unable to determine if it was cancer or not. Often, women were being called back for second and third examinations after something showed up on the mammogram.
“The number of call-backs to get additional views on their mammogram increases in those earlier years. That increases a women’s level of anxiety,” Goulet said. “I’m not trying to say we shouldn’t be screening if we’re going to be effective at saving lives, but we have to be careful about what the overall impact on the patient will be.”
False positives are more common in younger women, according to the Susan G. Komen organization. Researchers have found that over the course of 10 years, a woman’s chance of having a false positive for breast cancer is between 50 and 60 percent.Holding off on yearly mammograms will lower the chances of going through that ordeal, Goulet said.Still, the new guidelines are not saying that mammograms should not be done on women under the age of 45, Goulet said. If they want to get one, they have the option, he said.
“These are guidelines. Nothing is written in stone,” Goulet said. “If a woman is 40 years old and wants to start screening, they can do it without any concern. Right now, the ground rules are the same as they were a month ago.”
Women under the age of 45 made up nearly 11 percent of all breast cancer diagnoses from 2008 to 2012, according to the National Cancer Institute. They made up 6 percent of all of the breast cancer deaths over that time.
“Cancer in younger patients tends to be more aggressive and harder to treat,” Fisher said. “If it’s your mother or your wife, you would think the best-case scenario is finding that cancer earlier rather than later.”
‘At any time’
Fisher has discussed the announcement with his patients, and assured them that this will not change how they are screened for cancer.“I see so much cancer on a daily basis, and it’s in younger patients too,” he said. “Cancer can occur at any time.”While the mammogram guidelines attracted the most attention, other recommendations will also affect how women screen for breast cancer.
Breast exams, either by the patient themselves at home or by doctors in the office, are strongly discouraged, Goulet said.
“There is no data that shows it improves the diagnosis rate, or that it improves the death rate because of breast cancer,” he said. “Of all of the elements in this latest paper, I find this the least palatable. But then again, the recommendation is evidence-based. People looked at the literature, and made recommendations based on scholarly review of the literature.”
Despite what research says, Courtney Larson said she understands the importance of both self-exams and mammograms.
“It doesn’t make sense to me. That’s what saved my life,” she said. “That’s just knowing your body. It takes a minute once a month.”
Larson credits self-exams with saving her life. In 2012, the then-37-year-old southside resident was performing her regular self-exam when she found a grape-sized lump in her left breast.
A family doctor downplayed the severity of the lump, suggesting scheduling a mammogram sometime in the coming months. But Larson was insistent on getting her screening as soon as possible.
Dr. Erin Zusan with Community Breast Care in Greenwood conducted a mammogram, and subsequent ultrasound and biopsy, which revealed that the lump was cancerous. She was diagnosed with invasive ductal carcinoma, classified between stages 1 and 2.
The cancer had not spread out of the breast. They had caught it early enough.
Three surgeries, six rounds of chemotherapy and 30 rounds of radiation therapy later, Larson was declared to be cancer free. She still thinks what would have happened if she put off getting a mammogram, or didn’t do a regular self-exam.
“If I hadn’t been checking, I wouldn’t have noticed the lump. I knew that wasn’t normal, so I could get in and get that mammogram,” she said. “They talk about false positives, but I would so much rather the stress that it’s a false positive than to get that call saying you have breast cancer, and now it’s Stage 4 because we didn’t catch it in time.”
No room for excuses
Physicians such as Fisher fear that the recommendations could have unforeseen impacts down the line. Changing the emphasis of “get a mammogram every year” will only make some women less likely to get one at all.“If people have any excuse to not get it done, it won’t get done,” Fisher said.Patients and doctors are also concerned that in the face of these new guidelines, insurers will stop covering mammograms for women ages 40 to 44.
Goulet doesn’t see the reimbursement policies of private insurers and government agencies such as Medicaid changing yet. But if it does, that’s when a large change in how screening is done will happen.
“Once patients are being confronted with not having these services compensated, I think that will probably will begin to change how screening is being done,” he said. “The reality is, despite the evidence, clinical practice probably will not change until there is some change in that reimbursement policy. It sounds awful to talk about that, and as a physician, I find it abhorrent, but that is a reality.”
As someone who has been directly affected by breast cancer, Ross would find that to be a tragedy.
“I’d hate to see the insurance not pay for it, too. That could be the next issue,” she said. “Everybody needs to have it done, as you get older. That’s the only way you can find some of these tumors. It’s needed.”
60,310 — Estimated new cases of breast cancer diagnosed in women younger than 50 in 2016.
246,660 — Estimated new cases of invasive breast cancer will be diagnosed in women in 2016.
24 percent — Percentage of new breast cancer cases in women younger than 50 compared to overall new cases.
40,450 — Estimated women who will die from breast cancer in 2016.
61 percent — Likelihood that a woman will have a false positive for breast cancer if getting a mammogram every year.
42 percent — Likelihood for a false positive if getting a mammogram every other year.
100 percent — Five-year survival rate for Stage 1 breast cancers caught at the earliest form.
22 percent — Five-year survival rate for Stage 4 breast cancers that have spread beyond the breast to other areas of the body.
— Information from the American Cancer Society and University of California San Francisco School of Medicine
The new breast cancer screening recommendations:
- Women with an average risk of breast cancer – most women – should begin yearly mammograms at age 45.
- Women should be able to start the screening as early as age 40, if they want to. It’s a good idea to start talking to your health care provider at age 40 about when you should begin screening.
- At age 55, women should have mammograms every other year – though women who want to keep having yearly mammograms should be able to do so.
- Regular mammograms should continue for as long as a woman is in good health.
- Breast exams, either from a medical provider or self-exams, are no longer recommended.
The guidelines are for women at average risk for breast cancer. Women at high risk – because of family history, a breast condition, or another reason – need to begin screening earlier and/or more often. Talk to your medical provider to be sure.
— Information from the American Cancer Society