Do You Really Need a Mammogram?
These days, it's hard to know whether mammograms will save your life or do more harm than good. It's not just the headlines that go back and forth -- the major medical organizations, with their conflicting guidelines, keep you guessing, too. But one clear "rule" has emerged from recent research: Screening recommendations -- when to start and how often to go -- aren't one-size-fits-all. There are individual factors that each woman has to consider in order to make the best decision for herself.
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To choose the right mammogram schedule, you need to consider your personal risk for breast cancer. In a recent study of 10,000 women, 45% underestimated their lifetime odds, which might lead them to skip potentially lifesaving surveillance. Meanwhile, 46% overestimated their risk, "which can lead to unnecessary anxiety, testing, and interventions," explains lead study author Jonathan D. Herman, M.D., of Hofstra North Shore-LIJ School of Medicine, in Hempstead, NY.
To calculate your odds, you can use a risk-assessment tool, such as the one from the National Cancer Institute, (cancer.gov/bcrisktool) and then review it with your doctor. The tool asks just seven specific questions (such as your age), but you will need to know your family history and the diagnosis you received if you've ever had a biopsy. The calculator isn't perfect -- for instance, it doesn't take into account breast cancers on your father's side of the family, notes Dr. Herman. Still, "having an idea of your odds will guide you to far better decisions about screening than guessing would," he says.
How to interpret the number you'll get: A lifetime risk of 20% or above is considered "high"; 15% to 20% is "intermediate"; and below 15% is "average." Wherever you fall on the scale, the newest research will help you make the wisest screening decisions now -- and as you get older.
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If your risk is high...
First, find out whether you should have genetic counseling. Don't assume your doctor will tell you, even if you have a family history that suggests you might have the so-called "breast cancer gene" (made famous by Angelina Jolie); technically, it's a mutation in one of the BRCA genes. In a recent study, fewer than 20% of the women who had such a history were referred to counseling.
If your lifetime risk is 20% or higher, having a yearly MRI in addition to your annual mammogram triples the chances that a cancer will be correctly identified. If your risk is in the "intermediate" zone (15% to 20%), an MRI is not routinely recommended -- and it's usually not reimbursed by insurers. It's also pricey -- $1,000 and up. A breast ultrasound ($100 and up) may be covered by insurance, but you'll need to weigh the trade-offs, cautions Wendie Berg, M.D., Ph.D., a professor of radiology at the University of Pittsburgh. Although the test picks up about three or four additional cancers per 1,000 women at middle risk, some 4% end up with a biopsy that turns out to be benign.
If you've hit 40...
Along with this significant birthday comes the daunting question of whether to start screening. This is a topic of hot debate among experts, often fueled by disagreement over how much weight to give the pros and cons. The U.S. Preventive Services Task Force, for example, doesn't recommend annual mammograms for women ages 40 to 49, noting that some women would benefit, but others would be harmed through unnecessary biopsies and surgeries. However, the American Cancer Society considers the potential lifesaving to be worth the downsides -- and thus it advises annual checks.
To whom should you listen? Yourself! Learning how you feel about the pros and cons is the key to making the best choice for you. An online tool developed in Australia can help you sort it all out (mammogram.med.usyd.edu.au). Designed exclusively for women age 40 or so, the site guides you through the evidence, then helps you rate (on a scale of 1 to 10) whether a piece of evidence makes you feel inclined to "start screening now" or to "consider it later." For additional advice, print out the results of the interactive worksheet to discuss with your doctor at your next checkup.
Related: Actually, You're Not to Young to Worry About These Health Problems
If you have dense breasts...
Right now, more than a dozen states require that you be notified if your mammogram reveals dense breast tissue -- the case for about 40% of women -- and soon all states may have the same requirement.
But what do you do with that information? There are two concerns associated with having dense breast tissue: (1) that your susceptibility to developing cancer is greater and (2) that the tissue could mask a cancerous tumor, which reduces the odds it will be detected on a mammogram by 20% or more, some experts say.
When it comes to the first worry, the medical literature and the press often cite statistics in a way that exaggerates the risk for most women, says Jafi A. Lipson, M.D., a breast-imaging specialist at Stanford University School of Medicine. She and 16 other experts, known collectively as the California Breast Density Information Group, calculated the cancer risk for women with moderately high breast density to be only about 1.2 times greater than it is for those who have average density.
As for the danger of masking, make sure your mammogram is digital. A study of more than 300,000 women found that in those with dense breast tissue, digital was twice as good as film at correctly identifying cancers. And if you have other risk factors, talk with your doctor about getting supplemental MRI screens.
If you've celebrated your 50th...
This is a no-brainer: Virtually every major U.S. medical organization recommends that you get routine mammograms in your 50s and 60s. What does require thought is how often to have them. Multiple studies show that screens every other year are fine. "Postmenopausal women are more likely to have tumors that are slower-growing, one reason waiting an extra year doesn't result in dangerous delays in diagnosis," explains Laura J. Esserman, M.D., director of the breast cancer center at the University of California, San Francisco. An every-two-years schedule also cuts your chances of being referred for unnecessary tests and biopsies by almost half. So, the next annual mammogram letter you get? Consider it an invitation to talk to your doctor about screening frequency.
If you're past retirement age...
The guidepost that many doctors use: Keep going until age 74. After that, if a woman is in reasonably good health and can expect to live another 10 years, experts advise continuing screening. If, however, a woman has other health conditions that would make cancer treatment hard to tolerate, then she can stop.
- By Janis Graham
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