March 2010

The Mammography Debate

Last Fall, I gave a celebratory cheer when the new mammogram guidelines hit the news. As a health reporter, I’d long been privy to the fact that there is no medical evidence supporting annual mammograms for all women over 40. And it drove me nuts that no one seemed to care. All women over 40 kept lining up to get their boobs squished every year, like clockwork.

“Eureka!” I thought when I saw the headline. “Someone finally came to their senses.”

That someone was the United States Preventive Services Task Force, a 16-member panel of experts. Our tax dollars pay them to peer into such pressing issues as—does breast cancer screening really work?

Peer they did, and what they found was a dearth of scientific evidence supporting the current guidelines of annual mammograms for all women over the age of 40. As it turns out, breast cancer screening for all is not only a waste of time and money but the annual event feeds a cauldron of fear and erupts in false alarms for hundreds of thousands of women.

Here’s one way to look at the pros and cons of mammograms for all women over 40, via the NYT’s “Gauging the Odds (and the Costs) in Health Screening:”

The numbers show that about 2,000 women need to be screened regularly for a decade to avert one breast cancer death.

But…during that decade up to 20 women screened will be “overdiagnosed” and get radiation, chemotherapy or a mastectomy unnecessarily.

About 5 to 15 women will get treatment at a younger age than they would have otherwise, without improving their health outcomes.

Most were going to do fine without screening by beginning treatment of their cancer when the symptoms became evident,

…and a few were destined to die whether or not they had early screening because their cancer was fast-growing.

So, unless a woman has unusual risk factors for breast cancer, the Task Force recommends screening start at age 50 (not 40) and happen every two years (rather than every year).

Seems simple enough.

So, a few weeks later, when Mary and I were face-to-face with our primary care physician, I asked, if Mary (who had recently turned 40) should get a mammogram.

Of course, this was a trick question. Like the validation-seeking patient I am, I wanted my doctor to say, “Why, no. As a matter of fact, the scientific consensus shows that Mary getting a mammogram is as useful as me waving a magic wand over her tatas.”

Time out for a confession: A part of me (the scared shitless part) wanted Mary to get the damn mammogram. I wanted her to line up like a good 40-year-old, get her boob squished, and get the all-clear sign. Because, like every other woman, I desperately want to believe that breast cancer screening works.

But it doesn’t. At least not the way we want it to work. And, yes, I was being hypocritical. How could I ignore the numbers? How was I different than people who refuse to face facts in global warming or evolution? In my darkest moments, I even found myself gently coercing Mary to get the mammogram. “Why not just get a baseline?” I said in my most sensible, medical-reporter voice.

Back in the doctor’s office, my rational and irrational selves were clearly in a tug-of-war. I desperately needed our doctor to squelch my panic. I needed her to be a bastion of evidence-based care.

So imagine my disappointment when she didn’t skip a beat. “Oh yes,” she said, “go ahead and schedule one. We aren’t going to change our recommendations based on one study.”

Whoa, wait a second. This wasn’t a single study. The new recommendation was the final distillation of more than a dozen studies involving more than 600,000 women. The Task Force is made up of the top experts in the field.

Is my small town doctor really second guessing their work? Or is it just easier to ignore the facts and placate women’s fears?

Last month, an editorial in the Annals of Internal Medicine reminded me of the tightrope doctors walk (not mine, obviously, but others) when it comes to managing evidence-based care with patients’ emotions. As reported by the NYT, the editorial shows “a divide has merged between doctors and patients—with doctors more inclined to accept the new recommendations and the patients wanting to stick to early and annual screening.”

I think it’s time that women (myself included) buck up and face facts about the limitations of mammography. Demanding that doctors practice defensive medicine serves no one, especially women. Mammograms offer nothing more than false reassurances in a world where breasts have come to be seen as ticking time bombs.

Easy for me to say, I will never need another mammogram—one of the few perks of double mastectomy. But I hope that next Fall, when Mary’s annual appointment rolls around, I’ll be calm and rational enough to weigh the facts and give her my blessing…to cancel it.