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Recent News on Screenings

Below is an editorial article written by Ophelia B. Chang, MD, past Medical Director of the Breast Care Center at St. Joseph Hospital.

Much controversy has brewed over the US Preventive Services Task Force latest recommendations for screening mammograms. This group has recommended that mammograms be performed every other year for women between the ages of 50 and 74. The American Cancer Society, the American College of Surgeons, the American College of Radiology, the Society of Breast Imagers, and several other esteemed professional organizations remain steadfast in their recommendations that women have screening mammograms yearly beginning at age 40.

The difference between these recommendations and those that we have been following is that women in their forties and women over the age of 74 would no longer be screened for breast cancer. The US Preventive Services Task Force justifies its recommendations by stating that the “harm” of screening women in their 40s outweighs the benefit, (more about the harm of screening later.)

In the last 3 months, we at the Breast Care Center of St. Joseph Hospital have diagnosed eight local women in their forties with breast cancer. This is not unusual. Five of these women were diagnosed based on screening mammograms, which means they didn’t feel lumps but were following the recommendations of their doctors and the American Cancer Society to have annual mammograms. The three other women were diagnosed on the basis of lumps found by breast self-examination, the teaching of which is discouraged by the US Preventive Services Task Force because, “the available evidence is insufficient to assess effects on health outcomes.” I am optimistic that all eight of these young patients will do well, and will live to see their children grow into adulthood. I know that their spouses and parents will appreciate their continued presence in their lives. The difference that screening mammograms and breast self-examination made in these women’s lives may well be the difference between life and death.

Also in the last 3 months, we have diagnosed four women over the age of 74 with breast cancer. According to the US Preventive Services Task Force, women in their elder years have less time to benefit from early diagnosis. The implication that screening mammograms in the healthy elderly is not worthwhile is appalling. These women are individuals with full and exciting lives; they are active in their communities and in countless ways, enrich the fabric of our lives. To suggest that their remaining years are not as precious as younger women’s goes against all I hold dear about our society. We all know that humans do not live forever, but modern medicine has the capability to improve those years that we have, and early diagnosis of breast cancer beats late diagnosis any day.

So what, according to the US Preventive Services Task Force, is the harm of early detection and intervention using screening mammograms in the young and elderly? "The harms resulting from screening for breast cancer include psychological harm, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results." Perhaps this statement is the spark that caused the firestorm of outrage over these recommendations. Women are strong, capable, and resilient, and to suggest that there is lasting psychological harm from screening for breast cancer would be laughable if it were not so insulting. Is there stress associated with having an abnormal mammogram? Of course there is. Does it cause lasting harm in otherwise psychologically healthy women? Not in my experience.  The American College of Surgeons addressed the term “unnecessary biopsy,” but it applies to all tests that are, only in retrospect, called “unnecessary.” How simple it would be if we knew before any testing of any sort, who had breast cancer and who does not. Wouldn’t it be wonderful if, on a mammogram, we could easily and reliably know which masses were cancer and which were benign? The definitive test whether a breast mass is cancerous is to biopsy it. This does not make a negative biopsy “unnecessary.” These are the costs of finding early breast cancers, and we as a society have chosen to accept these costs because we believe human life to be valuable.

Is human life worthy of ANY cost? Maybe it is, but we are saddled with the reality of a health care industry that is slowing the growth of our economy, and we must work within the limitations of our sizable budgets. The breast health industry is the most highly regulated part of medicine. We are required to be recertified to the FDA on a three year cycle, (plus random surprise inspections,) proving that our images are excellent and that we are finding early breast cancers. The processes by which we read, report, communicate, and follow up with patients are inspected thoroughly. Mammography is the only test that requires patients receive letters in plain language with the results, and the only medical test that is price-fixed in Medicare by the US Congress. The existence of breast health centers is at best a break-even endeavor financially, and in most cases, these centers operate at a significant loss.

We have shown, time and again, that early diagnosis of breast cancer saves lives. Women in their forties and in their advanced years deserve the benefit of the advances we’ve made using screening mammography, and are far from being immune to breast cancer. Though the decision to have any medical test should be made on an individual basis with the consultation of a qualified health care professional, most will agree that screening mammograms should be performed annually beginning age 40.