In defense of mammograms

Earlier today, the U.S. Preventative Services Task Force (USPSTF) issued new recommendations on regular mammograms for women in their 40’s.  In short, they’re against them.

The findings are based, in part, on a finding from a meta-review of studies by the Oregon University Health Sciences Center showing that mammography reduced deaths from breast cancer by about 15% in women ages 40-49.  This data was put into a set of models that then predict that, if women postpone their first mammogram to age 50, only 3% more would die.  The study authors then weighed this risk of death versus the harms, identified in the study as “false-positive mammograms, unnecessary biopsies, and overdiagnosis,” and concluded that “the benefits of screening from ages 40 to 49 years were small.”

So, mammograms help save lives.  Just not enough lives.

Seriously?

One other point.  If you go to the original paper that discusses the models (Mandelblatt et al 2009), and click to see the data tables that show the details behind the 3% above, you learn that the 3% is a median of the six models used.  Individual, stand-alone models predicted additional deaths of 2-10% if women postponed their first mammogram to age 50.  That seems significant to me (perhaps because I can name so many women whose cancer was discovered by mammogram in their 30s or 40s, and I am better for having known them).  But beyond that, Table 3 shows clearly that mammography starting at age 40 not only saves lives, but results in between a predicted 11 and 57  “life-years gained because of averted or delayed breast cancer death,” for every 1000 women.

Let me translate that.

Because of effective screening strategies, such as mammograms, for every 1000 women, someone or some combination of them are living a collective 11 to 57 (median 33) years longer than they would have otherwise.

Let’s try that again.

Say I have 2000 followers on twitter who happen to be women.  If all of us get mammograms, there’s an extra 66 years of life to be lived.  66 years, among us, to raise our families.  To raise questions.  To raise hell.  Without mammograms, those 66 years evaporate.

Which would you prefer?

Annual or biannual mammograms, regular self-exams, and a chance to spend more time with your family?  More time at work?  More time laughing, and giggling, and throwing your kids in the leaves as you rake them?  More Thanksgiving dinners, more Christmas mornings, more birthdays?

Yeah, me too.  So before you write off mammograms, please read more about the report, find out what groups like the American Cancer Society have to say (there’s a good explanation at Dr. Len’s blog), and talk about these recommendations with your doctor.  Know the risks.  Know the benefits.  Know your own body … and always remember — if you notice a change in one breast but not the other, call your doctor right away.

As I meet more and more mothers with cancer, the importance of early detection just grows in my mind.  Tonight at 5 and 6, I’ll be on the Channel 5 newscast, talking about the importance of mammograms as one tool for early detection, as well as another important tool that we can all use … breast self-awareness.

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29 Responses to In defense of mammograms

  1. *m* says:

    Thank you for posting these links. This is definitely on my radar of things to learn more about. As someone with a family history who has been getting yearly mammograms for years, my heart sank when I read these headlines initially. I’m all about the birthdays!

  2. Karen says:

    Here in Australia there is free mamogram screening once you turn 50 – it is also avaible if you have a family history of breast cancer. Before that – you have to pay for it yourself. Almost every one of the many people I know who have been diagnosed was under 50 at the time – they deserved more birthdays.

  3. My playgroup friends and I have been talking about this article all day. I just sent them all this link. Thank you for putting this into terms we lay people can understand.

    Coincidentally, I’d scheduled an appointment for a routine breast exam just an hour before the article came out – to ask my doctor whether it was time for me to get a baseline mammogram.

  4. jaelithe says:

    Thank you for posting actual stats and talking about them in a meaningful way. The news coverage on this that I’ve seen on this thus far has been so fact-deficient (as news coverage of science usually is).

    3% is a huge number if you or your wife or your mother or sister or daughter is IN it.

  5. spruce hill says:

    You are so right! I think they need to look at woman as people with families and loved one not numbers in a statistic!!!!!!!!!

  6. Paul says:

    As an eight year old boy in 1980, even I knew it was wrong that my 38 year old mother was told by the doctor not to worry about the lump on her breast. Two years later, she lost her battle. If there was any way to prevent the pain I went through for anyone else, I wouldn’t hesitate to fight o their behalf.

    Maybe the solution should be to deny 3% of people any cancer screenings, starting with the council that made these recommendations.

  7. magpie says:

    I’m so glad you wrote about this. You were the first person I thought of when I saw the news.

  8. I have read and the jury on screening is not a compelling one from the standpoint of a woman (me) who has no significant risks factors.

    I don’t think they are saying that 3% is nothing, but it should give pause and force women to think and weigh options before just blindly accepting a paradigm that shouldn’t have been one size fits all in the first place.

  9. Margaret says:

    Ha!
    I was just coming to your website to ask you what you thought of this new information. Thanks for reading my mind and for your perspective.

  10. Sara says:

    That’s exactly what I thought after reading that article…Seriously??? Are you kidding me????

    I need to check out Dr.Len’s blog…sounds interesting.

    I’m 35yrs.old and have already thought about wanting a baseline mammo….So Important!!

  11. Kristin says:

    A lot of women are talking today, and I hope they take it farther than talk. Despite the talk, I am a little speechless in light of the recommendation. At age 34, I’m headed in for mammogram five, the first two of which happened before anyone realized how strong my risk was. We don’t have the mechanisms in place for identifying high risk women and telling us to stop checking ourselves is a slap in the face.

  12. JessicaAPISS says:

    Thank you so much for going on the air and posting here and advocating for mammograms. Although my health insurance won’t pay for mine until I’m 35, *based on my family history* I’ve paid out of pocket for annual ones since my 30th birthday. I’m not a hysteric, I just know my odds are high…so if it hits, I want to hit back as early as possible.

    I cannot believe this development.

  13. JustEnjoyHim says:

    I love the way you write it out so clearly. Thank you for this.

  14. Meg says:

    This troubled me, too, since my breast cancer was discovered at age 42 by routine mammogram.

    I am not trying to defend the study (believe me). If I understand correctly, however, this study dealt only with film mammograms, not the more detailed digital mammograms that are available in our DC area (and most metro areas). The study does not purport to say that digital mammograms are not “worth it.”

    That said, I still find this troubling….

  15. Michael Straight says:

    It’s great to see people looking critically at the statistics behind these recommendations.

    To be fair, the USPSTF isn’t saying “Mammograms help save lives. Just not enough lives.” What they’re actually saying is “For younger women, mammograms save lives, but they harm far more of them.”

    If you’re 40 years old, there’s maybe a .005% chance that getting a mammogram will save your life or prevent needing a mastectomy, but also something like a .01 % that getting a mammogram will lead to a false positive and perhaps unnecessary biopsy, treatment, and emotional distress. (That’s just a rough estimate to illustrate the issue, not actual percentages.)

    All USPSTF is saying is that, given those risks, women under 50 should decide for themselves if the possible benefit is worth the possible harm.

    And from a public health standpoint, we also need to ask the question, is it worth giving 100 women an unnecessary biopsy to save 1 life? What about giving 10,000 women unnecessary biopsies to save 1 life? You’ve got to draw the line somewhere, which is what USPSTF is trying to do.

  16. kimhaynescharleston says:

    We at the Medical University of South Carolina’s Hollings Cancer Center (a nationally accredited breast center) disagree with the new recommendations from USPSTF. We believe that women 40 and older should continue to have routine mammograms. See Dr. Megan Baker, breast surgeon, respond to the new guidelines in this video: http://www.youtube.com/watch?v=yMwSRI4PfXc

  17. Cassandra says:

    I’ve followed your blog for some time and have never commented before. I was diagnosed wtih Stage II BC just a few weeks before you, and had much of the same treatment and surgeries as you did. Though silent, I often cheer you on in so many of your efforts. Including this one.

    The study authors (and some of the commenters here) fail to take into account that not everyone knows their family history and BC risk. I am an example of that and I know I am not alone. I tested postive for BRCA 1, after I was diganosed with aggressive cancer, without any family history of BC. And teh study also fails to point out what the risks are of having “unneccessary” mammograms. Yes, I know that being exposed to radiation is not great for anyone, but are X number of women dying because of that?? Is there some other adverse effect that is greater than the risk of not having women undergo mammograms?

    Finally, I feel the study does such a disservice to young women because it now makes it seem like BC is a disease of “older” women, over the age of 50. Thus how many young women will not even do self-checks now, and in future generations, because they don’t think they have anything to worry about, at least not until they are older. It just sends the wrong message. And all I know is that if I had not been doing self-checks, I would not be here now.

    Keep up the good fight, Susan. We are behind you!!

    Cassandra

  18. Michael Straight says:

    Cassandra asks, “Is there some other adverse effect that is greater than the risk of not having women undergo mammograms?”

    1. False positives leading to unnecessary biopsies and unnecessary treatment and unnecessary emotional distress for women who don’t have cancer.

    2. True positives that find harmless cancers. Some breast cancers never become invasive and never threaten a woman’s health, but we can’t reliably tell the difference, so when a cancer is detected, doctors usually err on the side of treating it. As you increase the number of women screened, you end up catching more of these harmless cancers and giving women surgery and radiation that they never would have needed if they hadn’t been screened.

    Of course women should decide for themselves how to weigh the trade-offs and risks. Many women would say the risk of undergoing painful cancer treatment unnecessarily is much less important than the risk of dying from cancer.

    What these new guidelines are saying is that in women under 50 the benefits are rare enough and the risks substantial enough that women should be educated about the risks and told there is a choice to be made rather than simply told to get a mammogram.

  19. Cassandra says:

    I do not see how undergoing a biopsy to examine a suspicious growth is harfmul! Or so harmful that it means dismissing an entire age group from getting routinely examined for a deadly disease. I just don’t get it. And whatever emotional distress accompaniees that (of getting an “unnecessary” biopsy) it is nothing compared to the severe emotional distress of actually having cancer and undergoing the ensuing treatment. And even that pales in comparison to the emotional distress of finding out that your surpirse cancer diagnosis at the ripe old age of 42 is at Stage 3 or Stage 4. And the argument about “harmless cancers” and the supposed over-treatment of them seems like a seperate issue. After all, even under these new guidelines, if a cancer is detected–any cancer–then it still might be prone to “over-treatment.” But what is at stake is that now young women, those in their 20s and 30s, will never even think about breast cancer or their risk until they get much older. They will not have the vigilance to know and understand their bodies like teh generations before them have learned.

  20. Sixis says:

    I’m gobsmacked about the recommendation. It seems somewhat um… paternalistic. Uneccessary emotional distress? Sheesh

    I guarantee that some insurance companies are going to stop paying for mammograms for the under 40 crowd based on this. Tragic, tragic, tragic.

  21. Meg says:

    I’m violating my usual two post rule, but I just saw my breast surgeon today (routine checkup) and she is NOT happy about this. She said she understoond that there wasn’t even a breast specialist on the Task Force!!!! (She thinks this is all health-care related spin-mongering.) GRRRRRRRR……

    Meg — 2 year breast cancer survivor and mommy to 3.75 year old twins

  22. amanda says:

    Thank you, as ever, for your piercing, frank perspective. So glad that you are here to share it with us.

  23. Stimey says:

    Right on, Susan. It floors me when they say that, yes, mammograms will catch otherwise undetected cancers, but that those are less important than too many false positives. Shocking. That statistic totally doesn’t matter if it is your loved one who doesn’t get to have that life-saving mammogram. Health care should be run as if every patient were your own damn mother.

  24. Kathy U says:

    My first thought upon hearing these findings was – I wonder what insurance companies contributed to the funding of the study?

    This would not be the first time interest groups and even the US government swayed information so as to benefit a powerful lobby in this country. How about grain fed and hormone overloaded cattle and fowl that are now found to be less healthy food option for people? The shift to corn oil? The farmers benefited and the health of our nation has suffered with higher rates of vascular and heart disease.

    Today insurance companies do not want to pay for the health care their customers pay for. The companies bottom line can determine your future. Scary.

  25. Johanne says:

    Very pwerful links to drive your point.

  26. Edge Health says:

    Make sure to tune in to Kaleidoscope, an amazing women and cancer special that combines the beauty of skating, the excitement of song and the brave message of survivorship in an evening of family-friendly, holiday entertainment. Kaleidoscope airs Thanksgiving Day, from 4-5:30 PM EST, directly following the NFL on FOX.

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  27. Ruthie says:

    The first thing that I thought about was Universal Health Coverage…..trying to get the cost lowered before they even get it passed.

  28. Mammograms for women age 40 is around 1 life saving find for every 1900 mammograms. I agree that this may not be the best number. But women’s #1 health concern is breast cancer. I believe that the emotional side is also important as well. The well being of knowing that your mammogram was normal can also be quite helpful

  29. Cyndi says:

    Thanks for this — I’m borrowing your guest post and linking to this one, too. Will be up on Tuesday at juniandpip.blogspot.com with links to you. Thank you!

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