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Should Women Get Fewer Mammograms?

by — Last updated: 2015-11-16 in Women's Health

For decades, women have been told that it is important to get biannual screening tests for cancer, including mammograms. However, medical researchers have come to question whether erroneous results cause more harm than early detection does good.

Forty-four year-old mother of three Joan had an all-too-common experience with breast cancer.

In a routine mammogram, Joan's doctors found evidence of an 6-millimeter in situ ductile carcinoma. This was a cancer about 1/3 of an inch wide. It was "in situ," meaning it had not spread. It was ductile, meaning it was in a milk duct in the breast, poised to spread.

Joan's doctors removed the tumor two weeks later. She went home later the same day, but the next week, the doctors called again. They had received the pathologist's report. The edges of the tumor were not clearly defined, so it was possible that the surgeon had missed part of the tumor. Joan came back to the hospital for another operation, this time to remove lymph nodes under her arm. She was scheduled for radiation treatments, and had to have daily physical therapy to restore the use of her arm. After about a year, she had normal use of her arm. Of course, a large part of her breast had been removed, and Joan was offered yet another surgery to have it reconstructed. Joan seriously considered having the operation, since she was having to use an external prosthesis ("falsies") to make her breasts look equal and the scar tissue was very prominent. 

However, she was worn out from fighing cancer, she knew that breast reconstruction surgery doesn't always go as planned, and the expense was not covered by insurance. She simply wanted to go on with her life.

Joan had her surgery in 2001. Had she had her mammogram in 2015, the doctors probably would have advised not having an operation at all. Because so many women have had "unnecessary" breast surgeries with all their attendant pain and complications, some doctors have started questioning whether women should have as many mammograms as they do now.

Improved Diagnosis, Same Results

Dr Atal Gawande, an influential American cancer specialist summed up the opposition to mammographyevery other year in a comment published in the New Yorker. "Cancer screening with mammography, ultrasound, and blood testing," he wrote, "has dramatically increased the detection of breast, thyroid, and prostate cancer during the past quarter century. We're treating hundreds of thousands more people each year for these diseases than we ever have. Yet only a tiny reduction in death, if any, has resulted."
 
Moreover, as Joan's experience suggests, the process of treating tiny cancers results in major disruption to day to day life. Eliminating a possible threat to life can be utterly necessary, or it rob the patient of years of quality of life if treatment is too drastic and too soon.
 

Mammograms Are Big Business

A wide range of doctors are involved in mammography. They have different perspectives and different points of views. Generally speaking, if any one doctor involved in the test is concerned enough, their patient will be pressured to get cancer treatment.
How many doctors are involved in this one test? The primary care doctor schedules the tests and makes the referrals to specialists. The radiologist interprets the test and is involved in biopsy later. The pathologist examines the tumor itself, and an oncologist prescribes ongoing cancer treatment. A plastic surgeon will be involved in reconstructing the breast, and a small army of nurses, physical therapists, pharmacologists, and nutritionists will be involved in adjuvant care.

Should You Have Regular Mammograms?

Once a mammogram is performed, Pandora's box has been opened. If there is any sign of cancer, treatment cannot be withheld. Even if the tumor would likely remain in situ, without becoming malignant, for a year, five years, or ten years, treatment will be recommended immediately. The medical establishment has zero tolerance for most small cancers.
 
The problem with aggressive treatment is that mammography is not perfect. Between 1 and 10 percent of women who have positive findings on mammography don't actually have cancer, but they will still get surgery. 
 
As a result, the US Preventive Services Task Force, a group of medical decision makers mandated by the Affordable Care Act, has decided to change the rules for mammograms for women in America.
  • For women in their forties, mammograms every other year are given a "C" recommendation.
  • For women aged 50 to 74, mammograms every other year are given a "B" recommendation.
What's the difference for American women? A "C" recommendation means the test will still be covered by insurance, but women will have to pay any copay or deductible to get mammograms during the 40's. A "B" recommendation means that not only will the test be covered by insurance, but insurance companies will also waive any copayments or deductible. Some women will want to have a prophylactic mastectomy because they have the BRCA gene for cancer. Their medical costs will not be affected by this recommendation. 
 
Is this a good recommendation for American healthcare. Most women and most members of Congress, which writes the laws for the ongoing implementation of the Affordable Care Act, strongly disagree. 
 
Breast cancer is much rarer among women under the age of 50, but when it does occur, it spreads much more rapidly. 
 
Still, medical experts counter with two observations:
  • Breast cancer, like some forms of skin cancer, doesn't always spread. Ductal carcinoma in situ, which was what the woman mentioned earlier in this article had, tends not to become malignant (although the slightest hint of malignancy will trigger aggressive treatment). Some experts believe that up to 50 percent of all cases of breast cancer are of the non-malignant variety, although others place the number as closer to 10 percent. The American Cancer Society places the number at 20 percent. In other words, the experts don't really know how often breast cancer is not life-threatening.
  • Radiologists, who perform mammograms and the biopsies they may require, report that aggressive screening programs have reduced the rate of breast cancer deaths by about 30 percent. Other researchers, however, suggest that there has been no reduction in the death rate from breast cancer except on account of better treatment.
What should a woman do?
  • If you have any family history of breast cancer, get regular screenings, even if you are under 50.
  • If you feel a lump during your monthly breast self-exam, see a doctor right away. In both of these situations, your doctor can usually make a diagnosis that gets full insurance reimbursement.
  • If you over 50, get a mammogram at least every other year.
  • Be aware that all forms of breast cancer are not equal. If you are diagnosed with ductal carcinoma in situ, ask your doctor about the advisability of watchful waiting, leaving the tumor alone unless it begins to spread.
Read full article

  • Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med. 2012. 367:1998-2005. http://www.nejm.org/doi/full/10.1056/NEJMoa1206809 Accessed September 30, 2015.
  • Esserman L, Shieh Y, Thompson I. Rethinking screening for breast cancer and prostate cancer. JAMA. 2009.302:1685-1692. http://jama.jamanetwork.com/article.aspx?articleid=184747 Accessed October 5, 2015.
  • Photo courtesy of armymedicine: https://www.flickr.com/photos/armymedicine/6198092775/ and https://www.flickr.com/photos/armymedicine/14917131905/

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