Recently, as most of us were worrying about how holiday meals, travel and work schedules would work out, new screening guidelines for women came forth from the august American College of Gynecologists (ACOG) and from the U.S. Preventive Services Task Force. In keeping with our mission to inform women about the very best thinking on these guidelines, our medical advisory board rushed to respond, with unique essays by a radiologist, a breast cancer oncologist and one of the top breast cancer surgeons in the country.
Now, the turkey well digested, we’re realizing that all that advice may have receded, mixed as it was with our already planned and lovely Thanksgiving-week series. We therefore re-post below the words of breast surgeon Alisan Goldfarb, followed by links to the other parts of the series. Stay tuned for more, including an assessment from our own Dr. Pat. — Ed.
An expert on the intersection between emotional stress and breast cancer, Dr. Alisan Goldfarb was highlighted by The New York Times over 20 years go as a prime example of “the new generation of women surgeons.” Now a clinical professor at Mt. Sinai Medical Center, Goldfarb is a clinical surgical oncologist who continues to work on creating each patient’s best outcome in breast cancer surgery.
As a practicing breast surgeon and member of the Medical Advisory Board of Women’s Voices for Change, I was asked to review the U.S. Preventive Services Task Force (USPSTF)’s recommendation statement discouraging routine screening and regular breast self-exams.
I think folly is too kind a description. Outrageous would be my choice of words.
I seriously question how a group of educated men and women could evaluate the same data, which overwhelmingly demonstrated that routine yearly screening mammography saved lives, and come to the conclusion that the risk-benefit ratio was not in favor of screening for all women. On the risk side was the anxiety that an abnormal mammogram might cause. More testing, such as additional mammographic views, or even a sonogram might be ordered. A needle biopsy, or rarely a surgical biopsy, might be necessary to see if a mammographic abnormality was in fact an early cancer or a benign change.
Since when does becoming anxious, needing an additional test or requiring a biopsy get weighed on a scale against saving a life?
To state—especially in the group of women between 40 and 50—that a discussion with her health care provider should help determine whether mammography is indicated seems peculiar. Although we are now able to determine the patients at highest risk for breast cancer—those who carry the BRCA 1 or BRCA2 gene—we have no way to determine which women, if any, are at low enough risk to forgo yearly screening. The frightening truth: Most newly diagnosed breast cancer patients have no obvious risk factors.
Perhaps the issue is the word screening. Routine screening of a large population is reserved for an “important” health problem, where asymptomatic disease can be detected and in which early treatment will result in a better outcome. Screening should be reasonably accurate, reasonably priced and cost effective. Since the advisory panel stated that cost was never an issue in their analysis, their argument is clearly concerned with test accuracy.
Mammography is a relatively inexpensive and very sensitive test. The newer Digital Mammography Units, especially, get clearer and more detailed visualization, specifically in breast tissue that is more dense. This improved imaging can lead to a “false positive” reading. Since an abnormality could be either benign or malignant, a work-up would then be necessary.
Of course when a mammogram is abnormal, a patient becomes anxious. A biopsy relieves the anxiety, and either a breast cancer must be treated—sometimes not even so early a cancer—or the patient is reassured that she had a benign abnormality. No patient of mine has ever complained of “unnecessary biopsies.” Given a choice of following an abnormality which is possibly benign or doing a biopsy and knowing the answer immediately, very few patients will opt to “follow” an abnormal mammogram to see what happens next.
The suggestion has also been made that we are diagnosing cancers that would never cause a problem. Unless we are referring to women in their 90s with heart and lung disease which will shorten their life span, how do we have that information? What researcher has followed women with known cancers in place? While mammograms do pick up a considerable amount of in situ cancer—the cancer cells have not yet spread beyond the cell wall—we know that all of the invasive cancers, the ones that do spread, begin as in situ cancers. In no other medical specialty are in situ cancers left in place.
Prior to screening mammography, breast cancer was diagnosed when a breast lump was big enough to feel. Most of those cancers required mastectomy for their local treatment and had already spread when they were diagnosed. By finding breast cancer when it is smaller, or still in situ, we can offer the choice of breast conservation and often avoid chemotherapy.
The notion that more women between 40 and 50 have to be screened to save one life than women after 50 is reasonable, since breast cancer increases with age. Yes, it is also true that more false positives are noted in the younger women, since the hormonal changes of their menstrual cycle can cause changes on the mammogram. However, and more important: In this group the tumors are generally more biologically active, and the amount of time before the disease becomes systemic is much shorter, thus requiring very careful follow up.
For women over 50, and yes, over 70, as long as they are in good health, yearly mammography is still the ideal, as long as we consider women as individuals and not as statistics. When the doctor takes your blood pressure, is that screening? When your blood is sent to have cholesterol and triglycerides measured, is that screening? No, that is your “check up.” Yet check ups are essentially screening: We work to find asymptomatic problems that can be addressed in order to prevent more serious problems in the future and to save lives by appropriate intervention.
In my opinion, all women after age 40 should have a mammogram included in their yearly check up. Call it what you will.
New Mammogram Guidelines Are Wrong – Dr. Bonnie Reichman, Clinical Associate Professor of Medicine at the Weill Medical College of Cornell University, and attending medical oncologist at The New York Presbyterian Hospital;
The Loss of the Yearly Pap Smear – Dr. Elizabeth Poyner, practicing gynecologic oncologist and pelvic surgeon, on the ACOG guidelines;
The Folly of Limited Screening for Breast Cancer Dr. Thomas Kolb, Columbia University College of Physicians and Surgeons, famed in part for his landmark study describing the performance characteristics of mammography, clinical breast examination and ultrasound.