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.


If the patient chooses to forgo mamm0pgraphy and self exams based on the USPSTF guidelines, then she is likely to wait for these symptoms to be discovered before she can even receive an evaluation for cancer.


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.

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.

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  • Deni March 10, 2010 at 11:14 pm

    My aunt had breast cancer… I never realize how close we are with this disease. Thanks for the clear explanation. I do think people should know more about this.

    Reply
  • Elizabeth Hemmerdinger November 24, 2009 at 1:47 pm

    Thank you, Dr. Goldfarb, for this clear rebuttal. I’m going to keep a copy in my purse, to whip out whenever the topic is brought up — these days, daily!
    EGH

    Reply