What You Need to Know About Mammograms

How beneficial is mammography in detecting breast cancer, and when should you start getting mammograms?

A recent report published in the Journal of the American Medical Association suggests that mammograms are oversold and that the risks -- especially the potential for overdiagnosis of breast cancer -- are underappreciated. The study adds more fuel to the heated controversy about the real benefits of annual mammograms. “Some people assume that there is no benefit [to mammograms], and that’s not what we’re saying. I actually think that screening saves lives,” says Otis Brawley, MD, chief medical officer for the American Cancer Society. The problem, Dr. Brawley says, is that current mammogram guidelines lead to “an awful lot of false positives, an awful lot of biopsies, and then the number of lives saved is going to be relatively small.” Here’s an age-by-age guide to what you need to know about mammograms.

Mammogram Guidelines: Women Under 40

If you’re under 40 and at low risk for breast cancer, you probably don’t need more than a clinical breast exam every three years, according to the American Cancer Society (ACS). Risk factors that warrant an early mammogram include having an extensive family history of breast cancer, especially breast cancer in younger women; and having a family member with various genetic mutations, such as BRCA1 or BRCA2. But mammography isn’t always the best option for detecting breast cancer in younger women, who typically have dense breast tissue. “As women age, the breast density decreases,” Brawley says. “When I do a mammogram in a 20-year-old, I’m looking for something white on a white background. When I do a mammogram on a 70-year-old I’m looking for something white on a black background.”

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Mammogram Guidelines: Women Ages 40-49

While the ACS recommends annual mammograms for most women beginning at age 40, the U.S. Preventive Services Task Force (USPSTF) takes a more individualized approach toward routine screening, advising women ages 40 to 49 to make their own informed decisions. Why the difference? “Among women in their 40s, a large number of mammograms need to be done to save one life,” says Brawley. “The Task Force saw lots of inconvenience with few lives saved. The ACS said, ‘[Mammography] saves lives ­­-- therefore, we recommend it.’” But mammograms do have their limitations, Brawley adds. “Mammography screening is an imperfect test. It will miss some cancers we wish it would have found. It will find cancers we wish it wouldn’t have found, “ he says.

Mammogram Guidelines: Women Ages 50-74

According to the USPSTF, mammogram screening in women age 50 and up is somewhat more effective at saving lives than it is in women in their 40s because there seem to be slightly fewer false positives. In fact, the Task Force actually says the greatest benefit of screening seems to be for the 60 to 69 age range. But you don’t have to wait until you’re 50, or even 60, to get a mammogram if you’re concerned. “Most physicians would be willing to compromise and start screening at an earlier age,” says Brawley. “We are fortunate that insurance will pay for that screening for women starting at age 40.”

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Mammogram Guidelines: Women Over 75

The USPSTF is concerned about the potential for overdiagnosis in this age group, which they believe often leads to unnecessary early treatment. Brawley emphasizes that the decision of when to stop getting mammograms should be a highly personal one. “I would hope that a doctor who has a very healthy 75-year-old patient who is still physically active would screen them,” says Brawley. “And I would hope that a doctor who has a patient in their mid 60s who is very ill would not screen them for breast cancer.” Many breast tumors found in older patients never grow or metastasize, or the patient dies from other causes before the cancer spreads. “We harm a lot of women and men in their late 70s with medical interventions,” says Brawley.

The Future Of Breast Cancer Prevention

Because of advances in breast cancer detection, doctors are finding more cases of breast cancer than ever before. Yet, the death rate isn’t improving as much. The solution? Brawley believes we need to take a different approach when it comes to breast cancer screening. “The next thing we need to do, as we try to fix this mess with science, is to figure out who are the woman at high risk who need to be screened and the women at low risk who don’t need to be screened. The number of lives that we would save would go up. The number of false positives would go down,” says Brawley.

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