Most of us heard through the news or a friend, that in November 2009, the US Preventative Services Task Force (USPSTF) released new recommendations for routine mammography screening. They recommend that routine mammography begin at age 50 (previously it was age 40) and occur once every two years until age 74 (as opposed to every year). Their recommendations were based on studies that revealed that mammograms in 40-50 year old women led to many false positives and invasive testing that was unnecessary – meaning patients would have an abnormal mammogram, undergo biopsy, and find out there was no malignancy. Furthermore, the USPSTF believes that eliminating mammography in this age group would be cost effective and would prevent unnecessary biopsies and anxiety. Lastly, the USPSTF recommends against clinicians teaching women how to perform breast self-exams (BSE).
As a practicing physician these types of new recommendations can be frustrating! And I hear frustration from patients each day that they don’t know what to make of the changes.
First off, there are conflicting recommendations from different reputable organizations. The American College of Ob/Gyn (ACOG) “maintains its current advice that women in their 40s continue mammography screening every one to two years and women age 50 or older continue annual screening. . . . At this time, ACOG's position is that ob-gyns should continue to counsel women that BSE have the potential to detect palpable breast cancer and can be performed.”
Secondly, we worry how insurance companies will respond – will they stop covering the mammograms for 40-50 year olds and only cover one mammogram every 2 years after age 50? This essentially means patients will be angry if their doctor sends them for a mammogram and they have to pay out of pocket!
Do you see the dilemma that this puts us in as physicians and patient advocates?
Breast cancer is one of the leading causes of death in women. The risk that a woman will develop breast cancer during her lifetime is 1.5 % – this means 1 out of every 8 women will develop breast cancer. Yes, this number is much lower in women aged 40-50, about 1.44% or 1 in 69. However, breast cancer is still one of the leading causes of death in this age group!
What have I decided to do?
• Most importantly, high risk patients will still be recommended mammography at an early age (the exact age depends on the situation). High risk patients include those with BRCA1, BRCA2, and family history of breast cancer.
• I continue to teach patients how and when to do their monthly self breast exams. Mammograms are not perfect. . . every doctor (and many women) know of a patient, family member, or friend that had a normal mammogram earlier in the year only to discover a breast lump a few months later – and a cancerous one at that! My thought? What’s the harm in doing the self exams? And there is so much to gain – you could diagnose a cancer months to years earlier! An early diagnosis can make the difference of life and death.
• So far, I have continued to offer my patients aged 40-50 mammograms every 1-2 years and most everyone has decided to undergo the screening – even if it may mean additional testing or biopsies in the future. Those patients that opted not to get the mammogram were because insurance would not pay for the test. So what this boils down to is that the insurance company essentially is making the decision for the patient! In my opinion that is just way too much power for an insurance company to have!
If you are having a tough time deciding whether routine mammography screening is right for you, talk with your doctor. The Australian Screening Mammogram Decision Trial has a web based tool that also aids in making the decision.
Manisha Parikh, M.D., FACOG
OB/GYN on the medical staff at Texas Health Harris Methodist Hospital Hurst-Euless-Bedford
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