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Breast Cancer: To Screen or Not to Screen, That Is the Question

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Or perhaps rather than paraphrasing Shakespeare, we should ask, "When Should We Screen?" As evidenced by my patients' questions in my clinical office, the recently published policy revision from the American Cancer Society puts many women into a state of confusion. Since there were many false-positive results with mammography as practiced when prior studies were published, the revised recommendations suggest that for women of average risk of breast cancer, first screening mammograms should start at age 45 and continue until the life expectancy is less than 10 years.

What are false positive results? These are screening mammogram results that find a suspicious shadow that ultimately is not breast cancer but does result in calling back a patient for another more detailed mammogram (possibly with ultrasound, and even possibly resulting in a biopsy). Because women can get very nervous about possibly having a cancer, but then being relieved by finding that there is no cancer, the guideline developers felt that fewer mammograms should be performed to reduce that apprehension and anxiety when a false positive result occurs. False positive results are not uncommon: By a woman's ninth mammogram the risk of a false positive result is 5 percent to 100 percent depending on her breast cancer risk.

But is that the whole story for women? Or do women get mammograms because they actually fear breast cancer and want to find it as early as possible when it is most curable? Do they actually fear finding a cancer when it is so advanced that they will need a mastectomy rather then finding it earlier when a simple lumpectomy could be curative? Or do they really more strongly fear finding a cancer later when it may be metastatic and ultimately fatal? Those fears are different in different women, so each woman needs to discuss their greatest fear with their doctor to get the best advice on whether to screen starting at age 40, or 45, or even 50.

So let me describe some important undisputed facts about screening mammography and breast cancer. Screening mammograms save lives! With annual or semi-annual screening mammography exams, the death rate from breast cancer is 20 percent less. If a cancer is found by screening mammography, it is smaller and less likely to have positive lymph nodes (which makes it lower stage). This means that less surgery needs to be performed to get rid of the cancer (a smaller lumpectomy to remove the cancer, rather than a a mastectomy for a larger cancer) and less often needs chemotherapy. Most women I have cared for do not want to have a mastectomy, which is needed for larger cancers or cancers with multiple spots.

Screening mammograms are more frequently positive if there are higher risks of breast cancer. So the revised recommendations only apply to women of low to average risk. If a woman has a higher risk, then screening mammograms should be performed at earlier ages.

What factors raise the risk of breast cancer? Risk is higher if a woman has had radiation to the chest, taken post-menopausal hormone replacement to relieve menopausal symptoms, had a prior breast biopsy (especially if it showed hyperplasia or atypical hyperplasia, papillomatosis, or sclerosing adenosis), had prior breast cancer, has dense breasts (making mammograms less accurate and necessitating ultrasound or MRI), has a family history of breast or ovarian or pancreatic cancer, has a positive test for a gene mutation that can cause breast cancer (like BRCA 1 or 2, PALB2, CHEK2 or others), had the first child after age 30 (or had no children at all), had the first menstrual period before age 12, has been a smoker or used alcohol (especially two or more drinks per day), is overweight or obese, does not exercise, whose mother took diethylstilbesterol (DES) during your pregnancy, has night work schedules, or has a diet high in fats. These are a LOT of conditions, so many women have at least one of these, if not more. And for these women who have an increased risk, it is important to discuss these risk factors with their physicians to help decide when screening mammography should begin. Usually, screening should begin at a younger age with higher risk.

What is not a screen mammogram? If you ever have any breast symptom, such as a lump, or a dimple in the breast, or retraction of a nipple (it pulls inward), or a pain that does not go away, or a sore on the breast skin that does not heal, then you do not need a screening mammogram. Instead, you need a breast exam by the doctor and a diagnostic mammogram to help diagnose a potential problem, and you need them immediately, not waiting for an annual screening mammogram.

So here are my tips on getting screening mammograms.

• If you have any of the risk factors (described above) that raise your chance of having breast cancer, discuss this with your doctor and ask if you can start screening for cancer at age 40 (or 35 if your family history includes women who have had cancer at ages under 40).

• If you have a family history of cancer, ask your doctor if a BRCA 1 and 2 test (or a broader test for all the breast cancer genes) is appropriate. If your doctor does not know, ask for a second opinion. For advice on second opinions, see my book Surviving American Medicine.

• Check your actual risk of breast cancer by using the breast cancer risk tool from the National Cancer Institute. If your risk is above normal, consider risk-reducing medicine such as tamoxifen, raloxifene, or aromatase inhibitors. If your doctor does not know, ask for a referral to an oncologist to discuss the benefits and risks.

• If you have any breast symptom, immediately go to your physician to get an exam and diagnostic mammogram. Do not let breast cancer grow because you have procrastinated and not had it looked at.

• In considering cancer screening tests, understand what you are afraid of. Are you afraid of getting a call back for a suspicious spot, and afraid of getting a diagnosis of a curable cancer? Or are you afraid of missing a small cancer and letting it grow and possibly spread? Let your doctor know what most concerns you so the physician can make the right personalized recommendation for you.

• Newer methods such as 3D mammography (tomosynthesis) may reduce false positives and increase the accuracy of mammography screening. Discuss the availability of these techniques in your neighborhood, or ask for a second opinion.

Don't get paralyzed by the confusing national recommendations. Use your doctor and your common sense to understand your risks, and prevent cancer or diagnose cancer early. Make sure that the progress medicine has made in cancer (higher cure rates and reduced death rates) helps you to live a longer and healthier life.

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