Should You Hold Off on the Yearly Mammogram?
Maybe you shouldn't start those yearly mammograms in your 40s after all. So says the American College of Physicians.
In a new set of clinical guidelines published this week in the Annals of Internal Medicine, the influential ACP says a woman's risk factors and personal preferences should determine whether she seeks a yearly mammogram before age 50. The position puts the group at odds with both the American Cancer Society and Susan G. Komen for the Cure, which endorse annual mammograms beginning at age 40.
The issue is not that that the ACP doubts mammograms prevent breast cancer deaths; indeed, the available research seems to show clearly that mammograms for women in their 40s leads to about a 15 percent decrease in mortality from the disease. But since that benefit is smaller than the 22 percent decrease in older women, the risks of the test–namely the physical and emotional stress of a false positive finding–need to be carefully weighed, the ACP says.
Douglas Owens, an internist at Stanford University and director of the Stanford-UCSF Evidence-based Practice Center, chaired the committee that wrote the new recommendations. He says a woman in her 40s and her doctor should have a conversation about her personal risk, which can vary from a 0.4 percent chance of developing breast cancer over the next five years for a 40-year-old with no risk factors, to a 6 percent chance for a 49-year-old with many risk factors, such as a family history of the disease or multiple previous breast biopsies.
She also needs to consider both the benefits and harms of mammography–the small drop in mortality, on one hand, versus the chances of a false positive reading and possible unnecessary biopsy. Finally, women need to figure out how they feel about all this, he says. Some may decide they'd rather be safe than sorry, even if it results in some temporary worry; others would prefer not to have the test until they're old enough to reap a more significant benefit. "These are things only the woman knows," says Owens. "So women need to be as involved in this as they can be."
Susan Brown, manager for health education at Susan G. Komen for the Cure, an advocacy group, worries that these new recommendations may just muddy the waters. "They may lead to some confusion and make women think mammography isn't a useful tool," she says. She agrees that a conversation about risks and benefits of the test is important, but notes that a 15 percent decline in mortality is not insignificant. Moreover, research shows women of all ages are increasingly skipping their mammograms. "We're concerned that if there isn't a definite recommendation, compliance will fall off even more," she says. (Komen recommends an annual mammogram beginning at age 40 as well as a clinical breast exam at least every three years beginning at age 20 and then annually after age 39, plus monthly self-exams for all adult women.)
Owens says the guidelines should be read as a recommendation that a 40-something woman discuss the pluses and minuses of the test, not forgo it completely. "We're not against screening," he says. "But we want women to participate to the greatest extent possible in the decision."