Why Is Mammogram Advice Still Such A Tangle? Ask Your Doctor

Oct 21, 2015
Originally published on October 22, 2015 5:12 pm

Stephanie Nichols is a stay-at-home mom in Boston. She's 44 now and says she first thought about getting a mammogram when she turned 40.

"I had heard from a number of friends all around the same age that they're all getting mammograms," she says. So it came as no surprise when her doctor brought up the topic at her next routine exam.

But what was surprising, she says, was that, after discussing family history and personal health, her doctor determined that because Nichols was not at high risk for getting breast cancer, it was probably too soon to get that first scan. Together, they decided to postpone her first mammogram screening test until she was 45.

Nichols says she felt comfortable with that decision, "knowing that my risk for breast cancer was low compared to the risk of having to have more invasive procedures such as biopsies or lumpectomies."

She's right about the statistics. Researchers say that, across a 10-year period of getting annual mammograms, women overall have a 50-50 chance of being called back at least once for further testing that turns up nothing cancerous.

And that's one reason why the American Cancer Society changed its advice Tuesday. It now recommends that instead of getting that first screening mammogram at age 40, women who don't have an increased risk for breast cancer can start the screening later — at age 45.

But even that advice starts the screening too soon, according to the U.S. Preventive Services Task Force, which still advises most women of average risk to wait till they're 50. Meanwhile, the American College of Obstetricians and Gynecologists still suggests most women get their first screening at 40. So, which advice is best for you?

Dr. Lydia Pace, an internist and primary care doctor at Brigham and Women's Hospital in Boston, describes a "really wide range in the way women approach this question." She says some women come in already knowing they want to start screening at age 40; some ask about screening even before age 40; and some are seeking a more nuanced conversation with the doctor about the particulars of their situation.

And Pace says that discussion with your doctor is absolutely the best approach. If you're at higher risk than average — if your mother or sisters or aunts had breast cancer, for example — it might be reasonable to start screening at 40.

Other women who are very worried about getting breast cancer may reasonably start at 40, too, Pace says. This might include some women, for example, who have had strong personal experiences with family or friends who got the illness.

"That may be a much more powerful influence for them than any conversation we can have," says Pace.

And that's OK, she says. These women could reasonably decide that, for them, the increased peace of mind they'll get with a clear mammogram outweighs the increased risk that they'll also have to undergo further expensive scans, unnecessary biopsies and other testing.

If you wish the evidence about when and how often to screen for breast cancer were more clear-cut, or that the leading groups of doctors offering advice could get on the same page, you're not alone. Lots of doctors are frustrated too.

Dr. Laura Esserman, who directs the University of California, San Francisco Breast Cancer Center, notes that every year, roughly 40,000 women die of breast cancer. What's most important now, she says, is putting energy into finding reliable solutions instead of "arguing about it."

Part of the problem, she says, is that the data everyone's basing their argument and recommendations on are 30 to 40 years old. She says the studies "were done before we had modern treatments for breast cancer, before we knew about the different kinds of breast cancer, before we understood a lot about breast cancer risk."

"And so it's high time we do a modern trial where we put some new ideas to the test," Esserman says.

She recently received a grant to see whether a personalized approach, like the one Nichols worked out with her doctor, is as safe and effective at catching aggressive cancers as yearly mammograms starting at age 40.

In the meantime, when should women stop getting screening mammograms? That too, for now, depends on whom you ask.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.

Transcript

STEVE INSKEEP, HOST:

Let's sort through the confusion over mammograms. The latest recommendations involve a vital decision for some women over 40. The American Cancer Society says the average woman should not start breast cancer screenings until age 45. That's different from some other recommendations. For example, one group says women should start getting mammograms at age 40, another says age 50. NPR's Patti Neighmond reports on the conflicting advice.

PATTI NEIGHMOND, BYLINE: Stephanie Nichols is a stay-at-home mom who lives in Boston. She's 44 now. But when she turned 40, the buzz about mammograms was everywhere.

STEPHANIE NICHOLS: I had heard from a number of friends that are all around the same age and getting mammograms, so it wasn't a surprise. I anticipated that was going to come up.

NEIGHMOND: And the topic did come up the next time Nichols visited her primary care doctor.

NICHOLS: We talked about my family history relating to breast cancer and cancer in general, my health in general.

NEIGHMOND: And together, they decided to postpone mammograms until Nichols turned 45, which is exactly the age the American Cancer Society now recommends women of average risk, like Nichols, start screening for breast cancer.

NICHOLS: I was comfortable taking a risk knowing that my risk for breast cancer was low compared to the risks for having to have more invasive procedures, such as biopsies or lumpectomies.

NEIGHMOND: In fact, researchers say over a 10-year period of getting yearly mammograms, women have a 50-50 chance of being called back at least once for further testing that in the end turns up nothing. And that's one reason why the Cancer Society changed its advice and now says women should start screening at 45 not 40. But the advice is at odds with federal health advisers who say women should wait till they're 50 and with the American Congress of Obstetricians and Gynecologists, which says women should start at 40. As a result, it's no wonder women may be confused.

LYDIA PACE: There's a really wide range in the way that women approach this question.

NEIGHMOND: Dr. Lydia Pace is a primary care doctor at Brigham and Women's Hospital in Boston.

PACE: Some women come in already knowing that they want to start screening at 40. Some women ask about it before age 40. And then some women come in really wanting to have a more nuanced conversation with the doctor about whether they should start or not.

NEIGHMOND: Pace says some women at higher risk - those with a family history of breast cancer, for example - may choose to start screening at 40. Others who are super worried about breast cancer may do the same.

PACE: If they have had strong personal experiences with family or friends who had breast cancer, that may be a much more powerful influence for them than any conversation we can have. And so for those women, starting at 40 is totally the right decision.

NEIGHMOND: And it's not just patients who are unsure. Lots of doctors are frustrated, too. Laura Esserman is director of the UCSF Breast Cancer Center in San Francisco.

LAURA ESSERMAN: Let's put our energy into doing better instead of arguing about it.

NEIGHMOND: Esserman says part of the problem is that the evidence from clinical trials everyone's arguing about is 30 to 40 years old.

ESSERMAN: These trials were done before we had modern treatments for breast cancer, before we knew about the different kinds of breast cancer and before we really understood a lot about breast cancer risks. So it's high time that we do a modern trial where we put some new ideas to the test.

NEIGHMOND: Esserman recently received a grant to see whether a personalized approach, like the one Stephanie Nichols worked out with her doctor, is as safe and effective as yearly mammograms starting at age 40. As for when you can stop annual mammograms, the new guidelines from the American Cancer Society say you can switch to every other year starting at age 55. Patty Neighmond, NPR News. Transcript provided by NPR, Copyright NPR.