To Mammogram or not to Mammogram

Now that the dust has settled on the mammogram issue, I’ve had time to digest all of the news. In as much as I am from 3 generations of breast cancer survivors and carry the BRCA2 gene, I may be too biased to see any other perspective other than the pro-early detection side of the mammogram debate BUT I’m not too biased to be confused by the conflicting reporting of the last week. The new recommended standard of not having mammograms until the age of 50 (and then every two years) and the report that discourages doctors from teaching self-examination techniques are so foreign to how I’ve managed my own breast cancer threat as well as the other women in my family affected by breast cancer. Three out of the 5 women who had breast cancer were diagnosed years before their 40th birthday and self exam saved my Mother’s life so without early detection, mammograms and breast self-examinations, I would have to re-write my family history to say I’m from 3 generations of breast cancer victims.

The reason for the new recommended standards, according to the task force (USPSTF), is that studies show that “the additional benefit gained by starting screening at age 40 years rather than at age 50 years is small, and that moderate harms from screening remain at any age.” They also cite the potential harms of screening as anxiety, extra procedures and costs due to false-positive results. Anxiety should not have a bearing on whether women ages 40-49 are screened. I’ve experienced a false positive MRI breast cancer screening however the anxiety was a minor concern. I needed to know whether I had breast cancer which required an extra procedure. Furthermore, switching ‘recommendation gears’ so suddenly must also be considered anxiety producing! So what is the USPSTF referring to when they say “additional benefit” is small? They apparently are referring to the 1 in 2000 women who were screened (ages 40-50?) and were fortunate enough to discover their breast cancer through mammograms or other diagnostic testing. That number may seem insignificant unless that ‘one’ number is your mother, sister, daughter, partner or someone else you love. Are we to become just a number in a statistical model, a cost that outweighs a benefit in a cost/benefit ratio? I guess it depends on your perspective. Let’s face it, our perspectives can and do change based upon what life throws our way!

I guess what I’m saying here is that these are subjective questions and I’m afraid the answers are just as subjective, which raises another question - who is the United States Preventive Services Task Force? According to the U.S. Dept of Health and Human Services website, the “USPSTF” is “an independent panel of experts in primary care and prevention.” The mission of the USPSTF is to “evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care.” According to the U.S. Dept of Health & Human Service, the panel consists of a group of professionals, almost all of them being either academic medical professors or medical professionals. If you want to see who exactly are the current members of the USPSTF, you can view the entire list on the US Department of Health & Human Services web site. Apparently this panel was appointed during the Bush administration. The creation of the task force dates back to 1984, at a time when screening methods for cancer, cholesterol levels and diabetes were just emerging and rarely paid for by insurers. Dr. J. Michael McGinnis, deputy assistant secretary for health, decided to set up a group to evaluate how well such methods worked. McGinnis wanted the group to be insulated from politics and choose a panel that could objectively evaluate evidence. He wanted to avoid this group being exposed to political pressure. Although appointed by the Department of Health and Human Services, the group works at arms length and makes decisions without consulting the agency. This seems to be the case in as much as the current Secretary (Kathleen Sebelius) has publicly distanced herself from the panel’s recommendations by saying “mammograms have always been an important lifesaving tool in the fight against breast cancer and they still are today. Keep doing what you have been doing for years - talk to your doctor about your individual history, ask questions and make the decision that is right for you”. Stop - I don’t know who to believe!

Regarding the mammogram report, the group maintains that in their research, considering costs is prohibited, and that their findings are the result of scientific evidence. Some of the panel members are quite surprised by the public reaction to their findings. Some claim that the task force’s message was distorted and in fact they meant to report that women should make their own decisions. I ask, can it get anymore confusing? Women are so conditioned to yearly mammogram screening - it’s almost part of our culture - magnets for the fridge, reminders from your insurance companies, fundraisers for those that can’t afford screening - the list and media hype regarding mammograms is overwhelming. Did the panel really think they could overturn a 40 year old mindset by simply putting out new guidelines? Perhaps they didn’t take into consideration that women are no longer passive participants in their health issues. The days of women blindly following their doctors recommendations are long gone. Women have become pro-active in their health decisions and if they are unable to do so themselves they have someone else advocating for them. We’ve come a long way since the 1950’s when my grandmother was diagnosed with breast cancer. She went into the hospital with a suspicious lump and woke up without a breast! Glad those days are behind us!

Before I even had time to digest the mammogram issue, next up for debate is the Pap Smear guidelines - suggesting that women can now hold off until they are 21 for their fist Pap Smear and after reaching the age of 30 and having 3 consecutive normal pap smears they can be tested every three years AND finally, no pap smears recommended for women over 65! Is it pure coincidence that these guidelines were released just days after the mammogram debacle?

I can’t help but wonder if there is another shift in recommendations on the horizon? The fact is that all of this MAY in fact reflect evolving scientific evidence but only time will tell. Being prudent may still be the best way to go. It’s not a guarantee or insurance to good health but then again, there are no guarantees in life. Personally, I’ll continue to educate myself, be my own advocate and feel empowered by the decisions I make concerning my health. I know my proactive measures won’t control my destiny however I’m grateful I had the opportunity to make those decisions. Fortunately for me, I no longer need mammograms- one less thing to worry about and one less issue to try and sort out!

Susan M. Beausang