Fewer Mammograms?

What is your take on the mammography controversy? Do you think less frequent screening is advisable? What about the recommendation against teaching breast self-examination?

– November 23, 2009

For the record, you’re asking about the breast cancer screening recommendations issued in mid-November 2009 by the U.S. Preventive Services Task Force. This group is charged with conducting rigorous, impartial assessments of the scientific evidence for the effectiveness of preventive services – that includes screening tests such as mammograms, as well as counseling and medications.

However, the Task Force recommendations do not automatically become U.S. government health policy and therefore don’t change reimbursement for women on Medicare, nor are they likely to affect private insurance reimbursement for mammograms.

The new screening recommendations are that women between 40 and 49 need not have annual mammograms unless they’re at high risk of breast cancer and that women between 50 and 70 should have mammograms every other year rather than annually. The Task Force also said there is not enough evidence to make a recommendation for women over 70, because screening effectiveness hasn’t been researched adequately in this age group.  It also recommended against teaching breast self examination (BSE) to women.  While monthly BSE is no longer deemed essential, I believe that all women should be familiar with the way their breasts normally feel so that they can recognize any changes that may develop.

What seems to have been lost in the controversy is the finding that mammograms reduce breast cancer deaths by 15 percent. You would think from reading and hearing the coverage of the new recommendations that mammograms are foolproof and prevent 100 percent of breast cancer deaths among women screened. Here are the sobering numbers from the task force report: for women in their 40s, one death is prevented among every 1,904 women screened annually for 10 years, compared with one death for every 1,339 women age 50 to 59, and one death for every 377 women age 60 to 69. During that time, hundreds of women would be harmed by having unnecessary biopsies as a result of false-positive mammograms and, the task force said, unnecessary treatment for very slow-growing breast cancers that may never cause trouble during a woman’s lifetime. Anxiety engendered by unnecessary biopsies and treatment was listed among the harmful effects of overscreening.

Mammography is an imperfect test, and there is widespread medical disagreement about how best to use it. No panel, no matter how expert, can tell an individual woman what’s best for her. That is something she has to resolve with her physician, her familiarity with the evidence, how she sees her own risk of breast cancer, and her comfort level with having fewer (or more frequent) mammograms.

Andrew Weil, M.D.

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