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mammogram guidelines

The New Mammogram Guidelines: What You Should Know

Some find the new guidelines upsetting, but there are reasons for the changes.

By By Rodale.com editors


The New Mammogram Guidelines: What You Should Know

New guidelines about mammograms leave women with some decisions to make.

RODALE NEWS, EMMAUS, PA—This week, the U.S. Preventive Task Force published its new breast-cancer screening recommendations suggesting that most women don't need mammograms before they turn 50. The announcement set off a firestorm of controversy, since many women in this country are accustomed to annual screenings once they turn 40. Health and Human Services Secretary Kathleen Sebelius stepped into the fray on Wednesday. "There is no question that the U.S. Preventive Services Task Force recommendations have caused a great deal of confusion and worry among women and their families across this country. I want to address that confusion head-on," she said in a statement. "The U.S. Preventive Task Force is an outside independent panel of doctors and scientists who make recommendations. They do not set federal policy and they don’t determine what services are covered by the federal government." While acknowledging the new guidelines, Sebelius stressed that federal policies remain unchanged. "My message to women is simple. 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," she said.

For insight into the controversy about the new mammography guidelines, we talked to Diana Zuckerman, PhD, president of the National Research Center for Women & Families. Here are our questions...and her answers.



1: How do the new guidelines compare to existing recommendations?

2: What's the thinking behind giving fewer mammograms to women in their 40s?

3: Why do the new guidelines recommend not teaching breast self-exams?

4: Is this an example of women's health not being considered a priority?

5: Do you think insurance companies are likely to make changes based on these new recommendations? If so, how soon?

6: Some describe this as accepting one more cancer death among women in exchange for eliminating some stress and discomfort for many others. Is that a fair criticism?



Mammogram Q & A with Diana Zuckerman, PhD, president, National Research Center for Women & Families

Q: How do the new guidelines compare to existing recommendations?

A: The popular guidelines for breast cancer used to be: annual mammograms starting at age 40; teaching breast self-exams, especially for women who are too young to have mammograms; and annual breast exams by an OB-GYN or other doctor, to check for lumps. The new guidelines by the Preventive Services Task Force say most women only need mammograms every two years, starting at age 50; that the benefits of teaching breast self-exams do not seem to outweigh the cost; and that there is not enough evidence to say whether physicians should regularly perform breast exams on their patients.

These changes seem dramatic, but in reality expert views on early detection of breast cancer have evolved gradually over the years, and many experts and cancer advocacy organizations had already revised their recommendations even before this week's announcement. For example, many experts and advocates have been recommending mammograms mostly for women over 50, instead of 40, in recent years. And the recommendation of annual mammograms had already quietly changed to "every year or two" by most experts and advocates.

I remember learning more than 10 years ago that breast self-exams are not proven to save lives. So, that wasn’t new to me or many other breast-cancer experts and advocates, even though some foundations and advocacy groups continued to spend money training women to do self-exams, and making them feel guilty if they didn’t. It’s important to understand that the guidelines are based on all the research that was previously published, so the recommendations were not surprising to the experts who read cancer research studies. The evidence that supports these new guidelines has been building up for years.

But, let’s be clear, the guidelines are for the average woman, not every woman. Women at very high risk of breast cancer should probably continue to start mammograms at 40, or in some cases even younger, and some may want to continue to have mammograms every year. And the guidelines don’t apply to women who have found a lump—those women should immediately have a mammogram to get more information about whether it might be cancer.

Mammogram Q & A with Diana Zuckerman, PhD, president, National Research Center for Women & Families

Q: What's the thinking behind giving fewer mammograms to women in their 40s?

A: There are risks to getting mammograms so often. The biggest risks are radiation, which increases the risk of breast cancer even as the mammograms help detect it earlier, and overtreatment—false alarms usually result in fear and stress, expensive testing, and sometimes, in disfiguring surgery and unnecessary radiation.

We now know that some small cancers go away by themselves. And, experts now estimate that half of DCIS [ductal carcinoma in situ], the very earliest cancer detected by mammograms, will never spread even if never treated. Even fewer women with the precancerous condition called LCIS [lobular carcinoma in situ] will ever get breast cancer, even if never treated. If cancer or precancer often goes away by itself or doesn’t change to become dangerous, why undergo surgery and radiation, both of which are debilitating and upsetting? The key here is to find accurate ways to predict which will go away or at least stop growing, and which won’t. Meanwhile, less-frequent mammograms allow some of these very tiny precancers or cancers to go away by themselves.

There’s another reason to start mammograms at age 50 instead of 40: mammograms are more accurate after menopause. Younger women tend to have more dense breast tissue. Think of the black-and-white mammogram X-ray: The breast of a younger woman looks quite white. Cancer also shows up as white spots. So, it is very difficult to find the white spot that is cancer on an X-ray of a breast that also looks very white. After menopause, the breast tissue looks more gray on a mammogram, making the white shape of the cancer easier to detect.

Add to that the fact that most breast cancer is diagnosed at the age of 50 or later, and you realize that annual mammograms for women under 50 don’t give much "bang for your buck." They cost just as much as later mammograms, are less accurate, and are less likely to find any cancer. And, especially because of the lack of accuracy, the follow-up tests that ultimately prove there is no cancer can be very expensive, and meanwhile the woman has had several days or weeks of sleepless nights, terrified by the thought that she might have cancer. That stress is not good for her health, lowering her immunity to diseases.

Changing the guidelines for mammograms could save billions of dollars that could be better spent on other health care that would save more lives, and at the same time slightly reduce the number of women who get breast cancer as well as the number of women who need treatment.

Mammogram Q & A with Diana Zuckerman, PhD, president, National Research Center for Women & Families

Q: Why do the new guidelines recommend not teaching breast self-exams?

A: Although many of us know at least one woman who says that a breast self-exam saved her life, there is no scientific data to support that. By the time a woman finds a cancer in a self-exam, it has usually been growing for years and is relatively large. Most likely, she would have found it anyway in a few days, weeks, or months, while dressing, showering, etcetera. That delay almost never makes a difference in survival. And, if you are getting regular mammograms—even every other year—you should have already detected the cancer before it is large enough to feel it. The exception might be for women at very high risk of breast cancer who are too young to obtain accurate mammograms.

Mammogram Q & A with Diana Zuckerman, PhD, president, National Research Center for Women & Families

Q: Is this an example of women's health not being considered a priority?

A: For those who suspect sexism here, let me assure you—the same task force that wrote these new guidelines is even less enthusiastic about prostate-cancer screening tests. They are not recommending for or against prostate-cancer screening for men under 75, regardless of whether the patient is at high risk or not. They believe that diagnosis and treatment can be delayed until there are symptoms. For men 75 and older, they do NOT recommend prostate-cancer screening. The reasons are similar—very small cancers are being detected, and the treatment has very high complication rates (of incontinence and ED) and no measurable benefits in terms of saving lives.

It's actually rather ironic: The number one cancer for women (breast cancer) and men (prostate cancer) are both cancers of the reproductive system, both have screening tests that are very widely used but not very accurate, and both have treatments that can be debilitating and psychologically traumatic (especially to sexual self-concept). And both types of cancer are only recently discovered to sometimes go away by themselves, without treatment.

Mammogram Q & A with Diana Zuckerman, PhD, president, National Research Center for Women & Families

Q: Do you think insurance companies are likely to make changes based on these new recommendations? If so, how soon?

A: Yes, but it is not clear how soon. I think it will change women's behavior sooner. Most women don't like getting mammograms, whether they are paid for by insurance or not. Many women are likely to say, "Oh good, I don't need to make a mammogram appointment 'till next year!" I think, overall, the doctors are more upset than the patients. Patients will be relieved as long as their doctors are supportive of the change.

Mammogram Q & A with Diana Zuckerman, PhD, president, National Research Center for Women & Families

Q: A lot of critics seem to focus on the concept of accepting one more cancer death among women in exchange for eliminating some stress and discomfort for many others. Is that a fair criticism? Why is that OK or not OK?

A: I understand why they think that, but it is not really the main point. First of all, not enough attention has been paid to the following points:

1. Some of these cancers go away by themselves or never progress to anything that is dangerous. More than 60,000 women will be diagnosed with DCIS this year (a very, very early type of breast cancer that itself is not dangerous), and most will get either a lumpectomy or mastectomy because DCIS often changes into the kind of breast cancer that spreads and is potentially deadly. But even without treatment, only half those women with DCIS would ever have their DCIS progress to become the kind of cancer that spreads. So, why have all those women undergo mastectomy or a lumpectomy with radiation if they never would have gotten "real" breast cancer? You aren't just reducing stress, you're also saving a breast (and the physical and emotional feelings that go with it), avoiding radiation, and saving a lot of money on health care, some of which the woman has to pay.

2. Mammography is a type of X-ray, which means it exposes the breast to radiation. Radiation increases the risk of breast cancer. The benefits outweigh the risks, but you can probably save some women from breast-cancer deaths by reducing the amount of radiation that millions of women are exposed to. Ten years with zero mammograms and then having mammograms every two years instead of every year will cut the amount of radiation by more than half.

I want to say something about the financial aspect. Insurance doesn't pay for everything. I would rather have insurance pay for treatments that usually make a difference in survival or quality of life rather than pay for treatments that only occasionally make a difference.

That being said, these guidelines are for the average woman. They are NOT supposed to apply to the women at very high risk of breast cancer, and insurance companies should pay for their more frequent mammograms.

For more on this topic, see the National Research Center for Women & Families summary article. For more information about preventing cancer, see their website StopCancerFund.org.

Filed Under: BREAST CANCER, MAMMOGRAMS, RADIATION

Published on: November 19, 2009



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I think all the politicians can afford whatever they need so leave us alone. Without us you are nothing.
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Women under 50 are more

Women under 50 are more likely than older women to have false positive mammograms, resulting in their needing additional testing for something that turns out not to be cancer. They are also far less likely than older women to have breast cancer detected by mammograms.
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Mammogram

Vonia Serakos, Would love to have the money to get my yearly mammmogram as I have already had one large mass removed, but alas you stole my money.

Breast Cancer Risk Assessment

I realize I am another anecdotal occurence that falls outside of the statistics, but I find my situation ironic. I am a 48 year old Family Medicine physician with an identical twin sister who was one to get her mammograms every year. We did both have fibrocystic breast condition which does make the mammogram very challenging for even the most tnorough of radiologists. When we were both 45 years old (2006) I had had my annual mammogram which had been read as negative. My sister had hers later in the year and called me about her biopsy results after a fine needle biopsy of a lump seen on her mammogram in 2006 which had been read as negative in 2005. She had lobular breast cancer. At that time a sentinal node biopsy had been performed and the initial results were negative, but after going through all the sentinel nodes car-efully a few cancerous cells were noted. Fortunately, in the state of Minnesota I "qualified" for an MRI. This came after a repeat mammogram read as negative and an ultrasound also read as negative. Again fortunately the radiologist reading the MRI had a feeling that the ultrasound performed after the abnormality seen on MRI being negative was not accurate. She went on to perform a biopsy under MRI which was positive. I did go on to opt for a bilateral mastectomy with bilateral reconstruction started at the time of the mastectomy. I also opted for chemotherapy because the Oncodex equation placed me in a gray zone in terms of likelihood to benefit from chemo or not. Again I was very fortunate and had no complications and essentially no side effects from the chemo either. That is probably the exception and not the rule. My sister and I had no family history and our only risk factor (which is not found to be a true risk factor based on evidence based medicine) was that we had both been on oral birth control for many years and had fibrocystic breasts. My sister had children much earlier than I and nursed both. I didn't have children until I was 37 and 39 and nursed both to 2 years of age. My sisters cancer was much larger and into the lymph nodes and mine was not. We would possibly not have had any mammograms for years, and my cancer would have possibly been a stage further progressed if my sisters mammogram had not come after my annual mammogram. Just an isolated example.

Cancer in Women

I think the new guidelines are all about money!! I know many women of all ages that have had cervical and breast cancer. How can this be justified?

New Guidelines for Mammograms

Wow, what a slap in the face to the Susan G. Komen foundation! I found my breast cancer from doing a self breast exam after my sister-in-law was diagnosed with breast cancer found during her first mammogram. She is 41 and I am 33. Neither one of us has a strong family history. I wonder how long it will be before the insurance companies won't cover mammograms until the age of 50 and those whose cancer is found, denied treatment because it is "too far gone" (or rather too expensive to treat). This is just the beginning of rationing health care! One in eight women will develop breast cancer - 80% of those cases will have no family history! Don't jeopardize your life just so the government can save a buck.

New guidelines for mammograms

This is for all the young women out there. KEEP doing that monthly self exam, forget these new guidelines. I am speaking as a mother who's 33 yr. old daughter found a lump that turned out to be cancer. She saved her life by finding it early. Cancer is not going to wait till your at that age you SHOULD get a mammogram. You have to be aware of your breasts and any change or lump , you go to your Dr. and be persistant, make sure you have the proper tests taken, Don't take no for an answer, If your told you don't fall within the guidelines , tell them to stick the guidelines and give you the mammogram or needle biopsy or whatever it is will tell you it is or is not cancer. Its your LIFE !!Thank God my daughter has a fantastick surgeon and chemo doctor.

a breast cancer survivor wants her voice heard

I am a 47 year old woman who had her first diagnosis at the ripe old age of 29. I found the lump myself. Prior to this, I had watched my sister, who was twelve years older battle breast cancer and lose at the age of 39. She had been ill for less than 2 years. Neither of us fit these "new guidelines". My second diagnosis came when I was 44 years old, found in a routine mammogram. Again, I would not have fit these "new guidelines". While the treatment options would seem pretty harsh to some people, I far prefer to go out fighting than sit there and hope that the cancer would miraculously go away, as in the supposed 50% cases quoted. Equally troubling is the idea that breast exams should not be taught. The caveat line added here was that of course if you found a lump you should be examined, and have a mammogram. But if you didn't learn how to find the lump, chances are quite good that it would be at a later stage, and fatal, as it was with my sister. A women's health is more important than the profits of any doctor, hospital, or insurance company. The oath sworn in medicine is "first, do no harm." Well shame on the writers of the new guidlines. May they all follow them and suffer the consequences, however unlikely that may me, as they are mostly all male.

Mammogram Guidelines

There are thousands of women under the age of 30 that are diagnosed with breast cancer. I wonder who got bought off this time. They can promote viagra for men, but when it comes to women's health they come out with bogus studies like this. My daughters have two friends that were diagnosed under the age of 30 and my best friend was diagnosed at 45. This is crap.

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The senators and house members are protected by their high class health care insurance and forcing low class health care on the people. They need to remember that they have children and grand children and greatgrandchildren who will NOT be among the elite and they will suffer for the policies that THEY are putting into place now.
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Mamograms and cervical cancer tests

Do you mean that we have been lied to all these years ? There is MONEY in the air....money for cooperatives of the government run healthcare system. I am ashamed for the Am Cancer Association and all others who have bowed at the alter of the dollar.
God HELP us !

New guidelines for mammograms

This just rings with discrimnation and all about money. Women in their forties have raging hormones and for years we were told in was all in our heads. Now when there are new treatments being founded, we are being told to wait until fifty. Nonsense--we all now women in their 20's, 30's and 40's that have been diagnosed with breast cancer. Be safe and get your mammogram every year.

mammograms

Again women are at the bottom of the barrel. Prevention is the word and mammograms are a necessity. All the politicians can afford whatever they need so leave us alone. Without us you are nothing.

mammograms

this is not a new agenda... nothing on this issue has been passed.

New guidelines for mammograms

Ten years with zero mammograms and then having mammograms every two years instead of every year will cut the amount of radiation by more than half.
This statement itself gave me more comfort about waiting an extra year to get mammograms.
Thanks for all the information on this topic. I know women are interested in this.
I would hope that women under 50 would be aware of their family history and would get screened before age 50. I have two friends who have just been diagnosed and treated for breast cancer. Both are under 50.

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