Mammography–One Size Does Not Fit All

Ever since the U.S. Preventive Services Task Force suggested relaxing the rigid schedule for mammography testing in 2009, patients seeking a unified, authoritative voice on the topic have been rewarded with confusion. Probably because the medical community, too, is unresolved about who needs what kind of breast screening and when.

A study published this week in the Annals of Internal Medicine, is the latest participant in the discussion. It articulates as well as any previous research the notion that mammograms are situationally useful, and promotes the idea that such testing should be customized to each patient.

For women with a normal genetic profile, the timing and frequency of a mammogram, the researchers say, depend on the patient’s:

  • breast density;
  • age;
  • family history; and
  • personal preference.

Age, history and, to a lesser degree, density, are not new factors in the tricky equation of when to have a mammogram, but personal preference? Since when does science ever acknowledge, much less respect, that what’s preferable might also be good medicine?

Although the study researchers made clear that, apart from genetic mutation, breast density is the single-most important consideration in determining the suitability of relatively frequent screening, mammograms often result in false positives — the suspicion that you have cancer when you really don’t. That feeds a cycle of anxiety, unnecessary exposure to radiation, expensive follow-up procedures including surgery and physical discomfort. The artful conclusion here is that such a tangle of concern can undermine the utility of the procedure.

Because dense breasts (more muscle tissue, less fat) are the strongest risk factor for cancer, women with that anatomical profile should have mammograms more frequently. But after an initial screening at age 40 to establish a baseline reading and determine breast density, women lacking other risk factors–such as the two genetic mutations known to increase cancer risk–who aren’t comfortable with such frequency, might be acceptably excused from it.

The American Cancer Society and the Task Force would disagree. The former recommends that women screen initially at 40, and repeat the procedure every year or two thereafter. The latter recommended that women begin screening sometime between 40 and 49, depending on risk factors, and every two years after 50.

As usual, the best guidance for women seeking clarity is to establish and maintain an open line of communication with their physicians that results in a mutual decision about their treatment.

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