Is There an Alternative to Mammograms?

Susan Brissette | Aug 9, 2010

Mammography can be an inherently lousy screening test for breast cancer. Women deserve better! Now is an opportune time to replace this outmoded screening tool. The only problem is there is nothing on the horizon, yet

Is There an Alternative to Mammograms?

In November 2009 the U.S. Preventive Services Task Force (USPSTF) recommended that routine mammography screening for breast cancer start at age 50, as opposed to age 40. And in 2011 the Canadian Task Force on Preventive Care followed suit. As expected it caused quite an uproar both in Canada and the United States.1,2

The Task Force's findings shined a glaring and not necessarily positive light on the role of mammography in women's healthcare. The results not only questioned the value of early screening for younger women but the research also suggested that the use of mammograms may lead to unintended harm to women. In fact, the harm primarily comes from the consequences of the false positives produced by the test.

For close to forty years, mammography has been the screening tool of choice for early detection of breast cancer making it possible to see tiny cancers that may measure as little as half a centimeter (about one-fifth of an inch). A lump would have to be at least twice that size to be felt during breast manual examination.

The resulting X-ray shows the structures of the breast in varying degrees of black and white: white areas are typically milk ducts, grey and black areas are fat tissue; suspicious features show up as light or white spots. Depending on the shape and distribution of the spots, the mammogram may be read as abnormal. (Suspicious spots may look star-like, vary in size and shape or be lined up in a row.) Researchers are also beginning to report a reduction in false-positives by the use of three dimensional mammography, a technique that is not yet fully approved for use and not yet approved for insurance reimbursement.3

For years breast cancer screening guidelines in the U.S. agreed on by all major cancer detection authorities such as USPSTF, the American Cancer Society and the American College of Radiology have consisted of yearly mammograms starting at age 40 and continuing for as long as a woman is in good health as well as a clinical breast exam (CBE) about every 3 years for women in their 20s and 30s and every year for women 40 and over.4

The USPSTF determined that the risk of over diagnosis of benign lesions and the resulting, sometimes harmful treatments was greater than the value of detecting disease earlier in women under 50. They recommended that women under 50 talk with their doctors first, rather than simply undergoing mammography screening. They further suggested that mammograms could take place every two or three years instead of annually.

The USPSTF also couldn’t give a clear answer about the effectiveness of clinical breast examination. Two major studies, one from China and another from Russia, found no evidence that breast self-examinations reduced deaths from breast cancer, but instead the practice can lead to additional screening and biopsies.5 Research has shown that the effectiveness of breast examination by a healthcare provider depends greatly on the skill of the practitioner. A 2004 review of scientific literature showed that about 5% of breast cancers were found by clinical breast examination.6 Other studies suggest a success rate of up to 15%.

Many people, including most of the breast cancer organizations, reacted with shock and outrage at the reversal in clinical guidance. They accused USPSTF of conducting a cost/benefit analysis and concluding that the value of saving lives wasn’t worth the cost of screening for disease. Pretty tough stuff, especially against a backdrop of hysteria around “death panels” and other deliberate falsehoods about the U.S. President’s healthcare legislation. Fortunately, these “sound bite” interpretations of the USPSTF findings (and about the healthcare legislation) simply aren’t true.

So, why would the USPSTF turn the status quo upside down?

As a result of their findings, USPSTF recommends that earlier screening for women with no known risk factors should be a matter of discussion between women and their doctors. The choice boils down to the question of your comfort level with a higher likelihood of undergoing cancer treatment unnecessarily versus a much lower likelihood of earlier cancer detection, which dramatically improves survival rate.

So, is overtesting and extra stress enough reason to reduce the possibility that a 40 year old woman’s life could be saved?

As always, it’s a bit more complicated than that. Many of the breast cancers that are diagnosed and then treated may not need to be treated. According to a 2009 study conducted in Europe not all breast cancers are potential killers, some are inconsequential. If they were not picked up, women would not know they had them. But because they are detected through breast cancer screening, women usually undergo surgery and chemotherapy which are traumatic and potentially harmful.9

And, on top of this some critics continue to believe that the mammogram itself is harmful because of the level of radiation breast cells receive as well as the concern that breast compression may spread cancer cells. However, these concerns have not been supported conclusivly by evidence in the scientific literature.10

These revelations have also led many people to wonder if there are safer or more accurate alternatives.

Frankly, there aren’t very good alternatives at this point in time. However we’ve taken a look at most of the diagnostic tools currently available to give you a good sense of the options and the state of the art.

We would be remiss if we didn't talk about BRCA testing which assesses risk.

BRCA1 and BRCA2 are human genes that belong to a class of genes known as tumor suppressors. Mutation of these genes has been linked to the development of hereditary breast and ovarian cancer. Women who inherit a mutation of BRCA1 or BRCA2 have an increased risk of developing breast and/or ovarian cancer at an early age and often have multiple, close family members who have been diagnosed with these diseases. However, not every woman who has a harmful BRCA1 or BRCA2 mutation will develop breast and/or ovarian cancer. Several blood tests are available to test for BRCA1 and BRCA2 mutations.

Currently, there are no standard criteria for recommending or referring someone for BRCA1 or BRCA2 mutation testing. In a family with a history of breast and/or ovarian cancer, it makes sense to first test a family member who has breast cancer. If that person is found to have a harmful BRCA1 or BRCA2 mutation, then other family members can be tested to see if they also have the mutation. Women who appear to be at increased risk of breast and/or ovarian cancer because of their family history should consider genetic counseling to learn more about their potential risks and about BRCA1 and BRCA2 genetic tests.14

The Final Word (or words)

At this point in time, the mammogram remains the best screening tool for breast cancer detection. Most cancer authorities recommend the continuing use of mammogram as a screening tool for women aged 40 to 50. USPSTF recommends that women in this age group discuss the issue with their doctors and make individual decisions. What should you do? It depends.

If you’re under age 50, you have to weigh your options. If you choose to have routine mammograms, recognize that there’s a higher false positive rate for your age group. That means that if an abnormality is found, you will want to be sure that you have an in-depth follow up, possibly using one of these new techniques, to know as much as possible about a potential cancer so you can make an informed decision about treatment.

If you are 50 or older, you should be receiving a screening mammogram either annually as the current guidelines suggest, or at least every two to three years, as USPSTF suggests. In 2005, just 71.8 percent of women between the ages of 50 and 64 and 72.5 percent of women ages 65 to 74 had received a mammogram within the previous two years, according to government figures.15

The Bottom Line

Someday this controversy will disappear when the imperfect 'gold standard' mammogram is replaced by a less invasive screening tool. In the meantime the message here is clear – still get screened to protect your health and earlier screening for women with no known risk factors should be a matter of discussion between women and their doctors.

While breast self examination, like every other diagnostic tool, may lead to some unnecessary testing and treatment, it is a safe, painless and no cost way for a woman to take responsibility for her healthcare. On that basis alone, breast self examination makes sense.

Mammograms can be inherently lousy. Now is an opportune time to replace this outmoded screening tool but there is one problem - there is nothing on the horizon, yet, but hopefully soon. Women deserve better!

Watch Video: Breast Self-Examination


Published August 9, 2010, updated May 30, 2012

References:

  1. Nelson HD, Screening for breast cancer: an update from the U.S. Preventive Services Task Force, Ann Intern Med. 2009;151:727-37
  2. Summary of recommendations for clinicians and policy-makers, Screening for Breast Cancer, The Canadian Task Force on Preventive Care, 2011
  3. Kerr, M, Kerr M, 3-D mammography cuts false positive rate in half, Reuters, Nov 29, 2007
  4. American Cancer Society Guidelines for the Early Detection of Cancer, American Cancer Society, 3/05/2012
  5. Kösters JP, Regular self-examination or clinical examination for early detection of breast cancer, The Cochrane Library, Issue 4, 2008
  6. McDonald et al, Performance and Reporting of Clinical Breast Examination: A Review of the Literature, CA Cancer J Clin 2004;54:345-361
  7. Jackson et al, Variability of Interpretive Accuracy Among Diagnostic Mammography Facilities, JNCI J Natl Cancer Inst (2009) 101 (11): 814-827
  8. FAQ About Mammography, Canada Diagnostic Centers,
  9. Karsten et al, Overdiagnosis in publicly organised mammography screening programmes: systematic review of incidence trends, British Medical Journal, BMJ 2009; 339 doi: 10.1136/bmj.b2587 Published 10 July 2009
  10. Do Screening Mammograms increase your risk of Cancer? CancerActive
  11. Hoogerbrugge et al, The impact of a false-positive MRI on the choice for mastectomy in BRCA mutation carriers is limited, Ann Oncol 2008; 19: 655-659
  12. Arora et al, Effectiveness of a non-invasive digital infrared thermal imaging system in the detection of breast cancer, The American Journal of Surgery, 2008, 196, 523-52
  13. Kennedy et al, A comparative review of thermography as a breast cancer screening technique, Integrated Cancer Therapies, 2009; 8;9
  14. BRCA1 and BRCA2: Cancer Risk and Genetic Testing, National Cancer Institute
  15. Hobson, K, Everyone Is Talking About Mammograms, But Many Women Don't Get Them, U.S. News and World Report, Nov 29, 2009

Susan M. Brissette brings 30 years of experience in healthcare, ranging from positions as Chief Executive Officer and Chief Operating Officer in the acute care hospital setting to Senior Executive for a major national healthcare management company. Ms. Brissette holds a BS in Biology from Northeastern University and an MS in Health Policy & Management from the Harvard School of Public Health. She has lectured on healthcare management at the University of Massachusetts, developed a healthcare delivery system for a mining company in Cajamarca, Peru, and recently led the Afghanistan Public Health Redevelopment Task Force for the Washington Harvard Alumni Group. She has consulted on healthcare projects in Poland, Romania, Israel, Kuwait, Peru, Canada, and Mexico. She now owns and operates SB Cass Associates, a healthcare consulting firm located in upstate New York. Ms. Brissette’s consulting practice handles client projects ranging from business plan development for clinics, assisted living facilities, and clinical research groups to the development of market research reports for the pharmaceutical and biotechnology industries. She has written dozens of healthcare articles published on the internet and in national professional and consumer journals. She has also authored or edited online courses on HIPAA compliance, corporate security, childhood obesity, and business ethics.

Susan Brissette can be reached at SB Cass Associates sbrissette@sbcassassoc.com

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