Dr. Robert Legare, director of the Breast Health Center in the Women & Infants' Program in Women's Oncology, addresses the recent release of new recommendations regarding mammogram standards for women.
What do you think about the new recommendations from the U.S. Preventive Services Task Force that women do not need annual mammograms after age 40?
It is true that mammogram screenings will see the maximal effect in terms of "lives saved" in the 50 to 70 age group, in part because the incidence of breast cancer increases with age and also because younger women have denser breasts which limits the sensitivity of mammography. The maximal effect is actually for women ages 60 to 69. However, there still remains a role for screening mammogram in the 40 to 50 age group, although more women will need to be screened to achieve one life saved when compared to the 50 to 70 age group.
Ideally, a physician would discuss screening with his patients aged 40 to 50 and they together would decide whether to order a mammogram. If the woman has no personal or family history issues that would raise the concern for breast cancer, deferring screening would be reasonable. If there are personal or family history issues, I would continue to favor screening for women ages 40 to 50.
It is important to note that the information contained in this recent report is not new. There really has not been a significant amount of new data released since 2002 and we have known that screening is less effective in younger women. I believe the USPSTF report presents a different "posture," highlighting the economic issues of screening younger women. This is not inappropriate but it is important that the Task force talk about these issues transparently, openly and forthrightly.
Is there more risk than benefit to annual mammograms after age 40, as the Task Force report suggests?
The true risk of screening in women ages 40 to 50 is likely related to the risk of "false positive" results which can lead to further imaging including MRI, biopsy and more frequent follow up. This can certainly add to a woman's anxiety and frustration, as well as increase health care costs, but different women will make different decisions regarding how they feel about this issue. Again, when there are personal risk factors or family history, I would continue to favor screening in this age group.
Do you believe there is still value in breast self-exams, which the report also said were ineffective?
There has never been a study which documented a decrease in mortality from breast self exam, and I have never felt that there is overall benefit from breast self exam. So nothing has changed in this regard. If a breast self exam does not cause a woman anxiety, I think she should conduct them, even if their effectiveness has not been proven. If a woman had difficulty performing a breast self exam or it causes significant anxiety, a yearly clinical breast exam is very appropriate.
If women follow these new recommendations, do you think we will see an increase in the number of deaths from breast cancer?
We will no doubt miss early detection of some breast cancers in women ages 40 to 50 and this could lead to death from breast cancer for some women. This may have a more modest effect on population statistics because breast cancer, thankfully, is less common in this age group. I have to again emphasize the importance of women working with their physician to review the risks and benefits of screening and making a decision together.