Mammography: A Life-Saving Diagnostic Tool
A Statement by Dr. Sunil Upender, Washington Hospital Radiologist
There has been a great deal of controversy regarding the new guidelines proposed by the United States Preventative Services Task Force (USPSTF) in November 2009. With all the proposed changes, many women are uncertain on how to proceed.
Breast cancer is the most common cancer and the second leading cause of death for women in the United States. In fact, one in eight women develop breast cancer. These astounding facts are the reason that there has been a substantial push for mammography in the past few decades. Mammography has been the only screening tool that has shown a significant reduction in morbidity and mortality in breast cancer. Since the onset of regular mammography in 1990, the mortality rate from breast cancer, which had been unchanged for the preceding 50 years, has decreased by 30 percent.
The current recommendations established by the American Cancer Society and shared by numerous national organizations recommend yearly mammograms beginning at the age of 40 and continuing for as long as a woman is in good health.
The USPSTF recently proposed that women between the ages of 40 and 49 and 75 and older should not routinely do mammography but instead discuss the option of doing mammography with their physician while taking into account the benefits and risks. In addition, it was proposed that women between the ages of 50 and 74 should do mammograms every two years instead of annual mammography. Lastly, breast self examination was discouraged.
The American Cancer Society, the American College of Obstetrics and Gynecology and the American College of Radiology do not support these new guidelines.
The USPSTF panel agrees that breast cancer mortality has been decreasing since 1990 by 2.3 percent per year overall and by 3.3 percent for women aged 40 to 50 years. They stated, "This decrease is largely attributed to the combination of mammography screening with improved treatment."
USPSTF stated that screening 1,339 women in their 50s to save one life makes screening worthwhile in that age group. However, to save one life in women ages 40 to 49, 1,904 women would need to be screened and they believe this is not worthwhile. The possibility of having one’s life saved through early detection should outweigh financial concerns in an accepted and proven screening exam.
Twenty-five percent of the new cases of invasive breast cancer are found to be in women younger than the age of 50. These women often have more aggressive disease with a higher mortality rate. In addition, the majority of breast cancers are not associated with family history. Therefore, if only high-risk women between the ages of 40 and 49 are screened, then a significant number of aggressive breast cancers would be missed.
For women between the ages of 50 and 74, doing annual mammography has been shown to reduce mortality the greatest. Small cancers that are not visible on a mammogram one year may become visible by the next year but result in a higher stage of cancer in two years. Annual mammography finds smaller tumors while they are treatable. In addition, doing annual mammography reduces needless workup of questionable findings.
The risk of breast cancer increases with age. Women over the age of 70 have the highest probability of developing breast cancer. There is no reason to discontinue annual mammography after the age of 74 as long as a woman is willing to undergo treatment in the event that a cancer is found.
Women at high risk for breast cancer may benefit from an earlier initiation of mammography and consider screening Breast magnetic resonance imaging (MRI) to supplement annual mammography.
The USPSTF is a federal government funded committee with 16 task force members including primary care clinicians with individual interests in areas such as decision modeling and evaluation, effectiveness in clinical preventive medicine, clinical epidemiology, the prevention of high-risk behaviors in adolescents, geriatrics, and the prevention of disability in the elderly. No breast imagers, oncologists, radiology oncologists, or gynecologists were on the panel.
The key to early detection is annual mammography, routine clinical breast exams and monthly breast self-exams.
Regardless of age, each person with the guidance of her physician should consider her individual circumstance. However, there is a clear benefit to having annual mammography with minimal risk.
The bottom line is that mammography can potentially find cancers early while they are treatable.
About Dr. Sunil Upender
Washington Hospital Medical Staff radiologist Sunil Upender, M.D., graduated with honors from Wesleyan University with a major in Biology. He earned his medical degree from the University of Vermont, College of Medicine in 2003 and did his radiology residency at Norwalk Hospital, a Yale University affiliated institution in Norwalk, Connecticut. He was the Chief Resident in 2008. Dr. Upender completed a fellowship specializing in Body and Breast Imaging at Yale University Medical Center in New Haven, Connecticut before joining Washington Hospital’s Medical Staff.
Mammography at Washington Hospital
At Washington Hospital, mammography, a specific type of imaging that uses a low-dose x-ray system to examine breasts, is one of the most powerful tools used in the early detection of breast cancer.
Mammography has long been the hallmark of breast cancer screening, and advancements in the process have continued to improve the process, making it more versatile and convenient for the patient, according to Dr. Mimi Lin, Washington Hospital radiologist and the hospital’s physician champion for mammography.
"The advent of digital mammography has been more effective for patients with dense breast tissue and is as effective as conventional analog, film-screen mammography in all patients," Dr. Lin says. "Digital mammography generally has a lower radiation dose compared to analog mammography and is faster for the patient."
As for the effectiveness of annual screening mammography, the statistics don’t lie, according to Dr. Lin.
Washington Hospital’s Cancer Registry Coordinator Marianne Heltzel reviewed the 490 breast cancer diagnoses at Washington Hospital between 2004 and 2008 and her review showed that:
- 34 percent of the cancers were in women aged 29 to 49
- 61 percent of the cancers were in women aged 50 to 74
- Of the breast cancer cases, 51 percent were detected by mammography
- In women younger than 50, 38 percent of the cancers were detected at mammographic screening.
The most notable of the statistics, according to Dr. Lin, is that when cancers are found at mammography, 39 percent are at the earliest stages of 0 and 1, at which point the cancer is typically smaller and more easily treatable. This is why the use of annual screenings remains a vital tool for radiologists and treating physicians to maximize diagnoses in cases that might otherwise go undiscovered for a longer period.
"Although the U.S. Preventive Services Task Force (USPSTF) recommended changing the screening mammography guidelines, other professional societies including the American College of Radiology, the American College of Surgeons, The American Congress of Obstetricians and Gynecologists, the American Cancer Society and the National Cancer Institute continue to recommend the current screening recommendations," Dr. Lin says.
The current guidelines for annual screening mammograms, Dr. Lin says, recommend beginning at age 40 for those women of average risk for breast cancer.
In women with a first-degree family member (e.g., mother, sister, daughter) with breast cancer, patients should start screening 10 years earlier than the relative diagnosed with breast cancer. For example, if your mother was diagnosed with breast cancer at age 42, you should start screening at 32 years of age.
As with any routine screening, it is advisable to discuss your health and family history with your physician to determine the best screening schedule.
"Mammography has been proven to decrease the risk of dying from breast cancer, especially if the patient is over 50," Dr. Lin says.
For more information about Washington Hospital’s stance on the USPSTF’s recommendation, see the statement by Washington Hospital radiologist Dr. Sunil Upender, Mammography: A Life-saving Tool, on this page.
To make an appointment for your annual screening mammogram, call (510) 791-3410. You will need a physician order prior to your appointment date. Be sure to bring you physician order with you to avoid appointment delays.