Turning 40? You might want to skip this mammography primer from U.S. News

Mary Chris Jaklevic is a reporter-editor at HealthNewsReview.org. She tweets as @mcjaklevic.

An image from a U.S. News story on “12 Things to Know Before Your First Mammogram.”

While more doctors embrace the idea that women should make their own informed decisions about when and how often to get screened for breast cancer, news reporting doesn’t always reflect that nuanced approach.

Take a recent U.S. News feature entitled “12 Things to Know Before Your First Mammogram,” which could have provided women with balanced information on the benefits and harms of mammography.

Instead, it conveyed a misleading and one-sided message that annual screening starting at age 40 “saves the most lives.”

The lead said women turning 40 have a choice “to start regular screening for breast cancer or to push off commencing this annual or bi-annual wellness ritual.”

But the story that followed suggested there’s really only one sane option, and that’s to screen, screen, screen:

Although the recommendation of when to start varies based on personal risk and which agency’s guidelines you’re using, the fact remains that mammographic screenings have been shown to detect breast cancer at earlier stages when it’s more treatable.

Two ardent screening proponents backed up that assertion:

  • Breast surgeon Kristi Funk, MD is quoted saying she advises her patients who are at normal risk of developing breast cancer to “begin at age 40. Do it every single year, and don’t stop or don’t skip a year until you plan to die in the next five years.”
  • Radiologist Elizabeth Arleo, MD, offered: “Most women – those at average risk – should start annual screening mammography at age 40, as per the recommendations of the American College of Radiology and the Society of Breast Imaging.”

‘Just do it’ tone

HealthNewsReview.org contributor and breast surgeon Deanna Attai, MD, took issue with the “just do it” mantra.

“I think that women deserve a balanced discussion, and just a few comments about the possible downsides to screening mammography could go a long way to even out the information presented and could help women make informed choices about screening,” she said via email.

“Mammography isn’t perfect and in fact readers should be aware of the risks,” said another HealthNewsReview.org contributor, Mandy Stahre, PhD, who noted that rates of false-positives and overdiagnosis were among the many data points that went unmentioned.

This story stands in contrast to recent coverage of United States Preventive Services Task Force (USPSTF) guidelines calling for personalized decision-making around prostate cancer screening. Those stories generally did a good job of recognizing the complexity of screening decisions.

Saying all women should get screened starting at age 40, as the U.S. News article does, “takes away the realization that this is a human being who ought to be able to make choices about what is right for them,” said Otis Brawley, MD, chief medical officer of the American Cancer Society (ACS).

He’s concerned giving patients incomplete data perpetuates distrust, whether the message is from doctors or from the news media. “As people start learning there are two sides of the story, they’re going to wonder why they didn’t get both sides,” he said.

A shift in approach

Recent years have brought increasing recognition of the pitfalls of mammography. In 2009 the USPSTF — an independent panel of experts — recommended against routine screens for women aged 40 to 49 years, as had been common practice, stating that the decision to start regular mammography before age 50 should be an individual one that takes into account how each patient weighs specific benefits and harms.

The USPSTF recommended that women start mammogram screening at age 50 and get a mammogram every two years thereafter up to age 74, and reiterated that recommendation in 2016.

The ACS has also moved toward a more individualized approach, while recommending that women ages 45 to 54 be screened annually and those older than 55 be screened every two years.

A woman’s right to decide

“We try not to make a woman feel that we’re ordering her to do it,” Brawley said. “We are encouraging her to do it, but we’re trying to respect a woman’s right to say, ‘this is my body and I don’t want that.'”

Nancy Keating, MD, MPH, professor of health care policy and medicine at Harvard Medical School and a physician at Brigham and Women’s Hospital, said the article could generate confusion at a time when doctors should be shifting screening decisions to patients and equipping them with data.

“For too long we’ve been teaching women that all they need to do is get a mammogram every year and they won’t die of breast cancer. But the real story is much more complicated than that,” Keating said. “It’s going to be a lot of work to take back years and years of messaging that everyone needs a mammogram every year.”

Misleading data

In the article, radiologist Arleo, an associate professor of radiology at New York-Presbyterian/Weill Cornell Medical Center, quoted her own modeling study showing “the greatest mortality reduction is achieved with annual screening starting at age 40 – a nearly 40 percent decrease in breast-cancer-specific mortality compared with only a 23 percent decrease in breast-cancer-specific mortality associated with the U.S. Preventive Services Task Force recommendation of biennially screening women 50 to 74.”

But there are problems with that data.

For one thing, the 40% figure appears to be greater than real-world experience, Brawley said.

Further, those numbers leave out the drawbacks. In fact, women in their 40s might want to proceed cautiously before deciding to be screened, since they are far more likely to be harmed than helped due to false positives, unnecessary biopsies and overdiagnosis.

Keating offered this reality check: “Most women who get breast cancer won’t die of breast cancer whether or not they had a mammogram. A small number of women who get aggressive forms of breast cancer will die of breast cancer even if they had been getting regular mammograms. And then there is a very small number of women for whom the mammogram may make a difference.”

Looking at the numbers

Overdiagnosis is particularly worrisome. It refers to cancers found through screening that would never have become life threatening but get treated anyway because doctors can’t tell whether a cancer is life-threatening or not. Women who are overdiagnosed have treatment such as surgery and chemotherapy that they would never had needed if they hadn’t been screened, potentially leading to harmful side effects and anxiety.

Keating and Lydia Pace, MD, MPH, director of women’s health policy and advocacy at Brigham and Women’s Hospital, co-wrote a recent article in the Journal of the American Medical Association calling for individualized decision-making.

According to data presented in their article, for every 10,000 women in their 40s screened annually for 10 years, 32 women will die despite being screened and just three deaths will be averted. More than half of those women — 6,130 — will get a false positive result and 700 will get an unnecessary biopsy. Twenty-eight will be overdiagnosed and thus treated for a cancer that wasn’t going to kill them.

Those statistics vary for women in their 50s and 60s, when rates of diagnosis and death increase.

The radiation paradox

The U.S. News piece mentioned women may be told to return to have more imaging done, but didn’t explore the full extent of the potential harms.

It also portrays 3-dimensional mammography as superior to older 2-dimensional technology without explaining that the two haven’t been compared in clinical trials.

What is known, Brawley said, is that 3D mammography delivers more radiation, and that gets at another big drawback that isn’t mentioned: the accumulated harm of radiation exposure from repeated breast x-rays.

Radiation increases the risk for cancer, particularly for women who have BRCA gene mutations that impair the body’s ability to fix breaks in DNA. Brawley called that “a real paradox” of screening.

“This is something that drives the radiologists who are very pro-mammography absolutely bonkers,” he said.

A narrow range of sources

Keating also noted that radiologists — two of whom are quoted in the U.S. News article — “have been slow to acknowledge the limitations of mammography.”

The story’s other source, Funk, runs a practice in Los Angeles that provides screening and treatment of breast cancer.

Breast surgeon Kristi Funk made unsupported claims about her “cancer-kicking” smoothie on The Doctors TV show.

While she’s won fame for treating Angelina Jolie and Sheryl Crow, Funk doesn’t exactly come across as a stickler for evidence-based practices. She’s been promoting a newly published book with a smoothie recipe that she says contains “cancer-kicking” compounds. She also markets a supplement she says can counteract the bad effects of drinking alcohol.

“I think it would be nice to see evidence of a benefit before I spend my money on their products,” Keating said.

Brawley said of the supposed cancer-fighting smoothie: “I think we would have tremendous difficulty finding clinical trial data to support that claim.”

(In a weird coincidence, the ACS recently introduced its own smoothie, but the organization doesn’t claim it can prevent cancer. Rather, it’s a high-calorie version designed for cancer patients who have difficulty keeping their calorie intake up.)

Undercovered breast cancer stories

All in all, Brawley said he’d like to see more journalists focus on the need for better screening tests and on the opportunity to save more lives by making sure women get proper treatment.

“Every time I hear people argue about when we should start screening or how often we should start screening, I ask how come they don’t talk about the 30 to 40% of women who are currently diagnosed who get less than optimal treatment?” he said.

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