Controversy continues to surround the optimal time for
women to get their initial screening mammogram,
Diagnostic mammograms (unlike screening mammograms) can be started at
any age since they are used to “diagnose” palpable masses (lumps) or other
abnormal masses or lesions discovered on exam.
But true screening mammograms (in the absence of a visible or noticeable
lump) continue to pose a particular dilemma.
The United
States Preventive Task Force (USPTS) recommends
starting screening mammograms at age 50 while the American Cancer Society and
some other organizations still recommend starting annual screening mammograms
at age 45.
As a layperson, you might think the sooner the better,
but, in fact, early screening mammograms may reveal lesions that, after further
investigations (up to and including biopsy), are found to be false positives.
A false positive is when the screening mammogram shows
an abnormal area that looks like a cancer but turns out to be normal. False
positive test results are troublesome because of the added worry to the patient
and the unnecessary costs. According to the USPTF, screenings that are done
earlier than age 50 only result in rampant over diagnosis, which may be from
14.7 to 25 percent of all screen-detected lesions.
Organizations such as the American
Cancer Society that earlier annual screening mammograms,
contend that earlier diagnosis does justify earlier screening, and that women
should have the right to request screening mammograms as early as 40.
Earlier
diagnosis increases survival
Despite false positives (and the additional worry,
side effects and cost of additional tests), earlier diagnoses do increase
survival for certain women with certain types of breast cancers, but not all. The goal of screening, of course, is to save
lives. The theory is that the earlier the diagnosis, the earlier the stage and
the better the treatment options and survival.
Unfortunately, other factors such as insurance status
further complicates the issue of outcomes.
Women with private insurance demonstrate significantly higher five year
survival rates than women who are either uninsured or have Medicaid. Those
issues mostly revolve around social determinants related to poverty, low education
and low social status.
Further complicating the question and the outcomes is
the fact that breast cancer occurs in a host of variants related to cell type,
hormone sensitivity and other traits associated with their genetic map.
Genomics
is bringing hope
Genetic
mapping of breast cancers (genomics) has proven to be a boon
to scientists and oncologists. Formerly, most breast cancers were treated in a
similar way (with variations of surgical resection, radiation and chemotherapy,
depending on the type of cancer). With genomics, it has become possible to
identify breast tumors that only require tumorectomy and no other complimentary
therapies.
Results for such tumors remain excellent and spare
women from needless expense and side effects. Genomics also helps identify
tumors which will respond better to specific chemotherapy, which can be
tailored more specifically to the type of tumor. Some tumors do not represent a
clinical threat at all and can be safely observed.
While breast cancer survival has improved over time,
it remains a deadly foe, killing 40,000 U.S. women a year. Sadly, it can also
sometimes recur 10, 15 or 20 years after an apparent cure, a demoralizing fact
for patients and doctors alike.
Screening, treatment and prognostic indicators do,
however, continue to evolve. We now have breast CAT scans, 3-dimineitional
mammography, stereotactic biopsies and genomics. But while scientific progress
will surely to occur, we must also address the social determinants of poverty,
poor education and low social status that have proven just as tenacious as
breast cancer itself and just as deadly.
Whatever age you and your doctor decide to start
screening, be sure and get your mammogram.
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