Rethinking decisions on breast cancer

Before deciding to have a mammogram, you should consider the possible risks and whether they are outweighed by the expected benefits.

By: New York Times | Updated: November 15, 2014 12:31:22 am

American women face conflicting advice about whether to be screened for breast cancer, at what age and how often. The decisions they make are often more strongly influenced by fear or a friend’s experience than by a thorough understanding of the benefits and risks of mammography.

In 2009, the US Preventive Services Task Force recommended that women between the ages of 50 and 74 be screened with mammography every two years and that biennial screening of women younger than 50 be considered case by case.

Yet, screening rates have not declined. Under the Affordable Care Act, free screening mammography is available to all women every one to two years. But is this really free, in the fullest sense of the word? Many experts cite hidden costs — financial, medical and emotional.

Before deciding to have a mammogram, you should consider the possible risks and whether they are outweighed by the expected benefits.

Despite the controversy about annual mammograms, I still advocate them. But it behooves every woman to be aware of the arguments for and against annual screening. Too few are equipped to evaluate what Dr Lisa Rosenbaum, a national correspondent for The New England Journal of Medicine, has called “considerable uncertainty and complex trade-offs”.

Although expert groups have issued guidelines based on reviews of the scientific evidence, disagreements among them persist, the result of differing professional perspectives, financial concerns and assessments of the medical consequences.

Screening is largely responsible for the 30 percent decline in the breast cancer death rate since 1990, though advances in treatment have certainly played a role.

So what are the downsides of regular screening? A false-positive result — a suspicious image on mammography that turns out to be nothing — is a major one.

If a 50-year-old woman is screened annually for a decade, she has a 50 percent chance of receiving a false-positive diagnosis somewhere along the way. The woman receiving a false-positive diagnosis may need only a repeat examination, which may show the initial result to have been wrong. And what if a biopsy reveals a malignancy? Then the patient faces another possible consequence of screening: overtreatment.

There are lingering questions about whether every cancer detected really warrants treatment and how extensive the treatment should be. Some cancers don’t progress, some may even disappear on their own, and others may grow so slowly they would not become a problem during the remaining years of life. But doctors cannot tell with certainty which cancers are safe to leave untreated.

Decisions relating to breast cancer are often based more on emotion than reasoning. Unrelenting publicity by well-meaning organisations has frightened many women, who are inclined to accept more risk than they might in, say, screenings for heart disease — which actually kills more women than breast cancer.

And too many have seen first hand the devastation breast cancer can wreak. Breast cancer remains the most common cancer among women, and the second-leading cause of cancer deaths among women, many of them in the prime of life.

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