Mammography in One's 40s: Considering the Arguments

Ann Kelsall is a medical writer who reported on the NIH ConsensusDevelopment Panel meeting for Oncology News International. Here she considers,from the woman's perspective, the panel's arguments against mammographyscreening for women ages 40 to 49.

LANDOVER HILLS, Md--The NIH Consensus Development Panel evaluating thevalue of mammography screening for women ages 40 to 49, concluded theirreport with a recommendation that women "should have access to thebest possible information in an understandable and usable form," sothat they can make their own decisions in collaboration with their physician.

Having listened for two days to the debate among experts who agree onlittle beyond the need for further research, I have to wonder where thatcrucial information is going to come from for women making decisions hereand now.

I am not a physician. My comments on the ongoing debate are personal,based on my own experience as a woman (well beyond my 40s), who has hadquite a few mammograms, including two false positives. Suppose I were 40again. What would I make of the current confusion?

The results of recent randomized controlled trials related to mammographyfor women between 40 and 49 years old are extremely difficult for the laypersonto decipher. All parties do seem to agree, however, that there is somereduction in breast cancer deaths among the women in that age group whoare screened. But there is an acerbic parting of the ways when those benefitsare evaluated and weighed against the perceived risks.

The Possible Risks

The risks or "harms" to which the panel addressed itself includethe inappropriate sense of security that could come with a false-negativereading; the difficulties associated with additional diagnostic testingin the wake of a false positive; the potential risk of overtreatment oflow-risk ductal carcinoma in situ (DCIS); and the danger that accompaniesexposure to radiation.

The first two issues go to the point that mammography is not perfect.The results can be flat wrong. Not all cancers are detectable by mammography,especially in younger women. It is also true that false positives are notuncommon.

Neither of these possible outcomes seems a valid reason to avoid beingtested. Rather they are signals that good advice and follow-up from thephysician are crucial. To paraphrase one of the speakers at the panel discussion,should we avoid doing good because we know we cannot achieve perfection?

To be sure, it would be a grave mistake to be lulled into a false senseof security by a favorable test result. And false-positive readings docause distress. In my own case, the worry occasioned by an abnormal resultwas ameliorated by my physician's sensitive behavior.

I was notified of the potential problem early in the morning and advisedto come for further analysis that same day. On both occasions, the matterwas clarified within hours, and I was relieved to hear that all was well.Neither time did it occur to me to stop having mammograms because minewas a little hard to read.

The arguments about inconvenience or "psychosocial consequences"puzzle me greatly. There is about as much inconvenience associated witha mammo-gram as for any physical examination--hardly an argument for avoidingthem.

I do understand that early discovery and appropriate treatment of DCISare matters of much uncertainty. Clearly, more needs to be known aboutthe history of this disease and its treatment.

But if I had the condition myself, the panel's statement that "somecases of DCIS may not progress to invasive cancer," would not comfortme. I would not wish to be ignorant of my condition simply because it mightnot kill me. For me, the problem would be deciding on appropriate treatment,not on whether I should have had the mammogram.

Radiation exposure is an understandable concern, but, if I am to believethe evidence presented, it is nowhere shown that for the general populationor for women of the age in question, that theoretical radiation risk fromscreening mammography in any way outweighs the known benefit. It has notbeen shown that any woman has developed breast cancer as a result of mammography.So, assuming that I am dealing with a competent radiologist, the theoreticalrisk is one I am willing to take.

The panel did recommend that for women in their 40s who choose to havemammography, the costs should be reimbursed by third party payers or HMOs.It is hard to say just how seriously that recommendation will be taken,given the unwillingness of the panel to recommend the test.

My Decision

A woman in her 40s today does not have that "best possible information"called for by the panel. She has to make the best decision she can basedon the wild assortment of guidance that is available to her.

In my own case, assuming I were free of symptoms, I suspect my decisioncould well be based partly on cost. If I were 40 and not sure of coverage,I might well wait, at least until I was 45. After that, I am quite surethat I would be tested, and hope that I was among the great majority forwhom age 45 is not too late.