Yesterday, I shared my opinion about one controversial prostate cancer screening tool. So today, I’d like to switch gears—and share the latest development in the increasingly heated debate over the best way to detect breast cancer.
While PSA testing has gotten a lot of flak recently, mammography is coming in a close second—for reasons that raise a lot of the same challenging questions.
Chief among these is whether routine mammography really saves lives. If you’ve been a reader of mine for a while, you already know my answer to that question.
I have never felt that women needed yearly mammograms. There is just too much radiation and too much compression of the breasts (which impedes critical lymphatic drainage) for me to fully endorse this procedure on an annual basis.
Now, that’s not to say that there aren’t women who should be more heavily screened. But the bottom line is that mammograms need to stop being the gold standard for breast cancer detection—even (and maybe especially) among high-risk patients.
There’s simply no need to expose women to the additional risks posed by mammograms when there are safer alternatives. Such as ultrasound, which often detects cancer better (especially in denser breast tissue) than mammography. In fact, ultrasound is my No. 1 recommendation for breast cancer screening. Thermography is another alternative. (Though in my opinion, it has never been as rigorously studied as it needs to be, so it’s not a method that I routinely recommend.)
In short, I’ve always urged patients to think outside the mammogram. And I’ve always been conservative with my recommendations. (In the past, I’ve generally recommended that women without a strong family history of breast cancer get a baseline mammogram at 45, followed by screening every two years after the age of 50.)
That being said, more and more recent studies appear to be questioning the benefits of mammography altogether. Enough that even I feel the need to step back and re-evaluate.
Of course, these new findings work out great for insurance companies. If it’s true, they may not have to pay for routine mammograms much longer. And that alone makes any official statement on the matter suspect, in my opinion.
So I always like to look outside of the United States (where Big Pharma and lobbyists aren’t always running the show) for additional guidance when I can. And there have been some very strong opinions forming on this issue overseas.
More specifically, the Swiss Medical Board recently recommended that Switzerland stop introducing any new mammography screening programs in the country. And that they start putting an end to all the existing screening programs already in place.
The board reviewed the evidence, and decided that it couldn’t pinpoint a clear benefit that outweighed mammography risks. (Something that America likes to forget—radiation comes with very real risks. In fact, we now know that CT scans—many of which were probably unnecessary in the first place—produce 2 percent of all cancers in this country.)
Instead, the Swiss Medical Board would like to see women receive information, so that they can make their own individual choices about screening.
Needless to say, even in Switzerland, this recommendation made a lot of cancer experts very unhappy. But you have to admit—it’s hard to argue with the logic here.
And there’s a lot of support for it, too. Take the review of half a century of mammography data that recently appeared in the Journal of the American Medical Association, for example. Researchers concluded that all screening should be individualized.
And to me, this represents a nice “middle ground” in the debate—one that doesn’t throw the baby out with the bathwater.
The solution to the mammography problem is clear. Put an end to one-size-fits-all screening protocols and allow doctors to actually start making decisions again. I realize that this blanket approach to health care often stems from malpractice issues. But to screen women with radiation annually starting at age 40 to me is malpractice.
So obviously, something has to change. The sooner, the better. Because when used wisely, mammography can save lives. But as is the case with most things, it is overused in this country—and still misses many cancers.
So it’s way past time doctors started thinking about their patients as individuals. And factoring in both a woman’s risk for breast cancer, as well as the additional harms that mammography may actually cause, when choosing the best way to proceed with screening.
“Swiss Medical Board: Stop Widespread Mammography Screening.” Medscape. Apr 17, 2014.
“Abolishing mammography screening programs? A view from the Swiss Medical Board.” N Engl J Med. 2014 May 22;370(21):1965-7.
“A systematic assessment of benefits and risks to guide breast cancer screening decisions.” JAMA.2014 Apr 2;311(13):1327-35.