From the Desk of Dr. LeRoy
New Mammography Guidelines: It's About Time
About 12 years ago, after a detailed review of the literature regarding the use of mammography, I came to the conclusion that most women should not have mammograms until the age of fifty--and probably not every year thereafter. Granted, I am not a "medical researcher", but I do have a brain, and training in statistical analysis as well as in critical review of research. My conclusion was based on studies that examined the risk versus the benefit of regular mammographic screening. The risk, a topic rarely discussed, is due to exposing sensitive breast tissue to ionizing radiation. This exposure has been shown to increase the likelihood of developing breast cancer. The benefit is earlier detection; at least that is the hope.
I published my research-based opinion on my website about 10 years ago in the form of an article entitled "Sensible breast cancer screening". Needless to say it did not sit well with the Illinois medical board and it was one of several issues that I was forced to defend. Hence, my sensitivity and interest in this topic, and my satisfaction with the publication of the new guidelines on mammography.
The guidelines, which are exactly what I had been recommending for 12 years, were published by the US Preventive Services Task Force. This task force is a group of physicians and researchers, commissioned by the Department of Health and Human Services, who examined the credible, peer-reviewed research that exists regarding breast cancer screening. They found that there was insufficient research to justify that women under the age of fifty have regular mammographic screenings. They also recommended that women over fifty have mammograms every other year, not every year as had been recommended. What followed the initial media coverage was a litany of segments as the supporters as well as the detractors clambered to be heard.
The most common argument I have heard from non-physicians, including patients of my own, was that the new guidelines were an attempt by the government to ration services. Many of these individuals were angry that women were in the process of being robbed of a necessary diagnostic test that saves women's lives. During one of the many interviews that have appeared on this topic Dr. Susan Love responded to this belief best. When asked specifically about the issue of rationing, she stated "this isn't about depriving a woman of the right to radiate her breasts". Although I found this comment quite witty, I doubt the majority of viewers understood her reference to the fact that radiation is a proven cause of cancer. Dr. Love had further comments on her blog that address the issue of "rationing" better than I: "Are these new guidelines an example of rationing? You bet. They are an example of exactly how we need to ration health care, based on science. It is exactly this approach, health care standards by popularity rather than science that raise the cost of medical care in this country. The lack of a "comparative effectiveness" body to come up with recommendations and then enforce them, means that it is the third party payers willingness to pay for procedures that determines the standard of care. The absence of a government run screening program means that the uninsured cannot get screened at any age unless they are poor enough to qualify for a CDC program. The best way to improve the health care of all women and to prevent deaths from breast cancer is not supporting screening that is not effective but rather a health care reform that covers all with evidence based medicine." Well said. Bravo Susan Love.
Another criticism vocalized by some individuals was that they knew a person who had found breast cancer because of a screening mammogram. This criticism fails to understand one of the reasons for the change in breast cancer screening guidelines: mammography is a cause of breast cancer! When large populations of women are screened--especially under the age of fifty and even more so under the age of forty--the radiation from regular mammograms will cause breast cancer in some of the screened women. This is a simple fact and the basis for "risk versus benefit" studies. Therefore, for every one woman who finds breast cancer with screening mammograms under the age of fifty, another one, or possibly two, will develop breast cancer due to the ionizing radiation associated with regular screening. This was most significantly demonstrated in a study entitled "Estimated risk of radiation-induced breast cancer from mammographic screening for young BRCA mutation carriers" published in the Journal of the National Cancer Institute in February, 2009. To summarize, the researchers found that in young BRCA mutation carriers (i.e. those who have the breast cancer gene) performing regular mammograms would cause more cancer than what would be found. In other words, the risk outweighs the benefit.
To make matters more confusing--in the midst of all of the hysteria--was the secretary of Health and Human Services, Kathleen Sebelius, throwing the task force panel under the bus--the very scientists her department had commissioned. She stated about a week after widespread public criticism of the new guidelines, that women "should keep doing what they have been doing". ???? What???? The entire point of using the US Preventive Services Task Force to investigate an area of medicine is to determine what is scientifically valid. Anecdote and public perception is not science. The new guidelines finally take into account the risk of mammography and provide reasonable and safe recommendations for women and their doctors that are based in fact.
Many doctors and their patients, who are inclined to respect the validity of the new guidelines, are now uncomfortable "doing nothing" to screen for breast cancer. My recommendation is to use alternative testing, such as breast thermography to screen for cancer. Breast thermography doesn't use radiation and can thus be safely used at any age. To facilitate the use of thermography and introduce patients to the screening tool who haven't had this testing in the past, I have some special discounts that I am offering for the next 2 months.
Dr. Nick LeRoy, DC, MS