Ask the Expert
Dr. Katherine Alley (top) and Dr. Pamela Wright
New Breast Cancer Screening Guidelines Cause Confusion and Questions
In November 2009, the U.S. Preventive Services Task Force issued new recommendations regarding breast cancer screening for women. These new recommendations have caused much confusion and concern within the medical community as well as among women of all ages. In this month's column, two breast surgeons who are experts in the field of breast health share their views on the new task force recommendations and their advice for women. Dr. Katherine Alley is medical director of breast care services for Suburban Hospital. Dr. Pamela Wright is Suburban Hospital's associate medical director of breast services.
The U.S. Preventive Services Task Force now recommends biennial screening mammography for women aged 50 to 74 years, instead of annual screenings beginning at the age of 40. What do you think of this new recommendation?
Dr. Alley: The fact is that one in eight women get breast cancer and 80 percent of those women have no significant "high risk" factors. It has been well established that annual screening mammography improves survival. The bigger question for me is: Why did the task force choose to address an issue that was researched and answered 25 years ago by studies both in the United States and Europe? It's interesting to note that there were no breast surgeons on this task force.
Dr. Wright: I'm telling my patients that nothing has changed as far as my recommendations are concerned. Women should get a yearly mammogram beginning at the age of 40. There is plenty of data to show that screening mammography saves lives. Mammograms can often pick up malignant lesions before they are palpable. I have many patients who have been diagnosed with early breast cancer in their 40s, thanks to their annual mammogram. If these women had not undergone a screening mammogram, they may have had a significant delay in diagnosis and potentially a worse outcome.
When explaining these new recommendations, the task force cited the "harms" resulting from screening for breast cancer. Are there potential harms from having annual mammograms?
Dr. Alley: The task force was so concerned about the psychological effects of a false positive mammogram and a benign biopsy, yet I wonder if there were any consumers on the task force. It has been my experience that the vast majority of patients are thrilled with a benign result, and grateful for the newer technology that often allows them to avoid a surgical biopsy.
Dr. Wright: The radiation from mammography is quite minimal. The "harms" that the task force mentions are really just the anxiety related to a false positive study and the discomfort and/or anxiety associated with a biopsy. Most biopsies now are needle biopsies performed under local anesthesia. They are associated with only minor discomfort and require virtually no recovery.
It's also important to talk about the benefits associated with digital mammography, which is a newer type of mammography. Digital mammograms have improved the detection of breast cancer compared to film mammograms. Studies have shown that digital mammograms detect more breast cancers in women aged 40-49 and in women with dense breast tissue. GCM-Suburban Imaging (a collaboration between Suburban Hospital and the radiologists of Doctors Groover, Christie and Merritt) has been providing digital mammograms since 2004 and we have been providing all-digital mammograms since 2007.
How does early detection improve patient outcomes?
Dr. Alley: Just recently I operated on three patients with breast cancer. In all three cases the cancer was found on a yearly interval screening mammogram. Two of the patients had very early lymph node involvement, which would have been more invasive had the diagnosis been made a year later. As one of my patients said recently, an earlier diagnosis allowed her more choices in her treatment.
Dr. Wright: Early detection is the key to cure. Breast cancers caught at an early stage have a better prognosis and many of these patients can undergo less aggressive cancer treatments because their cancer was caught early. For example, they may have the option of a lumpectomy instead of a mastectomy. They may be able to avoid chemotherapy.
What are your patients saying about these new task force recommendations?
Dr. Wright: I've had a flood of phone calls from patients. They are confused about what they should do and they are anxious about what these recommendations ultimately may mean for them. The task force cited the desire to reduce anxiety for women. These recommendations have actually added to my patients' level of anxiety.
Is there any reason women should be discouraged from performing regular breast self-exams?
Dr. Alley: There is absolutely no reason that women should be discouraged from performing regular breast self-exams. These exams are an easy, cheap and accessible tool. Ten percent to 15 percent of breast masses don't show up on mammograms, usually because of dense tissue. I recently saw a 72-year-old woman who found a lump in her breast that proved to be cancer. She had a negative mammogram in March 2009 and again at the time of her diagnosis. An ultrasound confirmed a solid mass. No woman should be told that she doesn’t need to bother to check her breasts.
The task force concluded that "the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older." How do you respond?
Dr. Alley: The peak age incidence of breast cancer is 65. It doesn't disappear at age 75.
I'm due for my annual mammogram. What should I do?
Dr. Wright: Go for your mammogram. While mammography is not perfect, to date it is still the best screening method we have for the early detection of breast cancer and it has been proven to save lives. I will continue to recommend yearly digital mammograms for all women beginning at age 40. Because women are living longer, they should not stop getting mammograms at a certain age. If a woman is healthy, without any significant life-threatening illnesses, she should continue to get screening mammograms.
About the Physicians
About Dr. Alley
Dr. Katherine Alley is a board-certified general surgeon who specializes in breast surgery. She received her medical degree from George Washington University and completed her internship and residency at the GeorgeWashingtonUniversityHospital.
Dr. Alley's office is located in the Champlain Building, 6410 Rockledge Drive Suite 504, in Bethesda. The phone number is 301-493-8500.
About Dr. Wright
Dr. Pamela Wright is a board-certified general surgeon and a fellow of the American College of Surgeons who specializes in breast surgery. She received her medical degree from the University of Maryland School of Medicine. She completed her surgery residency at the University of Maryland Medical System in Baltimore. She is the associate medical director of the Suburban Hospital Breast Programs as well as the Cancer Program's cancer liaison physician to the Commission on Cancer.
Dr. Wright's office is located in the Suburban Hospital Outpatient Surgery Center, 6420 Rockledge Drive, Suite 3700, in Bethesda. The phone number is 301-530-5151.
For more information about Suburban Hospital's breast services, click here.