If you’re a woman and just turned 40, there’s a rite of passage: your first mammogram.
You are asked to place your breasts, one at a time, between two pieces of clear plastic.
A kindly, often smiling technologist turns a dial that squeezes and slightly flattens the breast, necessary to get a good image.
Before the digital image is taken, patients are given a gentle reminder: “Don’t breathe” — to which women sometimes want to mutter, “As if.”
This first, or baseline, mammogram at age 40 has been considered part of a long-term strategy for detecting breast cancer in its earliest stages, when it is the most treatable.
It was one piece of health advice that most women remember, considered near-gospel.
That is until last year when it was challenged by the U.S. Preventive Services Task Force, a government advisory panel.
Rather than have women start getting mammograms in their 40s, the task force suggested that most could wait until their 50s. And even then, it said, women between the ages of 50 and 74 should be tested once every two years rather than annually.
The guidelines were based in part on the number false-positive tests, when women appeared to have a cancerous lump that further testing showed was benign.
These false positives could occur nearly twice as often among women between the ages of 40 and 69 who received mammograms every year rather than every other year, the report said.
In short, having mammograms every other year provides a better balance of benefits, it added, including fewer unnecessary biopsies.
The task force wasn’t alone in this stance. The University of California at Berkeley took a similar position in its February Wellness Letter. However, it urged patients, particularly those with a family history of breast cancer, to talk to their doctor about the issue.
The recommendations have triggered a fierce and sometimes emotional national debate over what advice women should follow.
“Women are really confused and scared,” said Dr. Lisa Ivanjack, an internal medicine physician at The Everett Clinic.
“My mother-in-law died of breast cancer. It’s a scary personal issue. It’s hard for patients constantly to be told different things.”
She said she advises patients to stay the course and continue with previous guidelines.
“It’s been shown that women getting screened between 39 and 49 help reduce breast cancer mortality rates,” she said.
Shauna McBride, a spokeswoman who works at the American Cancer Society’s Seattle office, said mammograms are the best tool now available for detecting beast cancer.
Women in their 40s who decide not to be screened, while eliminating the possibility of false positive tests, “wouldn’t benefit from the proven, life-savings benefits of mammography,” McBride said.
Nationally, approximately 17 percent of breast cancer deaths occur in women who were diagnosed in their 40s, and 22 percent occurred in women diagnosed in their 50s, she said.
Some women coming to Providence Regional Medical Center Everett for their mammograms have asked about the new recommendations.
“Some had friends in their 40s who had breast cancer,” said Mary Wickert, a technologist who administers mammograms at the hospital’s Comprehensive Breast Center. “They can’t understand why the recommendations were what they were.”
Statistics show women living on the West Coast have higher-than-normal rates of breast cancer. And women living in the Puget Sound region have some of the highest rates in the nation, said Joy Knox, a nurse practitioner at the breast center.
No one knows why, but it could be because more women in the Puget Sound region have babies later, in their 30s, than in some other parts of the country. “That in itself is a risk factor for cancer,” Knox said.
“It’s probably a combination of factors,” she added, “not just one thing.”
Calcifications are small growths, part of aging, that can either be cancerous or benign and can indicate an early stage of breast cancer.
Mammograms help detect these earliest forms of breast cancer which other screening techniques, such as ultrasound or a breast MRI, don’t, Knox said.
When there is a change in the shape or distribution of calcifications, biopsies are recommended.
“We do biopsies knowing a larger percent will come back benign,” she said. “We need to do that so we don’t miss early breast cancer.”
In 2008, the most recent data available, one out of every 451 women under 50 screened at the center had breast cancer.
The anxiety over mammograms that show a spot of concern, triggering biopsies that later turn out negative, were other reasons the national task force gave for going to every-other-year mammograms.
Dr. Tom Smith, a surgeon and the breast center’s medical director, disagrees. Getting annual mammograms helps detect cancer at its earliest stages, cancers as small as 1/8 to ¼ of an inch. Some microscopic cancers can be detected by a few small calcifications spotted on a mammogram, he said.
“The benefits are clearly there with screening and with modern mammography.”
Mammograms cost about $150 while the cost of treating cancer can be $6,000 for surgery, about $12,000 for radiation, and an initial treatment of chemotherapy can cost about $14,000, even in relatively straight forward cases.
“I think for me it’s a compelling argument that discovering early breast cancer can save some of this,” he said. “It’s an interesting argument that was left out: What it costs to discover breast cancer in that early age group.”
Sharon Salyer: 425-339-3486 or firstname.lastname@example.org.
The American Cancer Society statement on mammograms:
“Despite recent controversies over its usefulness, especially in women under age 50, mammography is still considered to be the gold standard for early detection of breast cancer. Women are still advised to get a mammogram every year, starting at age 40.”
The University of California at Berkeley Wellness Letter:
“For most women, it would make sense to switch from annual screening to every two years. The evidence shows that mammography every two years saves nearly as many lives as annual screening.”