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Mammography in One's 40s: Considering the Arguments

Mammography in One's 40s: Considering the Arguments

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

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

Having listened for two days to the debate among experts who agree on little beyond the need for further research, I have to wonder where that crucial information is going to come from for women making decisions here and 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 had quite a few mammograms, including two false positives. Suppose I were 40 again. What would I make of the current confusion?

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

The Possible Risks

The risks or "harms" to which the panel addressed itself include the inappropriate sense of security that could come with a false-negative reading; the difficulties associated with additional diagnostic testing in the wake of a false positive; the potential risk of overtreatment of low-risk ductal carcinoma in situ (DCIS); and the danger that accompanies exposure 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 not uncommon.

Neither of these possible outcomes seems a valid reason to avoid being tested. Rather they are signals that good advice and follow-up from the physician 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 sense of security by a favorable test result. And false-positive readings do cause distress. In my own case, the worry occasioned by an abnormal result was ameliorated by my physician's sensitive behavior.

I was notified of the potential problem early in the morning and advised to come for further analysis that same day. On both occasions, the matter was 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 mine was a little hard to read.

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

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

But if I had the condition myself, the panel's statement that "some cases of DCIS may not progress to invasive cancer," would not comfort me. I would not wish to be ignorant of my condition simply because it might not 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 believe the evidence presented, it is nowhere shown that for the general population or for women of the age in question, that theoretical radiation risk from screening mammography in any way outweighs the known benefit. It has not been shown that any woman has developed breast cancer as a result of mammography. So, assuming that I am dealing with a competent radiologist, the theoretical risk is one I am willing to take.

The panel did recommend that for women in their 40s who choose to have mammography, 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 based on the wild assortment of guidance that is available to her.

In my own case, assuming I were free of symptoms, I suspect my decision could 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 sure that I would be tested, and hope that I was among the great majority for whom age 45 is not too late.

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