Mammograms Aren’t Panaceas

With everyone clamoring for unequivocal guidelines about how often women in their 40s should get mammograms, I am reminded of a button I once saw that said, “Clinical studies show there are no answers.”

Last week, changing its previous and somewhat vague advice that women in their 40s should have mammograms every year or two, the American Cancer Society officially recommended that women begin getting annual mammograms at age 40. Two months ago, the National Cancer Institute declined to make the same recommendation, saying that it could not make generalized recommendations for women under 50.

With these conflicting messages, what’s a woman to do? What, moreover, is her doctor to do?

It should come as no surprise to anyone that the detection of breast cancer is far from a perfect science. An early but rapidly growing cancer may not be apparent on one mammogram and involve the lymph nodes by the time another one is done a year later. Similarly, a very slowly progressing tumor may appear as a questionable area that is followed on serial mammograms and doesn’t demonstrate any detectable change over several years. By the time a change becomes apparent, metastasis may have occurred.

In addition to these quirks of the detection process, several radiologists can look at the same mammogram and each offer a different opinion. One might see something that she feels needs to be biopsied immediately, another might recommend that the mammogram be repeated in three months, another might say six months. Tissue density, technician experience and the machine being used to take the mammogram all can affect the quality of the study and its results. Younger women may have complicated ductal architecture from breast feeding or denser breast tissue. Younger doesn’t always mean simpler when it comes to mammography.

Keeping this in mind, one might well ask what women and physicians gain from having specific guidelines. It is possible that by pushing the recommendations about annual mammograms toward younger women, the science of detection becomes less, not more perfect. Codifying recommendations also may create the false sense among health care consumers that physicians and researchers have a better handle on breast cancer than they do, that finding a breast cancer at an advantageous time is as simple as following a recipe in a cookbook.

This sense of certainty opens a Pandora’s box of legal ramifications when the realistic limitations of breast cancer detection and treatment fall short of expectations. “Why did I have all those mammograms if they weren’t going to save my life,” a woman might ask after the detection of a cancer. Unfortunately, the next question many distressed women ask is, “Whose fault is this?”

And yet . . . When last I saw my gynecologist for my annual Pap (an institution now, ironically, giving way to biannual Paps), what he stressed most was the importance of getting an annual mammogram. His exact words to me, someone not quite halfway through her 40s, were, “This is the single most important thing you can do for your health at this point in your life.”

I agree with my gynecologist and have made the same recommendation to my patients for years. Annual breast exams for women in their 40s are a good idea. But I give this advice knowing that I place myself at risk of being the messenger in a world in which the only thing we messengers have to work with is imperfect science, not infallibility, medical cookbooks or miracles. Regardless of what the experts say.