The U.S. Preventive Services Task Force, an independent panel of experts, recently issued a recommendation that women not start undergoing mammography screening until age 50, and between ages 50 and 74 have the procedure only every two years — not every year, as has been previously recommended.
Prior guidelines recommended mammography starting at age 40.
The problem was that in the 40 to 50 age group, most women still have fairly dense breasts, which decreases the sensitivity of mammography for detection of cancer. With dense breasts, there is also a greater radiation to produce a readable mammogram.
In the February 1971 issue of the American Journal of Cancer Research, Dr. Al Segaloff, and I an article showing that there was a synergism between radiation and estrogen in production of breast cancer in rats. These data indicates that women who still are premenopausal are at greater risk for problems from mammography than those who are postmenopausal — unless they are taking estrogens.
If they are taking estrogens, then there is again the risk of synergism between the radiation and the estrogen in production of breast cancer.
In addition, women who take estrogen have an increasing density in the breasts.
Congress has permitted reimbursement for mammograms starting at age 40. But it is necessary for women to determine whether or not mammography would possibly be of benefit to them. If there is the presence of BRCA 1 or BRCA 2 pattern in the patient, then mammography is indicated. In addition, if there is a family history of breast cancer, then the mammography is indicated.
What has not been recognized, however, is the fact that there are alternative ways to look at the breast. Years ago, breast thermography was a fairly routine procedure in the United States, but then its use fell off due to promotion of mammography. It is now coming back as a way of looking at the breast without the risk of radiation.
Ultrasound is particularly valuable for patients with dense breast tissue.
Another technique that is gaining popularity is MRI of the breast. If data continue to show the value of MRI spectroscopy, it may be possible, in time, to eliminate the need for needle biopsy of lesions, thereby eliminating the risk of cancer cells spreading along the needle track.
The negative factor not mentioned is that the incidence of positive biopsy based on mammography alone is only 20 percent, meaning that 80 percent of biopsies come back negative. One way of avoiding this problem — but again utilizing additional radiation — is positron emission mammography (PEM).
By using these techniques, we could positive biopsy rates into the 60 percentages, almost reversing the incidence of negative biopsy by using just mammography alone.
All of these factors need to be considered when making a decision about mammography.
Posts by William Maxfield, M.D.
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