The Mammogram Debate

Much of the debate over whether or not women in their 40s should have mammograms centers around medical studies and the statistics they generate. One simple fact in the debate is that studies have shown that the survival rate for women in their 40s is not effected by receiving routine mammograms. That said, we can begin to look at the numerous other factors that come into play in the debate, namely the emotionally loaded term "survival rate." Says Russell Harris of the University of North Carolina, even "if you screen 1,000 women in their 40s for 10 years, you prolong one or two lives." For many, the prolongment of one or two lives is one very essential outcome of mammography and breast cancer screening.

In light of the controversy, the recent panel on mammography convened by the National Institutes of Health's National Cancer Institute was unable to voice a clear or emphatic position on the topic. While claiming that mammography had no effect on the survival rate for women in their 40s, they also advised that women in their 40s should, based on their individual doctors' recommendations, make up their own minds about whether or not to have a mammogram. Despite the conflicting reports that serve to muddy the issue and confuse women, this advice may have social ramifications as well. Without a clear directive on their effectiveness, Medicare and other health care plans may choose not to pay for mammograms for women in their 40s.

THE FACTS OF THE DEBATE

PRO: Women in their 40s should get mammograms.

Statistical data

A study written up in the December issue of the International Journal of Cancer suggests that women who get mammograms in their 40s can decrease their risk of dying from breast cancer by at least 15%. The studies goes on to say that the death rate would decrease further if every woman in her 40s had an annual mammogram. For many women and their families who are fighting for their lives and the lives of their loved ones, this statistical ray of hope is all they need in order to believe in the benefits of mammography for women in their 40s.
The studies that claim mammograms do not effect the survival rate of women in their 40s include data from the 1960s, when mammography techniques were much cruder than they are today. The data from more recent studies, when looked at alone, does show that mammograms help save the lives of women in their 40s.
In addition, the studies that claim mammograms do not effect the survival rate of women in their 40s cannot be considered reliable because breast cancer is rare in women in their 40s to begin with. Says Newsweek writer Sharon Begley, "Since relatively few die of the disease in the first place, it would take an awfully powerful detection technique, not to mention effective treatment, to make much of a dent in the death rate." (Newsweek, February 24, 1997, p. 56)

Biological and Physical Reasons

Mammograms are capable of detecting tumors earlier than a woman could during a self-examination.
Tumors seem to grow faster in younger women, leading one to believe that younger women would benefit from earlier detection--detection that takes place before the tumor has a chance to grow.
Mammograms are capable of detecting lumps that are smaller than the lumps a woman could detect during a self examination.

CON: Women in their 40s should not get mammograms.

Statistical Data

The panel on mammography convened by the National Institutes of Health's National Cancer Institute has stated: "Breast cancer mortality is no lower in women who [received mammograms in their 40s] than in controls."

Biological and Physical Reasons

Mammography in younger women is not always accurate because it cannot see through the dense breast tissue of pre-menopausal women. (It is important to note that age 50 is not the magic cut-off date; what the age groups really refer to is whether or not a woman has gone through menopause.)
Due to the biological nature of tumors, mammograms may never be capable of extending the lives of women in their 40s. There are three different kinds of breast cancer tumors, and the factors involved with detecting each one lend themselves to the statistical argument that mammograms for women in their 40s do not effect their survival rate.
- Indolent tumors - These types of tumors can grow for years before they are large enough to be detected by a mammogram. Fortunately, this kind of tumor is curable by lumpectomy.
- Ductal carcinoma in situ (DCIS) - This type of tumor is not fatal, but while the presence of DCIS is detectable by mammogram, the mammogram is incapable of telling whether or not the tumor will spread. Women who are diagnosed as having DCIS are often encouraged to have mastectomies because doctors fear that the cancer will spread, but mastectomies are not always necessary to cure DCIS. In terms of the mammography debate, opponents of early mammograms claim that the mammogram itself leads to unnecessary surgery in cases of DCIS in women in their 40s.
- Agressive tumors - This type of tumor spreads so quickly that even a yearly mammogram is usually unable to detect it early enough.
There is some danger of the radiation from the mammogram actually causing cancer. Women who have a gene called ataxia-telangiectasia are particularly sensitive to radiation; numerous mammograms could cause cancer in these women.
Mammograms alone are not an effective tool for detecting breast cancer. Mammography must be combined with self-examinations to enable early detection of breast cancer tumors.

Social Reasons

The time and the money spent on social programs encouraging women in their 40s to get mammograms would be better spent on women in their 50s, because they are the group that is more likely to benefit. (Women in their 50s are more likely to have cancer; mammograms are not as likely to detect tumors in younger women because of denser breast tissue.)
The time and the money would be better spent on improving methods of detecting early invasive cancer.

Emotional Concerns

The risks of over-treatment and emotional distress outweigh the small benefit to the overall survival rate. If a mammogram results in a false negative, a woman could be lulled into a false sense of security, leading her to slack off in her self-examinations. If the mammogram results in a false positive, doctors might be lead to perform unecessary biopsies. Biopsies have the potential for scarring, which decreases the future ability to detect cancer.

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Ordinary Life: A Memoir of Illness

Sources:

Begley, Sharon. "The Mammogram War." Newsweek. February 24, 1997.

Love, Susan M. Dr. Susan Love's Breast Book, Second Edition. Reading, MA: Addison-Wesley, 1995.

Rubin, Rita. "The Great Mammogram Debate." U.S. News & World Report. January 27, 1997.

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