Mammography & beyond.

The American Cancer Society recommends a yearly mammogram beginning at age 40 and continuing "for as long as a woman is in good health."

The U.S. Preventive Services Task Force, however, recommends all women "over 40" get a mammogram "every year or two," (15) while the National Cancer Institute recommends women in their "40s" get a mammogram "every year or two." (16)

Why the variation?

"This is more a political and a public health policy issue than a medical debate," says radiation oncologist Marisa Weiss, MD, president and CEO of the nonprofit Web site breastcancer.org. "The bottom line is you should have a mammogram once a year from age 40 on, unless you have a history of breast cancer at young ages in your family, in which case, earlier is probably more appropriate."

Unfortunately, too few women heed that advice.

A Harvard study of 72,000 women found that only a fraction of those who need mammograms get them every year, with just six percent of those screened in 1992 returning for another mammogram every year during the next decade. That's despite the hospital's "aggressive reminder program." (17)

"This suggests that women are either reluctant to comply with recommendations, are not being counseled appropriately by their physicians or are not going for routine preventive health care," says Carol L. Kornmehl, MD, a radiation oncologist at Valley Hospital in Ridgewood, NJ, and author of The Best News About Radiation Therapy.

Other reasons, notes a 2004 Institute of Medicine report on the topic, range from a lack of health insurance coverage to a fear of breast cancer to the fact that some find the procedure painful. (18)

Yet there's no doubt that mammograms identify breast cancers at an earlier stage, when they're most treatable and less likely to spread. (19)

However, mammograms are not perfect. They carry a high risk of false-positives, meaning women may undergo needless worry, expense and biopsies only to find that they don't have cancer. Overall, one study found, a 50-year-old woman having annual mammograms for 20 years has a one in five risk of receiving a false-positive report. (20)

Mammograms also don't work well in women with dense breasts, common in younger women.

Still, for women with a low risk of breast cancer, they're an excellent screening tool. For women with a high risk of breast cancer, or those whose mammograms show an abnormality, there are other options, such as MRI. One major study of 1,909 women with a high risk of breast cancer found that MRI worked better than mammography at detecting tumors. (21)

So why not offer it to all women?

"MRI is a useful tool as a supplement, but not as a replacement to mammograms," says Dr. Kornmehl. "Besides being an expensive test that many insurance companies are reluctant to pay for, it can open a 'Pandora's box' by leading to false-positive findings and the need for stressful procedures, such as biopsies."

Another, less expensive option, particularly for younger women with dense breasts who feel a breast lump, is ultrasound, which sends sound waves through the breast to create a picture on a screen. It's often used to tell if an abnormality is solid or filled with fluid, but it isn't specific enough to be used alone as a screening technique.

When choosing a mammography center, Dr. Kornmehl recommends looking for the following:

* An American College of Radiology-accredited facility.

* Radiologists who spend the majority--if not all--of their time reading mammograms in a set-aside block of time known as "batch reading." One study found it could significantly reduce the number of women who have to return for additional mammograms.

* A center with immediate readings and follow-up. One study of more than 8,500 women found those who received immediate screening results and underwent follow-up tests within the same office visit had significantly less anxiety than those who had to wait several days for results.

References

(15) US Preventive Task Force Screening for Breast Cancer, February 2002. www.ahrq.gov.

(16) Get a Mammogram, National Cancer Institute. www.cancer.gov.

(17) Blanchard K, Colbert JA, Puri D, et al. Mammographic screening: patterns of use and estimated impact on breast carainoma survival. Cancer 2004;101(3):495-507.

(18) Saving Women's Lives: Strategies for Improving Breast Cancer Detection and Diagnosis. Institute of Medicine. June 2004.

(19) Joensuu H, Lehtimaki T, Holli K, et al. Risk for distant recurrence of breast cancer detected by mammography screening or other methods. JAMA. 2004;292(9):1064-73.

(20) Hofvind S, Thoresen S, Tretli S. The cumulative risk of a false-positive recall in the Norwegian Breast Cancer Screening Program. Cancer. 2004;101(7):1501-7.

(21) Kriege M, Brekelmans CT, Boetes C, et al. Efficacy of MRI and mammography for breast-cancer screening in women with a familial or genetic predisposition. N Engl J Med. 2004;351(5):427-37.