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Scoring the Exams
Mammographies annually? Or biannually? Starting at age 50 or age 40? Should it be a film or digital mammography? And what about a breast MRI? Who should get what? When?
The "mammograms annually beginning at age 40" mantra came under fire last year. In November 2009, the U.S. Preventative Services Task Force stated that, for women of average risk, mammographies should begin at age 50 and should be performed biannually.
The task force's pronouncement was denounced by many in the medical community. "I thought it was disgusting," states Kathryn Evers, M.D., director of mammography at Fox Chase Cancer Center. "There were no clinical people or breast cancer specialists on that panel, so where were they were getting their so-called 'expert' information? The impact of that announcement could have affected not just what women do for preventive screening, but what insurance companies decide to cover. The only reason they moved it to age 50 and biannually was to save money."
"Basically, it was a statistician sitting in a dark room looking at numbers," says Susan Roth, M.D., of the Breast Imaging Center at the Hospital of the University of Pennsylvania, where she is also a professor of radiology. "They looked for a way to find the least benefit against the lowest risk. Most of us in the community came out and said this made no sense and should be disregarded."
The task force did state that women under 50 should receive mammograms based on their individual risk. "But that assumes women know their risk, and many, many do not," states Sue Friedman, executive director of FORCE: Facing Our Risk of Cancer Empowered.
Friedman herself did not know that she was at risk for breast cancer until she was diagnosed with it. At age 33, Friedman was told that she had an aggressive breast cancer that had spread to her lymph nodes. She had a mastectomy and went into remission. Then, she read a magazine article about BRCA 1 and 2, the genetic mutations that are indicators for breast, ovarian and other cancers. The BRCAs, Friedman learned, are prevalent in the Jewish community.
Ashkenazi women -- and men -- carry the mutations in dramatically high proportions. According to Fox Chase Cancer Center, mutated BRCA genes occur in one in 500 people in the general population. Of people born to two Ashkenazi parents, one in 40 carries the BRCA mutations.
The average woman's risk of having breast cancer is 12 percent. With the BRCA 1 mutation, the average risk for breast cancer jumps to 65 percent. With BRCA 2, the average risk for breast cancer is 40 percent. The BRCAs are also indicators of ovarian cancer, with the rate being as high as 40 percent.
Happening upon the magazine article might have saved Friedman's life by motivating her to get tested for BRCA; she tested positive for BRCA 2. That, combined with the aggressive nature of her breast cancer, led to Friedman's decision to have her other breast and her ovaries removed.
But that was possible, Friedman says, only because she learned about her risk. "So for any medical group to give recommendations to women based on their risk level assumes that women know their risk level. And many do not."
What puts a woman at high risk? "If your mother, grandmother or aunt had breast or ovarian cancer, you are at high risk," Evers explains. "That's especially true for cancers that developed in a relative who was young, which is defined as premenopausal or below the age of 40."
"Every Jewish woman with breast or ovarian cancer in her family should consider genetic testing for the BRCA mutations to further determine her risk level," says Richard J. Bleicher, M.D., FACS at Fox Chase Cancer Center. "Having all of that information determines what kind of breast cancer screening a woman should receive."
That's where breast imaging comes into the picture. There are three varieties of imaging: film mammograms, digital mammograms and breast MRIs. What's right for whom?
Women at average risk can get either a film mammogram or a digital one. "Don't feel that you are getting an inferior mammogram just because it is film and not digital," Evers says. "If you like your health care providers, stay with what they can provide. The technologist and the radiologist -- and their skills -- are the two most important pieces of the puzzle. The actual piece of equipment is not."
Women at high risk should get more screenings, Roth says. "Twice a year. Every six months. Once with a mammogram and once with a breast MRI."
What exactly is the breast MRI and how does it differ from a mammography? "Mammograms look at the architecture of the breast," Evers explains. "MRIs look at the blood flow through the breast. It's very sensitive but not specific."
"Here's the dilemma with the breast MRIs," says Bleicher. "It's more information. But is it accurate information?"
That inaccurate information can lead to false positives and overtreatment. To assess the diagnostic impact of breast MRIs, Bleicher conducted a study at Fox Chase, the results of which were published in the Journal of the American College of Surgeons in 2009.
"We have yet to see any evidence that MRI improves outcomes when used routinely to evaluate breast cancer and, in fact, the high incidence of false positives has a direct, harmful effect," Bleicher says. "What's happening is that many women, when faced with what appear to be abnormal findings on an MRI, are deciding to have a mastectomy whether the physicians determine malignancy or not. Women are saying, 'Just take it off. I don't want to take any chances.' But our study found that many, many of those mastectomies are unnecessary."
While Roth has seen the same reaction in her patients, she says that there is a way to get the benefits of breast MRIs and deal with the effect of false positives. "I advise women to be assessed at a high-risk clinic at HUP, or one of other major hospitals," she says. "One of the things they will have access to is psychiatry. There is a psychological effect of not only being high risk, but of having false positives. But we need those women to get MRIs because MRIs find more cancers than mammograms do. What I've seen is that, if a woman is psychologically prepared in advance for false positives, then she is more able to handle them and less likely to have a prophylactic mastectomy."
But Roth points out that women with a family history of breast cancer and/or the BRCA mutations comprise only 20 percent of the women who are diagnosed with the disease. "A full 80 percent of women who develop breast cancer have no risk indicators and are not getting additional screening," she says. "That's why annual mammograms are so important."
"Annual mammogram beginning at age 40," Evers says. "That's what the American Cancer Society says, what the National Cancer Institute says, and what I say. So it must be right."
Melissa Jacobs is the senior editor for both the Special Sections of the Jewish Exponent and Inside magazine.