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Mammograms & Breast Cancer Screening - New guidelines debated

As some of you may be aware, there's been a lot of brouhaha about the new breast cancer screening recommendations by the US Preventive Services Task Force (USPSTF). The new recommendations were published in the November 17 issue of the Annals of Internal Medicine and now recommends against routine screening mammograms for women under 50 years and suggests that screening end at 74 years. They also recommend against teaching breast self-examinations.

This advice is in contradiction to the guidelines of the American Cancer Society and the American College of Radiology which recommend yearly mammograms from 40 years old. However, many advocacy groups like the National Breast Cancer Coalition, Breast Cancer Action, and the National Women’s Health Network are in favour of the new guidelines.

So again, like I always say, things are not so clear cut in medicine. There will always be experts with piles of research on both sides of the issue and my job as a health care practitioner is to help you figure out what's best for each person. Individualized medicine, right?

Here's my stab at tackling this complex issue.

Should I continue to do Breast-Self Examinations?

My answer is a resounding yes!

The USPSTF states that current evidence is insufficient to determine the additional benefits and harms of breast exams by clinicians beyond screening mammography for women 40+ years of age. Essentially, they're saying there's no proof that it benefits or harms you. However, if breast exams are done consistently & properly, women can detect hard masses and abnormalities in which case, they definitely need to go in for further testing.

Yearly mammograms starting at 40 years? or Bi-yearly mammograms starting at 50?

The reason for the USPSTF's new guidelines is that they believe that the stress & anxiety that women are put through to do these procedures outweighs the benefits. Many false positives are detected and women can undergo unnecessary biopsies and follow-up testing. One scientist noted that women in their 40s have about a 10 percent chance of a false positive and a 1 percent chance of having a biopsy each time they have a mammogram. That compares against the relatively small risk of cancer for women in their 40s of 1.5 per of 1,000 women.

A greater harm is overdiagnosing by finding cancers that are better off not being found. Dr. Barnett Kramer of the National Institutes of Health describes overdiagnosis as "pure harm" because it means that women are treated with measures like chemotherapy, radiation and surgery for tumors that do not need treating. One scientist says that you can view cancer as three different types. One type grows so fast that early diagnosis is futile. Another grows so slowly it does not need to be found early to be cured. And as many as a quarter of those slow-growing cancers would never be noticed in a woman's lifetime. Cancers in the third group can be cured if they are caught early. But with breast cancers, that third group makes up only 15 percent of the deadly cancers.

This breast cancer screening question has also been posed for prostate cancers as well. There are a number of experts who believe that screening for prostate cancers is unnecessary later in life as many people die of other causes rather than the cancer.

These are all legitimate concerns so it makes this question of to mammogram or not to mammogram more complex.

What risk factors do you have? How worried are you? Would you rather have peace of mind and get the yearly mammograms even if it means getting a false positive? Are you someone who believes that they must take all preventative measures available? There are different levels of prevention. Some women with the BRCA1 & BRCA2 genes decide that the risk of breast cancer is too high and choose to have mastectomies, whereas others choose to live as healthy a life as possible to prevent these cancer genes from turning on. We know that genetics only accounts for a fraction of your health because what you put in your body and your lifestyle can determine which genes get activated or turned off.

Each person needs to weigh the risk factors and figure out what kind of personality they have. After doing all this, you will probably be able to come to a satisfactory conclusion and you can definitely discuss your thought process with your doctor.

Risk Factors
  • Personal & family history of breast cancer
  • Ethnicity - White women are at a slightly greater risk of getting breast cancer than African-American women, but African-American women are more likely to die of this cancer. Asians, Hispanics & Native-American women have lower risks of developing and dying of breast cancer. The BRCA genes are found more in women of Jewish Eastern European background.
  • Drink 2 or more cups of alcohol per day. Technically even 1 cup/day increases your risk!
  • Dense breast tissue
  • Women who started menstruating early (before 12 years old) &/or had late menopause (after 55 yrs old). Scientists postulate it's due to total lifetime exposure to the hormones estrogen and progesterone.
  • Current oral contraceptive use appears to elevate risks slightly, but women who have stopped for 10 yrs do not appear to have any increased risks.
  • Not having children or having children later in life seems to increase the risk slightly, though frankly, I do not recommend having kids just to reduce your risk.
  • Not breast-feeding may increase the risk. However, studies suggest that you may need to breastfeed for 1.5 - 2 yrs to get the protective effects. That's tough to do, but I have met patients who have done this.
  • Some forms of hormone replacement therapy (HRT) increase risks
  • Being overweight
  • Lack of physical activity
  • Smoking
Yours in health,

Ian Koo, ND
Doctor of Naturopathic Medicine

Naturopathic Essentials Health Centre
"The care you want, the health you need"

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