As We See It

Personal decisions and sorting through new guidelines for breast cancer screening

Items from Battle of the Bras, a fundraiser for the American Cancer Society at Planet Hollywood.
Photo: Wade Vandervort

Change is hard, especially when we get used to the idea that a particular way of doing things saves lives. On October 20, in Breast Cancer Awareness Month’s pink swath, the American Cancer Society released revised guidelines for early detection of the disease. Among the handful of new bullet points, clinical breast exams are no longer recommended as part of screening for women at average risk. Women 55 and older are now advised to get screened every other year. And the age when most women should start yearly mammograms rose from 40 to 45.

That last one has been the bomb that keeps exploding, with reaction from the media, the medical community and the public focused on the potential for confusion and far worse things, whether it’s insurance companies limiting coverage or cancers being missed. The ACS emphasizes that women “should have the opportunity” to start screening earlier if they wish, and that these guidelines are for women at average risk—meaning no family history, BRCA gene mutations or other obvious factors that up the odds of developing the disease from 12 percent to as high as 80. Even those at average risk might have a hard time deciding what to do when the experts don’t agree (for example, the American Society of Breast Surgeons supports the change to 45 while the American College of Radiology doesn’t). So I went to my expert, decorated breast surgeon Dr. Souzan El-Eid of the Comprehensive Cancer Centers of Nevada.

“It’s true that earlier mammograms do save lives. All of the studies have shown that. But now we’re weighing risk versus benefit—yes, we are saving lives, but is it worth all the other false positives?” She’s talking about the fact that younger women have denser breast tissue, so it’s much harder to pick out subtleties on a mammogram. As a result, the chance that a lesion a radiologist spots will turn out to be benign is pretty high in a 40-year-old. On the flipside, hormones play a role in the aggressiveness of most breast cancers, and they’re more active the younger you are, making early diagnosis vital. “The patient is anxious, the doctor doesn’t want to miss something and then be liable and then be sued or accused of delayed diagnosis. So we do tend to over-biopsy things, and the radiologists perhaps over-read things. And so, this is a national movement, so to speak, to control all that, in my opinion.”

That doesn’t mean El-Eid agrees with all the new guidelines. She still recommends clinical breast exams (“How am I going to examine a woman’s breast if I don’t touch it?”) and that routine screening begin at 40. If you’re high-risk, the key is determining “your specific risk” (though it’s important to know that breast cancer strikes women with no known risk factors other than being female). There’s an assessment tool on that will give you a rough number, but El-Eid isn’t much for percentages. “When patients ask me about statistics I never get into statistics, because if it’s 99 percent yes and 1 percent no and you happen to be that 1 percent, what difference does it make?”

It might be wise to approach the ACS numbers in that vein. El-Eid points out that 35 used to be the recommended age for a baseline mammogram. The ACS changed it to 40 about a decade ago, and insists that the change to 45 is based on the best medical evidence up to this moment, one representative telling NBC News that women must make “a personal decision” about when to start. For me, it’s easy. My mother had a mammogram in her 30s, and was diagnosed with breast cancer.

Tags: News, Opinion, Health
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