The New Mammogram Recommendation: Is it cost-saving or live-saving?

Twenty years ago, as a fellow oncologist at the University of Missouri, I published an article in the New England Journal of Medicine addressing the issue of breast cancer risk after radiation therapy to the breast. My conclusion was that a small dose of radiation is more likely to cause breast cancer than a larger dose. The reasoning is that a large dose of radiation kills cells, whereas a small dose of radiation creates a small damage in the DNA of normal cells. That damage is the prerequisite for cancer development. Canadian researchers did scientific trials testing whether screening mammography should be started at the age of 40 or 50. The conclusion was that if we start mammograms at the age of 40, those women between the ages of 40 and 50 have a slightly, but significantly, higher risk of developing breast cancer proving the theory outlined by myself and others. Based on those studies, the Canadian health care system recommended and decided that screening mammograms should be delayed until the age of 50. Some people say that it was a cost-saving measure and that is true; but, there is science and evidence of safety that justified the policy. In fact, a very close family member of mine at the age of 42 saw her gynecologist who was shocked to realize that she had not had a screening mammogram despite her personal relationship with me. His comment was based on the herd instinct that in America we do mammograms at the age of 40. However, we have no scientific basis for that--the Canadians do!

The myth of “doing more is better” is nothing but a myth

In this day and age where economics, politics, and patient care are intimately intermingled, the business of mammography is a business. Sometimes in the free market economy business prevails over scientific evidence.

So, what is the risk of starting screening mammograms at the age of 40? Money aside, in America we can afford basically anything we want; however, this is not about money. This is about two issues. First is safety. The small dose of radiation to which patients are exposed to promotes mutation of normal cells with potential of becoming cancerous. More critical is the fact that mammography is not very sensitive when the breast is still “juicy,” meaning that the breast tissue is still exposed and influenced by the female hormones. It is more difficult to detect breast cancer when the breast is under the influence of estrogen. The influence of estrogen on the breast tissue continues as long as the woman has functioning ovaries or is taking hormone replacement therapy. The density of the breast in women between the ages of 40-50 can create two problems. When the breast tissue is too dense, it creates false shadows which translate into marginally abnormal mammograms. That, by itself, results in two scenarios: either a biopsy which results in normal histology or the mammogram is repeated in 6 months or less hence exposing the breast to another dose of low dose radiation which increases the risk of developing breast cancer.

There is no doubt that the psychological impact and anxiety of the false abnormal mammograms cannot be underestimated.

The second problem is that dense breast tissue that is under the influence of normal levels of estrogen can hide breast cancer. In fact, studies have shown that women in their mid 40s who have breast cancer that is felt by the patient or their physician have normal mammograms 23% of the time. That is a real challenge. I always advise patients like this to have a biopsy regardless of what the mammogram shows, because of that “high false negative” mammogram.

I am not a big fan of the health care policies under the current administration, but as a physician and scientist I have to draw the line in issues like this. Some people would say that the policymakers are suggesting limiting mammograms to women after the age of 50 based on economics and cost containment. But, when the scientific evidence is on their side, science and clinical judgment has to prevail regardless of their motives.

Medicine is the art of balancing benefit vs. potential complications

Finally, because medicine is an art, science, and profession, we cannot treat all individuals the same. A woman who has a strong family history of breast cancer or other cancers should not be treated the same according to the cookbook medicine we have these days. Such women should be counseled, maybe genetically tested and, certainly, a thorough family pedigree has to be established. If the risk of such women to develop breast cancer is very high, the treating physician has the artistic and professional duty to treat them with a special recipe. They have to be counseled about methods of prevention, self examination, and maybe such women should be subjected to screening mammograms at an earlier age. I say “maybe” with hesitation, because actually such women are more likely to be harmed with screening mammography since they are genetically predisposed and they are more likely to have their cells mutated by the mammograms than by women in the general population. Maybe such women should have the more expensive breast MRI done routinely (on an annual basis) coupled with self examination as well as a physician’s physical examination. I call that custom-tailored medicine. That is what we need in America.

Nash Gabrail, M.D., M.R.C.P.

Medical Oncologist,

Canton, OH