As a young surgeon, I was really interested in academics. I wanted to publish papers. I wanted to present at major meetings. I felt that I had little or no guidance in the arena of trauma (where I practice now), so I turned to a breast surgeon and helped him with cases. We discussed the literature. I also went to the tumor conferences (a monthly conference that most hospitals have in which they talk about the cancers that have been discovered over the last month or so).
I learned a lot about breast cancer. I learned a lot about mammograms and CT scans of the breast. I learned a lot about how to operate on the breast and how to get the best cosmetic result. I saw a lot of women with breast cancer. With this as my backdrop, I would like to reiterate that I am not an expert but I know more than your average Joe.
First of all, I think it's important to say that breast cancer is still a very serious disease in the United States. Close to 200,000 women will be diagnosed with invasive breast cancer this year. Over 40,000 women will die in the United States as a result of breast cancer. Lung cancer is the only cancer that kills more women in the United States. So this is not a benign disease.
The incidence of breast cancer increases with age for women. The incidence peaks between ages 75-79. Women ages 20-24 have a rate of breast cancer of approximate 1.4 in every 100,000 women, whereas the incidence for women in their late 70s is approximately 400 cases for every 100,000 women.
The next thing is that it's important to know before you can evaluate the recommendations which were handed down by the US Preventive Services Task Force is how a woman's breast changes as they age. For the most part, women in their 20s have extremely dense breasts filled with breast tissue. (I know this sounds stupid but stay with me.) By the time a woman reaches her 50s, this breast tissue is replaced by fat.
The reason that this is important, is that it relates to the imaging modalities that physicians use to diagnose breast cancer. Mammograms are very sensitive in patients with fatty breasts. Mammograms become far less sensitive when women are young and their breasts are very dense.
So, it is clear that mammograms in women who are in their 20s and 30s are extremely difficult to read. This is the reason why most physicians do not recommend routine mammograms in this age group. Mammograms in women over 50 make sense because they are relatively easy to read and the incidence of breast cancer in this age group is increasing. For over 30 years, the question has been what to do with women between the ages of 40-49.
In my opinion, in this age group, the risk benefit ratio should be individualized. What is the risk of not getting routine mammograms? What is the risk of radiation? What is the risk of a false positive causing women to worry unnecessarily when it turns out that the little dot on the mammogram was nothing? (What effect does the negative biopsy have on the woman's ability to have follow-up mammograms?) On the other side of the equation, there are huge benefits from early detection of breast cancer. Small breast cancers usually have not metastasized and the five and 10 year survival rates are greater than 95%. Once a breast cancer grows greater than 2 cm (a little less than an inch), survival rates began to drop dramatically. So, I think it's extremely important for women to have open and honest discussions with their physicians. They need to talk to physicians who have an excellent knowledge of the breast literature. They need to have physicians who will take the time to sit down and talk to them about their individual risks. It may turn out with the reduction of prolonged hormone replacement therapy that the incidence of breast cancer will drop dramatically, I have my doubts. Personally, I think it is extremely important for women to diagnose their breast cancers early. Breast self-examinations are good, but most women do not do them on a routine basis.
This is an extremely important topic. I've only scratched the surface of its complexity. I'm extremely disappointed that the talking heads of the media have gotten a hold of this issue and are using it as a way to drive ratings. I urge women to talk to their physicians. If you don't like your physician, find another one. This topic is crucial. You need to understand the various recommendations that are out there. Finally, it is important to realize that the American Cancer Society, the National Cancer Institute and several other organizations have stated that they will not change their own guidelines.