I have read and listened to all of the calls and emails that have come into the Foundation since I first appeared on TV talking about the new United States Preventive Services Task Force guidelines. It’s very distressing to me that many of you think that I’ve abandoned you and your concerns.

I have spent my entire career working in the breast cancer field. I want to find an end to this insidious disease. If I thought that these guidelines would harm women, I’d be the first person to speak out.
These guidelines are just that—guidelines. The guidelines aren’t saying that women between 40-50 should never have a mammogram. Women under 50 who are high risk should have a more intensive screening program that includes mammography. Women younger or older than 50 who see or feel a change in their breast should have a mammogram or ultrasound so that the problem can be diagnosed.

What they are saying is that a careful review of the scientific evidence shows that in younger women of average risk the risks outweigh the benefits of routine screening. Understandably, this is a shocking statement to hear, as it completely contradicts the “women should get an annual mammogram starting at age 40” recommendation that we’ve been hearing for the past decade.

What many people don’t know is that this recommendation to extend screening to women under 50 was fraught with controversy. The decision was not based on evidence; it was based on political will. Virginia Ernster wrote an excellent article about this in the American Journal of Public Health in 1997.
Since then, we’ve become even more focused on the need for health care that is evidence-based. This is not just because of the cost factor. (The evidence may show that a more expensive drug or procedure is better, and that’s what we will need to then follow.) It’s because studies have shown us that treatments or tests we thought would be more effective were not. That’s why research is so important.

The problem with mammography in women under 50 is that it doesn’t work very well. Breast tissue is dense in young women and appears white on a mammogram. Cancer also appears white on a mammogram. This means that trying to find cancer on a young woman’s mammogram it is like looking for a polar bear in the snow. As a result, mammography misses many cancers in young women. And not only does it miss many cancers– giving a false sense of security–it also finds many things that are NOT cancer but need to be checked out through biopsies or other tests. In addition, the risk of the radiation is higher in younger women and cumulative so that the additional cancers caused by the radiation have to be weighed against the ones found by the test. It is not as simple as we would like to believe.

The guidelines do not say women can never have mammography under 50 or even over 75, another change that seems to have been overlooked. What it says is that women need to stop and weigh their own risks and beliefs and talk to their doctor and make a conscious decision about the way they personally want to go.

Additionally the guidelines do not say “never do breast self exam or touch your breasts again.” The data shows that formal four-position 20-minutes breast self exam is no better than the usual poking around we all do. The guidelines continue to suggest that women be aware of their breasts; they just do not recommend that physicians spend time training women in formal BSE. Most cancers in women under 50 are still found by the woman herself and not screening mammograms.

Finally, another point that has been missed by the media is the recommendation that mammography be done every other year in women 50-75. This too is based on data. The magic of 50 is menopause. As a woman’s hormones wane her breast tissue becomes less dense and the mammograms become easier to read, shifting the risk benefit balance.

The real issue is not whether mammography can find cancers but whether it can find them at a point that will make a difference in the outcome. The problem is that it is really the ability to find all cancers early that is being questioned. We now know that there are at least five different kinds of breast cancer and that some are so slow growing that it doesn’t matter when you find them, they would never kill you. Others are so aggressive that they will have spread before you can see them on a mammogram. It is only some of the kinds where you can make a difference with screening and it is mostly in women over 50.

What I hope these guidelines will do is push doctors to have a conversation with their patients about the risks and benefits of mammography so that women can make a decision that is right for them. If, knowing the risks, you want to have a mammogram, that should be your choice. But you should also know that mammograms are not all that good at detecting breast cancer in women under 50, so that you can be alert for any changes you see in your breasts. If you are high risk, you and your doctor should develop the appropriate screening program for you. Depending on your age, and your breast density, this might also include MRI. And no matter how old you are, you should see your doctor if you see or feel any changes in your breast.

I had nothing to do with formulating these guidelines but if you look back at what I have written over the years, it is consistent with what I am saying today: mammography is not a good tool for finding breast cancer in younger women and we need to put our efforts to finding something better. I try to do just that and have been involved in the development of ductal lavage, which washes out the milk ducts and collects cells. While we hoped it might be a good early test it has not been found to be as accurate as we had hoped and is now used only as a research tool. At the Foundation, we continue to both fund and do research to find something that will work better than mammography, especially in young women at risk of getting breast cancer.

Also, to be clear, I have not been influenced or received any donations from any insurance companies, nor have I been bought off by our Federal government, nor do I think that these guidelines are part of a government conspiracy. These guidelines come from a respected independent group that issues similar reports on a regular basis. Their last set of recommendations was in 2002. These recommendations are based on an extensive review of the data and took years to develop. It is just coincidental that they came out during the health care reform debate.

I hear your anger. I’m angry too. But not for the same reason. I’m angry because we’ve oversold the benefits of mammography to the extent that there is no longer room to look objectively at the evidence. I am angry that we still don’t know what causes breast cancer and how to prevent it. I started the Army of Women to channel that anger into positive action. I ask that you also channel your anger and frustration into helping us keep breast cancer from going on to another generation! We can do it. We can go beyond finding cancers that are already there to ending this disease all together. But we can’t let ourselves be distracted from the goal. We can agree to disagree about mammography screening guidelines, but we can not let up the pressure and efforts to stop breast cancer once and for all!

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163 Responses to A Message from Dr. Love about the New Mammography Guidelines

  1. Lynn DaCosse says:

    My mother was diagnosed with breast cancer in 1979 at the age of 52. She died three years later of metastatic disease in her bones and brain. I was diagnosed with Stage IIB, ER, one positive lymph node, in 2006 at the age of 42. What amazed me was that my doctor told me that it appeared that my tumor had been there “for about 7 years.” I had two mammograms in the time period. Most survivors I have talked to said they were told their cancer had been there anywhere from 10 years to 3. Clearly we need an earlier detection method. I heard Dr. Love on NPR in October of 2006 stating that “by the time a cancer shows up on a mammogram it has been there anywhere from 10 years to three” Why don’t more women know this? We would be fighting for true early detection, a blood test or something similar. If I had known this, I would have known that my mother’s cancer started in her early 40’s putting me at much higher risk and perhaps I would have had an MRI and found my cancer earlier. In my 20’s I was told by several doctors that because my mom was diagnosed at 52 – supposedly post-menopause, I was not at high risk. I now know she actually would have been diagnosed in her 40’s today. Where are the statistics on how many women are diagnosed at the time of their FIRST mammogram? Or how many mammograms did a women have prior to diagnosis? This could be answered with a survey. I have to assume my Mom never had a mammogram prior to diagnosis, would she be alive if she would have? I have often wondered if my mammograms contributed to the growth of my cancer. This is a complex disease, many questions still to answer. Now, more than ever, we need the Army of Women and better research on the causes of breast cancer. It is being diagnosed in women younger and younger, I have three young daughters and a son and I am gene positive. I NEED answers. Are these women being diagnosed in their 20’s and 30’s also being screened? How many of those diagnosed in their 20’s and 30’s had mammograms? My guess is not many but if it is a large number than maybe there is evidence that mammograms can contribute to the cause of breast cancer in young women. Where are these studies and why aren’t we answering these questions? These new guidelines are very confusing and unclear, but don’t kill the messenger. Dr. Love has been the only one to speak out about the fact that most breast cancers start years prior to being diagnosed via mammogram. If I had known this in my 20’s I might have had a different outcome. We are not getting all the facts, Dr. Love is trying to shed more light on the issue. We need to lobby for more funding of MRI’s in high risk women. So much to do, now is not the time to turn your backs on the Army of Women. Let’s not ignore the elephant in the room – what environmental or chemical development has so drastically increased the number of breast cancer diagnoses in recent years? That is what we need to know. BSE and mammograms are all we have now and the guidelines should reflect that they should be done with the understanding that we need something more conclusive. I agree with the what about thermography questions? We need a funded study for that.

  2. Lori says:

    Very disappointed with your stand on mammography screening. My mam at age 41 saved my like.

  3. A well written story. I’m an internet gamer and I’m always looking for news like this.

  4. Suzanne says:

    My understanding is that early mammograms are primarily to establish a baseline against which changes can be detected and monitored – they don’t really expect to find cancer in a 40 year old, although of course sometimes they do.

    Also, the “if you want an exam in your 40s you can still get one” comments are disingenuous. Tell someone they are “low risk” in one sentence and ask if they want a mammogram in the next. Not going to happen. Most people have heard that if their relatives had breast cancer, they are at higher risk. Very few people have heard that most people with breast cancer have no family history of it.

  5. Remember, says:

    It’s love that makes the world go around

  6. Great. Thanks for writing this. It is always great to see someone educate the public.

  7. Very interesting, thank you for sharing!

  8. Thanks a lot for the helpful content. It is also my belief that mesothelioma cancer has an very long latency period of time, which means that warning signs of the disease might not exactly emerge until 30 to 50 years after the initial exposure to asbestos. Pleural mesothelioma, that is certainly the most common kind and influences the area throughout the lungs, will cause shortness of breath, chest muscles pains, and also a persistent coughing, which may produce coughing up blood.

  9. Lori says:

    Dr. Love,
    I support your comments. I am now 60 yrs. old and I have had 20 mammograms. Thankfully, all of them were perfect. So, now I question the frequency of the mammogram. Yes, I do get a bit anxious. Between anxiety and not totally believing an annual or even every other year testing is needed, I question how soon to make another appointment. Thankfully, I am healthy, on no medications, not overweight, do not smoke, exercise pretty regularly, and have never had an abnormal pap. I would like to be able to stretch out appointments. What would your suggestion be? Thank you, Lori

  10. It’s actually a nice and useful piece of info. I am happy that you
    shared this helpful information with us. Please keep us informed like this.
    Thanks for sharing.

  11. Harriett says:

    I find it hard to believe Lori above, at 60 years old experienced 20 mammograms, radiation 20 times into her breasts and no cancer…..glad to hear it. However, I think mammograms are barbaric and unnecessary, it should be replaced by simple blood test or scan, NOT delibratelly putting Radiation into women’s breasts which could and probably does, spread and increase cancer growth. Never be a test for me nor mine.
    Dr. Love’s message was enlightening, I hope most women will learn from it. More Research needed.

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