by Kenneth L. Smith, MD

Q: My husband and I are expecting our first child. Until now our dog and cat have been our “babies.” How can we be sure our pets adjust well to the new baby?

A: What seems like a simple question to answer actually has a very complex and controversial history. In 1997, The National Cancer Institute (NCI) convened a blue ribbon panel to address the issue of screening mammography. The scientific data clearly demonstrated a survival benefit to screening mammography in women age 50 to 69, however the data on benefit for women 40 to 49 and 70 and over was felt insufficient to recommend for or against screening of these populations. Thus the NCI recommended this group of women discuss with their physician the benefit for each person individually for screening.

Many national and international organizations were disturbed by this recommendation. Such a hue and cry arose that Congress convened a panel to review this recommendation by NCI, with the NCI subsequently changing its recommendation from annual to biennial mammograms for the 40-49-year-old age group. The point remains controversial with the American Cancer Society, the American College of Radiology and others recommending annual mammograms, while other groups are still recommending against or at least making the decision on a personal basis after consulting one’s physician.

Why is there such controversy over what would seem to be a simple question? Eight major scientific studies have evaluated the benefit of screening mammography and a meta analysis of these studies suggests that screening reduces breast cancer related mortality by 16 percent, although the Swedish Two County study reported by Tabar et al demonstrated a 30 to 50 percent mortality reduction. (Perhaps we should all be getting our mammograms in Uppsala Sweden!!)

There are, however, other components to consider such as the accuracy of mammography in this age group. Younger women tend to have greater density of breast tissue, which can reduce the ability to detect cancers in this age group and may also lead to identification of abnormalities on the film that require additional studies and sometimes even a biopsy. It is estimated that for every 10,000 women 40-49 years old who are screened, 640 will be found to have an abnormality on the mammogram requiring additional studies, and 150 will ultimately require a biopsy, and 17 will be diagnosed with invasive cancer. Some consider this a less than profitable way to spend health care dollars, while others do not see a problem with this level of return on investment, particularly if you are one of the 17 cancers detected at an early stage.

As to the patient’s lack of family history, there are a number of risk factors felt to be associated with increased risk for breast cancer development, including current age, age at first pregnancy, age at onset of menstrual periods and at onset of menopause, history of breast feeding and history of combined (that is estrogen and progesterone) hormone use. However, the fact remains that over 75 percent of breast cancer patients have none of these
risk factors at the time of diagnosis.

Certainly, mammograms have limitations in ability to detect cancer in all age groups and even more so in patients with dense breast tissue. Are there other studies that are more sensitive in this situation? Indeed, many other tools are being investigated such as: breast MRI, tomosynthesis (sort of a CAT scan for the breast), elastrography (a variation on ultrasound), PEM or Positron Emission Mammography, along with numerous other methods are being investigated, but none have data to suggest its use for population-wide screening protocols. Thus, mammography, with all of its limitations, is still our best bet for screening and detecting breast cancer at an early, treatable stage in the general population.

My personal opinion, as a fellowship trained breast surgeon, is that every woman should have a mammogram annually beginning at age 40 and continuing until her life expectancy is less than three years. However, I recognize that some people are willing to take greater risks than others, and therefore I do not chastise those who don’t wish to follow protocol.

Dr. Smith was the Rachleff Fellow in Breast Surgery at Stanford University School of Medicine, where he received training in state of the art techniques for the treatment of breast diseases. He joined Surgical Associates of Columbus in August 2000 as a board certified general surgeon and is currently on the medical staffs of The Medical Center, St. Francis Hospital and Doctor’s Hospital.

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