Hold off on that mammogram?

New guidelines for breast cancer screenings say you can wait -- but should you?

By Mary Elizabeth Williams

Senior Writer

Published November 18, 2009 6:19PM (EST)

On a beautiful June Saturday last year, my friend, neighbor and comrade in motherhood Martha died of breast cancer at age 45. Summer dissolved into fall, and when our community returned in September, I noticed another friend, her head swaddled in a scarf, in the schoolyard. She was in her mid-40s, and in the midst of chemo for breast cancer. (And thankfully, she’s currently doing great.)

But my friends aren’t the only reason that I’m skeptical of the new U.S. Department of Health and Human Services guidelines that have raised the suggested age to start getting mammograms to 50. The recommendations, which went off like a bombshell earlier this week, not only up the screening age by a full decade, they go on to suggest mammograms only every two years for women 50-74, and to discourage self-exams, which have never been conclusively linked to mortality prevention.

Why the sudden change? The report, the department’s first in seven years, notes the high prevalence of false positives for mammograms, “which can cause anxiety and lead to additional imaging studies and invasive procedures (such as biopsy or fine-needle aspiration).” Frankly, given the choice between “anxiety” or not living to see my children grow up, I’d go for the first one. But the report does make a persuasive case that not all cancers are life-threatening, and that “over detection” and “over treatment” pose their own -- often considerable -- health risks. And at the heart of the new guidelines, which are similar to those from the World Health Organization,  is the sobering fact that detection is not the same as curing anything.

The American Cancer Society promptly shot back that it’s sticking by its recommended guidelines to start mammograms at age 40, noting that “Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider.” The American College of Radiology went even further, saying that the “cost-cutting” recommendations “will result in countless unnecessary breast cancer deaths each year.” Noting the steep decline in breast cancer rates in the last three decades, the ACR said that “At least forty percent of the patient years of life saved by mammographic screening are of women aged  forty-49.” And Florida Rep. Debbie Wasserman Schultz, who detected who own breast cancer via self exam at age 41, lambasted the guidelines as “totally inappropriate.”

Yet there’s plenty in the new guidelines worth considering. The radiation from regular mammography poses a health risk of its own. And loathsome as the American College of Radiology may find the phrase “cost-cutting,” the truth is that mammograms are expensive. Want a potentially better healthcare system for everybody? Then we need to reconsider what’s necessary and what’s optional.

But what’s optional for one woman may be the difference between life and death for another. The U.S. National Institute of Health itself estimates that a woman aged 30-39 has a 1 in 233 chance of being diagnosed with breast cancer. For women 40-49, those odds leap to 1 in 69.

A birthday isn’t an automatic excuse for anything other than cake. I didn’t run out and get me a big old burst of breast-centric radiation the day I turned 40 (I must have been getting one of those abortions of which we feminists are so very fond), any more than I’m going to shrug my shoulders and figure I can worry about cancer when I hit the magic half-century mark.

I’m a healthy woman under the age of 50. There’s no history of breast cancer in my family. And I wouldn’t mind blowing off those cold, painful dates with the machines that squeezed me so hard I cried at my last appointment.

But not so fast. I grew up in New Jersey, which has one of the highest breast cancer rates  in the country. I started menstruating young. I smoked. I had my first child in my mid-30s. All of which are risk factors. And, as I’ve learned from the mammograms I did start at age 41, I have dense breast tissue, which means that not only do I run an elevated chance of developing breast cancer, it could be harder to detect if I do get it.

I’m no believer in the word “routine,” whether applied to getting a procedure or skipping it. Healthcare is about active self-advocacy and not being shy about speaking up. Every woman with an opinion about breast cancer has to figure out her own risks -- and share them with her doctors. I’m not my age. I’m not my breasts. I’m not the 10:15 appointment being hustled out the door before the 10:20 appointment. Blanket guidelines are just that -- they're fine for covering the many, and they are not laws we have to follow. They don’t mean much to my little neighbor who lost her mother the day after she finished kindergarten. And they’re no substitute for the individual care the rest of us who plan on making it to 50 need and deserve.

By Mary Elizabeth Williams

Mary Elizabeth Williams is a senior writer for Salon and author of "A Series of Catastrophes & Miracles."

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