Mammography benefit and harm, risk, danger, caution, side effects, controversy of testing by Ray Sahelian, M.D.
Feb 19 2014

This article reviews the latest guidelines for mammography screening and discusses the benefits and the risks, side effects and dangers. See breast cancer for suggestions on diet, food, and lifestyle changes you can make to reduce your risk for breast cancer. There is a great deal of controversy regarding the age of testing and frequency. Until this is settled, I suggest you make as many positive lifestyle and dietary changes as possible in order to reduce your risk.
   Is it possible that women who get mammograms are more likely to be overall more health conscious and in better financial shape with better diets compared to women who do not get mammograms either due to poverty or lack of interest in health maintenance? And could this influence results of epidemiological studies?
   In European countries that screen every other year, the breast cancer death rates are no higher than in the United States.
   Hormone replacement therapy after menopause interferes with the accuracy of mammograms used to screen for breast cancer -- and the risk may be greater with hormones delivered by patch or injection compared with pills. Menopause, 2010.

Latest updates
2014
- A large study has questions the benefits of regular mammograms to screen for breast cancer leaving women more confused than ever. The study was done by a group in Toronto, Canada. They followed 90,000 women aged 40 to 59 for 25 years who were randomly assigned to either have mammograms every year for five years, or an occasional physical breast exam. They found that the screening didnít save lives, and 22 percent of the women screened got diagnosed with cancers that would never have harmed them. They said 180 women who got mammograms died of breast cancer over the 25 years, compared to 171 who didnít get mammograms.

2013 - While the number of women dying from breast cancer is decreasing, mammography screening can't take the credit, according to a study from England that looked at 40 years of data. In their study, published June 11 in the Journal of the Royal Society of Medicine, researchers found the greatest reduction in breast cancer deaths over the nearly 40 years studied was in women under 40, an age group not routinely offered screening.
   The growing use of MRI in breast cancer patients is leading to unnecessary breast removal in older women.

2013 - For older women ages 66 to 74, getting a mammogram every two years appears as good as getting one every year. Feb. 5, 2013, Journal of the National Cancer Institute, online. False-positive findings on screening mammography causes long-term psychosocial harm.

2012 - Regular mammography screening has limited -- if any -- impact on breast cancer deaths. "Our analysis found no or limited influence of mammography screening on breast cancer mortality," said Dr. Philippe Autier, at the International Prevention Research Institute in Lyon, France. The report is published July 17, 2012 in the Journal of The National Cancer Institute. Finding no or limited impact in Sweden, he said, suggests that the same might be true in other countries, including the United States.

2011 - Women aged 40 and older who follow recommendations to have annual mammograms may do themselves more harm than good. Study author James Raftery, a professor of health technology assessment at the Wessex Institute at the University of Southampton, said that "this is due to reduced quality of life of those who receive diagnoses that turn out to be false and to those who are treated unnecessarily." James Raftery, Ph.D., professor, health technology assessment, Wessex Institute, Faculty of Medicine, University of Southampton, England; Dec. 8, 2011, BMJ.

2011 - The Canadian Task Force on Preventive Health Care  issued new recommendations on breast cancer screening, and they're similar to controversial guidelines issued in 2009 by a U.S. governmental panel. As the U.S. Preventive Services Task Force (USPSTF) recommended two years ago, the government-appointed Canadian panel of experts is also suggesting that women aged 40 to 49 who are at average risk for breast cancer not get routine mammograms. The Canadian task force has also dropped recommendations for breast self-exams and clinical exams for women with no symptoms.

2011 - More than half of healthy women who have an annual mammogram will get at least one false positive result over a 10-year period, and 10 percent will undergo a biopsy that doesn't turn out to show cancer.

2011, British Journal of Surgery, Damage of 'False-Positive' Mammograms Overlooked:
Women who receive a false-positive result experience a significant reduction in their quality of life, especially if they are prone to anxiety, and the effects of this can last a long time.

Risks and dangers of mammography in women younger than age 50:

Higher risk for breast cancer risk due to radiation exposure
Routine mammograms in young women increase the risk for future breast cancer due to direct radiation exposure to breast tissue.
For young women who have a high risk of breast cancer because of genetic mutations, the radiation from yearly mammograms may make the risk even higher. It is quite possible that women who may never have developed breast cancer in their lifetime may get this disease in their 50s, 60s, or later, from having routine yearly mammograms in their 30s or 40s. We are exposing millions of young women to such radiation without fully understanding the future impact. Low-dose radiation from mammograms and chest X-rays increases the risk of breast cancer in young women who are already at high risk because of family history or genetic susceptibility. High-risk women, especially those under 30, may want to consider switching to an alternative screening method such as magnetic resonance imaging, or MRI, which does not involve exposure to radiation.
   
The annual mammograms gives a much higher dose of radiation than a typical chest x-ray. and it has accumulative effect on the body. In addition to exposing the body every year to radiation, many women must have additional screening when they receive a false-positive result, adding to further radiation exposure. Nobody knows exactly how much the risk for cancer is increased due to having regular mammograms in young women, but it is quite possible that the medical establishment and the American Cancer Society are not emphasizing this risk, or are not aware of it, as much as they should. The premenopausal breast is very sensitive to radiation, each rad of exposure increasing breast cancer risk by 1 percent, resulting in a cumulative 10 percent increased risk over ten years of premenopausal screening, usually from ages 40 to 50. Risks are even greater for "baseline" screening at younger ages, for which there is little or no evidence of any future relevance.
   Statistically, some women have approximately as much chance of getting breast cancer from repeated mammograms as they have of the testing finding earlier cancers. Yes, you might be one of those rare women whose life expectancy may be enhanced by early detection. But you might also be someone who develops breast cancer from the yearly radiation exposure.
   See this excellent article written by a respected university affiliated medical doctor that reviews the risk of radiation from mammography and exposes the profit motive of certain corporations and organizations, and forward this article to anyone who you think would benefit, including your doctor, http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=4194

False negatives
Some breast cancers do not show up on mammograms, or "hide" in dense breast tissue. A normal (or negative) study is not a guarantee that a woman is cancer-free. The false-negative rate is estimated to be 15 to 20%, higher in younger women and those with dense breasts. A normal mammogram can give a false reassurance that everything is okay with the breast tissue. Mammograms often miss very aggressive cancers that develop between screenings, while finding slow-growing tumors that may not pose a threat.

False positives
It is estimated that a woman who has yearly mammograms between ages 40 and 49 has about a 30 to 40 percent chance of having a false-positive mammogram at some point in that decade and about a 10 percent chance of having a breast biopsy within the 10-year period. It is estimated that 80% of all breast biopsies result in benign (no cancer present) findings.
   
The radiologist may notice something unusual, and due to the fear of being sued, will suggest a biopsy even though it may not be necessary. Doctors are so afraid of missing a potential tumor that they will send their patients with minor abnormalities for additional testing even though technically they may not be needed thus significantly increasing the rate of false positives and further x-rays, blood tests, other diagnostic procedures, and biopsies.
   
Screening mammography, like all cancer screening tests, has potential drawbacks, including adverse effects on survival, comfort, function and psychological well-being emanating from all procedures that result from screening. Since the average risk of dying from cancer during the 40s is relatively low, 1,900 women in that age group would need to be screened for a decade, and suffer all kinds of emotional, financial, and other hardships, to PERHAPS increase life expectancy of one life.
   Some researchers estimate that as many as one-third of cancers picked up by screening would not be fatal even if left untreated. But right now, nobody knows which ones.
   As women age, their breasts usually become more fatty (therefore, less dense), and breast cancers become easier to detect with screening mammograms.
   False positives are more common in younger women, women who have had previous breast biopsies, women with a family history of breast cancer, and women who are taking estrogen (for example, hormone replacement therapy).

Mammograms may find a small cancer that may not cause death in the long run
According to an analysis by The Cochrane Collaboration, an international not-for-profit organization providing up-to-date information about the effects of health care
, one in 2,000 women aged 40 to 50 will have her life prolonged by 10 years of screening, however, another 10 healthy women will undergo unnecessary breast cancer treatment that are not life threatening. Screening mammography does not reduce death overall, but causes significant harm by inflicting cancer scare and unnecessary surgical interventions. It is possible that many slow growing tumors are found during these mammograms that may never have come to clinical attention during a woman's lifetime had she not been screened. Yet, by catching these early tumors, unnecessary surgery, chemo and radiation are done which reduce quality of life and cause various forms of health deterioration. Tens of thousands of women may be getting mastectomies and chemo and radiation that they did not need. Furthermore, spontaneous regression of breast cancer has been reported.
    Even without mammography detection, many of these small cancers would eventually grow large enough for a woman to notice herself while taking a shower or putting on a bra, and appropriate treatment can be done at that time without any change in overall outcome. Breast cancer treatment has improved over the past decade so that most of later diagnosed cancers are fully treated and cured.

Reduced quality of life or death due to treatment
Most of the time treatment for breast cancer improves survival by many years. It's quite possible, though, that a breast cancer detected during mammography may get treatment that causes sickness, malaise, nausea, loss of hair, fatigue, and other symptoms for a number of weeks, months and years, and even premature death, whereas if the cancer had not been treated and the woman was diagnosed later, she could have had another year or two or three of living without worries and all the pain and horrible experience of going through surgery, along with radiation and chemotherapy.

Physical pain, scarring
Pain occurs from breast compression during mammography, and from biopsies. Some women have pain after a biopsy that can last weeks or months. Permanent scarring can occur from biopsies particularly if the site gets infected.

Risk of hematoma and infection from biopsy
There is a small risk for infection from the surgical procedure resulting in the need for antibiotics and the potential harm from such medications. There is a risk of bleeding and forming a hematoma, a collection of blood at the biopsy site. Doing a biopsy of tissue located deep within the breast carries a slight risk that the needle will pass through the chest wall, allowing air around the lung that could collapse a lung -- this is a rare occurrence.

Missing a diagnosis with the biopsy
A fine needle aspiration biopsy can sometimes miss a cancer if the needle does not get a tissue sample from the area of cancer cells. The chances of a needle biopsy causing a cancer to spread are low. In the past, larger needles were used for biopsies, and the chance of spread was higher.

Mental pain and anxiety
Increased anxiety occurs  from unnecessary testing due to many false positives, and simply the anxiety naturally occurring between scheduling the screening procedure and receiving the results. This can lead some women to lose sleep, feel sad, develop an anxiety disorder, or even get hooked on anti-anxiety medications. Women who undergo treatment for inconsequential disease found by screening have suffered serious psychological and physical harms from screening, which may include adverse effects from surgery, radiation, or chemotherapy such as delirium, functional decline, or even death. Some women with positive mammograms, even after getting a negative biopsy, have heightened anxiety for a period of time leading to poorer health and quality of life. The anxiety and depression can negatively impact work performance, interactions with spouse, family members and friends, and the care of children.
    Something else to consider: By focusing on mammography testing in one's 40s, and subsequent false positives and further testing and biopsies, many women shift their thinking about their breasts from that of sensitive, erotic and sensual tissue to that of tissue that can cause a horrible disease such as cancer.

Increased risk from compression?
Mammography entails tight and often painful compression of the breast, particularly in premenopausal women. Some have claimed that this may lead to distant and lethal spread of malignant cells by rupturing small blood vessels in or around small, as yet undetected breast cancers. There is a great deal of controversy regarding this claim and I am currently not sure how valid it is.

Danger of early removal of cancer?
Women who get screened find small tumors sooner. This leads to earlier surgery. Some of these tumors might not really be dangerous. Some claim that removing them might be dangerous since excision of the primary tumor may remove a negative growth factor that discourages metastases from growing, I am not sure whether this claim is accurate or not.

Financial burden
Due to the economic downturn, more women have no access to health insurance and the cost of the mammograms, doctor visits, and subsequent biopsies can cost 10,000 dollars or more during a 10 year period. The cost of a breast biopsy can range from approximately $1000 to approximately $5000 depending several factors, including the type of biopsy performed, the equipment used during the biopsy, and whether image guidance or other additional equipment is necessary to perform the biopsy,. Even if you have insurance through the company you work for, the cost of such testing and the higher rate of insurance premiums may result in your salary being less or perhaps not getting a raise. Health care costs are having a significant impact on businesses in this country. Eventually, one way or the other, everybody pays for higher health care costs, except the companies making money from such testing.
  
Appropriate use of limited health care funds
There are limited funds for health care in this and every country on the planet and we have to use these funds in a way that give us the most benefit with the least harm. Could the billions saved by avoiding these unnecessary mammograms be used for other purposes that yield a higher benefit? What about a campaign to educate people on how to eat healthier and exercise more thus reducing the risk of cancer and heart disease? What about using these savings to provide dental care or vision care for millions of children whose parents can't afford such expenses? What about educating the public to increase their vitamin D consumption or promoting nutritional education?
     Could the money you save from mammograms be better used for eating healthier meals, for instance buying wild salmon instead of farm grown salmon, or buying more expensive, fresher and healthier produce, oils, or eating at better restaurants that prepare food with less oils and with organic produce? Or, could you use the money to do more yoga classes, take a yoga retreat, take more vacations and relax, or do other activities that improve your quality of your life?

Miscellaneous additional costs, concerns and hassles
There are various other minor problems and hassles with testing. Filling out insurance forms, the cost of co-pays, the cost of baby sitters, scheduling hassles, time off from work or home that could be spent in more enjoyable and relaxing activities, the hassle of waiting at the testing centers or the doctors office, driving back and forth to the appointments and the gas expense, the risk for a car accident while driving to and fro from the appointments, etc.

Making money from mammography
Certain corporations and organizations are profiting from such testing and may not have the best intention of women in mind. Companies like General Electric and DuPont, both which manufacture mammography equipment, are large donors to organizations that are against any change in the recommendations. I highly suggest you read this article written by Adriane Fugh-Berman, M.D., an associate professor in the department of physiology and biophysics at Georgetown University Medical Center. I suggest you send this link to everyone who you think would benefit from this honest expose. See http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=4194

Bottom line
The medical establishment told women for decades that hormone replacement therapy offered benefits without adequately mentioning the risks of increased cancer, heart disease, and blood clots. Is it possible that again the same thing is happening with mammography testing, that the potential downside is not being adequately explained? Now that you have reviewed the potential harm from such screening, you can make up your mind if you wish to have mammograms in your forties. Ultimately you have to make the decision, it's your body.
    My suggestions: Starting at age 50, get about 10 mammograms in a lifetime, one every two years. This way you get the most benefit and the least harm from the tests. A woman can reduce her chances of getting breast cancer through good nutrition and making the right lifestyle choices.

In January 2009, The American College of Radiology and The Society of Breast Imaging sent out a press release supporting routine mammograms starting at age 40. Are these recommendations based on science or profit? The American Cancer Society has donors such as Hologic, which makes breast imaging products, and Johnson and Johnson, which makes an image-guided breast biopsy product. The American College of Radiology has donors that include GE Healthcare, Siemens, Phillips, Hologic, and many others that make mammography machines or related products. The Society of Breast Imaging is an organization managed by the American College of Radiology. I do not trust the opinion of the these organizations. I trust the recommendations of the USPSTF.

I do not trust the opinion of the following organizations:
In November 2009, soon after the news USPSTF guidelines were announced, The American Cancer Society sent a press release telling the American public to disregard these reasonable guidelines. In January 2010 the American College of Radiology and The Society of Breast Imaging also announced that they disagreed with the newer guidelines.

Mammograms not recommended for women under 40
A report in the Journal of the National Cancer Institute finds mammograms detect few cancers in women under the age of 40 but cause expense and anxiety because women frequently get "false positives" that require follow-up to rule out cancer. Radiologist Bonnie Yankaskas of the University of North Carolina at Chapel Hill examined the records of women aged 18 to 39 when they got their first mammograms starting in 1995, following them for a year to see what happened. There were no tumors among the women under 25. For women aged 35 to 39, 12 per 1,000 got called back for further checks after the mammogram produced a suspicious-looking lesion. Very few actually had a tumor. "In a theoretical population of 10,000 women aged 35 to 39 years, 1,266 women who are screened will receive further workup, with 16 cancers detected and 1,250 women receiving a false-positive result," according to Dr. Bonnie Yankaskas. "Harms need to be considered, including radiation exposure because such exposure is more harmful in young women, the anxiety associated with false-positive findings on the initial examination, and costs associated with additional imaging." About 30 percent of U.S. women aged 30 to 40 have had a mammogram. Journal of the National Cancer Institute, 2010.

Women aged 50 to early 70s
A mammogram is recommended every 2 years.

Women ages 71 and over
Women over 71 or 75 can stop being screened, because no studies have shown that it helps them. If they do develop breast cancer, it is likely to be a slow-growing type that will not kill them or they are likely to die from heart disease or other causes and avoid a diagnosis of cancer along with radiation and chemotherapy. Finding tumors in older people turns them into cancer patients and erodes their peace of mind forever. The psychological cost of becoming a cancer patient is underrated.

Women with dementia
Some elderly women with severe cognitive impairment are getting mammography breast cancer screening even though they are unlikely to ever benefit from it. American Journal of Public Health, 2010.

Mammography testing controversy, studies show conflicting results
A major problem is the issue of over-diagnosis. This is when a mammogram picks up something called ductal carcinoma in-situ (DCIS), which are cells - often described as "pre-cancerous" or non-invasive - that may progress into life-threatening cancer if left untreated. The problem is there is also the chance they would never progress or cause a problem, but instead leave the woman to live in blissful ignorance and die years later - but not of breast cancer. The fear is that regular population-wide screening programs are causing over-treatment of such cancers, ruining women's lives with unnecessary mastectomies or chemotherapy. But other researchers disagree.

March 2010 - mammograms don't save lives
Scientists from Norway and Denmark found no evidence that screening women for breast cancer has any effect on death rates, adding to an already fierce international debate about routine testing. Reductions in breast cancer death rates in regions with screening were the same or actually smaller than in areas where no women were screened. Karsten Jorgensen of the Nordic Cochrane Centre in Copenhagen, says it is time to question whether screening has delivered the promised effect on breast cancer mortality. Karsten Jorgensen said that although breast cancer screening programs vary by country, Denmark was a good benchmark. In Denmark, women are screened every two years from age 50 and in Britain the policy is for women over 50 to be screened about every 3 years. Critics of widespread screening programs say they can be more harmful than helpful if the extra hospital time and costs they require, added with the stress and worry of false alarms, are not outweighed by the benefit of preventing more deaths. In Britain, for example, experts say around 7,000 women get an unnecessary breast cancer diagnosis when screening picks up tumors that would never have caused them any problems. Evidence now suggests that for every 2,000 women who are screened over 10 years, only one stands to have her life saved by the mammogram program whereas the risk of getting an unnecessary breast cancer diagnosis is 10 times that. The scientists compared annual changes in breast cancer deaths in two Danish regions with screening programs against non-screened regions across the rest of Denmark. In women likely to benefit from screening (those aged 55 to 74 years) breast cancer mortality fell by 1 percent a year in screened areas and by 2 percent a year in non-screened areas. In women too young to benefit from screening (aged 35 to 54 years), breast cancer mortality declined by 5 percent a year in screened areas and by 6 percent a year in non-screened areas during the same period. British Medical Journal March 2010.

Men and mammography testing
Men are by no means immune to breast cancer. Just over 2,000 men were diagnosed with breast cancer in 2007, and approximately 450 men died. Since routine screening for men is next to nonexistent, men are more likely to be diagnosed with advanced disease, and therefore have poorer chances for survival. Does this mean that all men should be tested? it would bankrupt the country if we were to screen tens of millions of men just to potentially find 2000 breast cancers (and not all will be found by testing due to false negatives). Tons of false positives will be found which would require an enormous number of biopsies and further evaluations.

Mammography versus thermography
There are many tests that can be done to detect breast cancer, but no one test that can detect 100% of all cancers. Thermography is a heat-imaging screening technique that does not use radiation or breast compression to detect tumors. Thermography, a physiological imaging procedure, cannot replace mammography, an anatomical imaging procedure. The two tests image for completely different pathological processes. Some slow growing non-aggressive cancers may only be detected by mammography. A thermogram detects subtle heat changes that point to an area of evolving pathology in the breast. This may or may not be cancer. A mammogram is used to detect a mass that has already formed in the breast, often identified by a cluster of calcium specks. By the time a mammogram locates a tumor, it has been growing for several years.

May 2011 - The FDA ordered Joseph Mercola, D.O. to stop making claims for thermography that go beyond what the equipment he uses (Meditherm Med2000 infrared camera) was cleared for. The warning letter claims that statements on Mercola's site improperly imply that the Meditherm camera can be used alone to diagnose or screen for various diseases or conditions associated with the breast.

April 2011 - The FDA has ordered Central Coast Thermography to stop representing that its FLIR Telethermographic camera is useful as a stand-alonedevice to diagnose or screen for breast diseases, including cancer. The scientific consensus is that thermography adds little to what doctors can readily diagnose from the patients history, physical examination, and other studies

With all the talk about mammograms, would you comment about thermograms. I have read that they are infinitely safer with respect to radiation, at least and maybe more accurate, less costly and no side effects.
    Thermograms are also effective in detecting breast cancers but they do not detect some cancers that may be detected by mammograms. We need a few more years of studies to determine the benefits and risks of doing thermography scans in different age groups of women in order to know whether these scans are superior to mammograms.

The FDA has warned women not to substitute breast thermography for mammography to screen for breast cancer. Some health care providers claim thermography is better than mammography as a screening method for breast cancer because it does not require radiation exposure or breast compression. However, thermography has not been demonstrated to be effective in screening for breast cancer. The FDA has cleared thermography devices for use only as an additional diagnostic tool but not for use as a stand-alone device for these purposes. The agency has sent warning letters to several health care providers and a manufacturer who claim that the thermal imaging can take the place of mammography. Thermogram no substitute for mammogram. FDA Consumer Update, June 2, 2011.

A medical doctor with decades of experience
Lou Mancano, M.D. is a dear friend of mine. We met during residency in the mid 1980s back in Pennsylvania. I later moved to California while Dr. Mancano stayed locally. I have extremely high regard for his experience, honesty and knowledge. He has taken the American Family Medicine Board certification every 7 years since graduation and has scored in the 99th percentile each time, a feat that is extremely difficult to accomplish. I spoke with him recently and this is what he says, "I see so many false positives from mammograms in younger women. The radiologists are so scared about missing a tumor and getting sued that they recommend all sorts of minor abnormalities on the mammogram to have further testing. I am also concerned about secondary malignancy from radiation exposure. Some of my female patients ask for a medication to relax them and relieve anxiety while waiting to get the biopsy and the results of the biopsy and some get hooked on Xanax or similar meds. I had a patient get into a car accident while driving for her appointment with me since she was so nervous. I don't think self breast exams help. Most women find benign nodules and when they mention it to their doctor, he or she is practically forced to do testing in order to avoid a potential lawsuit. I cringe when a when a young woman tells me there is a lump in her breast and if I can't find it during my exam, I am in a difficult situation since the vast majority of these lumps are normal nodularity, but if I don't suggest a mammogram and in the rare case there is a tumor in the breast I can be sued. Here we go again with more testing and more false positives. I have reduced the frequency of routine PSA testing since false positives lead to painful biopsies, bleeding, infection, and have a high complication rate. Many doctors will continue recommending some types of unnecessary cancer screening due to legal reasons.