Mammography benefit Mammography harm: by Ray Sahelian, M.D.

Mammography benefit and risk, danger, caution, side effects by Ray Sahelian, M.D.

This page 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.
   In European countries that screen every other year, the breast cancer death rates are no higher than in the United States.

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.

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.

Women younger than age 40
Younger women are less likely to have cancer, and they tend to have dense breast tissue, so mammograms are more likely to miss tumors. For them, radiation exposure causes harm without much benefit.

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. Among more than 2,100 U.S. women age 70 and older, 18 percent of those with advanced cognitive impairment had received a screening mammogram in the past two years. American Journal of Public Health, online January 14, 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.

December 2009
The U.S. Preventive Services Task Force issued new breast cancer screening guidelines that question the current practice of starting routine mammography screening at age 40. After evaluating recent studies, the USPSTF determined that the decision to begin screening before the age of 50 "should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms." The USPSTF is the leading independent panel of private-sector experts in prevention and primary care. Its recommendations are considered the "gold standard" for clinical preventive services. The highly respected Medical Letter on Drugs and Therapeutics agrees with the USPSTF. Its consultants have concluded that "offering routine mammography to women 40-49 years old would save many women from radiation exposure, unnecessary surgery, pain, anxiety and expense, at the cost of some lives."

December 2009
Dutch scientists reviewed six previously published studies, four examining the effect of low-dose radiation exposure from mammography among women with the genetic mutation boosting breast cancer risk and two looking at the effect of radiation from screening in women with a family history of breast cancer. Martine Jansen-van der Weide, an epidemiologist and researcher at the University Medical Center Groningen, in the Netherlands says, "Women who were exposed before the age of 20 had a 2.5 times increased risk of breast cancer, so did women with five or more exposures. These new findings come in the wake of a controversial recommendation made in mid-November by the U.S. Preventive Services Task Force for the general public, that women delay routine screening mammograms from age 40 to 50, asking their doctor the best time to begin, and that older women switch to every-other-year mammograms. Currently, the American Cancer Society and other organizations advise yearly mammograms for women beginning at age 40. For high-risk women, the ACS recommends a mammogram and MRI every year.

Women who undergo mammography are less likely to die of breast cancer, but they're also more likely to be diagnosed and treated for a cancer that poses no danger to their health, according to a new review of six trials including half a million women. This means that of every 2,000 women screened over a 10-year period, one will live longer thanks to diagnosis and treatment of breast cancer, but 10 will receive unnecessary treatment, Drs. Peter C. Gotzsche and M. Nielsen of the Nordic Cochrane Centre in Copenhagen, explain. "It is thus not clear whether screening does more good than harm," they write. "Women invited to screening should be fully informed of the risks and benefits."

Screening mammography has been studied extensively, but its benefits and potential dangers remain controversial. To investigate further, they pooled the results of six large studies in the U. S. and Europe comparing mammography to no mammography in healthy women in their 40s, 50s and 60s with no history of breast cancer. The analysis included about 500,000 women who were randomized to screening or no screening. After seven years, they found, the women who underwent screening were 15 percent less likely to have died of breast cancer than the women in the "control" group. The risk that a woman would be treated for a non-life-threatening cancer, however, was 30 percent higher in the screening group. The real differences involved are small; an individual woman would find her risk of dying from cancer reduced by 0.05 percent with regular breast cancer screening, while her risk of overdiagnosis would increase by 0.5 percent. Advocates of screening focus on its benefits while saying little or nothing about its risks. The Cochrane Library, October 18, 2006.

MRI benefit and risk
Breast MRI is very sensitive, but it also detects masses or dense areas that with follow-up turn out to be benign � false positives. For young women, the chance of a false positive during a first MRI is from one in five to one in 10, compared with about one in 20 for a mammogram.

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. Thermography is more sensitive than mammography. However, 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.

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.

My wife recently had a thermogram of her breasts done (baseline and followup 3 months later) which we read was actually more effective at detecting early cancer than a mammogram and is, of course, radiation-free. Her physician scoffed at this technology as being useless. What is your view?

States funding mammograms
Some U.S. states have begun using new breast cancer screening guidelines to stop offering routine mammograms for uninsured women in their 40s, a survey by the Avon Foundation for Women. The 2010 Avon survey of more than 150 breast cancer health educators and providers from 48 states and Washington, D.C. found a quarter of the states have either cut or eliminated screening mammography and other early detection services for women under 50.

Questions and concerns about mammography testing
I appreciate your thoughtful and sensible remarks concerning questioning the financial motivations behind the debate over the efficacy and frequency of mammograms. However, I think you overlook the financial motivations behind the USPSTF's position. It is disturbingly and conveniently coincidental that, just as the health care debate in Congress has heated up and the AMA, AARP and other politically active (and not necessarily representative of their supposed constituencies) groups have come out in support of a government option, along comes the USPSTF report which dovetails nicely with their need to curb Medicare (and future government controlled healthcare for all) expenses. It also seems obvious that the near bankrupt British healthcare system would have a vested financial interest in restricting mammograms to every 3 years. As advocates for our own best healthcare, we all need to be skeptical of ANY changes in protocols without thoroughly analyzing the motivations and pressures that may have prompted them.
Because of the political climate we are in where everyone suspects everybody else's motives and opinions, it is up to each person to decide, after reading and listening to various viewpoints, which people or organizations they most believe to be trustworthy. To the best of my knowledge I believe the USPSTF, having reviewed their opinions on various topics for more than 2 decades, appears to be truly independent and I have respected their viewpoints and recommendations. Each woman has to decide for herself whether she wishes to have a mammogram done in her forties recognizing the benefits of early detection versus the risks for false positives and unnecessary biopsies and treatments along with anxiety and excess medical expenses that may not always be covered by insurance (and many people cannot afford insurance).

I am really concerned that there are individuals making decisions about no need to have mammograms before the age of 50 years. Who can one talk to about this that will listen without thinking of $ signs? My daughter was recently diagnosed with breast cancer at the age of 43. It was discovered when she had a mammogram. Other tests followed and finally surgery. Thank goodness it had not spread to her lymph nodes. I dread to think what would happen if she HAD WAITED UNTIL SHE WAS 50 YEARS OLD to have a MAMMOGRAM which her FEMALE doctor had advised her to have. I have recently talked to many people about my concern. There are many women who have had breast cancer discovered from 28-40s. We are talking about a person's LIFE. Cancer is a threat and should not be taken lightly. I had a friend who died from cancer. She had a husband and three children. I also had a friend and neighbor who died after a recurrance of cancer. She had had one breast removed. She was in her seventies when she died. My daughter said she is a living example of someone who is going to survive because of a Mammogram, a second one, a sonogram, an MRI, a biopsy and surgery. She has excellent doctors all of whom are women.

Congresswoman Debbie may not be an expert, but if I had waited until age 50 to get a mammogram, i would be dead! I think this applies to many, many women. I met many young women, as young at 18 who have had double mastectomies. I think you'd better change your thinking about the so called experts. They don't know it all. I met you many years ago when you gave a class at Culver city High School. While you may be an expert in your field, you have never experienced breast cancer and it's devastating effects, I have.
Having a disease, or not having it, should not make an influence on interpreting the overall statistics of dozens of studies with hundreds of thousands of people evaluating the overall benefits and risks. It is possible to detect a lung cancer in people in their 30s by finding one person who has this condition but requiring tens of thousands of people to get a chest x-ray and finding false positives on chest x-rays that lead to unnecessary ct scans and biopsies. One has to balance the overall benefits and harm of testing and not get emotional while interpreting studies. Basing decisions that affect tens of millions of women through one person's experience does not do justice to the masses.

What are your recommendations for mammograms for a women aged 70 who had surgery a little over 2 years ago for endometrial cancer and is doing well at this time?
One has to consider the whole person and overall health rather than base the decision on just one medical factor. As a general rule it is not advisable to have a mammogram after age 75, but it depends on how healthy a woman is. If a woman is 70 years old and has heart disease, diabetes, and is on multiple medications, they are more likely to die from the other conditions than breast cancer but if she is perfectly healthy and is expected to live to her 90s and beyond, then it may be ok to do a mammogram. It's a case by case decision.

Politicians get involved, buy they should not
January 2010 0 Sen. Jenny Oropeza in California, who authored Senate Bill 148 as a result of David Goldstein's mammogram investigation, is introducing more legislation to assure women have access to free screening and diagnostic services. She has now introduced Senate Bill 836 in response to the California Department of Public Health's decision to change the breast cancer screening eligibility age to 50 under the Every Woman Counts program. New enrollments for screenings have also been suspended until July 2 2010.