Story by Anna M. Park.
When the U.S. Preventive Services Task Force announced that women should not be getting mammograms until they reach 50, it ignited controversy within the medical community. For years, doctors have insisted on mammograms starting at 40, and the American Cancer Society and Susan G. Komen Foundation still recommend an annual mammogram starting at the age of 40, citing early detection key to saving lives. Just do a quick search and you’ll find stories of all sorts of young women in their 40s whose lives were saved from early detection. Nonetheless, most major health organizations have concluded that the modest survival benefits of mammography in women ages 40 to 49 outweigh the risks of false positives and further unnecessary procedures. So what’s a woman to do? Dr. Maggie DiNome, chief of General Surgery at Saint John’s Hospital in Santa Monica, Calif., who specializes in breast cancer surgery, answers our questions.
Q. My OB/gyn insists I get annual mammograms starting at 40, even though I have no family history. But the new U.S. Preventive Services Task Force recommends mammograms starting at 50, and then every two years. What do I do?
Dr. Maggie DiNome: You would need to weigh the data to know what is right for you. The U.S. Task Force came out with their consensus statement based on their recommendations of what is most efficient for screening, meaning what has the biggest bang for the buck for the population as a whole. According to their review of the existing data, starting mammograms at age 40 only results in one life out of 1,000 being saved. That might not seem like much, but if you were that one patient, it means the world.
So what is the trade-off for starting mammograms at age 40? Well, the argument is that it leads to more false positives, which leads to more unnecessary biopsies and imaging. It may also be finding stages of “cancer” (i.e. DCIS, or ductal carcinoma in situ) that truly do not need treatment, although currently we treat everyone diagnosed with DCIS because we don’t yet know who can safely avoid treatment. As a breast surgeon, I see more than one might expect of breast cancers diagnosed by routine mammograms in women in their 40s, so it’s hard for me to say “stop.” I wouldn’t necessarily argue that biennial mammograms is a bad thing though, and maybe a compromise would be biennial mammograms beginning at age 40. In Europe, it is this way.
My recommendation to you would be to start mammograms at age 40, and plan to get them every year or every other year.
Q. Even if a woman holds off on regular mammograms until she’s 50, should she get a baseline mammogram in her 40s?
Dr. DiNome: That’s a difficult question to answer because, if you are starting your screening at age 50, that means you agree with the U.S. Task Force data that it is not efficient to begin screening at age 40. So a baseline at that age would not make sense. There is no doubt that starting annual screening at age 40 reduces death from breast cancer, but the argument is that it is too low of a number to be considered significant. The probability of dying from breast cancer after age 40 is 3 percent. If you screen biennially between ages 50-74, you can reduce that to 2.5 percent. If you start screening annually at age 40, then you reduce it to 2.4 percent, which hardly seems significant when you talk about numbers. It’s just difficult when you equate it with a life because in my mind any life is worth saving.
Q. I got a mammogram and was told I have dense breasts, which I believe most Asian women have. Should we insist on an ultrasound?
Dr. DiNome: Almost every premenopausal female will have dense breasts because it’s a reflection of the hormonal stimulation on our breast tissue. After menopause, there is significantly less (unless they’re on hormone replacement therapy) and the breast tissue becomes more replaced by fat. The downsides of mammograms are that they are notoriously less sensitive in a woman with dense breasts, and that’s why we don’t recommend beginning screening in a woman under age 40. The ability of the mammogram to show anything helpful in that scenario is so low it’s not worth doing. For women over 40 who have dense breasts, a mammogram should still be performed because it is the only imaging modality that will pick up calcifications reliably, and this can be one of the earliest signs of breast cancer. A screening ultrasound does have some value as an adjunctive screening test to a mammogram, but not in place of. I do think it is worthwhile for women with dense breasts to advocate for a screening ultrasound, but it is not yet a test that is covered by insurance for routine screening.
Q. The risk of breast cancer for Asian American women seems to be rising (compared to women in Asia) — is there anything in particular we should be doing to protect ourselves?
Dr. DiNome: I think this has a lot to do with adopting a western diet. Population studies have demonstrated that if you followed immigrants from Asia to America, that over two generations the risk of cancer increases significantly. Right now, the risk of breast cancer in Asia is five times less than the risk in America. My recommendation would be to adopt a more whole food, plant-based diet and to minimize the amount of animal protein, which we eat way too much of in the U.S. My husband and I went vegan a few years ago for the health effects. I have a strong family history of cancer (not the least of which is my father who died from colon cancer at age 39) and I now have 3 1⁄2-year-old twin girls. Because my husband and I had kids later in life, we feel it’s our responsibility to do whatever we can to ensure that we will be around for them as long as possible. So we did a lot of research and we both independently concluded (my husband before me, mind you) that a vegan diet has the most evidence-based data for a cancer protective diet.
Dr. Maggie DiNome is the current chief of General Surgery at Saint John’s Hospital in Santa Monica, Calif. She is a board certified general surgeon, who focuses her clinical expertise on cancer surgery and advanced laparoscopic techniques. As a fellow of the Society for Surgical Oncology and a member of the American Society of Breast Surgeons, Dr. DiNome is particularly dedicated to caring for patients with breast and colorectal cancer.
This story was originally published in our Fall 2013 issue. Get your copy here.