The Annual Mammogram – It’s What Women Want, But Is it For the Right Reasons?

Most women in their 40’s believe they should have annual mammograms, regardless of what screening regimen their doctor might recommend.

So say researchers in Massachusetts who surveyed women (primarily white, highly educated) ages 39-49 presenting for annual checkups. They gave the women a fact sheet about the new USPSTF guidelines on mammogram screening in their age group, and asked them to read one of two articles either supporting or opposing the guidelines. The researchers then asked women about their beliefs, concerns and attitudes about breast cancer and mammogram screening. Here’s what they found –

  • Women overwhelmingly want annual mammograms – Close to 90% of women surveyed felt they should have annual mammograms, regardless of what their doctor might recommend.
  • Women overestimate breast cancer risks – Eighty eight percent overestimated their lifetime risk for the disease, with the average estimate being 37%. (The correct lifetime risk for breast cancer is 12%). This is consistent with previous research on breast cancer beliefs.
  • The media may not influence women’s opinions about screening guidelines – No matter which article they read, close to 90% felt that that the (USPSTF) guideline changes were unsafe and 84% would not be comfortable delaying screening mammograms even if their doctor recommended it.
  • Friends and Family are a strong influence. Seventy six percent of women reported having a close friend or family member who had been diagnosed with breast cancer. Secondary analysis showed that 92% of those with a close friend or family member with breast cancer vs 77% of those without a close friend or family member with breast cancer felt women should continue to undergo routine mammography in their 40’s despite the new USPSTF guidelines.
  • The experience of false positive mammograms only reinforces women’s faith in mammogram screening. Ninety two percent of those with a prior false positive mammogram expressed discomfort with the USPSTF guidelines vs 79% of those who had not had a false positive mammogram.

This finding suggests that these patients were more likely to view the additional imaging and biopsies as a near miss rather than a false alarm. This is an important finding because it is in direct contrast to the conclusions drawn by the USPSTF, which cited psychological harm from false-positive results as one of the major risks of screening mammography in the fifth decade. Our findings are consistent with other research showing that women are very tolerant of false alarms if they perceive the issue being addressed as significant.

Breast cancer awareness or breast cancer misinformation?

Previous studies have shown that women not only over-estimate their personal risk for getting breast cancer, but also inflate their 10-year chances of dying from breast cancer by over 20-fold. They also wildly overestimate the efficacy of mammograms in lowering breast cancer mortality, believing it to be almost 100 times as effective as it actually is in reducing breast cancer deaths.

Who can blame women for believing they are at higher risks for breast cancer than they actually are? After all, breast cancer awareness campaigns have been among the most successful outreach programs ever created, with the pink ribbon being used at this point to market everything from jewelry to Kitchen Aid mixers. Whether these campaigns have actually had any impact in reducing deaths due to breast cancer remains a point of some debate, and there are those who credit the declines in breast cancer mortality more to new treatments than to increased uptake of mammography screening.

Have we lost women’s trust? 

With the disagreement among doctors about guidelines, the miscommunication of recommendations by the very folks writing the guidelines and the resulting confusion in the media attempting to report these guidelines, it’s no wonder women don’t trust their doctor’s recommendations and have made their own decisions about screening.

At this point, it’s probably easier to just write the mammo referrals once a year and move on. After all, the American College of Obs-Gyn agrees that women should be offered annual screening. And my medical-legal risks align nicely as well, since failure to diagnose breast cancer is one of the biggest reasons gynecologists get sued.

But it that the right thing to do?

Call me crazy, but I happen to think that an informed screening choice is still the best one.

I’m not giving up yet. My patients want to make their own decisions about mammograms, and that’s just fine with me. But I’m going to do my best to be sure that decision is not just a gut response to an inflated sense of risks, but a careful decision informed by risks as well as benefits of screening and realistic expectations about what mammograms can and can’t do to lower breast cancer mortality.

To that end, here are some great resources for getting better informed about breast cancer screening –

  • National Cancer Institute  mammogram information. NCI recommends having mammograms every 1-2 years starting at age 40
  • ACOG pamphlet on mammography – ACOG recommends that women be offered annual mammograms starting at age 40.
  • American Cancer Society information on breast cancer screening – ACS recommends having annual mammograms starting at age 40.
  • USPSTF guidelines on mammogram screening – USPSTF recommends having mammograms every 2 years from ages 50-74. The decision to start biennial screening in women under age 50 should be individualized.
  • Breast Cancer Coalition -31 myths and truths about breast cancer

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Davidson AS, Liao X, Magee BD. Attitudes of women in their forties toward the 2009 USPSTF mammogram guidelines: a randomized trial on the effects of media exposure. Am J Obstet Gynecol 2011;205:30.e1-7.

9 Responses to The Annual Mammogram – It’s What Women Want, But Is it For the Right Reasons?

  1. I just got a screening mammo. I’m still (barely) in my 40s. My last mammo was @ age 40. I elected NOT to get annual or QOY mammos because I am average risk. Figured that false + was not worth the worry. When I went in for my repeat mammo this year the tech lambasted me for not getting annual mammos. Tried to educate her re: changing recs over the past decade, but she insisted that the recs have been to always get regular mammos after age 40. Sigh. Got my EOBs showing the facility fee and the interpretation fee, made me wonder if radiologists had any input on the guidelines.

    • Cardio-
      Radiologists have their own guidelines, which call for annual mammography starting at 40.

      You attitude about false + is apparently not common – or at least not the same as in the group of women surveyed in this study. Of course, they represent the socioeconomic group most screened, so they are not truly representative of all women.

      Thanks for reading!

      Peggy

    • so much depends upon the experience and comfort of the radiologists. I find the more seasoned rads are less likely to biopsy, while the younger ones appear to be more nervous about almost every abnormality they see.

      The good news is that the biopsies are generally small. But the worry associated with them is enormous.

      Peggy

  2. i have a lot of issues with the breast cancer awareness things — buying a pink spatula, etc., will not cure cancer. pinkification has become an industry in itself. a side-effect of these campaigns is that there is a lot of inflated worry, and a lot of guilt assigned and assumed if someone who is not at increased risk, and who does not have worrisome changes, fails to have frequent mams.

    i’m getting annual mammos now, in my 50’s, following my sister’s breast cancer diagnosis. i started early, first mam in my 20’s, because my people have lumpy breasts, but did not see a reaason to do annual mams all that time in the absence of worrisome changes.

    all 3 of my sisters had surgical biopsies that turned out to be benign. these are not small deals for the patient: general anesthesia, stitches, time off work, and the big worry. one friend was told that she had a malignant breast tumor; she found others to take over a law class she was teaching, put all her other work on hold, mentally prepared herself for a radical masectomy + other treatment; friends were talking about carpooling her kids, setting up a schedule for people to bring dinner, etc. and her lump turned out to be benign. these are reasons that i think false positives are awful.

    it seems to me that it’s important to notice any changes. when routine screening uncovers a cancer, it is likely to be small, early, treatable. a few cancers are just aggressive beasts, like my sister’s — it was not revealed on routine screening less than a year before diagnosis, but because she noticed a lump. (it’s been close to 3 years now, and she’s doing well.)

    • kathy –
      Your posts summarizes so perfectly all the issues around mammo screening, and presents a balanced and intelligent personal approach to the issue.

      It’s so hard to get away from the hype and emotion around breast cancer and just focus on how best to maximize benefits of screening without doing harm.

      Thanks for your thoughtful comment.

      Peggy

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