Flashback Friday: Should Women Get Mammograms Starting at Age 40?

Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.

“Various [health] organizations offer clashing [mammogram] recommendations” that range from annual “mammograms start[ing] at age 40,” to eliminating routine mammograms “altogether.” It’s hard to know who to trust, given all the various conflicts of interest, but a good place to start is the USPSTF, the U.S. Preventive Services Task Force, whose 2009 recommendations “ignited a firestorm” of controversy by recommending pushing back routine mammograms from age 40 to 50, and doing them every other year, instead of annually. This evoked “a swift and decidedly passionate condemnation from members of the public, the media, and [medicine].”

Most people have never even heard of the USPSTF, but it’s “considered the leading independent panel of [nongovernmental] experts” when it comes to prevention—considered the “gold standard for preventative care,” since they have a reputation of sticking more with the science, for example, “recommending against” teaching women to do breast self-exams. Why? Because it doesn’t appear to work. It was put to the test—hundreds of thousands of women randomized to do self-exams or not, and no benefit—in fact, only harms: doubling the number of women who had to get biopsies taken, but not actually shown to decrease the risk of getting breast cancer, or dying from breast cancer. It didn’t catch tumors in earlier stages.

Now, to be clear, they didn’t come out against breast self-examination, but “against teaching” women how to do them; reminding them to do them only appears to cause harm with no benefit. If you do discover an abnormality, then definitely tell your doctor, but telling women to get into the practice of looking seems to do more harm than good. Yet, most doctors continue to teach women to perform self-exams. But wait; it’s not been shown to help, and in fact, has been shown to harm, so why do doctors keep doing it? Because that’s just what we’ve been telling women forever. So, there’s this medical inertia that may trump women’s health—even without a multibillion-dollar industry pushing for the practice to continue. Even without Big Business tipping the scales.

Now, consider mammograms. Billions of dollars of revenue every year from sticking with the status quo. Maybe the $7.8 billion spent annually on mammograms “might be better spent on something else.” Of course, “[o]ne person’s cost is another person’s income.” These billions of extra dollars from the status quo may “best explain the organized resistance to the…USPSTF panel [conclusions].” For example, breast radiologists denounced the panel, “implying that the panel members were guilty of a callous disregard for the life and well-being of women,” all while the American College of Radiology is receiving millions of dollars of donations from mammogram machine manufacturers.

Yeah, but in the case of self-exams, it was put to the test, and the science was clear. It’s a no-brainer that harms outweigh the benefits, when apparently there are no benefits. And, the same appears to be the case with starting mammograms at age 40. It was put to the test to specifically address “the population-wide efficacy of mammography screening starting at..age…40…,” and it started out looking like it might help, but ultimately failed to show any benefit in terms of lowering one’s risk of dying from breast cancer. Instead, they just found harms, so-called “overdiagnosis”—all the chemo, radiation, and surgery from the detections of what looked like cancer, but may have never caused any problems had they never been picked up.

So, it may have just resulted in like unnecessary mastectomies. Yet, when the USPSTF tried to explain that again in their 2016 recommendations, the firestorm was reignited, with full-page ads taken out in major papers asking, “Which of our mothers, wives, daughters, and sisters would it be OK to lose?” But, that misrepresents the science—disrespecting women, rather than saving their lives. It’s time to “douse the flames,” “clear the smoke so that we can clearly see what the evidence shows…”

Evidence, schmevidence, said Congress, who snuck in some language to interpret any reference to “current” USPSTF breast cancer-screening recommendations to mean those issued “’before 2009’—in other words, its 2002 recommendations” that recommended annual mammograms starting age 40. “Essentially, Congress is requiring health insurers to ignore modern scientific assessments, and instead use [a 15]-year-old guidance.” “Although many women’s health advocates applauded the congressional mandate, it [could be viewed as undermining] women’s rights to make informed decisions based on the best scientific evidence.”

The same thing happened 20 years ago, when “a National Cancer Institute…consensus panel arrived at [the same conclusion],” but the Senate voted unanimously “to ignore” them. The number one killer of women is heart disease. Why not focus our billions on more effective interventions? “Since health care dollars are limited,” maybe we could be doing more for women’s health.

But hey, it could have been worse. The original bill “would have denied funding for any future USPSTF mammography recommendation[s],” period. And “[s]ome members of Congress [even proposed] to alter the Task Force’s composition to include ‘stakeholders from the [mammogram machine manufacturers],” so they can play a more direct role in influencing policy.

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• Quanstrum KH, Hayward RA. Lessons from the mammography wars. N Engl J Med. 2010;363(11):1076-9.
• O'donoghue C, Eklund M, Ozanne EM, Esserman LJ. Aggregate cost of mammography screening in the United States: comparison of current practice and advocated guidelines. Ann Intern Med. 2014;160(3):145.
• Keen JD. Aggregate cost of mammography screening in the United States. Ann Intern Med. 2014;161(4):304.
• Lantz PM, Evans WD, Mead H, Alvarez C, Stewart L. Knowledge of and Attitudes Toward Evidence-Based Guidelines for and Against Clinical Preventive Services: Results from a National Survey. Milbank Q. 2016;94(1):51-76.
• Laine C, Dickersin K, Mulrow C. Time to Douse the Firestorm Around Breast Cancer Screening. Ann Intern Med. 2016;164(4):303-4.
• Sohn E. Screening: Don’t look now: Mammogram screenings are an established part of women’s health care, but are they more trouble than they are worth?. Nature. 2015;527(7578):S118-S119.
• Loh KP, Stefan MS, Friderici J, et al. Healthcare Professionals' Perceptions and Knowledge of the USPSTF Guidelines on Breast Self-Examination. South Med J. 2015;108(8):459-62.
• Lin KW, Gostin LO. A Public Health Framework for Screening Mammography: Evidence-Based vs Politically Mandated Care. JAMA. 2016;315(10):977-8.
• Luqmani YA. Breast screening: an obsessive compulsive disorder. Cancer Causes Control. 2014;25(10):1423-6.
• Keen JD, Jørgensen KJ. Four Principles to Consider Before Advising Women on Screening Mammography. J Womens Health (Larchmt). 2015;24(11):867-74.
• Autier P. Breast cancer: Doubtful health benefit of screening from 40 years of age. Nat Rev Clin Oncol. 2015;12(10):570-2.
• Mundy A. New Breast Screening Limits Face Reversal. WSJ. 2010.
• Woolf SH. The 2009 breast cancer screening recommendations of the US Preventive Services Task Force. JAMA. 2010;303(2):162-3.
• Beard C, Beard V. Re-examining current breast cancer screening: An analysis of the 2009 U.S. Preventive Services Task Force guidelines for breast cancer screening. Women Health. 2016;56(3):281-295.

Image credit: Colin Charles via flickr. Image has been modified.

Motion graphics by Avocado Video