Some stuff about screening mammograms
This isn't medical advice; I'm not that kind of doctor
Hi! Things are stupid and I still have cancer, but I am having surgery on June 24th and will not have cancer after that! Some folks have asked, so if you would like to throw some cash into my Gofundme, I would be grateful, but your good wishes are what I value most.
Anyway, I meant to write about this a million years ago. Since I was diagnosed in January, I have learned a lot about the efficacy of screening mammograms. (This was, in fact, how my cancer was detected!) It’s helpful, I think, for people to know where this recommendation that all women start getting annual mammograms at 40 comes from.
First: there’s a difference between screening mammograms and diagnostic mammograms. The latter is what you get when you have found a lump or something, a test that diagnoses, if u will, whatever the problem is. Those aren’t what I’m talking about. Screening mammograms are the kind you get as part of your yearly care when there’s no indication of disease. For example, my initial mammogram last fall was a screening mammogram. The subsequent mammograms I had once that first test showed an abnormal result were diagnostic mammograms.
The short version is this: not everyone needs to get annual screening mammograms before the age of 50. There isn't any science that demonstrates that routinely screening women for breast cancer between the age of 40 and 50 has produced meaningful changes in diagnosis stage, treatment plan, and survival rates. Now, there are lots of qualifiers to that and I will explain what those are, but first I’ll explain how screening mammograms became part of medicine.
Mammograms were not really used in the diagnosis and treatment of breast cancer until the 1970s. No one really even thought they would be useful until the 1950s. In the early 1960s, this radiologist named Philip Strax, which I think is a great name, became interested in that question. His wife had died quite young of breast cancer, and he was really invested in figuring out whether radiography offered a useful early detection tool. So he conducted a study in the 1960s and he did it with the members of a health insurance plan, the Health Insurance Plan of Greater New York, which formed the participant pool for the study. And the Strax study did find significant efficacy in the use of screening mammograms— for women over the age of 50. One in eight women are diagnosed with breast cancer in their lifetimes and/but the chance that you might develop breast cancer increases as you age, and it makes sense, the Strax study suggested, to screen women whose ages make a cancer diagnosis more likely. (I was diagnosed at 38, and only about 4% of breast cancer diagnoses are made in patients under 40. Screening mammograms were a good idea for me, which I will explain!)
So how and why did the American Cancer Society, urged on by the American College of Radiology, recommend that every woman over 40 should get an annual screening mammogram? (The ACR still makes this recommendation.) Where did that come from? Well, it didn't come from science!
The Strax study is the only randomized controlled trial of screening mammography. A subsequent study on which the 40 and up recommendation was based was what’s called a demonstration trial: mammogram centers were opened across the United States in the early 1970s and as many women as possible were encouraged to get screened. That’s … not a valid research trial, and even so, the demonstration trials supported the prior evidence that screening mammograms were most useful for women over 50. And yet it has become, literally, taboo for physicians and scientists to say that they think there's no efficacy to screening mammograms under under the age of 50.
So what should people do? I think there are some people who are going to want to get annual screening mammograms beginning at 40. Those would be people who have a genetic disposition to breast cancer, who have what are called “first degree relatives” who have had breast cancer—a parent or a sibling; or extended family with lots of cancer history; and Ashkenazi Jewish women.
And, frankly, women from racial groups that are underrepresented and under-treated in medicine should get annual screening mammograms as a kind of bulwark against that. It makes a lot more sense for a Black woman with no family history of breast cancer to start getting screening mammograms at 40 than it does for a white woman with no family history of cancer. Black women and white women are diagnosed with cancer at about the same rates, but black women are significantly more likely to die and they are often diagnosed later. The ACR specifically says that Black women will benefit from screenings under 50 because so much medical care is shaped by structural racism.
So what should everyone else do? Well, first, everyone should do what they're comfortable with. Insurance companies have to cover annual screening mammograms for women over 40. Get them if you want them! BUT if you are under 50 and have no family history of cancer, no genetic history, no structural or demographic determinants that generally affect medical outcomes for you, I think you would be okay getting them every few years, rather than yearly. You might want to get a baseline mammogram when you're 40; if you have dense breast tissue you're going to want to also get a baseline ultrasound, and you should talk to your doctor about it. (Mammography doesn’t always reveal cancer in dense breast tissue.) If you don't get in there every single year, that's probably okay. We also don’t know what that extra radiation exposure from annuals does, and if that’s something you want to minimize, you can definitely talk to your doctor about it. (There is also an argument that screening lots of people finds irregularities that might become cancer but won’t actually progress to invasive cancer. This is a subject for another day.)
So: you might not need a screening mammogram every single year from 40-50, but if you feel better getting them, you absolutely should! Regardless, what's more important for people of any gender under 50 (and at any age) is monthly self exams. Early detection isn’t just possible though mammography. Please please do monthly self-exams and don’t be afraid to go to your doctor about anything suspicious. Most of the time it won’t be cancer. If it is, you’ll be glad you found out as soon as possible.