When to start? How often to repeat?
Although new technologies are emerging, breast experts still call the mammogram the gold standard for detecting breast cancer, and the benefits of early detection are staggering.
Still, among the major research collectives that make recommendations on such topics, there is little agreement on when women should begin having mammograms, how often they should have them and how long they should continue.
Cancers caught at Stage I have a 100-percent, five-year relative patient survival rate, whereas survival rates drop to 22 percent for patients whose cancers are not treated until Stage IV.
"The major societies all evaluated the available data, and all came up with different recommendations," says Kristine Slam, MD, medical director of Cancer Services at Mount Carmel East Hospital and board-certified surgeon with Central Ohio Surgical Associates. "Even the experts don't know," she says.
The American Cancer Society, which previously recommended annual mammograms beginning at age 40, now recommends getting a test annually between ages 40 and 54, then biannually at age 55 and beyond.
American College of Obstetricians and Gynecologists and the American College of Radiology both recommend starting mammograms at age 40 and having one every other year.
Meanwhile, the US Preventive Services Task Force recommends that women not start regular mammograms until age 50, and then have one biannually until age 74.
Slam says the recommendations she will make depend upon the patient. That includes looking for elevated risk factors, which may include family history, prior biopsies, smoking, sedentary lifestyle, high body mass index, and even moderate consumption of alcohol.
She says she has received no pushback from either hospital officials or insurance companies when women elect to pursue mammograms beginning at age 40.
"They give the woman the option to start if she wants," Slam says. All of the societies, she says, encourage doctors to speak with patients about expected risks versus expected benefits.
"We explain accuracy, and the expected callback rate," Slam says. Over the course of a lifetime, about 50 percent of women will get a callback to redo a suspicious mammogram, and about 20 percent of women will undergo biopsy, in which questionable tissue is surgically removed and examined for evidence of cancer.
There is some concern since biopsies, while minor surgery, still carry the risk of bleeding, bruising or potential infection. Likewise, some believe that too-frequent mammograms and the high callback rate can cause heavy anxiety. But the callback rate represents very little to worry about, Slam says.
She says of every 1,000 women to receive a mammogram, statistically, 100 will be called back, and of those, five will have cancer. She says she also likes to remind people that risk is very relative.
"If your lifetime risk of heart disease is 30 percent and you see that your risk of breast cancer is only 12 percent, it puts things in perspective," she says. "The breast is only one part of the body."
Deepa Halaharvi, DO, is a breast surgeon with OhioHealth Breast and Cancer Surgeons and a strong supporter of mammograms beginning at age 40. She bases many of her recommendations on those of the National Comprehensive Cancer Network, which pushes for annual exams beginning at age 40.
"They recommend continuing as long as you are in good health," she says. Even after age 80, if the person has an expected life span of at least five more years, she says mammograms should continue.
Halaharvi says that some of the recommendations to stop screenings are due to the belief that another disease might kill the person before the cancer could, so there is no reason to test for cancer.
She says there isn't much discussion about whether or not reduced screenings could save money, but there is discussion about the anxiety over false positives and biopsies that come back negative. She dismisses that as a minor concern.
"Most women don't complain when they've been through a biopsy," she says. "They are just happy they don't have cancer."
On the other side of the coin, early detection brings fear at first but then potentially great relief to the patient, the family, the doctor and even the insurance company because treatment is so much easier, less physically taxing and less expensive.
"It is easier on everyone when we catch it early," Halaharvi says. "Patients usually don't need these toxic therapies, and there are no big surgeries and adjunct treatments." Halaharvi says hospital officials offer strong support for early mammograms, and she has received no resistance from any quarter when recommending the screening exams for her patients.
Delaying the exams doesn't make sense statistically. "Of all the people who die of breast cancer, 25 percent of them are in their 40s," she says.
Halaharvi has always been a strong advocate of breast screenings, but now more than ever, she knows whereof she speaks. She was recently diagnosed with breast cancer at age 42 and received successful treatment. "If I hadn't had the screening and I had waited until 50, I would be dead," she says.
Kristin Campbell is a freelance writer.