Do I really need a mammogram?

I hear this question every week. My quick answer to any question that starts with, “Do I really need to do this test?” is “Only if you want to know the answer”. I’m not trying to be trite or sarcastic. My philosophy is to only order tests when the results will make a difference in my patient’s health or well being. My job is to help my patients navigate the healthcare system. You always have choices and responsibilities when it comes to accepting a physician’s advice.

The usefulness of mammograms has been the focus of recent research.

For an in depth review, see these articles.
Screening Mammography: Making an Informed Decision
Tom G. Bartol, NP
February 27, 2014 WWW.Medscape.com

Quantifying the Benefits and Harms of Screening Mammography
Welch HG, Passow HJ
JAMA Intern Med. 2014 Mar 1;174(3):448-54. doi: 10.1001/jamainternmed.2013.13635.

The benefit of mammograms in reducing breast cancer deaths is in question. There is compelling evidence that the number of deaths from breast cancer has been reduced very little in the last few decades, despite a marked increase in diagnosed breast cancers. The implication is that we are finding more cancers with the improvement in and availability of screening tests, i.e. mammograms, ultrasounds, and magnetic resonance imaging (MRI) but we aren’t reducing deaths from breast cancer.

In Screening Mammography: Making an Informed Decision, Tom Bartol, NP makes the case for patient education concerning mammograms. I agree that patients should be given more data about their choices before the provider orders a mammogram. You would probably be surprised if your doctor asked you if you would like to have a mammogram since 40% of patients are not given a choice and 54% of patients never have their choices explained.

The mammogram is a very good screening tool to detect early breast cancers. Patients and physicians believe that having a mammogram will reduce the patient’s risk of dying from breast cancer, and they do reduce deaths. However, all of us are probably overestimating that benefit. Breast cancer accounts for 40,000 deaths per year or 1% of all deaths. Those are very small numbers so it is easy to see that if a mammogram only saves 16-49 lives per 1000 women that statistically the mammogram is not a cost effective test.

Am I saying that mammograms are unnecessary? Absolutely not and I hope you are asking yourself “but what if I am one of those women who’s life is saved by a mammogram?”. The answer of course is that the test was extremely cost effective for you.

Population studies don’t take into account the benefits of any one test to the individual. The benefits of a mammogram increase with the age of the patient being studied. I know that we will be seeing more and more of these types of reports on the cost effectiveness of medical testing as we try to curb escalating healthcare costs in this country. You should expect to hear your physician talking about necessary and unnecessary testing more often as we venture farther into cost effective, evidence based medicine. (That’s a discussion for another day.)

Have a seat at my kitchen table and let’s chat about your choices.

As always my advice is general and every woman should make decisions with the assistance of her personal physician who knows her history and physical exam findings.

Lesson #1
A mammogram does not replace the physical exam! Get an exam and do a breast self exam.

Lesson #2
If you have a lump that you or your physician can feel then you need a diagnostic mammogram and/or breast ultrasound and the statistics for screening mammograms no longer apply. Twenty percent of breast cancers that you can feel are not seen on screening mammograms.

Lesson #3
Do not panic if you are called back for additional views. You have a 50% chance of having a false positive result in your lifetime that will necessitate additional views. Of those having additional views, about 10% will result in a biopsy. Only a few of those women will actually have cancer.

Lesson #4
If you are notified that you have a dense breast on mammogram don’t be scared into paying cash for unnecessary additional testing. The younger you are, the more dense your breast will be. Make an appointment with your doctor to discuss the results first and if you haven’t had a recent breast exam then HAVE A PHYSICAL EXAMINATION OF THE BREAST. See Lesson # 1. Your doctor can interpret the results in light of your exam, family history, age, and your personal risk factors. The radiologist doesn’t know you when she dictates your mammogram report.

Lesson # 5
You have a choice but you are also responsible for your choice. Ask questions. Consider your options and ask yourself, “What if I’m one of the 40,000 women who will die from breast cancer because I didn’t have a mammogram?”. You are the only one who can answer that question. Always remember Lesson# 1 and Lesson # 2 and don’t make your decisions in a vacuum with too little information.

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Be well