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To Screen or Not to Screen, That is The Question

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Mammography’s…what are we to do, screen or not to screen?! In case you haven’t yet had the experience, the procedure involves placing each breast on a flat X-ray plate while a compressor pushes the breast down to even out the thickness of the tissue. The equipment uses ionizing radiation to take images of the breast tissue, allowing the radiologist to identify calcifications and masses that could be breast cancer. The amount of radiation exposure varies based on the type of equipment used and the density of the breast tissue.

We know that radiation is not a good thing, but is the amount used in mammography a concern? To answer that question, it’s important to understand that we are all exposed to some amount of background radiation in the environment that comes from naturally occurring radioactive materials such as radon as well as cosmic radiation from space. The amount of radiation exposure from the average mammogram is roughly equivalent to 7 weeks of background radiation exposure. Estimates have stated that the lifetime risk of cancer death due to bilateral mammography in a woman aged 40 years is one in 70,000, with the risk decreasing with age. The American Cancer Society states that mammograms should be optional for women aged 40 to 44, then done annually from 45 to 54. Women 55 and older should switch to mammograms every other year, continuing as long as they are in good health and expected to live at least 10 years. There is a cumulative effect of radiation exposure, and because mammograms sometimes need to be repeated due to questionable results, this could have an impact on risk.

Any medical procedure has benefits and risks, so the question is whether there is good reason not to follow the American Cancer Society’s recommended mammography schedule. This is where the discussion of over diagnosis and overtreatment is more pertinent than radiation risk. Numerous studies have shown that mammography does not reduce cancer death rates as much as previously thought. And what’s more troubling is that mammograms find masses that in some cases may never grow or spread, but doctors currently do not have a reliable way of knowing which masses fall into this category, and the current protocol is to treat all cancerous masses rather aggressively. False positives are also extremely common, with about half of the women getting annual mammograms over a 10-year period having a false-positive finding. This overdiagnosis leads to overtreatment, subjecting patients to surgery, radiation, and/or chemotherapy to treat something that was never life-threatening in the first place. A breast cancer diagnosis creates a tremendous amount of stress for a woman and her family, which we know contributes to other health problems. Not to mention the enormous risks that are associated with the treatments, such as infection, pain, heart and lung problems, development of secondary cancer, infertility, osteoporosis, and nerve damage. Furthermore, most women are not aware of the risk of overdiagnosis and overtreatment when consenting to a mammogram. A recent study found that women’s awareness of overdiagnosis (16.5%) and overtreatment (18.0%) was low, and women under age 40 were least likely to have heard about overdiagnosis.

While early detection is the goal of mammography, what is the potential harm caused by overtreatment or non-life-threatening cancers, and how common is it? A study published in The New England Journal of Medicine last year provided a pretty shocking statistic: for every woman in whom mammography detected a breast cancer that was potentially life-threatening, about four are diagnosed and treated for a tumor that never would have harmed them. In other words, the relatively small benefit associated with mammography comes at the price of unnecessarily subjecting more women to disfiguring, risky, and oftentimes harmful procedures. The lead author of the study, Dr. H. Gilbert Welch, recorded a video in which he summarized the findings of his study into four main points:

  1. Death rates from breast cancer are decreasing largely because of improved treatment, not early detection
  2. While screening mammography does help some women by providing earlier diagnosis of cancers that were destined to grow larger, more often it finds small cancers that never would have caused harm
  3. There may not be a benefit of early diagnosis for small cancers that are destined to grow, because they are equally treatable at either size
  4. Screening mammography is a choice, and women should feel equally good about the choice to have a mammogram or not to.

The Swiss Medical Board has taken a stringent stance on mammography and recommended that no new systematic mammography screening programs be introduced and that a time limit is placed on existing programs. The reasoning cited is that for every breast cancer death prevented for U.S. women over a 10-year course of annual screening beginning at 50 years of age, 490 to 670 women are likely to have a false positive mammogram with repeat examination; 70 to 100 an unnecessary biopsy; and 3 to 14, an overdiagnosed breast cancer that would never have become clinically apparent.

If you choose not to have a mammogram but still want to proactively screen for breast masses, there are several other options to consider. Breast self-exams are a quick and harmless way to regularly “check in” with your breasts, making it easier to identify changes as soon as they arise. One survey found that 43% of breast cancer survivors detected their cancer either during breast self-examination or by accident by themselves or by their partner. There are many resources available online to learn how to perform regular breast self-exams. Ultrasonography is another screening tool that has similar cancer detection rates when compared to mammographyand is useful in assessing changes in breast tissue, especially in women with dense breasts. Ultrasounds are able to distinguish between fluid-filled cysts and solid masses and do not use any radiation. However, just like mammography, there is still a risk of false positives that could lead to more tests and treatment. Many women prefer ultrasounds over mammograms because they are more comfortable, don’t use radiation, and can be more beneficial in screening dense breasts. Some states have passed laws that require physicians to offer ultrasonography to women with dense breasts and mandate that health insurance companies cover the screening. To find out if your state has passed legislation regarding breast imaging, visit

Another tool that is gaining traction in the holistic health community is thermography. Thermography seeks to assess a woman’s risk of developing breast cancer by using digital infrared images to visualize vascular and metabolic activity in breast tissue. The goal of this technology is to find thermal indicators that suggest a pre-cancerous state or early tumor that is not yet large enough to be detected by other types of imaging and to teach the patient lifestyle interventions and strategies to reduce their risk of developing breast cancer. Thermograms are generally not covered by insurance and are offered in a direct-to-consumer fashion with your provider working with you one-on-one to interpret the results and provide next steps. Many patients appreciate that this tool is virtually risk-free and allows them to take charge of their own health by making more informed decisions about the need for further evaluation or screening measures.

Whatever you decide, it’s important to know that we have choices and to be an informed consumer when it comes to breast cancer screening. All women (and men, to a lesser degree) are at risk of developing breast cancer, so it’s something to be taken seriously. And above all, know that your dietary and lifestyle habits have a profound effect on your risk level for developing any type of cancer.

Cadie Berrian, BA, MNT

Image:  Image by Burst is licensed under CC0 1.0

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