“So, will this mammogram save my life?” she asked.
I thought for a few seconds …
“I have no idea.”
“What?” she sounded perplexed.
“Well, if you have a cancer that’s aggressive enough to kill you before everything else, but not aggressive enough to have already had cells metastasize, and not so aggressive that it responds appropriately to chemo but it still needs to be rapidly dividing enough to respond to chemo, and we hit this all with perfect timing — then it absolutely will save your life. Assuming you’re currently asymptomatic …”
I continued, “But, of course, simply by ordering this test, there’s no guarantee that you won’t have any sort of overtreatment. It’s possible that we may find cancer that wouldn’t have caused any problems. It’s also possible that we’ll find irregular cells that could resolve on their own, or you could have cancer that’s not picked up by mammography, falsely reassuring us. Or, we could find cancer, you could get all of the cells removed surgically, and you could develop a deep vein thrombosis postoperatively or a horrendous infection at the surgical site.”
“So you’re telling me that there are campaigns for mammography, but you can’t quote me exact numbers?” She sounded flabbergasted at this point.
“Yes. Unless you consider that there have been recent advances in technology.” I replied confidently.
“So that technology should make things better, right?” She sounded reassured again.
“Well, I really don’t know. It’s possible that it’s picking up on smaller tumors that would evolve into aggressive cancers, or it’s possible that it’s picking up on smaller tumors that won’t cause any problems.”
She looked at me again and said, “So what should I do?”
“Well, the United States Preventive Services Task Force says you should get a mammogram every two years from age 50 through 74 assuming you’re at average risk. You could also start at age 40 according to them. The American Cancer Society says you should get yearly screening from 45 until 54, then get screened every two years until you have a ten-year life expectancy, unless you want to get screened annually after fifty-four. They also say you’re more than welcome to get screened from 40 until 44. The American College of Radiology recommends that you get screened annually starting at age 40. And I’m not sure what the American College of Obstetricians and Gynecologists says.”
She looked as confused as I was.
I continued, “And I’m sorry, but it’s all very possible that those guidelines have changed since I last read.”
“So what should I do to reduce my risk of breast cancer?” She almost seemed angry.
I thought for a while again: “Stop smoking. Stop drinking alcohol. Start exercising more. Normalize your BMI. Breastfeeding would have been a good idea. Avoid radiation. You may want to consider something for birth control other than oral contraceptive pills. And let me know if you ever find any lumps on your breasts. If you truly want to decrease your risk of breast cancer, do all of that. I’ll order a mammogram too, but that other stuff is far, far more important.”
Justin Reno is a family physician.
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