Regarding an article in NY Times on mammograms

There was an article in yesterday’s New York Times by Jane Brody entitled, “Older Women, Mammograms and Confusion.” I’ve always enjoyed reading Jane Brody as I usually find her to be extremely on point and accurate. However, I found this article to be exactly as the title implies – confusing. I agree with her that one cannot go by the recommendation of various Societies because they are conflicting. The United States Preventative Services Task Force, which, I believe, in many other domains, is extremely draconian, recommends stopping routine mammograms at age seventy-five regardless of a woman’s remaining life expectancy. I could not disagree more. The American Cancer Society suggests continuing mammography indefinitely as long as a patient has the life expectancy of ten or more years. That begins to make some sense. 

One of the studies that she quotes, however, found that two-thirds of women over seventy-five who were found to have cancer had a tumor, “of a grade that should get treated.” This is in contrast to those who believe that the tumors found in older women are relatively low-grade and patients would die with them not from them. They go on to say, “the age to stop screening should be based on each woman’s health status and not determined by her age.” I could not agree more.

It is important to realize that the five-year survival for Stage 1A breast cancer is 99%. Yes, 99%! The key is early detection. I expect quality breast imaging sites to detect breast cancer at least four years before I or you could palpate it. Early detection allows a lumpectomy and a single sentinel lymph node. These are not very invasive surgeries and, as I have told many patients, the psychology of such a diagnosis often is much worse that the physical reality. The word cancer is scary. If you’re old enough, you’ll remember when people thought of breast cancer as a potential death sentence. I talk to many of my patients about early detection of breast cancer should and can result in nobody dying from the disease. Most patients can avoid a disfiguring mastectomy and can be treated, as I mentioned, with simple lumpectomy and a single lymph node. 

What patients should be concerned about is bone health. Nationwide, if one suffers a hip fracture, the statistics show that 25% of women will not live independently again and 30% of women will be dead within a year (some short term from pulmonary embolism or pneumonia, others, long term, simply failure to thrive). Admittedly, many of my patients who are in better physical shape with less comorbidities (that’s “medicalese” for other medical conditions) might not suffer such extreme numbers as those just quoted, but a fall with hip fracture later in life can be much more debilitating and, perhaps, even fatal compared to Stage 1A breast cancers.

Finally, I often have patients of advanced age who say, “why bother getting a mammogram, I wouldn’t do anything anyway.” I find this mentality disturbing. There is a saying in medicine – “don’t perform a test, if it will not change your management.” I explain to patients that if they had a very small, early tumor and could undergo a simple removal of a lump and a single lymph node and get on with their lives, of course they would undergo such therapy. It is not the same as saying to a patient, if they had an 8 cm tumor around the head of their pancreas, would they undergo a seven-hour Whipple operation and chemotherapy afterwards. For this situation, I understand the concept of, “I wouldn’t do anything anyway.”

In summary, I don’t think that this situation about mammography in older women needs to be confusing. I believe that annual screening in a quality imaging site is important indefinitely, although, as stated above, I do believe that a decision to stop should be based on each woman’s health status and, certainly, not determined by age alone.