There is a surprising amount of controversy about the effectiveness of breast screenings and how often to receive them. In part 2 of Dr. Christina Weltz and Dr. Nathan Fox’s discussion on breast cancer, they explain a few reasons for this controversy and offer recommendations, focusing on the need to provide personalized care.
Advancements in Targeted Treatments
The most significant breakthrough for breast cancer comes from how it is treated, not advancements in screening. This comes from a recent understanding of breast cancer as multiple different entities, or different types of breast cancer. As Dr. Weltz explains, estrogen-positive breast cancer and estrogen-negative breast cancer are very different and therefore require different treatments.
Controversy About When to Receive a Breast Cancer Screening
Despite widespread public awareness of breast cancer, there is still surprising controversy about when women should begin screening and how often they should continue. The confusion arises because different professional groups evaluate the evidence from very different perspectives. Experts at the National Institutes of Health (NIH) have studied the frequency of breast cancer diagnosis within specific age groups and determined that the cost of screenings and the anxiety that comes from false positives outweigh their benefits. However, this may be upsetting to people who have had loved ones diagnosed with breast cancer because of the results of their screening test. Additionally, Dr. Weltz touches on her personal experience as a breast surgeon, stating that “many women who have gone through such a process of having a biopsy because something was detected on a clinical exam or a mammographic exam that turned out to be benign…could not be happier.”
It is also difficult to state a specific age for when women should receive a mammogram, since some women may develop breast cancer younger than that specified age. Dr. Weltz also notes that large studies often lag behind real-time changes in research developments because the people making those recommendations are not seeing patients firsthand. While studies and recommendations can provide good guidelines, Dr. Fox emphasizes the need to treat each patient individually based on unique risk factors and individual opinions about testing.
An Example of Controversy
A report on ductal carcinoma in situ from the U.S. Preventive Services Task Force, contradicting studies from the American College of Radiology, national OB-GYN groups, and other breast surgery groups, illustrates this disconnect. This is a zero-stage cancer, meaning the cancerous cells are still contained within the breast tissue ducts and can be easily removed before they metastasize. However, because there is still more that needs to be known about ductal carcinoma in situ, the report does not recommend screening. This is something that Dr. Weltz and Dr. Fox disagree with. Dr. Weltz also notes the difference in diagnosis and treatment required for patients in situ, explaining that these women do not need chemotherapy.
The History of Breast Cancer Treatment in the US
The history of breast cancer treatment reflects both medical progress and social change. For much of the early 20th century through the 1980s, the standard treatment was a radical mastectomy, an extensive operation that removed the breast, underlying muscles, and lymph nodes. By the 1970s, screening improved and more cancers were found earlier, yet surgeons still insisted on radical procedures. Women began to push back, led by advocates who questioned why less aggressive surgeries like lumpectomy, already used in Europe, were not offered for small tumors.
For patients with larger tumors or those who are at high risk and wish to prevent breast cancer development, mastectomies are still performed, but in combination with reconstructive breast surgery. High-risk patients typically include those with BRCA 1 or BRCA 2 mutations and/or a family history of breast cancer. The need to perform more frequent screenings can also be determined by the presence of this mutation, but it is an individual choice that should be carefully considered. Some women may be reassured by frequent screenings, while others may find them daunting. Insurance coverage and finances can also play an important role in the decision to get a mammogram screening.
Recommendations for Average Risk Women
For women at average risk, meaning no significant family history or known genetic mutation, Dr. Weltz supports beginning clinical breast exams in their 30s and annual mammograms at age 40. Self-exams are, surprisingly, no longer strongly recommended, but this is because recent studies have shown that self-exams do not lower the mortality rate. Still, women know their own bodies better than anyone, and any new or unusual change in the breast should prompt a visit to a clinician.
Learn More on the Healthful Woman Podcast
Ultimately, the conversation around breast cancer screening highlights the need for nuance in medical care. Guidelines offer helpful frameworks, but the most meaningful decisions are made between a patient and her clinician. To learn more about breast cancer screenings and treatment advances, check out the full episode on the Healthful Woman podcast. If you are considering a breast cancer screening or genetic testing, we encourage you to schedule an appointment with our team of experts at Carnegie Women’s
