Doctors still divided on when women should start mammograms

Despite what the American Cancer Society and other health organizations advise, many doctors still recommend routine mammograms to screen for breast cancer in younger and older women, a new paper suggests. Experts are divided on whether more screenings are beneficial. The American Congress of Obstetricians and Gynecologists recommends annual mammograms starting at 40 for all women, whereas the US Preventive Services Task Force recommends biennial mammograms starting at 50 for all women. In 2015, the American Cancer Society updated its guidelines to recommend that women with an average risk of breast cancer have the option to start screening with a mammogram every year starting at age 40, and should undergo regular mammogram screenings starting at age 45. n the new paper, many of the primary care physicians and gynecologists surveyed said they still recommended screening for women ages 40 to 44 last year. The paper was published in the journal JAMA Internal Medicine on Monday. "All guidelines agree that discussions about mammography should begin at age 40. There is universal agreement on this age.

Where the difference comes is the age at which screening should be recommended without the need for an informed decision," said Dr. Richard Wender, chief cancer control officer of the American Cancer Society, who was not involved in the new paper. About 12% of women born in the United States will develop breast cancer at some time during their lives, according to the National Cancer Institute. The new paper involved data on 871 primary care physicians and gynecologists in the United States who self-reported their breast cancer screening practices in a mailed survey from May to September 2016. The data came from the Breast Cancer Social Networks national survey, which included physicians who were randomly sampled from the American Medical Association's physician masterfile. Overall, 81% of physicians who completed the survey recommended screening for women 40 to 44; 88% for women 45 to 49; and 67% for women 75 and older. "Our results serve as a benchmark for breast cancer screening recommendations as guidelines continue to evolve," said Dr. Archana Radhakrishnan, a researcher at Johns Hopkins Medicine in Baltimore and lead author of the new paper. "Despite changes to guidelines, doctors are continuing to recommend routine mammograms to both younger and older women," she said. "The recommendations varied depending on physician specialty; gynecologists were the most likely to recommend screening." Among the physicians in the paper who recommended screening, 62.9% recommended annual examinations for women 40 to 44, 66.7% for women 45 to 49 and 52.3% for women 75 and older. "I trust the results of the paper. The response rate was high for a survey. The distribution of specialties was reasonable and clearly reported," Wender said. Dr. Mitva Patel said that she not only recommends annual screenings for women 40 and older, she follows those guidelines herself. "I am 42. I have had my annual mammogram at age 40, 41 and 42," said Patel, a breast radiologist at the Ohio State University Comprehensive Cancer Center, who was not involved in the paper.

She added that the American College of Radiology and the Society of Breast Imaging both recommend yearly screenings for women 40 and older. "I put myself in patients' shoes when I make a recommendation as a doctor, and I say, 'this is what I would do for myself,' " Patel said. "There are so many different recommendations, and it can be confusing. So it's important for patients to make their decision for screening with their primary care physician, and I'm encouraged that this study shows most primary care physicians still believe in annual screening starting at age 40." Guideline groups bring different perspectives and weigh different types of data differently, said the American Cancer Society's Wender. "Screening guidelines will constantly change in response to the emergence of new evidence. This is a good thing. As we learn more, we can refine guidelines based on new information. That's why it's important to keep updating guidelines. Groups are asked to balance the risks and benefits of a screening test," Wender said. "Ultimately, there is no perfect answer. Guideline groups must bring their own values into the recommendation. Breast cancer is a good example," he said. "The risk of developing breast cancer steadily increases as a woman gets older; that makes it very hard to choose one starting age that is right for everyone. That is why shared and informed decisions in younger women are recommended by some of the groups."

 Neither the American Cancer Society nor the US Preventive Services Task Force recommend routine mammograms for women 40 to 44 because they are more likely to offer downsides than benefits, according to an editorial published alongside the new paper in the journal JAMA Internal Medicine. Drs. Deborah Grady and Rita Redberg, professors at the University of California, San Francisco School of Medicine, co-authored the editorial. Potential risk factors that can come with mammograms are overdiagnosis, in which a cancer that would otherwise never cause symptoms or death is found, and false-positive results, in which a patient could unnecessarily experience anxiety and take on the discomfort and financial costs of additional tests, such as a biopsy. "One important issue is that payment systems in the United States typically reward ordering tests and procedures over taking the time to talk to patients about risks and benefits. The fear of litigation is often mentioned as a reason for unnecessary testing," Grady and Redberg wrote in their editorial. "Other excuses range from the influence of many decades of hype in the general and medical media, the idea that early treatment must be good, that knowing is better than not knowing, the allure of doing something rather than nothing, and the conviction that patients like more testing," they wrote. "Limiting coverage of tests known to be harmful is a win-win for patients and the national health care system." Grady and Redberg pointed to the US Preventive Services Task Force's recommendations to screen women 50 to 74 every other year as the appropriate guidelines to follow.

Dr. Andrew Kaunitz said he encourages his patients begin screening every two years at age 50, which is consistent with the US Preventive Services Task Force's recommendations. "There are many factors explaining differing recommendations," said Kaunitz, professor and associate chairman of the University of Florida's Department of Obstetrics and Gynecology in Jacksonville, who was not involved in the new paper. "Clinicians are concerned that if they do not recommend starting screening earlier and they have a patient diagnosed with breast cancer at a young age, they may be sued," he said. "Although the best evidence indicates the benefits of screening mammograms are in fact quite limited, breast cancer advocacy organizations have been vocal and effective in convincing the public as well as health professionals that screening mammograms have major unequivocal health benefits. This makes it hard to move away from recommendations to start screening early." Similar to the findings in the new report, a previous study found that 75.7% of primary health care providers reported screening practices in excess of those recommended by the US Preventive Services Task Force. That study was published in the Journal of General Internal Medicine last year. "From my experience, working with patients, most say that they want to catch the cancer early. They'd rather find out," said Patel, the breast radiologist. Although most breast cancers are found in women 50 and older, about 11% of all new cases of breast cancer in the US are found in women 45 and younger, according to the Centers for Disease Control and Prevention. "These women who are diagnosed in their 40s, their cancer can be more aggressive," Patel said.

Even if a woman receives a false-positive screening result, Patel said, the anxiety that woman may feel is often short-lived, and as for the risk of overdiagnosis, there seem to be conflicting data on how often breast cancers are overdiagnosed. "Overdiagnosis is a difficult concept for clinicians and patients to comprehend," said Kaunitz, who wrote a commentary in the journal OBG Management last month reporting that more than one-third of tumors found during breast cancer screenings represent overdiagnosis. Some studies suggest that less than 5% of screened breast cancers are overdiagnosed while others suggest that more than 50% are overdiagnosed. "So, there's a lot of talk about all these different risk factors, and some of these societies are placing more emphasis on one of these areas, whereas we should focus on saving the most number of years of life, which comes with early detection," Patel said. "Rather than emphasizing the negative aspects of screening such as cost, anxiety or overdiagnosis, we should focus on the most important benefit of early screening, which is early detection and the number of years of life this can bring to the patient," she said. Some experts argue that more research is needed to help inform recommendations.

"We are continually understanding more about breast cancer screening -- about who should get them, the different age groups of women who really benefit from it and how frequently women need to have mammograms," said Radhakrishnan, lead author of the new paper. "The guidelines are continuing to evolve, and there is more similarity now between the American Cancer Society and US Preventive Services Task Force guidelines," she said. "American Congress of Obstetricians and Gynecologists also reports convening a group to look at their own breast cancer screening guidelines. Amidst all of these changes, we need to make sure that both women and physicians are made aware of what the recommendations are."

Mammograms may do more harm than good for many women with breast cancer, study says

One in three women with breast cancer detected by a mammogram is treated unnecessarily, because screening tests found tumors that are so slow-growing that they’re essentially harmless, according to a Danish study published Monday in Annals of Internal Medicine, which has renewed debate over the value of early detection. The study raises the uncomfortable possibility that some women who believe their lives were saved by mammograms were actually harmed by cancer screenings that led to surgery, radiation and even chemotherapy that they didn’t need, said Dr. Otis Brawley, chief medical officer of the American Cancer Society, who wrote an accompanying editorial but was not involved in the study.

Researchers increasingly recognize that not all breast cancers pose the same risk, even if they look the same under a microscope, Brawley said. While some early tumors turn into deadly monsters, others stop growing or even shrink. But assuming that all small breast lesions have the potential to turn deadly is akin to “racial profiling,” Brawley wrote in his editorial. “By treating all the cancers that we see, we are clearly saving some lives,” Brawley said in an interview. “But we’re also ‘curing’ some women who don’t need to be cured.”

Although experts such as Brawley have long discussed the risks posed by “overdiagnosis,” relatively few women who undergo cancer screenings are even aware of the debate. The American College of Radiology, which strongly supports breast cancer screenings, acknowledges that mammograms lead some women to be treated unnecessarily, but said the problem is much less common than the new study suggests. Another study from Denmark – whose national health program keeps detailed records – estimated the overdiagnosis rates at only 2.3 percent. “The amount of overdiagnosis really is small,” said Dr. Debra Monticciolo, chair of the American College of Radiology’s Commission on Breast Imaging. “Articles like this aren’t very helpful,” she said, because they leave women confused about how to be screened for breast cancer.

Yet treating women for cancer unnecessarily can endanger their health, said Fran Visco, president of the National Breast Cancer Coalition, an advocacy group. Radiation can damage the heart or even cause new cancers. Visco notes that breast cancer activist Carolina Hinestrosa, a vice president at the coalition, died at age 50 from soft-tissue sarcoma, a tumor caused by radiation used to treat an early breast cancer. Women should understand these risks, Visco said. Instead, women often hear only about mammograms’ benefits. “Women have been inundated with the early detection message for decades,” Visco said. The risks of overdiagnosis and false positives, which can lead women with benign growths to undergo biopsies and other follow-up tests, have caused some experts to reevaluate breast cancer screenings.

Although mammograms don’t find all tumors, they reduce the risk of dying from breast cancer by 25 percent to 31 percent for women ages 40 to 69, according to the Agency for Healthcare Research and Quality, part of the Department of Health and Human Services. In the new study, Danish researchers estimated the rate of overdiagnosis by comparing the number of early-stage and advanced breast tumors before and after the country started offering mammograms. If screenings work as intended, the number of small, curable breast tumors should increase, while reducing the number of large cancers by about the same amount. Although mammograms in Denmark detected a lot more breast cancers, these were mostly small, early-stage tumors, said study coauthor Dr. Karsten Jorgensen, a researcher at the Nordic Cochrane Center in Copenhagen, Denmark. The number of advanced cancers did not fall. The debate about overdiagnosis illustrates the limits of medical technology, Brawley said.

Although researchers can estimate the statistical rate of overdiagnosis, doctors treating actual patients can’t definitively tell which breast tumors need treatment and which might be safely ignored, Brawley said. So doctors tend to err on the side of caution and treat all breast cancers with surgery and, in many cases, radiation and chemotherapy. An estimated 253,000 new cases of breast cancer will be diagnosed in U.S. women this year, with nearly 41,000 deaths, according to the American Cancer Society. An additional 63,000 women will be diagnosed with ductal carcinoma in situ, also known as DCIS, which has some, but not all, of the typical traits of cancer. Although DCIS cells have changed to appear malignant under the microscope, they haven’t invaded surrounding tissue. The American Cancer Society defines DCIS as the earliest stage of breast cancer, and women with the condition typically undergo the same treatment given to women with early invasive cancers.

Although DCIS isn’t life-threatening, doctors recommend treating it to prevent it from becoming invasive. Other experts note that DCIS carries such low risk that it should be considered merely a risk factor for cancer. Researchers are conducting studies to measure whether it’s safe to scale back treatment of DCIS.

New technology may help women with breast cancer forego chemotherapy

For women who are diagnosed with breast cancer every year in the U.S., a leading cause of cancer death among Hispanic women, one of the toughest choices to make is what type of treatment to choose. 

A new test, called MammaPrint, is making it possible so women could forego chemotherapy. Such was the case for 46-year-old Zaida Vazquez when she was diagnosed with breast cancer this May. Breast cancer is the most commonly diagnosed cancer. Among Hispanic women, breast cancer will be the leading cause of cancer death this year (16 percent), followed by cancers of the lung (13 percent) and colorectum (9 percent), according to the American Cancer Society. Vasquez had surgery in July and then opted for chemotherapy – but stopped midway because she said it made her feel terrible.

Her days were ridden with nausea and exhaustion. That was when her oncologist, Dr. Mayra Rivera, suggested forgoing chemotherapy based on her MammaPrint results that analyzed 70 genes associated with a breast tumor’s chance of metastasizing. “MammaPrint gives me a biology footprint of the tumor,” said Dr. Rivera of Puerto Rico. “And, with patients like Zaida in the early stages of their breast cancer, also known as low risk, this test would benefit more women like her.” MammaPrint is among a growing number of tests attracting interest in the medical world because it lets women know if they could avoid chemotherapy with little risk that they’ll relapse. The tests examine a woman’s genes to determine whether the cancer has a chance of spreading. The tests and MammaPrint gained stature last month when a study exploring its effectiveness was published in The New England Journal of Medicine.

MammaPrint was used in the study, called MINDACT, which analyzed 6,693 breast cancer patients across 112 centers in Europe with newly diagnosed early-stage breast cancer. J. Leonard Lichtenfeld, deputy chief medical officer for the American Cancer Society, said these types of tests are not new. Lichtenfeld said that in the late 90s, there was a substantial amount of tests being developed that looked into the tumor tissue to predict how it would behave over time. Similar to MammaPrint’s approach was Oncotype DX, which took off but only analyzed 21 genes.

MammaPrint looks into the activity of 70 genes. MammaPrint is lesser known and used less often, but has become more popular the past few years. Still, it’s stirred discussion in the medical community because the tests are not 100 percent accurate and could falsely tell a woman she doesn’t need chemotherapy when she actually does. Others, however, believe it will spare thousands of women with early-stage breast cancer the painful – and expensive – experience of going through chemotherapy. The Journal of Medicine article said the MammaPrint clinical trial offers probabilities and not necessarily concrete guidance.

“The reality is that there haven’t been real life trials over an extended period of time to show that these tests work the way they are supposed to work,” Lichtenfeld said. The first author of the MINDACT study said it’s worth noting that this is the first clinical trial of its kind. “There hasn’t been another clinical trial wherein diagnostic tests were evaluated like this, that looked into the biology of the disease, for as long as we did,” said Dr. Laura van ’t Veer, chief research officer of the study. Of the European countries involved in the study, Spain was one of the most active in the trial coming in at about 700 participants.

In centers in Barcelona and Madrid, MammaPrint is already being used frequently. “Everyone can agree that avoiding chemotherapy is the end goal but one thing to look at is tumor tissue and the history of a woman and the treatment she got but it’s quite another thing to use forward-looking studies to try to determine the accuracy,” Lichtenfeld added. Rivera says the new test offers more options to breast cancer patients at low risk who might be hesitant to undergo chemotherapy.

“We are moving toward finding out more about tumors in breast cancers that will help patients make a decision more objectively about next steps,” Rivera said. Vazquez says she doesn’t regret her decision even if at first her family was on the fence. But after finding out she was at low risk post-surgery, she’s thankful there was another medical option.

Women with dense breasts may need annual mammograms

(Reuters Health) - While most older women might not need breast cancer screening with mammography more often than every three years, some women with dense breasts may need mammograms every year, U.S. research suggests. Among women aged 50 to 74, those without a high risk for breast cancer or dense breast tissue didn’t have an increase in breast cancer deaths if they went for mammography every three years instead of every two years.

But with dense breasts and a higher risk for these tumors, yearly mammograms were associated with fewer breast cancer deaths than screening every other year, researchers report in the Annals of Internal Medicine. “Women at low risk and low breast density will experience more harms with little added benefit with annual and biennial screening compared to triennial screening, whereas women with dense breasts and high breast cancer risk may have added benefit from annual compared to biennial mammography,” lead study author Amy Trentham-Dietz of the University of Wisconsin-Madison said by email. Doctors are conflicted about when and how often to recommend routine screening mammograms for women who don’t have lumps or discomfort in their breasts. Even though these exams can save lives, they can sometimes subject women to unnecessary and painful treatments that don’t find tumors or lower their risk of dying from cancer.

Last year, the American Cancer Society shifted its guidelines to encourage women to start annual screenings at 45 instead of 40 and to cut back to every other year once they turn 55. The U.S. Preventive Services Task Force recommends mammograms every other year for women ages 50 to 74. Worldwide, breast cancer is the most common malignancy in women. About one in nine women will eventually develop it, and the risk increases with age and when a woman’s mother, sister or daughter has been diagnosed with the disease. Typically, if there is a suspicious area on a mammogram, women get additional imaging to rule out cancer, followed by a biopsy if more information is still needed to determine if the suspect cells are malignant.

When the extra tests don’t find cancer, the mammogram result is considered a “false positive.” For the current study, researchers estimated the odds of false positive mammograms, biopsies that didn’t find cancer and deaths averted based on age, cancer risk factors and breast density. Compared with screening every two years, getting mammograms every three years could reduce false positives, biopsies and over-diagnosis without much effect on the number of cancer deaths averted for the majority of women – the ones with average cancer risk and lower breast density.

When women had a high risk of breast cancer, however, annual screening was better regardless of breast density, noted Dr. Christine Berg of Johns Hopkins University School of Medicine in Baltimore, who wrote an accompanying editorial. However, “breast cancers are also more difficult to detect in dense breasts,” Berg added by email. “Therefore annual mammograms allow for comparison of subtle changes.” The way women know if they have dense breasts is to get a mammogram - and density can change over time, noted Dr. Pamela DiPiro of the Dana Farber Cancer Institute in Boston. “Annual mammography is a patient's best chance of detecting breast cancer early, with the known caveat that additional imaging, ultrasound or even a benign biopsy may be recommended,” DiPiro, who wasn’t involved in the study, said by email.

Still, the take-home message for women is complicated, said Dr. Kathryn Evers, director of mammography at Fox Chase Cancer Center in Philadelphia. “There are numerous risk factors for breast cancer and women have different levels of comfort with the risks and benefits involved,” Evers, who wasn’t involved in the study, said by email. “The fact that there are so many different recommendations regarding when and how often women should be screened points out that there are no definitive answers – women should talk to their doctors about what regimen will be best for them, taking all of these factors into account,” Evers added.

Task Force Issues New Breast Cancer Screening Recommendations

Cari Nierenberg

Women who have an average risk of breast cancer should have mammograms every two years from ages 50 to 74, according to the latest recommendations released today by the U.S. Preventive Services Task Force (USPSTF).

Women in this 50-to-74 age group are the most likely to benefit from regular breast cancer screenings, suggested the USPSTF, a 17-person, government-appointed panel of medical experts that makes recommendations on the effectiveness of preventive health services.

Average-risk women in their 40s also may benefit from getting mammograms, but their overall likelihood of seeing a benefit is smaller, and the potential for harm is larger than for average-risk women age 50 and older, according to the USPSTF's recommendations, published online today (Jan. 11) in the journal Annals of Internal Medicine.

These latest USPSTF guidelines are basically the same as those the panel released in 2009. But since that time, there has been greater agreement among the guidelines of several major groups of experts, such as the American Cancer Society, the American College of Physicians and the American Academy of Family Physicians, said Dr. Albert Siu, chair of the task force and a professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai in New York City. [6 Things Women Can Do to Lower Breast Cancer Risk]

These groups have independently concluded that mammography is effective and that its benefits increase particularly in women age 50 and over, Siu told Live Science.

All of the groups recognize that there is a role for starting mammograms in women in their 40s and support the idea of a personal, informed choice for women in this age group, he said.

"The decision to start mammogram screening before age 50 should be an individual one" for average-risk women, the new guidelines state.

In other words, women ages 40 to 49 should consider starting breast cancer screenings, but their doctors should inform them about the potential benefits and possible harms of the screening test so that they can weigh both sides in making their decision.

After reviewing the newest scientific evidence on mammograms, the task force found that the number of deaths from breast cancer that the screening test can prevent in average-risk women under 50 is smaller than that in older women, and that the number of false-positive results and unnecessary biopsies is larger.

A false positive is a result that suggests a woman may have cancer but additional testing and procedures later show that she does not. False-positive findings can be stressful and provoke anxiety, and they may lead to the possibility of overdiagnosis and overtreatment.

Still, the task force supports the decision of women who want to start screening in their 40s, and the new guidelines note that the risk of problems from screening may increase decrease as women move from their early 40s to their late 40s, Siu said.

Weighing risks and benefits

Various organizations that make breast cancer recommendations have come to relatively similar conclusions in the areas where the science is fairly black and white, Siu said.

Where the groups diverge is in their different interpretations of the gray areas, where studies have not been done, or the areas for which the groups weigh the benefits and risks differently, he said.

For example, one gray area is whether average-risk women in the 45-to-55 age group should start mammograms and, if so, how frequently they should get them, he noted.

Unlike the USPSTF recommendations to start mammograms at age 50 and rescreen every two years, the American Cancer Society advises women to begin mammograms at age 45 and to have them yearly until age 54. Then, at age 55, women should get mammograms every two years, according to the group's latest recommendations, released in 2015.

Recommendations from other groups, such as the American College of Obstetricians and Gynecologists and the National Comprehensive Cancer Network (a worldwide alliance of cancer centers), call for yearly mammograms in average-risk women age 40 and older.

The differing recommendations about when and how often to get mammograms can leave women feeling confused, but ultimately, the decision all boils down to personal choice and consideration of the benefits and risks, Siu said.

The majority of American women fall into the average-risk breast cancer category, Siu said. Women are considered to have average risk if they do not show symptoms of breast cancer, such as a breast lump or high-risk breast lesion, have never had breast cancer, do not have a known genetic mutation for breast cancer, such as a BRCA1 or BRCA2 gene mutation, and did not receive chest radiation at an early age.

The average-risk group also includes women age 40 and over who have breast cancer in their family, such as a mother, sister, aunt or daughter who was diagnosed with the disease, but did not have a genetic mutation for it.

New to the USPSTF guidelines this year was the group's evaluation of the effectiveness of three-dimensional mammography, as well as an evaluation of the effectiveness of adjunctive treatment for dense breasts with MRI, ultrasound or 3D mammograms, Siu said. The task force made no recommendations in these two areas because they found insufficient evidence to determine the balance of benefits and harms. [6 Foods That May Affect Breast Cancer Risk]

The task force also said that there was insufficient evidence to recommend that average-risk women age 75 and over continue getting mammograms.

Mammography is an effective but imperfect tool, Siu said. Over the past decade, science has begun to recognize that there are potential harms from cancer screening, including overdiagnosis, or the detection and treatment of cancer in people who would have never been bothered by the disease in their lifetimes, he explained.

There is increased recognition that overdiagnosis does exist, and it may be on the order of one in five women diagnosed with breast cancer over approximately 10 years, Siu said.

Even knowing this chance for overdiagnosis, the task force recognizes that many women, especially women under 50, may choose to get screened more often, but they should be aware and informed of the risks, he said.

Top Six Free Health Services for Women

Did you know the Affordable Care Act mandates that new insurance plans provide 19 free, preventive health services for women?

In the past, many health plans covered some or all of these services, but they often required cost-sharing (e.g., copays). Now -- as long as these services are administered by a provider in your network -- they are free of charge. They do not incur copays or coinsurance, and are free whether or not you've met your annual deductible.

The following is a list of the top 6 services that all women should have.

1. Breast cancer genetic test counseling (BRCA)
If you're a woman with a family history (e.g., two or more first-degree relatives) of breast cancer or ovarian cancer, you should ask a trained medical professional about whether to get genetic testing. If your provider recommends it, you will be tested for mutations in the BRCA gene and can be counseled on whether taking certain medications to lower your risk is right for you.

2. Breast cancer mammography screening
Women over 40 should start getting annual mammograms, and women over 50 should get mammograms every two years. Talk to your doctor to determine how often you, personally, should get a mammogram.

3. Breast cancer chemoprevention
Your provider can counsel you about medications to lower your breast cancer risk. Your plan will also cover you if you choose to go ahead with these cancer-prevention medications. There are currently two FDA-approved drugs -- tamoxifen and raloxifene -- that may lower your risk of breast cancer, if you have a significant family history of breast cancer or ovarian cancer.


4. Cervical cancer screening
Sexually active women should have regular cervical cancer screening tests every three to five years depending on your age and how often you get HPV tests. Cervical cancer deaths are preventable if women get regular Pap tests and abnormal cells are found before they turn into cancer. Pap tests should be administered every three years and can be provided during your well-woman visits.


5. Human papillomavirus DNA test
This can be done in concert with the cervical cancer screening during your Pap test, which in turn can be done during your well-woman visit. If you're not at high risk, you should be tested every three years once you turn 30. Speak your provider to determine how often you should be tested.


6. Well-woman visit
All women under 65 should have a well-woman visit every year. These visits provide age- and developmentally appropriate care, and often provide other preventive services as well.

What's Your Mammogram Risk?

BY DR. NANCY SNYDERMAN

A review of 50 years of studies of mammograms released Tuesday finds that the benefits have often been overstated and the harms minimized — adding to the confusion about what remains an annual ritual for many American women.

But do the benefits of a mammogram outweigh the risks for you or your family members? That's a very personal question, and not one with an easy answer.

Each patient has different risks that should be discussed with a doctor, but here are answers to some of the questions raised by the latest research.

We're seeing a lot in the news about this. What should I know about this particular study?

The study published Tuesday looks at 50 years' worth of international studies. It reminds us that mammograms are not perfect tests and that the benefits of the screening are often overestimated, while harms are underestimated.

According to the review, mammography screening is associated with a 19 percent overall reduction in deaths from breast cancer. This rate was not the same for all women, however. It reduced deaths by only 15 percent for women in their 40s and about 32 percent for women in their 60s. All of this underscores what we already know: This is not a perfect test and there is no hard and fast rule for mammograms that fits every woman.

What are the risks of mammograms? Isn't it better safe than sorry?

This study finds that for a 40- or 50-year-old woman who gets an annual mammogram, the risk of getting a false positive over 10 years is 61 percent. That means that 61 out of 100 women will have a false positive test. False positives don't just cause emotional distress — they often require repeat imaging and can also mean more invasive procedures like a biopsy.

I'm 40 and healthy. Should I get a mammogram?

What this study shows is that there is not a one-size-fits-all approach to breast cancer screening. What is appropriate for one woman is not always appropriate for her mother or her best friend. Decisions about whether to have a mammogram should be made with your doctor and based on your individual risk for cancer.

Women with a higher risk of breast cancer based on family history or individual risk factors will benefit more from mammography than women of lower risk. Factors to consider include age, a history of cancer, genetic risk factors like the BRCA1 and BRCA2 genes, use of certain medications like some hormone replacement, increased alcohol use, obesity and not having a child before age 30.

We're seeing studies talking about the risk of mammograms. Why are doctors still using them?

Breast cancer kills 40,000 American women per year. At this point, mammograms are the best screening tool that we have. They aren't perfect, but used correctly, they can be lifesaving. However, doctors and researchers are working to develop better tools and one day these might replace mammograms.

Should I do breast self-exams?

While an awareness of your body is always a good idea, the evidence does not show that self-exam does a good job of detecting breast cancer. The U.S. Preventive Services Task Force recommends against teaching breast self-examination.

What age should women stop getting mammograms?

There is not enough evidence to recommend for or against mammograms after age 75, according to the task force. Another study published Tuesday suggests that this decision should be based on your life expectancy. For example, if your life expectancy is less than 10 years due to an illness, mammograms might not be the best choice. Again, it's an individual decision and should involve a thoughtful conversation and consideration of your unique medical profile.