I received a text message the other day. It was from my cousin. Well, you could really call her my sister because we are seven months apart in age and have been together since I was born. The message said, “call me … it’s important.” Being in the middle of my never-ending list of urgent tasks, I messaged her back that I would call her as soon as possible.
She responded, “the doctor called … I have breast cancer.”
Suddenly, those urgent tasks were the last on my list of priorities.
Her story is like many who have had this unwelcomed diagnosis thrust upon them unexpectedly, only in her case, her cancer was found not by the mammograms she religiously endured every single year, but by her own hands. Mammograms had missed this cancer, as well as the five additional masses a later MRI scan found in that same breast, and if she hadn’t thought to do a breast self-exam, all of it might have gone on undetected.
She, like many women, including myself, rely on these machines to see all and tell all, and when the imaging is normal, feel confident enough not to worry about breast self-exams. However, in some cases, as her and I are now well aware, forgoing this simple at-home procedure might be a tragic mistake.
According to the Susan G. Komen Breast Cancer Foundation, the sensitivity of mammography is around 87 percent, meaning the imaging identifies cancerous tumors in about 87 percent of women who have breast cancer. This imaging test is better at picking up the disease in women over 50 and in those who do not have dense breast tissue. Mammograms can also miss cancer depending on where it is. My cousin? When playing this mammogram game, she had three strikes against her right off the bat, as she is younger than 50, has dense breast tissue, and the initial tumor is in a difficult area for mammography to detect.
Nonetheless, if women continue to do breast-self exams as doctors recommend, wouldn’t cancers like these be found early despite the false-negative mammograms?
Herein lies the problem. Physician’s guidelines no longer recommend it.
At least some of the organizations that develop the formal physician’s guidelines for breast cancer screening no longer do, and these include the American Academy of Family Physicians (AAFP,) the U.S. Preventive Services Task Force (USPSTF) and the American College of Physicians (ACP.) The AAFP and USPSTF go as far as to recommend against health care providers teaching women breast self-examination, and also conclude, “the current evidence is insufficient to assess the benefits and harms of clinical breast examination (examination by a physician) for women aged 40 years and older.”
The ACP concurred with the AAFP and USPSTF, and published their recommendations online on April 9, 2019, in Annals.org. Their latest guidance for health care providers outlines the screening protocol for mammography, clinical breast exams, as well as breast self-exams in average-risk women.
“Guidance Statement 1: In average-risk women aged 40 to 49 years, clinicians should discuss whether to screen for breast cancer with mammography before age 50 years. The discussion should include the potential benefits and harms and a woman’s preferences. The potential harms outweigh the benefits in most women aged 40 to 49 years.”
“Guidance Statement 2: In average-risk women aged 50 to 74 years, clinicians should offer screening for breast cancer with biennial (every other year) mammography.”
“Guidance Statement 3: In average-risk women aged 75 years or older or in women with a life expectancy of 10 years or less, clinicians should discontinue screening for breast cancer.”
“Guidance Statement 4: In average-risk women of all ages, clinicians should not use clinical breast examination to screen for breast cancer.”
As far as breast self-examination? The organization states, “this guidance statement does not address breast self-examination because no evaluated guideline recommends it for screening.”
The USPSTF also recommends this protocol and has done so for several years now. Their guidelines, as well as those of the ACP, are vehemently opposed by the American College of Radiology (ACR.)
In a news release dated April 8, 2019, the ACR states these new ACP guidelines would “result in thousands of unnecessary breast cancer deaths” and urges both women and their health care providers to be skeptical of the ACP and USPSTF guidance for average-risk women. The organization says the guidelines site inaccurate claims of a low risk of breast cancer in those under 40, and “also fail to address groups who have a greater risk of developing the disease, such as black women who have a 30% higher breast cancer death rate than white women.”
The reasons for less screening and the elimination of breast self-exams? According to the ACP, potential harms such as false-positive results, overdiagnosis, overtreatment, radiation exposure, unnecessary anxiety for women with inconclusive results, and for clinical breast exams, physician examination time.
Meanwhile, while health organizations continue to lessen the amount and frequency of breast cancer screening recommendations, my cousin is scheduled to undergo a double mastectomy, the option she chose, and her doctor agreed with, to reduce her chances of recurrence down to 10%. The doctors say her prognosis is excellent, which is most likely because she took her health care into her own hands and opted to do a breast self-exam. One can only wonder what the prognosis would have been if she had followed the breast cancer screening guidelines that these healthcare organizations promote.
Kimberly Drake can be reached at [email protected]