To test or not to test? Or more specifically, when to test? That's the crucial query. Last November, the U.S. Preventive Services Task Force (USPSTF) recommended that women swap their after-40 annual mammograms for biannual ones starting at 50, and quit breast self-exams altogether. It cited evidence that less frequent mammos could be equally effective at catching cancer. (Fewer tests would also save money, though the group insists it didn't consider cost.) Plus, the USPSTF argued, self-exams haven't been proven to reduce deaths but can lead instead to lots of unwarranted doctors' visits.
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The screening revisions ignited a firestorm of controversy (after all,some 40,000 women die of breast cancer each year), thanks to conflicting data on mammogram efficacy. Current research hasn't yielded any hard conclusions, leaving patients confused and aggravated. "One disturbing aspect of the guidelines is that they're based on the idea that having a mammogram is anxiety provoking," says Karen L. Hiotis, M.D., a breast surgeon at the New York University Cancer Institute. "That's almost an insult to me as a woman."
Hiotis continues to favor self-exams and annual screenings for average-risk patients starting at age 40 (high-risk patients should start earlier). Yet she has noticed that fewer of her younger patients have booked mammos since the USPSTF recs were released. "Those happened to coincide with the recession, when more people were without work and health insurance," she says. "So, many thought it was OK to have fewer tests. I've spent the past year telling patients, no, it's not OK."
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The majority of breast docs agree, despite evidence that benign tumors are being misdiagnosed as cancer, sometimes resulting in unnecessary biopsies or mastectomies. The problem, notes the USPSTF, is that women under 50 tend to have denser breasts, making malignancies harder to spot. On the other hand, cancerous tumors in women under 50 can be much more lethal, and overlooking one could be a fatal mistake. "Ethically, you don't want to be a doctor who misses cancer," says Sharmila Makhija, M.D., the director of gynecologic oncology at the Emory University School of Medicine in Atlanta.
For its part, the American Cancer Society issued its own review in September, reinforcing 40 as the recommended age to begin annual mammos. The group neither endorsed nor discouraged self exams— essentially, it says, they won't hurt you, but they won't help you either. Hiotis disagrees. "I can't tell you the number of patients I see who have noted masses in their breasts themselves," she says. Adds Laura Lawson,M.D., a breast surgeon at Baptist Hospital in Nashville: "I have many breast-cancer patients in their twenties and thirties. And these are not women who were getting mammograms, so self examination is crucial."
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The bottom line for now is that while mammos aren't perfect, they're the best breast-cancer detection we have. Research on new tests is in the works, and more precise digital mammogram technology is already out. Because the breast-care debate will likely wage on, it's up to you to be proactive and talk to your doctor about your individual risk, and to weigh the pros and cons of early testing. Lawson points out you can never be too careful: "For the person whose cancer is caught early, regular screening is lifesaving."
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