Sun 15 Sep, 2013 09:22 am
Mammograms are important, but they're not the whole story
By Judith Potts
As I walked out of the mammography room two days ago, I reflected on the differing opinions of this screening method.
When I was diagnosed with breast cancer, four years ago, I was fortunate enough to be seen by a consultant after a routine mammogram and scan – both of which were read as clear. Luckily for me, I then had a clinical breast examination and – lo and behold – when I raised by arms above my head, his experienced eye spotted a suspect patch of skin.
Whether or not I would have noticed the puckering, I am not sure (I would probably put it down to the wrinkles of age!) but never had I stood in front of the mirror and raised my arms above my head. Now it is my mission to tell every woman how essential is this part of a regular self-examination.
What would have happened if I had simply undergone a mammogram, with no access to a doctor or trained breast nurse? I would have received the all-clear and an invitation for another mammogram in three years time. Although I would have found a lump sooner than that (I hope), the cancer would have been much more advanced and more radical surgery and treatment would have been necessary. I fear this must happen to far too many people. As it was for me, I had a wide local excision and six weeks of radiotherapy.
I understand why some women refuse to accept their mammogram invitations – as I experienced, false negatives and false positives do happen, but they are not the norm and many more women have their cancer detected early through a mammogram. However, I believe that each patient should also be seen by a specially trained doctor or nurse, whose eye and hands might see or feel something untoward.
Listening to a group of ovarian cancer consultants a couple of weeks ago, I was made aware how the current training of young doctors leaves them unsure or uncomfortable about carrying out clinical examinations. These consultants were adamant that cancers are being missed for just this reason. The same must apply to breast cancer.
A report from the USA gives us the "sojourn times", the time when a breast cancer can be detected before it gets big enough to cause symptoms – for women of different ages. Those aged 40-49 have a sojourn time of 2-2.4 years and those aged 50-59 have 2.5-3.7 years. For the under 40s the sojourn time is much shorter – and the cancer tends to be more aggressive – and for the over 70s, the sojourn time is longer.
Consequently, in the USA, annual mammograms are now offered to women once they reach the age of 40 and, along with the test, goes an appointment with a doctor or breast care nurse.
Here, women between the ages of 47 and 73 are invited to undergo a mammogram every three years but not always the chance of a clinical examination too.
Clearly there is a problem with cost, but would it not make more sense to catch the cancer early – thereby avoiding huge NHS bills for surgery and treatment? Never mind that early detection is paramount for the patient.
Apart from the rare possibility of false negatives and positives, women who do not attend their mammogram give as their reasons either that they are too busy, or they are concerned that the test will be too painful or they are too embarrassed. Some women also state that they "just don't want to know". The fear factor element is one which needs addressing. Yes, a mammogram is not a comfortable experience and it may be painful – but only for a minute or so. The radiographer is female – which will help with the embarrassment problem reported by some women.
The other two concerns are, firstly, whether or not the dose of radiation required for a mammogram could, in itself, cause breast cancer. Cancer Research UK tells us that their scientists have worked out that there is "less than a 1 in 25,000 risk of the radiation causing breast cancer" and it is estimated that screening "saves 1,400 lives each year". There are no long term studies of the result of regular exposure to mammography but, until another test is developed, this is the best available way to detect early breast cancer and mammography is signing up to the digital age.
In its "Improving Outcomes: A Strategy for Cancer 2011", the Department of Health committed itself to making digital mammography available in all Primary Care Trusts "as quickly as possible". As of May this year, there are only 6 screening programmes still to implement the new system – so that is real progress.
I asked Dr Lisa Wilde, director of research at Breast Cancer Campaign, for a comment. She said, “It is important that, in a changing commissioning environment, this commitment to digital mammography is maintained and delivered.
There are several benefits to moving to digital mammography, one of which is that it would allow the image to be manipulated so it improves the radiologist’s ability to interpret breast tissue.
"Digital images can also be exchanged electronically between radiologists at different hospitals to discuss difficult cases and has been shown to be more sensitive and specific for pre-menopausal women who have denser breasts. Finally, it also provides revenue savings in terms of reduced radiographer time and less chemicals or film handling and printing. Breakthrough Breast Cancer is campaigning to make sure all eligible women have access to the best possible breast screening services."
The second concern in some people's minds is – will a false positive reading provoke unnecessary or harmful treatment? There is much discussion about whether or not a common form of early breast cancer called Ductal Carcinoma in Situ should be treated as cancer or a precancerous condition – and whether or not surgery is really necessary. The problem here is that no one yet knows which tumours will regress and which will progress. Removal of all tumours seems the safest way forward until medical knowledge can differentiate between them. I certainly would not have wanted to give my tumour a chance to regress – waiting and seeing is not for me. Although I am very aware that, for some people, living with a cancer – which might or might not develop – is not a problem. We are all different.
However, I do wonder how many of the 1.6 million women screened by the NHS Breast Screening Programme each year also see a breast cancer clinician for an examination? I suspect the answer is – only if something suspicious is detected on the mammogram. Is this good enough?
Today I see my esteemed consultant to hear my mammogram results – and have an examination, which will give me huge confidence for the next six months.
In the US, women are encouraged at the age of 40 to have mammograms. Some physicians have suggested, that at age 40 to about 50, mammograms be given to women every 6 months. There after, mammograms from about 50-6o years , according to some physicians, should be given every year, and after age 60, every two years to age 73-74 years.
These recommendations are not cast in stone, and probably vary throughout the US and indeed with different physicians.