September 29th, 2010
08:31 AM ET

Should I get a mammogram?

Every weekday, a CNNHealth expert doctor answers a viewer question. On Wednesdays, it's Dr. Otis Brawley, chief medical officer at the
American Cancer Society.

Question asked via e-mail:

Is it really worth it to get a mammogram? Should I be getting mammograms?

Expert answer:

There have been a number of articles in the press about mammography, and this has caused me to get quite a few questions about breast cancer screening.

Mammography, which is an X-ray of the breast tissue, is a technology that has been available since the 1950s. It was first used to get a better look at a breast in which there was a concern that a cancer might be present. Mammography can find some breast cancers when they are small and most treatable by surgery. Over time, a number of clinical studies showed that asymptomatic women given regular mammography have a lower breast cancer death rate compared with women who do not get mammography. Due to a lot of research done over the past three decades, we have developed better treatments for breast cancer. We can even cure some tumors that were almost always deadly just 20 years ago.

Breast cancer death rates have been falling for two decades in the U.S. and Europe. The average risk of breast cancer death for an American woman has declined by 30 percent from 1990 to 2007. We have good evidence that risk of death is falling for three reasons: screening with mammography and clinical breast examination; improvements in treatment of all stages of breast cancer; and increased awareness that any breast mass that a woman notices should be evaluated by a health care provider.

Breast awareness is very different from the monthly breast self-examination that was once advocated. Monthly self-examination has been abandoned in favor of breast awareness after several clinical trials showed that monthly self-examination did not save lives.

Very recently, a study done by a well-respected group of scientists was published, suggesting that mammography contributes less to the decline in mortality than it did a decade or two ago. Bottom line: The study did not say mammography is now worthless. One of the study authors, Dr. Howard Zellen, a noted cancer clinical trial researcher, said he still recommends mammography screening.

The message really is that women should practice all aspects of breast cancer prevention and early detection, and we should all support research efforts to improve mammography and find better ways of screening. Awareness and a woman feeling a mass may be especially important in younger women. Indeed, there are studies showing that most women diagnosed with early stage disease in their 40s are diagnosed when they seek medical help after feeling a breast lump while dressing or showering. It may be many of these cancers would have been caught had these women received mammograms, but we don't have the studies to show that.

Although breast self-awareness is critically important, it does not negate the impact that mammography has on reducing mortality from breast cancer.

The American Cancer Society and the National Comprehensive Cancer Network, which is a collaboration of America's major cancer centers, have separately commissioned experts to look at the scientific data and issued statements recommending women get a high-quality mammogram annually beginning at age 40. Both note that a high-quality mammogram includes review of previous studies. Both note that women should be informed of the limitations of mammography.

Although those groups have recommended annual mammography and clinical breast examination by a health care provider starting at age 40, other respected organizations have pointed out that mammography is a far better test for women age 50 and over.

There was a lot of controversy over this issue last year, when the U.S. Preventive Services Task Force issued its screening guideline. The task force recommended that routine biannual mammography start at age 50 and that women in their 40s who are concerned about breast cancer should have a conversation with their physician and possibly start mammography in their 40s.

As with any test, there are limitations and downsides to mammography. There are some cancers that will be missed. There will be some women inconvenienced by being called back and given extra testing, only to learn that they do not have a problem. There will even be some women who get treatment for pre-cancerous conditions that never would have become cancer.

I like to point out that if the current screening, treatment and awareness available were to be used by all Americans, experts estimate, more than 60,000 and perhaps as many as 120,000 breast cancer deaths could be prevented over the next decade. This still means 450,000 women will die from breast cancer over the next decade. This points to the fact we should use what we have now and work for better screening and better treatment.

It is also important to note that 35 percent to 40 percent of women who should be getting mammography are not. This means at least 20,000 to 40,000 women will die of breast cancers that could have been prevented through screening done over the next 10 years.

soundoff (35 Responses)
  1. Debbie

    so should she get one or not????

    September 29, 2010 at 12:02 | Report abuse | Reply
    • Gen Putnam

      Too bad there's rarely any mention of Breast Thermography as a tool to detect breast cancer. More and more credible research is showing this as a very effective method for catching breast cancer even earlier than Mammography, and there is no radiation risk. If you are considering getting a Mammogram, do yourself a favor and research Thermography.

      September 29, 2010 at 15:24 | Report abuse |
  2. KittyKitty7555

    Dr. Brawley glosses over the major harm of screening mammography: treatment for "cancers" that are meaningless healthwise. Many of the abnormalities seen by mammograms and subsequently biopsied and labeled "cancer" would never harm a woman's health at all. Yet the woman receives full-blown cancer treatment anyway. Read this, and look at the multi-media graphic: http://www.nytimes.com/2010/09/23/health/research/23mammogram.html

    For every 2500 women who receive 10 years of mammogram screening at age 50, 1000 will be called up for more tests (more radiation). 500 will have a biopsy. 5 to 15 will have unnecessary surgery and radiation/chemotherapy. 1 woman will avoid dying of breast cancer.

    So you see, the odds of getting unnecessary cancer treatment are between 5 to 15 times greater than the odds of avoiding a breast cancer death. So if 20,000 to 40,000 women will die over the next 10 years because they weren't screened then between 100,000 and 600,000 will escape unnecessary cancer treatment. They will avoid a breast cancer diagnosis and not be put at risk from grueling, debilitating, mutilating UNNECESSARY cancer treatment. Their female relatives will not wrongly labeled as high risk.

    September 29, 2010 at 12:25 | Report abuse | Reply
    • jendfly

      Well KittyKitty, I gues I'm one of the ones. I had a 1.5 cm tumor, invasive. Surgery and chemo saved my life. I still get mammograms. It's a small price to pay for a quality life.

      September 30, 2010 at 03:39 | Report abuse |
    • haca

      You can quote your science all you want. I prefer life over statistics you may or may not be presenting accurately. I guess you haven't experienced the tragedy of losing a loved one to cancer.
      What about the emerging tomosynthesis technology, which takes a 3-D image of the breast and can dectect breast cancer at very early stages. Current clinical trials are showing this breast scan can cut down on false-positives seen in traditional mammography meaning healty women won't be called back and/or treated unnecessarily.

      September 30, 2010 at 10:20 | Report abuse |
  3. Kristy

    What is the age? No one ever addresses the age. High Quality ones at 40. How about getting one in general, what is the age range?

    September 29, 2010 at 12:29 | Report abuse | Reply
    • Julie

      What is your age now? I had my 1st mammo at 36. No family history but working in the health field and doing mammograms every day we see breast cancer in very young women. I will have my next 1 at 38. Make sure you do your BSE every month and I would have 1 by age 40 for a baseline.

      September 29, 2010 at 13:54 | Report abuse |
    • Dawn

      The advise I was always told was a baseline at 35 and then talk to your doctor. Your OB/GYN should discuss this with you during your yearly check.

      September 29, 2010 at 14:12 | Report abuse |
  4. cleat

    funny how all these important tests are suddley "not important" when you have "free" healthcare shoved down your throat. lets see, mamograms, colonoscopy and the last one is saw... cancer drugs... all newly deemed "not as important". Hmmm funny how this wonderful new plan is working.

    September 29, 2010 at 13:31 | Report abuse | Reply
  5. Janice

    I feel that all these screenings are highly unnecessary and has caused screening fatigue. Same goes for all the unnecessary prescription medication that are prescribed. Now that October is Breast Cancer Awareness month we are going to be bombarded with breast cancer awareness promotions. I feel that health care in this country has gotten completely out of hand. Another example of this over promotion fatigue is" Get Your Flu shot".
    I feel educated people are finally saying enough is enough. And yes the original question was conveniently never answered!

    September 29, 2010 at 13:50 | Report abuse | Reply
  6. Dawn

    It should also be noted that women with strong family histories of breast cancer should talk to their doctors about when it is appropriate for them to start screening. With a strong family history my doctor has agreed that starting at 30 I should have a yearly mammogram.

    It is all about being proactive, taking care of yourself, and fighting the fear that is associated with the trip to the radiologist.

    September 29, 2010 at 14:07 | Report abuse | Reply
    • kittykitty7555

      Babydoc and Dawn,
      I love it – I direct you to research performed by doctors that states that HIGH RISK women get much more cancer when they have early mammograms and you spout that silly propraganda about mammography and flying cross country.

      OK, here goes – high risk women will get called back and irradiated again and again. Mammo after mammo after mammo on the same day. Year after year. Just to be "sure" that such and such a tiny speck isn't cancer. Until they actually get cancer. NOT like flying cross country, which is a dumb comparison in the first place. Radiation from mammography is concentrated on and actually completely penetrates a small area of a women's body. NOT like a tiny amount of radiation on a person's total body.

      I'm so tired of the propaganda. And it's bad enough that women who are not high risk get pushed into screening mammo – these women they just get their chance of being diagnosed with breast cancer raised about 50%. For high risk women the risk is SO much larger.

      And please don't spout any more silly, dishonest propaganda in response. Heard it all before, and it makes me sick.

      September 29, 2010 at 20:23 | Report abuse |
  7. KittyKitty7555

    Dawn, if I were you I would be very careful about radiation exposure – it REALLY increases your cancer risk if you have a certain genetic mutations or a strong family history of breast cancer. Please see:

    The article explains that high-risk younger women who had 5 or more mammograms increased their risk by 2.5 times. MRI might be a better choice for you.

    And it's unconscionable for doctors to recommend yearly mammos for 30-year old women with strong family histories of breast cancer. You might as well just get treated for BC now, because you are pretty much assured of getting it if you start irradiating your breasts at 30.

    September 29, 2010 at 15:09 | Report abuse | Reply
    • babydoc

      Kitty - you get more radiation flying in an plane across the country than from a mammogram. No test is perfect, and mammo is no exception. If you are really concerned about radiation exposure - worry about the unncessary CT scans patients are getting. 300 x the exposure rate of mammograms! By the way, breast MRI is also available as a diagnostic tool, but once again, does not and should not replace mammograms.

      September 29, 2010 at 16:08 | Report abuse |
    • babydoc

      I love uninformed people trying to seem educated, but in reality have no idea what they are talking about. Radiation levels during mammo are extremely low. Thanks the the Mammo Quality Stds Act of 1992, stringent quality control standards and reviews are required by each facility by federal regulations. This mandates the FDA to inspect, review each facility yearly; an independent state medical physicist to certify each machine yearly (or when major service is done) including radiation dosage; weekly quality control tests, and case outcomes analysis & review yearly. This ensures machines are putting out low amts of radiation. By the way, if a patient really wanted to know how much radiation they actually received, that is available (actual readout prints out on each film).

      Since 85% of cancers originate in the ducts, the "specks" as you put it - can indicate an early stage (DCIS) before it infiltrates into the surrounding tissue. Mammo is the ONLY test available that is sensitive to calcifcations. MRI is not as sensitive for them, thats why mammo is still the gold standard for screening. Dont know about you, but if I get breast cancer, I want it found at its earliest stage - before it speads throughout the body. Caught early, survival is 90-95 %. Mammo's look for change from year to year. Calcifications can indicate benign disease as well. Change in calcifications can indicate a problem which is why additional work up is sometimes neccessary.

      Treatment decisions are indivdualized & between the patient & MD based on type & aggressiveness of cancer, family history, genetic makeup of cancer, hormonal status, and comfort level of the patient. What may work for one patient, may not work for another. Patients are not pushed into treatments; Patients have the right to get 2nd opinions, opt for alternative methods of treatment, or refuse care all together. No one forces them to do anything.

      While mammo is not perfect, it is the best & low cost screening test available. Many womens lives have been saved due to annual screenings which picked up early stage cancers and prevented them from infiltrating into the lymph nodes/body.
      In high risk patients, mammo is recommended to be used in conjuction with breast ultrasound, and breast MRI.

      It is inappropriate for anyone to try to discourage patients from seeking medical care. Its especially inappropriate for someone who appears to be uneducated in breast diseases and imaging protocols to be so critical. While everyone is entitled to their personal opinion, some people should keep it to themselves.

      September 29, 2010 at 21:58 | Report abuse |
  8. d.barlow m.d.

    us task force is nothing more than the bean copunters who now think that catching 1/1900 women in 40' is not worth it . but catching 1/1200 over fifty is.... this is not just a recommendation it is the gold standard with which insurance co's cover or do not cover a procedure..... the rationing is beginning... look at psa test and pap smears.... wake up folks.....

    September 29, 2010 at 15:43 | Report abuse | Reply
    • JC

      Please site a credible study that shows improvement in morbidity or mortality improvement with PSA screening.

      Also in terms of cervical cancer screening, if you are really a physician, you would realize that carte blanche annual screening reccs for cervical cancer make no sense with what we now know about the pathogenesis and the natural disease course. Making evidence based progress on the quality of our disease prevention and surveillance measures does not equate to merely rationing or a "government conspiracy". As a true physician your role is to improve health not to generate RVU's. This requires you to be aware of current evidence and use your intelligence on a patient by patient basis.

      Shame on you for twisting the topic into a scare tactic to demonize "the government" and purport an ineffective and costly status quo as good medicine.

      September 30, 2010 at 00:14 | Report abuse |
    • JC

      Sorry...please cite*

      September 30, 2010 at 00:17 | Report abuse |
  9. Blondegeisha

    Interesting that the mammogram has been around since the 1950s. It seems like very primitive technology to me. Ultrasound of the breast is available but is done only after a questionable mammogram. I was told ultrasound is the preferred test but insurance will not pay for it. I believe a lot of women do not go for mammograms because they are painful and very de grading. There has to be something better out there.

    September 29, 2010 at 16:01 | Report abuse | Reply
    • stpaul

      Actually US is the preferred method for breast screening of dense breasts (ie: younger females who have not been pregnant). It has nothing to do with cost. Depending on the patient, they may reorder a mammogram or an US when you go in for your appointment depending on what your breast are like. And, the mammograms are so much different than they were in the past. They are now computer aided so that they are able to zoom in and better define areas so that they don't have to do repeat films and so that they are able to get better definition of the area in question. The mammogram is not that what it used to be – it is better

      September 29, 2010 at 22:38 | Report abuse |
  10. bluebird71

    WIth family history I was told to start getting screened with a mammogram at age 35. I put it off until I was 37 and they found cancerous microcalcifications that by the time I had surgery had advanced to my lymph nodes. A year and a half later I'm happy, healthy, and glad I had a mammo when I did.

    September 29, 2010 at 16:11 | Report abuse | Reply
  11. Healthy & Grateful

    I really take issue with the last sentence of this article: "This means at least 20,000 to 40,000 women will die of breast cancers that could have been prevented through screening done over the next 10 years." Cannot believe that a Doctor would in good conscience state that having a mammogram can prevent cancer. This is a scare tactic to threaten women by implying that NOT having a painful test will harm one's health.

    September 29, 2010 at 16:34 | Report abuse | Reply
    • mtngrrll

      They are certainly not saying that having a mammogram prevents cancer, just that it can catch it earlier if mammo's are done on a regular basis. I have absolutely no history anywhere in my family of breast cancer, have never felt a lump or anything else wrong with my breasts, but started having mammo's when I was 40. At 48, the mammo caught some calcification in the milk ducts, and a biopsy showed that it was highly cancerous. If I had waited until the now recommended age of 50, I would not be here today. I had a total mastectomy on the one side, and cancer meds for several years. My husband and children are very thankful for my yearly screenings.

      September 29, 2010 at 19:05 | Report abuse |
  12. mami

    Why do they have to hurt so much?

    September 29, 2010 at 20:10 | Report abuse | Reply
  13. Christine

    I am 31 years old, Asian, with absolutely no family history. I do not drink or smoke yet I found out 4 weeks ago that I had breast cancer. The only mammo I had was when I was diagnosed. I never thought it would happen to me. Who thinks of these things when they are 31 with two small kids?? I am getting a mastectomy tomorrow because the area of calcifications are so wide that a lumpectomy is not even an option. My point is that I was too young to get a mammo so basically I had one done when I already felt something was wrong. This is an excellent screening tool that yes it is really painful but if its available for you to have yearly why not have it? If I am on top of my kids doctors appointments, shots, etc. why shouldn't I extend the same fastidiousness and vigilance with my own health?

    September 29, 2010 at 22:38 | Report abuse | Reply
  14. puglove

    Thermography is a heat detecting scan that shows neo-vasculature (new blood vessels) forming that are the supply to a group of unhealthy cells. These "hot spots" are the first indicators of inflammation, the precursor to cancer. Thermography is truly the best screening tool we have available because it can show cancer cells forming up to 10 years EARLIER than mammography. At this stage subtle life style changes can be implemented before cancer actually forms. Mammography exposes one of the most sensitive and sacred parts of your body to unnecessary radiation year after year, in the toxic world we live in we need to limit our exposure in every way we can. Also limit exposure to pesticides, plastics and household chemicals which mimic estrogen in the body and increase your risk.

    September 29, 2010 at 22:43 | Report abuse | Reply
    • babydoc

      thermography is a test that gives vague results. Hot spots could be from inflammation (as you said) as well as infection or cancer. But it is non-specific meaning that if your thermography is positive, you still have to be worked-up to rule out cancer. And that is most generally done with mammo. That is why thermo has not really caught on as a sensitive tool for breast cancer detection

      September 29, 2010 at 23:16 | Report abuse |
  15. CanUfixit

    I'm 58 & presently going thru MRI & mammos, ultra sound, both breasts are now affected, have had cystic breast disease for yrs. Have had a cyst? in one breast for yrs now. I wanted excision of this one quite a while ago but my Dr. advised against surgery at this point, "they're keeping an eye on it" I'm now waiting for further screening results. After reading comments, I will ask my Dr about thermography as I'm concerned radiation exposure could trigger cancer in the end.The whole thing is nerve racking.

    September 30, 2010 at 01:10 | Report abuse | Reply
  16. Kerrie

    All I can tell you is that at 40 I had a routine, 1st mammogram. This all happened right around the "new guidelines" that advised women to wait until 50 for 1st mammo. Well, long story short, they found early DCIS, and I have no family history whatsoever. So, I for one am very glad I had my first mammo at 40. Imagine if I had waited 10 years..? I don't even want to think about it!

    September 30, 2010 at 07:04 | Report abuse | Reply
  17. DocUSA

    For once, this is an article that is written by an expert and not a hack like Ms. Cohen and her groupies. When one reads the comments below, it is clear that there is a lot of skepticism amongst the public and there is a lot of people out there spreading misinformation. In fact, if you look carefully, you can see uninformed people actually advising other people against getting screened. Then you will see those few who report having found their cancer, often before the age of 50.

    The reality is that medicine is a complicated issue – both from a medical knowledge stand point and from an economic stand point. While the USPSTF recommendations on mammo does not go far to express cost in their recommendations, one could easily read between the lines and understand what they are talking about. I am aware of how painful mammo can be, how painful a biopsy can be and the fear that comes along from waiting for your biopsy results. The task force argues that these problems are so common that it outweighs the life of someone with true cancer being found with mammo. (Whenever you see someone say that you needed to screen 1000 people to catch one case of cancer or that you need to do biopsies on 50 patients to catch one cancer, this is a person making an argument that it is "not worth it" to trouble these people – or cost so much to the system – to save one life. This is looking at the cancer problem on a population basis and not on an individual basis. Beware of these arguments). Essentially, the USPSTF concludes it is not worth all the hassle (be it the financial cost of screening so many women or the need for a biopsy to determine if a mammographic lesion is truly cancer or not, etc) on a population basis. Therefore, their plan is to screen fewer women less often, meaning that there was once a large pool of women screened and now the pool of people screened has become smaller – in essence, rationing of care for the greater good. This is not an anti-government slur, but rather one concerned health care provider pointing out the obvious.

    II would strongly urge people to stop spreading misinformation as it causes great damage to the health of our nation. This problem runs all the way from the bottom (Elizabeth Cohen and friends) straight to the top. I recall watching the presidential debates and was appalled to see the lies being spread on a national level by President Obama. He made a comment that the incentives in medicine are all wrong and that docs want to do as much procedures as possible to make money. While there may be some issues with incentive and there are some dishonest docs out there (as there are in any field of work), the example cited was nothing but a complete and utter lie. The president said that our system is set up in such a way that if a child came to their doc with a sore throat, the doctor would opt to take his/her tonsils out so that they could get paid more money for the surgery (as compared to a more conservative approach such as antibiotics). Apparently, he was not aware that pediatricians do not perform surgery (making his example scenario impossible). Children must be referred to an ENT (a surgeon) for this surgery to be performed and therefore the person making the recommendation for tonsil removal has no financial incentive for making such a recommendation.

    Medicine has its limitations. As someone above mentioned, the PSA screen for prostate cancer is a screening method that has fallen our of favor because studies show that it does not improve mortality significantly. That said, there is another point about prostate cancer screening that should be pointed out. The general approach by many docs is that most cases of prostate cancer are slow growing. Given enough time, nearly 100% of males will end up with prostate cancer. However, often, this cancer is so slow that the patient is likely to die from something unrelated to the cancer first.

    As for the cervical cancer screening issue someone raised, it is a great screening tool. It is cheap and available. It saves lives. Every time I see a patient dying of cervical cancer, it is so sad to me. This is a terrible disease and it can often be prevented by screening with a pap smear. I strongly disagree with the person above saying it was about RVUs. This person is doing great harm by discouraging people from going to get screened.

    Lastly, there has been discussion about vaccinations. Someone above complained about flu shots. Others have been aggressively pushing this vaccine causing autism nonsense. I would like to point out once again that the man responsible for this whole conspiracy theory has his medical licence recently revoked, his journal article about autism withdrawn and was cited for unethical behavior during his autism vaccine studies including not disclosing that he was taking money from a law firm that was trying to push a legal case about autism and vaccinations. These vaccines save lives and reduce suffering. Look at the whooping cough come back in the US. This is all because people listen to ignorant people spewing lies about vaccinations. We are remember Jenny McCarthy from singled out. Maybe I missed this, but when did she become a medical researcher or a doctor? She had a big voice and was a celebrity and pushed her anti-vaccination agenda among the public. Now we have whooping cough. I cannot tell you the sorrow I felt when I watched a baby stop breathing because he was infected with whooping cough. I have made this point before, but the selfishness of refusing vaccines does not only affect you. If you become infected with rubella and then transmit it to a pregnant women, she can have a baby born with congenital rubella syndrome. This child will potentially be mentally retarded, blind, deaf and may have heart defects as well – all because you and Jenny McCarthy knew better about vaccines. Shame on you.

    In short, beware of hacks like Jenny McCarthy and Elizabeth Cohen. They are nothing more than opinion editors and you need to take all of their "advice" with a grain of salt.

    September 30, 2010 at 09:05 | Report abuse | Reply
  18. Survivor

    Should she get one? The answer is yes. My sister was the first in my family to have breast cancer a couple decades ago. Because of mammography, I was diagnosed and treated a few years ago. My sister lapsed on her mammography screenings, she just passed away from a recurrence.

    September 30, 2010 at 09:36 | Report abuse | Reply
  19. kittykitty7555

    Something is missing here – we have to realize that ALL medical interventions have benefits and harms, and that includes screening mammography. But all we ever hear about are the benefits. No one ever admits that mammograms can have any downside, but screening mammography results in unnecessary cancer treatment FAR more often than it saves lives. Please see screening.dk for more info. Read the brochure – you will learn that if 2000 women are screened for 10 years 1 will avoid a breast cancer death. At the same time, 10 healthy women (who would not have been diagnosed with breast cancer without screening) will lose all or part of a breast. They will have radiation treatment and perhaps chemotherapy – all unnecessarily.
    When anyone discusses the “benefits” of screening without mentioning all the unnecessary cancer treatment it produces they are peddling deceit. Any health professional who has followed the controversies surrounding screening mammography knows that there is conflicting evidence. There is no conclusive proof that the benefit of screening greater than its harms, and women need to know this. What happened to informed consent? Why can’t women be told the truth? The consequences of unnecessary cancer treatment are absolutely devastating – poverty, divorce, mutilation, chemo brain and female relatives falsely labeled “high risk”. Shame on any health professional who continues to obfuscate about the “benefits” of screening.

    October 19, 2010 at 10:07 | Report abuse | Reply
  20. K H

    I am also tired of being pushed into having these stupid mammograms. I HAVE lost family members to cancer. I am wondering if these are medical "guidelines" or MANDATES to have these things. I wonder because of all the pressuring by the medical professional to have all the screenings for cancer. I want to live a natural life and die a natural death!!!! Nobody gets out alive and I will be glad someday to enter into a new afterlife! So, medical professionals.... back off!!!!

    September 30, 2011 at 13:34 | Report abuse | Reply
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