The Great Mammography Debate: "Peace of Mind" Or "Power Of Me?" What Kind Of Person Are You?

The news last week that the Unites States Preventive Screening Task Force was recommending women without risk factors begin mammograms at age 50 instead of 40 was the medical shot heard round the world. Within a day we had thousands of angry and confused emails from Americans scared by the loss of an essential protection against arguably the most feared of all cancers. This announcement caused an immediate reaction and backlash among survivors, the American Cancer Society, and even the White House. The frustration among Americans was so palpable that for the first time ever we broke into our production schedule to prepare a show for Monday. On the show, we bring together experts and patients to sort through the emotions, confusion, fear, anger and worry and attempt to answer the question on ever woman's mind: "What do I do now?"

In general, discouragement against mammography is the wrong message for anyone to take from these findings. A realization that one size doesn't fit all is a more productive social epiphany. This is not an occasion where standard medical protocols are radically changing or reimbursement by insurance companies suddenly takes a dramatic turn. It is however an occasion for analysis and reflection, and an important teaching opportunity for all women.

With so much disagreement over the new recommendations, there exists a greater risk of ambiguity than clarity. I do not want to offer an endorsement or a rejection of the recommendations, I want to give you the tools to make your own decisions. I believe that is best done by offering the following perspectives as a way of looking at the findings. There are pros and cons on each side of the debate, and they boil down to what type of person you are: do you subscribe to "peace of mind," or "power of me"? The "peace of mind" crowd doesn't mind trading the risk of a false positive for the benefit of early detection. They'll do anything to stop disease in its tracks, no matter the cost or inconvenience. "Power of me" folks, on the other hand, believe in the power of prevention and may defer screening tests until their age puts them into a high risk group.

There's no right answer, and both perspectives are perfectly appropriate. But I'm convinced that when people make decisions about their health, they fall into one of these two categories. By knowing your type and arming yourself with good information, you'll make smart choices about mammograms, especially given the controversial and somewhat confusing new recommendations.

That's exactly how we approach the story on our show on Monday. And then we explain exactly how these new screening guidelines might influence your decisions. First, a major reason for the heated response to the government appointed group's report has been the lack of clear understanding about what, exactly, a medical task force does. These groups consist of impartial and unbiased experts from various specialties who synthesize the latest scientific evidence to guide practicing physicians. Half of the task force members are women. We want these folks taking an aggressive stance against the status quo when appropriate because this pushes medicine to improve and catalyzes a national conversation so you are more informed and better cared for, even if you disagree with the task force's insights.

The recommendations are sometimes controversial, but it's important to remember they're designed to maximize benefits of screening while minimizing its risks. Of course there are many women who have had life-saving mammograms in their 40s and even 30s. Their stories are valid and important. But, when looking at the bigger picture, the task force has decided that younger women are much likelier to get unneeded biopsies or operations, or to have tumors missed altogether, than to have a true cancer detected early on. Plus, many identified cancers in younger women are not found in time, so the mammogram offers a false sense of security. We need better screening tools, so it's healthy to have an open debate and keep medicine self-reflective and accountable so it does not complacently tolerate currently available screening techniques.

Moreover, the task force recommendations on mammograms are not a blanket, one-size-fits-all prescription for every woman. Guidelines should never replace a dialogue with your own doctor that considers your individual risk. After all, you are the expert of your own body. That's also why I will say I disagree with the recommendation that physicians not focus on teaching breast self-exams. I continue to advise and encourage women to examine their breasts. Studies show that, especially in younger women, half of breast tumors are first detected during self-exam. So, get to know your breasts any way you like and don't worry about any specific examination techniques since none appears better than your own insightful fingers.

Finally, let me remind everyone that detection does not equal prevention. Mammograms do not cure or prevent cancer; they just find it. So do not forget the things YOU can do to help prevent breast cancer. For example: lose weight if you're overweight, keep it under two alcoholic drinks a day, and take 1000 units/day of Vitamin D. Remember, we cannot test to safety; we must live to safety.

 

Follow Mehmet Oz, M.D. on Twitter: www.twitter.com/droz.com

Comments

[AuntieLola]

11:21 AM on 11/24/2009

Mammography is not a perfect tool, but until something better comes along, it is our only tool. Pretending that ignorance is empowering women is a crock. Assuring women that if they feel lucky, they will be lucky will cost many women their lives. A panel deciding that a little anxiety is more important to prevent than a little cancer, is paternalistic at best. Women have always been able to decide whether or not to be screened, and they do. With only a 60-80% screening rate in many parts of the country, 20-40% of women are continually deciding not to be screened. Women don't need a panel's permission to make health decisions for themselves.

[DrP]

10:24 PM on 11/23/2009

Wow. I may become a fan of Dr. Oz! Great opinion piece, Doctor. I recently had my first routine physical in 3 years because I have to pay for all medical care out-of-pocket. No, I'm not uninsured, but I have so few medical expenses that I never meet my deductible. A routine check-up, blood work, and pap smear cost $300.00, which is a lot of money to me. My doctor suggested I get a mammogram and colonoscopy, and said "your insurance should pay for it." I said no, it would not because I would still be under my deductible. I asked if there were alternatives, and she said that a physician exam every year (since my partner is a retire physician, I'll let him do it - more fun anyway) would be as good as a mammogram and a yearly hemocult meets the screening guidelines for colon cancer! Why don't more patients question their doctors and get the simpler, less expensive screenings?
Finally, amen to prevention. One of the reasons I'm not concerned about the screening issues is that I take care of my health, exercise, eat a very low-carb diet (absolutely no sugars, since cancers feed on sugar) and get lots of sun exposure to boost my Vitamin D levels. By the way, I'm 56 and have a genetic insulin-resistance and a family history of heart disease - but I'm in excellent health. Yes, Dr. Oz,it's about personal responsibility and talking to your doctor.

[quinndiesel]

01:38 PM on 11/24/2009

Because your doctor is incorrect. Yearly breast exams are not an equivalent substitute for mammography in screening for breast cancer. There is NO evidence to suggest that a breast exam by your physician is an adequate screening tool for breast ca. As for colon cancer, yearly hemoccults need to be done in conjunction with either colonoscopy, flex sig, or ct colonoscopy. They WILL NOT be successful by themselves. This is in no way a discouragement for your husband to "perform breast" exams on yourself. I'm sure that ounce of prevention is probably the most helpful.

[BluePatriotWoman]

06:03 PM on 11/23/2009

As a clinical research nurse I am flabbergasted at the way we respond to medical news. When the results of the Women's Health Initiative were announced, everyone ran around with their hair on fire. Millions of women who may have benefited from HRT either stopped or were too scared to start. WHI found a 0.0008 risk of breast cancer from HRT. Now we have large, long-term studies that found no benefit for mammograms or instructed self-breast exam for low-risk women before the age of 50. There will always be patients who fall outside of the guidelines and they have been quite vocal in this discussion. What about the millions of women who have undergone invasive procedures based on false-positive mammograms? We don’t hear their voices because the fear so pervasive that we cannot see the facts: breast cancer is a distant second to lung cancer as a cause of death for women and the majority of women will die of heart disease.

The data do NOT support Dr. Oz's statement that both choices are valid. If we insist that evidence-based medicine as the best choice for medical care decisions, why is breast cancer exempt? (Ask yourself who benefits from maintaining the status quo.)

I believe the good doctor has it backward: the "Peace of Mind" folks will follow the guidelines unless clinical indications dictate otherwise, while the "Power of Me" folks will demand everything, no matter how low their risk.

[hatmadder]

06:25 PM on 11/23/2009

I agree, BluePatriot: I was a participant in the terminated Early Lung Program, which was a nationwide study of the use of early lung cancer detection via CT scans. The idea sounded worth a try, but physicians ended up doing a (LUNG!) biopsy on one benign artifact after another, and the study was terminated early because benign and malignant artifacts could not be distinguished, even by experienced pulmonologists.

Cancer is a scary word, but "unnecessary chemotherapy" and "unnecessary surgery" also have horrible connotations.

Medicine really does not have all the answers. We should at least try to listen with open minds.

[quinndiesel]

01:40 PM on 11/24/2009

Bravo Well articulated. Evidence based medicine+Healthy communication with your doctor=better health. By Dr. Oz's standard, people who are "peace of minders" should all get full body scans. Now, how do we get doctors to practice evidence based medicine?

Dr. S

[MsCanuck]

05:57 PM on 11/23/2009

I started getting yearly mammograms at age 40. Last year an abnormality showed up on the film, so I was sent to the specialized mammogram unit at the hospital where they took more films of the area breast tissue, as well as an ultrasound of the area to determine that there was no worry, everything was fine. If further testing would have been needed, they would have done the needle biopsy and all other test required right then and there. I'm glad we have this program, and that it's covered under our national health care system.

[Rubyfoo]

04:49 PM on 11/23/2009

Bottom line. The medical community has no way to tell you whether the thingie that showed up on mammography is really dangerous or not. So if you want to be safe, you have to undergo dangerous treatment that you quite possibly don't need. It's more a condemnation of our research community, which has it in their power to focus down on the problem of defining molecularly which tumors are likely to metastatize (people die from metastasis, not from localized tumors). But this is not happening. Rather medical science is split investigating a great many other issues. This one is key.

[J G H]

04:32 PM on 11/23/2009

The idea that only women in high risk groups need the procedure under age 50 ignores the fact that we can not identify all members of the high risk group; cancers have genetic and environmental factors. Given the large number of chemicals we are exposed to with minimal screeening (bisphenol in plastic drinking bottles, for example) how many women have been exposed to carciniogens without their kowledge? What is really disturbing is that the authors of the report, at least judging from the news coverage, have offered no alternative screening method. To eliminate false positives they are willing to see thousands of women die.

[Rubyfoo]

05:49 PM on 11/23/2009

They have no alternative to offer.

[tilted windmill]

03:18 AM on 11/24/2009

With yearly mammograms for every woman in her 40s, for every one life "saved" there are 1,000 women who have the bejeebers scared out of them for a false positive. The people who disregard the stories of those 1,000 women haven't gone through the fear, pain and, yes, expense of further testing and surgery for what turns out to be nothing.

I've been there, but I insisted on another radiologist and ultrasound which allowed for a 6 month follow up instead of an immediate stereotactic biopsy. The follow up mammogram showed that the suspicious area was just a lymph node. The radiology team told me that surgery would likely have resulted in complications with no upside. It cost me nearly $500 at the time(10 years ago). I had to pay all of it because my medical expenses do not exceed my deductible. No idea what that would cost today, especially with the fancy biopsy methods, but I have to pay everything up to my $5,000 deductible, and I'd rather not spend it chasing ghosts.

And for anyone who is offended that I put the word "saved" in quotes, I wrote it that way because medical technology is not able to determine which cancers would have been fast growing and deadly vs the ones that would be slow growing and perhaps never cause the woman any problem.

[DeeDeefromNM]

03:42 PM on 11/23/2009

Started mammograms at 40. Skipped when 44 and 45. Next mammogram at 46 diagnosed as Stage IIIB, large tumor, lymph node involvement. Wish I had it to do over again so i would have never skipped my mammogram. No risk facts, no HRT use, no family history. Based on these recommendations, I wouldn't have had a mammogram until 50!...and probably wouldn't have survived until then.

[AnnfromCA]

03:24 PM on 11/23/2009

I had a bad pap smear when I was young. I frankly ignored it. Call it youth. I just didn't take it seriously, in spite of an insurance team who tried to tell me I had cancer.

I just ignored it. Had a baby. Never had another bad smear.

I figure this is part of what goes on. Freak people out, they end up demanding biopsies, etc.

I wouldn't recommend MY path. I laugh now thinking how "silly" I thought it was.

Yes, I was right. BUT!

[DrD]

03:21 PM on 11/23/2009

I'm one of the women who's life was saved by a routine mammogram that I had when I was 46. The lump was not palpable by self-exam, but it showed up as a well-defined, 1 cm, stage 1 lump. The only other mammogram I had was when I was 41, five years earlier, which was completely negative. I probably would not have had the second mammogram if it not been for the guidelines that said that women should start having mammograms in their 40s. At the time, I thought I was invulnerable to breast cancer, even though my mother had breast cancer and I never had children. Those were and still are considered two risk factors. I thought I was invulnerable because I was doing all the other preventive "right" things. I exercised, took vitamins, was an appropriate weight for my height, and didn't drink, with the exception of an occasional glass of wine. My point: Age guideliness are important. How many women are going to wait until they are in their 50s to get preventative screenings, when it might be too late?
Dr. Oz, I disagree with your two categories of health seekers: "peace of mind" or "power of me. I don't believe that getting check ups and working on prevention are mutually exclusive categories. I do agree that it's time to come up with diagnostic protocol that are less invasive and that do not yield false positives.

[singermuse]

02:40 PM on 11/23/2009

I come from a family where the women lived well into their eighties and beyond. They didn't use HRT, ate a "traditional" Mediterranean diet, didn't get mammograms, or use the plethora of symptom/mood management drugs currently available on the market. When they were sad, they cried and talked with friends, extended family members and they shared in life's joys as well.Toward the end of their lives they lived with family (not in a "home"). I am in my fifties and intend to do as they did. Since mammography doesn't seem to decrease over-all mortality rates, but just gets a woman "into the system" sooner, I don't see the point.

[WhatsLeft]

02:17 PM on 11/23/2009

I would suggest that you go with your "gut". I was encouraged to take HRT but didn't. Estrogen and cancer have been linked, oh wait, estrogen doesn't "cause" cancer, it mearly "predisposes" you to get it. After one PAP test I asked my nurse practioner about the connection and she went on to tell me the benefits of HRT and poo pooed my concerns. I became angry and told her that if there was a med on the market that "predisposed" mens' testes to fall off it would be taken off the market. She left the room in a huff and I left the room knowing I made the right decision. (for me)

[KateCa]

02:10 PM on 11/23/2009

Dr Oz- thank you for recommending breast self-exam. Even if women are not absolutely perfectionist about this, it will save lives. My daugher died at 45 of Inflamatory Breast Cancer, an aggressive form that shows up as swelling and skin change. She could see something wrong but it was mis-diagnosed for two months and despite heroic measures she died 18 months after it began. This cancer doesn't start from a lump and would not show up on a mammogram, but would be easily evident to touch and appearance.
Plese, women- find out more about this type of breast cancer and know that lumps are not the only symptoms.

[tehixe]

01:32 PM on 11/23/2009

I don't think people have even the vaguest sense of rationality on this issue. They say they want to avoid breast cancer "no matter the cost." But if you have no family history of it, then mammograms at a young age actually DO NOT HELP. THEY HURT. They lead to exposure to hazardous radiation, and doctors slicing into your breasts for no good reason. This is not part of prevention, it's part of the problem. The test simply is not helpful for women under 50, and this is according to science. The scientists in charge of this study aren't trying to save money, they are trying to promote women's health. There's no question that women should talk to their doctors before deciding, because if they have extra risk factors, younger mammograms might make sense. But for most women, the desire to catch cancer early "no matter the cost" might end up costing money for tests and surgeries that hurt more than they help.

[blue53]

01:22 PM on 11/23/2009

Anybody remember the recommendation on hormone replacement therapy? The doctors and the drug companies were wrong. Stress doesn't cause ulcers either. How many women in their 40's who had cancer were on HRT or birth control pills, at the time or within 2-3 years of their diagnosis. How many found a lump? Breast cancer rates dropped 6-7 % when rampant HRT use stopped. As a mammographer and someone at high risk, I must say -- 10 years of extra radiation, along with whatever else you may need, say CT, Upper GI, Esophagram, Rib studies, chest -x-rays, which all expose the breast--you need to be understand the risk. Mammography doesn't prevent anything. You can still have your mammogram if you need it, and even if you want it. These guidelines change nothing. What they do is start the conversation-and give you some more information. Women claim they don't want to be lead by the nose-- well this is the process by which you learn.
An entire “industry” has grown around breast cancer, and some of it has been for the good, but most of it just makes people feel better. Feelings are not science. All the races and runs, and non-profits in the world have not moved the medical community to investigate the environmental causes, or develop new safer imaging techniques. This is where your concern should be placed.

[tehixe]

01:33 PM on 11/23/2009

Rationality. It doesn't just make sense, it's cool!

[mrsL]

01:18 PM on 11/23/2009

Someone close to me got mammograms every year in her 30s and 40s. Just found out she had breast cancer at 49. Surgeon told her that the cancer looks like it had been there for about ten years. So I guess that illustrates that mammography isn't fool proof and what younger women really need is a better way to screen for breast cancer.