I agree that we have overstated the value of screening mammography to some degree. This is partly due to the fact that chemotherapy is now more effective at improving the survival of women with larger breast cancers, which reduces the harm of delayed detection. However, would you rather be diagnosed with a larger cancer that requires chemotherapy or a smaller, early stage breast cancer that may not require chemotherapy? I think most women would favor earlier diagnosis.
We must also remember that not all breast cancers are the same. About 20% of cancers are “HER2/neu-positive” and another 20% are “triple negative” in reference to the types of proteins they possess. These breast cancer subtypes are more aggressive and more likely to spread, so early diagnosis is especially important. However, it is not possible to tell which subtype of breast cancer a woman will develop until she has been diagnosed and biopsied. Skipping mammograms increases the chance that detection of these tumors will be delayed, which raises that chance they will need aggressive treatments.
This study is unlikely to change general screening recommendations, but it should prompt a discussion between women and their doctors about how to apply screening guidelines to individual women, and how to manage abnormal mammogram findings that may be found. Every woman should perform a breast cancer risk assessment and adopt a screening plan that reflects her personal lifetime risk of breast cancer. For example, average risk women are generally advised to undergo yearly mammograms beginning at age 40, low-risk women may begin screening mammograms less often and/or later in life, and high-risk women may begin screening mammograms before age 40, combined with breast MRI. Only by knowing her personal lifetime risk of breast cancer can a woman and her physician make an informed decision about breast cancer screening. Genetic counseling and testing should also be considered if personal or family history suggest the presence of a hereditary breast cancer gene mutation.
It’s simple. Smaller breast cancers require less extensive treatment. Therefore, the goal should be to detect and manage breast cancer at its earliest stage. The more challenging question is HOW a woman should manage her breast cancer if diagnosed. The answer to this question should depend upon her personal risk-tolerance, unique tumor biology, and tumor size and extent. The answer also depends upon the available treatment options. As a breast surgeon and cancer researcher, my mission over the past 15 years has been to expand the range of treatment options available to women with small breast cancers with the goal of reducing the burden and side effects of treatment. Examples of these newer treatments include cryoablation, an office-based procedure that uses a needle-like instrument inserted into the tumor that kills small, non-aggressive tumors by freezing without requiring surgical removal; targeted intraoperative radiotherapy, a focused radiation treatment administered to the lumpectomy cavity during surgery at the time of lumpectomy that replaces the usual 6-week course of post-operative radiation therapy while also reducing radiation side effects; and axillary reverse mapping, a lymph node-sparing procedure the reduces the risk of lymphedema or arm swelling resulting from lymph node surgery by identifying and preserving lymph nodes important for the arm. Treatment innovations such as these shift the benefit-risk balance in favor of early detection, since the risks of treatment are greatly minimized.
Second opinions are a great way for women to make sure that they have been informed about their breast cancer screening and treatment options. However, the best way to protect themselves from breast cancer and aggressive treatments is to prevent or reduce the risk of breast cancer altogether. Each of the following efforts has been shown to reduce the risk of breast cancer by approximately 20%: 1) cardio exercises at least 30 minutes daily, 5 times per week, 2) eating 5 servings of fruits and vegetables daily, and 3) eliminating excess body fat. These efforts reduce the risk of breast cancer, but can’t eliminate the risk completely. So, instead of worrying excessively about breast cancer, I encourage women to continue breast cancer screening and to channel their anxiety into the activities that have been shown to reduce risk.