Published: November 25, 2009 10:41 am      

Patient, doctor will still decide mammogram testing

DEAR DR. MONA: I am lost. What am I to make of the news that we don’t need mammograms each year? I just turned 40. — Melody

DEAR MELODY: The U.S. Preventive Services Task Force came out last week with some recommendations about breast mammograms and, similarly, at the end of last week the American College of Obstetrics and Gynecology (ACOG) published new guidelines for Pap smear screening. So we need to think and understand the rationale of those changes.

The recent relaxed recommendation is an excellent indication of the success in reducing the incidence (due to early detection and treatment) of both breast and cervical cancers. The task force examined the evidence collected from studies looking at types of screening (breast self examinations, mammography, digital mammography, MRI) and detection rates, the rate of false positives and the resulting harm (over-diagnosis and biopsies), as well as the cost of testing.

This extensive review led to the suggestion that mammograms every two years in patients aged 50 to 74 with average risk factors provide the best benefits from mammography. The task force also suggested that women between the ages of 40-49 should not routinely have mammograms. In addition, it was suggested also that women over the age of 75 should not have mammograms because of the increased potential for harm from over-diagnosis, cost and the lack of any change in life expectancy.

Breast MRIs have not shown any benefits and were thought to be costly and more cumbersome than mammograms or digital mammography.

Having said that, the task force said the following: “The precise age at which the benefits from screening mammography justify the potential harms is a subjective judgment and should take into account patient preferences. Clinicians should inform women about the potential benefits (reduced chance of dying from breast cancer), potential harms (for example, false-positive results, unnecessary biopsies), and limitations of the test that apply to women their age. Clinicians should tell women that the balance of benefits and potential harms of mammography improves with increasing age for women between the ages of 40 and 70.”

As you can see, Melody, we should not be overly concerned. When you talk to your doctor at your annual exam, the two of you can assess those issues and together make a determination as to whether to have the testing done or not. As far as my patients are concerned, I plan to continue to screen patients and encourage breast self examinations and evaluate the data until there is a more general consensus and data is clear, and if a patient wants to postpone her mammogram and she understands the risks and the benefits, I will support that.

Last week also, to confuse matters more and to raise concerns about motivation, the ACOG made new recommendations about Pap smear screening. Since these were two entirely separate events, this is simply a matter of strange coincidence. But let me also clarify the new Pap smear suggestions.

The first Pap smear screening should be started at the age of 21 since earlier screening would lead to unnecessary interventions in patients with low risk. However women under the age of 21 should be counseled about safe sex and contraception

Pap smears should be done every two years in women between the ages of 21 and 29, and women at the age of 30 who have had three consecutive normal pap smears and no abnormal pap smears could chose to have pap smears every 3 years.

Patients with HIV, those who are immuno-compromised, or exposed to diethylstilbestrol (DES) in utero should have closer monitoring and surveillance. Women who have had a hysterectomy for benign (not cancerous) reasons and never had abnormal pap smears can stop having pap smears altogether. But women who had a history of abnormal cells and then had a hysterectomy should have yearly pap smears for 20 years, as the abnormal cells can recur in the vaginal cuff.

Women over the age of 65-70 and with no history of abnormal pap smears can choose to stop having pap smears. Patients with abnormal pap smears (CIN 2 or CIN 3) should continue to have yearly pap smears for 20 years before trying to cut down on the pap frequency.

It is important to mention that regardless of the Pap smear, the yearly examination is still important and those general recommendations should be tailored to fit the needs of the individual patients. So, no woman should be too concerned that her needs will not be met, as health care and what is needed is always a matter of discussion and understanding with her health care provider.



Dr. Mona Alqulali is a board certified OB-GYN.