DR. EISEN: The prognosis is better and the treatment required may not be as intensive as for someone diagnosed at a later stage. At the most basic level, if you have a very large tumour you may require a mastectomy instead of a lumpectomy or breast conserving therapy. You may require chemotherapy versus no chemotherapy, or if you do need chemo you may need a more aggressive chemo regimen.
What impact could the mixed messaging around mammography have on breast care in Canada?
DR. YAFFE: In the United States, the volume of mammography in women in their 40s has gone down, despite the fact the U.S. federal government almost instantly rejected the American task force recommendations in 2009 [that suggested screening every other year for women aged 50 to 74] Nevertheless, just because of the publicity, fewer women – not just in their 40s but for all ages – are actually getting mammograms in the U.S.
DR. EISEN: I think that is really a concern in general because the uptake of screening mammography, even for women eligible for the organized screening program in the over-50 category, is far from ideal. In Ontario, it’s about 70 per cent of women who are eligible that obtain routine screening mammography.
What about using mammography to diagnose a breast concern, such as a lump? Is there any debate?
DR. YAFFE: There is no controversy whatsoever about the value of diagnostic imaging if a woman has symptoms or any kinds of signs of breast cancer. Even those who most strongly oppose screening don’t dispute that. The issue is really screening. But frequently, when the media conveys that message to the public, they will simply say something like, “Mammography not useful, experts say.”
Early Screening: One woman’s story
Susan Silverman, 62, watched with concern late last year as the debate over screening mammography was making headlines. More than a decade earlier, when the Thornhill, Ontario, resident was 48, a mammogram detected a tumour in her breast. “It showed right away,” says Susan, a mother of three who has been married to her husband, Albert, for 42 years. She opted to have a mammogram after two family members were diagnosed with breast cancer in their 30s and 40s.
Further imaging and surgery followed, plus post-surgical chemotherapy and radiation at Sunnybrook, leaving Susan cancer-free to this day. At the time of her diagnosis, she was in the category the task force now says should not be routinely screened with mammography. “That’s a very bad idea,” she says of the recommendation average-risk women should wait until their 50s to get mammography screening. “Just like any other part of your body, you have to be on top of everything.”
Susan worries about the impact the recommendation will have. She wonders if it will discourage women in their 40s from being proactive about their breast health. She also thinks the health-care system will be worse off if breast cancers are discovered later. “To save a few pennies at the front and then pay for it at the end, what are they achieving? I don’t get that.”
She is thankful the mammogram 14 years ago detected the cancer that might have robbed her of the chance to see her grandchildren. Susan was finishing up her breast cancer treatments in 1998 when she learned she would become a grandmother for the first time. “I said, ‘I want to see this little boy grow up, and be at his bar mitzvah.’” She is getting her wish this spring.