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Carol Toller is a former features editor for The Globe and Mail.
I’m not much of a talker when I’m waiting for a mammogram, but if I do feel like striking up a conversation, I look for the women whose hospital gowns are splayed open. They’re the ones who aren’t scared to death. Someone who isn’t fussed about whether the cloth tie goes at the front or the back (and now has one breast casually flashing anyone who cares to look) isn’t sweating what lies ahead.
Women with gaping robes tend to have time on their side. They’re old enough to have racked up decades of negative results. Or they’re scarred veterans who’ve been through cancer, have come out the other side and plan to stay there. Either way, they’re usually ready to crack a joke about how their last technician kneaded their breasts like sourdough.
The ones I suspect are first-timers haunt me, and I leave them alone. Especially when they’re too young to be eligible for routine screening, like I was when cancer found me. So I didn’t say anything to the fortysomething-looking woman I saw last month in a mammogram waiting room. But what I thought was this: you aren’t supposed to be here.
She was staring hard at her laptop, typing with an intensely determined look. Her back was straight, as if it was pressed up against a boardroom chair instead of a flimsy plastic seat. Everything about her seemed to suggest she should be at work. And her gown? It was perfect. She’d read the instructions in the changing room. Do everything right, she may have been thinking, as I once did, and this won’t go wrong.
I was 44 when I was diagnosed with breast cancer. That’s an age when you’re not meant to be at a high enough risk to need early detection screening. The Canadian Task Force on Preventive Health Care doesn’t recommend mammograms for women in their 40s – its current guidelines call for them only at age 50 and up. In the U.S., meanwhile, federal recommendations recently changed to include women in their 40s – a response to rising rates of breast cancer among the 40-50 demographic.
The fact that this fortysomething woman was in a mammogram waiting room, gazing intently at her screen, meant she was either in a high-risk category – a family history of breast cancer or a genetic predisposition – or she’d found something concerning, just as I did one day back in 2010.
It was a lump in my left breast, and though I had the good sense to book an appointment with my doctor, I shoved that acorn-sized nub of tissue out of my mind and decided it was nothing to worry about. I was in my 40s; I didn’t belong in a cancer treatment queue. There was nothing to see here.
One of my favourite authors, Joan Didion, often told interviewers she’d grown up believing you should never turn away from your fears. If you saw a snake in the grass, you needed to keep it in your sightline, and as long as you did, “the snake wasn’t going to bite you.” I refused to see the snake.
When it struck, it struck hard. It turned out I had not only breast cancer, but thyroid cancer too. (Cancer jackpot!)
What followed was a whirlwind of interventions: two lumpectomies, one mastectomy, eight rounds of chemo, a month of radiation, one thyroidectomy, a few days in hospital for radioactive iodine treatment plus several reconstruction surgeries. Now I’ve passed my 10-years-out milestone and my appointment regimen has been reduced to an annual mammogram.
But when I think about the snake in the grass and what I was afraid of seeing then, I wonder whether we’re doing the same at a societal level when we downplay the risk of breast cancer for women in their 40s. In the U.S., that cohort has seen a 2-per-cent increase each year since 2015. In Canada, the rate is rising too, though at a slower pace (about 0.5 per cent annually).
The Canadian task force says that when it comes to lowering breast cancer mortality rates, women under 50 see the lowest “absolute benefit” from routine mammograms. “Screening leads to overdiagnosis, resulting in unnecessary treatment of cancer that would not have caused harm in a woman’s lifetime, as well as physical and psychological consequences from false positives,” its website says.
What the task force doesn’t say is that the decision is also about economics. Lowering the age to 40 would cost Canada an additional $2,000 to $3,000 per person, according to a 2015 study. Multiply that by the 2.5 million women in the 40-50 age group and the cost climbs into the billions. And only about 17 per cent of new cases occur in women younger than 49. To prevent even one death, we’d need to screen 1,724 women, according to the task force’s figures. The pragmatist in me understands that public health systems need to reduce people to numbers on a spreadsheet. But what if that one life was mine? Or yours?
If we have to focus on balance sheets, shouldn’t we at least take a closer look at the numbers and acknowledge that gen-pop studies don’t reflect the realities of cancer?
Here are some other figures we need to consider: Black women have disproportionately higher rates of breast cancer in their 40s, along with higher mortality rates. In the U.S., they are 40 per cent more likely to die of breast cancer, and among women under 50, the disparity is even greater. Women with dense breast tissue are at higher risk too.
If extending mammogram eligibility to all women in their 40s isn’t feasible, surely certain cohorts deserve earlier screening, just as women with family histories and genetic mutations do. A change like that wouldn’t have personally benefited me, but I’d like to see it happen. I’m still not entirely comfortable with mammograms – I see the snake now, and its constant presence unnerves me – but I’d feel better for the women with the perfectly tied hospital gowns.
Marianne
Marianne Kushmaniuk for The Globe and Mail
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