To Screen or Not to Screen: What's the Right Answer?

Megan received a birthday card from her younger sister, reminding her she's turning 40 in few weeks. Megan's sister always likes to rub in another birthday. A mother of three, Megan works for an advertising agency, exercises regularly and has been a strict vegetarian for the past 10 years.

Always a planner, Megan made a checklist of things she needs to do once she turns 40. She wants to take that trip to Ireland she's been planning for many years -- and take up yoga and meditation.

What about getting a mammogram?

Her aunt had breast cancer when she was in her 70s and was treated with surgery and radiation therapy. Because Megan was very close to her aunt, she always paid attention to breast cancer issues. And she's been keenly aware of the mammogram age and interval guidelines often discussed over the past four years.

Megan happened to run into her primary care doctor, Alison, at the gym. They've known each other for many years. Megan asked Alison when she should get a mammogram, but it seemed Alison didn't want to give a direct answer.

"Megan, let's talk about that when you come to see me next time," Alison suggested.

"That's six months from now. Is that too late?" Megan was worried.

"No, you'll be fine," Alison said, before she walked away.

Megan was well aware of the controversies around mammogram screening guidelines and the risk of procedures and over-diagnosis. But she still sought a clear answer. She asked her friend Janice, who works at a cancer center.

"I talked to our cancer doctors, and they strongly recommend a mammogram starting at age 40," Janice said. Megan could always count on her for a direct answer.

Megan searched for more information online. She's not the only one who's confused: Since the U.S. Task Force and Preventive Services came up with the mammogram recommendations, the debate has heated up. Just this past April 15, the guidelines were modified again.

According to the draft release, "The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years .... All women undergoing regular screening mammography are at risk for the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not have become a threat to her health, or even apparent, during her lifetime (known as "over diagnosis"). This risk is predicted to be increased when beginning regular mammography before age 50 years."

After reading this, Megan was even more confused. She visited websites of a number of reputed physician organizations to see what she should do. What she found was much inconsistency:

After Megan shared her story with me, I reviewed her mammogram and biopsy report, discovering she has Stage I breast cancer. Since it was found in its early stage, it's highly treatable and curable. She was happy to hear that, and extremely relieved she had a mammogram.

As a breast cancer doctor, my view is skewed because I see only patients who have been given a breast cancer diagnosis. But I hear stories like Megan's all the time, and it's troubling to me. My personal view is that a mammogram is a low-cost, low-risk procedure that can save lives, regardless of what recommendations may say. I surmise many 40-something women with a breast cancer diagnosis would agree.

Dr. Jame Abraham is the director of the Breast Oncology Program at the Taussig Cancer Institute, and co-director of the Comprehensive Breast Cancer Program at Cleveland Clinic. At the Case Comprehensive Cancer Center, Dr. Abraham is the co-principal investigator of the Lead Academic Participating Site (LAPS) grant, an essential component of the NCI's new clinical trials network (CTN). He is the National Surgical Adjuvant Bowel and Breast Project (NSABP) principal investigator for Cleveland Clinic. In addition, he is vice chair of the Research Review Committee for the NSABP Foundation and a member of the NSABP Scientific Advisory Board. Dr. Abraham is also a member of the Breast Cancer Research Committee, part of the newly formed NRG (NSABP/RTOG/GOG) Oncology group. Dr. Abraham currently holds two patents; one titled System and Device for Tumor Characterization Using Nonlinear Elastography Imaging (2014) and one on risk stratification of patients with breast cancer. He is a past member of the NSABP breast committee (2002-2014) and member of the Breast Cancer Working Committee of the NSABP (2010-2014). He also served on the Board of Directors for the American Cancer Society - South Atlantic Division (2007-2010).