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Recent controversy over the need for annual mammograms-especially for women older than age 40-has prompted many women to wonder: Should I get a mammogram this year?

Annual mammograms have been incorporated into the best practices of many primary care physicians since Swedish studies praised the lifesaving benefits of screenings back in the mid-1980s. Throughout the following decade, the quality of mammograms improved as women's healthcare advocates successfully lobbied for the 1992 passage of the Mammography Quality Standards Act, a law that sets national standards of quality for mammography clinics. And HMOs emphasized the importance of regular screenings by grading physicians on the percentage of patients who received annual mammograms.

But in recent years, hard questions have raised doubts about the value of annual mammogram screenings. In 2001, for example, Dutch researchers challenged the 1985 Swedish study, claiming there is no proof that mammogram screenings prevent deaths from breast cancer. To make matters worse, a series of articles in the New York Times questioned the competence of radiologists interpreting mammograms. Additional studies claimed that women in their 40s are just as likely to die of breast cancer whether or not they get annual mammograms.

Disagreement among researchers and other experts confounds the issue. How can you know if annual mammograms are right for you if the experts can't agree?

Although the diagnosis and treatment of breast cancer can be complicated, understanding the role of mammograms is important to every woman older than age 40. Let's look at some of the arguments surrounding the mammogram debate.

Controversial Issues

Critics contend that early detection of breast cancer through mammography does not necessarily save lives. Others claim the variable nature of breast cancer impacts the effectiveness of diagnosis and treatment. Truth is, all breast cancers are not alike, and early detection and treatment may not always make a difference. Some cancers are relatively benign, existing harmlessly for many years without diagnosis or treatment. On the other hand, aggressive tumors may spread to lymph nodes and bones while the primary tumor is still small, allowing little or no time for lifesaving measures.

Everyone agrees that mammographic detection of cancer is not a simple process. For example, for every 1,000 American women who get mammograms, about 100 will return for further imaging. Biopsies will be recommended for about 10 of those women, and two to four of those biopsies will show cancer.

Some studies, however, point out that mammography does not distinguish between life-threatening tumors and benign abnormalities, in spite of multiple imaging sessions. Of the cancers detected by mammography, about 35% are "carcinoma in situ," or not invasive cancer, that may never threaten the patient's life or well-being. Detecting these cancers not only demands a great deal of work and money, but also can cause many nights of worry.

Finally, some women fear that radiation exposure from repeated mammograms will increase the risk of getting cancer. In actuality, the overall cancer risk from mammogram screenings is low. Age plays a more important factor because the rate of naturally occurring cancers increases greatly with age. According to one estimate, 1,200 invasive cancers will be detected over the course of a decade among 100,000 women in their 40s, resulting in 400 deaths. By contrast, the risk of this same group getting cancer due to a decade of repeated mammogram screenings is much lower, resulting in a maximum of eight additional deaths.

Benefits Outweigh Risks

Considering the arguments, many experts have reached the same conclusion: Although mammography is not ideal, the benefits far outweigh the risks. Mammography is not a perfect science, but it offers the best screening available for early detection of breast cancers that can't be found during a manual breast exam. Proper screenings are too important to ignore, especially for women who have a high risk for the disease.

The American Cancer Society recommends an annual mammogram for women every year after age 40. Still, annual mammograms are only one part of a woman's healthcare program. Every woman plays an important role in determining choices about her individual health. For optimal care, women should follow these guidelines:

Perform monthly breast self-examinations.
Visit a doctor for a clinical breast exam each year.
Keep appointments for their annual screening mammograms.
Commit to follow-up imaging and biopsy if recommended.

by Charles W. Piez, M.D.

Dr. Piez is a radiologist with Associates in Diagnostic Radiology and the Medical Director of the Erlanger Breast Center. He is also a Clinical Instructor of Radiology at the UT College of Medicine-Chattanooga Unit.