Below 40 You’re On Your Own

 Is there anything left to be said about the 40 vs. 45 vs. 50 debate when it comes to the starting age for screening mammography? Not really, but there are always new ways of representing the old. For instance, one could summarize the entire controversy by stating that those favoring age 40 are more concerned about women’s lives, while those endorsing age 50 are more concerned about cost-effective medicine.

This is a very old debate, by the way. Yes, the U.S. Preventive Services Task Force stirred the pot in 2009 with their position reversal – switching to 50 rather than their 2002 recommendation for age 40 – even though their meta-analysis of benefit (15% mortality reduction) was identical in 2002 and 2009. “Science,” they said. But in fact, they had merely orchestrated a new way of calculating the harms of screening. And then, for that final step – harms vs. benefits – there is no science at all. It is 100% subjective.

I have a 35mm slide from 30 years ago showing which organizations favor 40 vs. those that favor 50. Indeed, the debate was launched with the very first mammography screening trial in the 1960s – the Health Insurance Plan of Greater New York. Investigators made several errors in study design that put the 40-49 results into question. You can read the details of the HIP study in my book, Mammography and Early Breast Cancer Detection: How Screening Saves Lives (McFarland & Co., 2016) where I have done my best to tell the story of breast cancer screening as though I were writing a novel. As one reviewer correctly noted, “Many of the fun facts are in the Chapter Notes at the end” (even though I originally placed them within the narrative so that the reader didn’t have to flip back and forth).

But 40 vs. 50 is not what this blogatorial is about. I’m writing this month about women under 40. What do we offer them for early detection? The answer is: Prior to 2007, we offered absolutely nothing. They were disenfranchised. Self-exam is often touted, in spite of no evidence of efficacy in this age group. I keep a database on patients diagnosed at our breast center at Mercy—OKC, and one of the things I follow is “method of detection.” 95% of the time, if the patient is under 40, her diagnosis will be made by palpation, and the Stage will be II or worse.

In 2007, the American Cancer Society introduced high-risk screening with MRI as a recommendation if patients met certain criteria for elevated risk. Every bit as important as introducing supplemental MRI to mammography was the lowering of the age to begin screening from 40 to 30 (and later, age 25 with certain genetic predispositions).

But this option is greatly underutilized. Even though we have a busy risk assessment/genetic testing program at my facility, with many women undergoing early-age MRI screening, the overwhelming majority of breast cancers discovered in the under-40 group are through palpation. Sometimes, these patients would have qualified for high-risk MRI, but did not undergo risk assessment (for a variety of reasons). But most of the time, these young women develop breast cancer without substantial risk factors. They don’t meet the requirements for early-age screening.

In 2009, I was halfway finished writing a book on the “under 40 problem.” My premise was simple: “Now that we’ve settled on 40 as a starting age for routine screening mammography, here’s what we can do about women under 40.” But then came the U.S.P.S.T.F. move to age 50, and I was forced to start over writing a different book simply to support the status quo of age 40. This became the aforementioned book on screening, published in 2016.

In that book, I presented a diagram on breast cancer incidence per annum plotted by age. One can see that the incidence starts creeping up in the 20s and 30s, but the steep rise occurs in the decade of the 40s. It is this curve that prompted the inclusion of women in their 40s in the historical screening trials.

Incidence of BC from mammo book


I make the point in my book that if we start at age 50 rather than 40, we will exclude 20% of eventual breast cancer patients from an opportunity at early detection. Furthermore, the U.S.P.S.T.F. and others have suggested stopping screening at age 70-75, which will exclude another 25% of eventual breast cancer patients. And when you add the 5% of new cases under age 40, then the Task Force’s dream-come-true will be the exclusion of ONE-HALF of the eventual breast cancer patients from early detection.

And to think – I was writing a book about what to do with the neglected 5%!

To that end, by the way, I have several proposals for younger women, but the most intriguing option has always been blood testing that could prompt diagnostic imaging only if the blood test is positive. Today, everyone is a-buzz about “liquid biopsies” and the Grail Trial, etc., but my quest for the Holy Grail began in 1991 with the “placental ferritin assay” developed by Dr. Chaya Moroz in Israel. Nearly 30 years have passed since I began working with basic scientists to develop a screening blood test for breast cancer. 10,000 samples later, distributed worldwide, working with multiple entities, we still do not have an approved test (though we’re getting closer).

Such a test would provide an option for young women under 40, women over 40 who refuse routine mammography, and for women in countries without a screening infrastructure.

The remarkable thing to me has always been the apathy that surrounds the under-40 group when it comes to screening. Apparently, it was easy to forget about these women when we were allowed to screen 95% of eventual breast cancer victims. After all, we were neglecting “only” 5%.

But my approach on this neglected 5% has always been casting the number in a different light. How many breast cancer diagnoses are we talking about?

First, let me ask the reader this question: How many cases of cervical cancer – all ages – are diagnosed in the U.S. every year? We have huge awareness on this problem. Pap smears became an institution. Well, the answer is 13,000 women every year.

Now, how many women under age 40 are diagnosed with breast cancer every year, with nearly zero awareness and no good options outside of high-risk MRI screening. Well, the answer is 13,000 women every year.

 Breast cancer has that unique feature of being so incredibly common that small percentages translate to a large number of women. The sad state of affairs today is that the disenfranchised 5% will now be joined by an additional 20% (or, approximately 50,000 disenfranchised women per year) if the Task Force, the American College of Physicians, and the American Academy of Family Physicians were to have their way. Yet, this tragedy has been portrayed to the public with an Orwellian ring, couched in language that is nearly opposite to the truth. Science writers ask, “Why do so many breast radiologists and surgeons ignore the scientific evidence and still recommend age 40?”

Yes, the benefit of screening is relatively small when considered in terms of the general population. Yes, the sensitivity of mammography has been overstated for many years. Yes, the false positives are an issue. Yes, some cancers found on screening would have been unlikely to cause problems during the lifetime of the patient.

However, consider the alternative – if you want to rely on self-exams, you are settling for Stage II breast cancer much of the time, or worse. With the American Society of Breast Surgeons recently endorsing age 40, supporting the American College of Radiology/Society of Breast Imaging, hopefully we can get back to worrying about the 5% rather than the 50% of eventual breast cancer victims whose lives are being jeopardized by the Task Force and their ilk.

As a post-script, it is a curious fact that the “engine” behind the HIP of Greater New York screening study – the first effort at early detection through screening mammography – was a general practitioner turned quasi-radiologist by the name of Philip Strax, MD whose wife died of breast cancer at age 39.

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