11.17.09

The Great Mammogram Debate

This week’s stunning reversal on when women should get mammograms lays bare our disturbing ignorance about women’s bodies. Liesl Schillinger on why a fundamental female health issue is so difficult to resolve.

I can hardly remember a time when I wasn’t being warned of the menaces that threaten the female body. Pregnancy, rape, herpes, AIDS, and chlamydia; breast cancer, uterine cancer, and so on and so on. In junior high school sex-ed class, when we girls were 12, and only half of us had anything to put in a bra, a conscientious health worker visited our class with a “cancer”-riddled bust: a mannequin of a female torso whose breasts had been mined with tumors. Before we necessarily had breasts, we were instructed to palpate the diseased, curvaceous effigy to feel for lumps. That way, if—or more likely, when—our own developing chests betrayed us one day, we’d know the signs. One day, we were giggling over Are You There God? It’s Me, Margaret and chanting that “we must increase our bust”; the next, we were learning that the sweatered protuberances that were of such intense interest to our male peers were a source of latent disease.

We were shown a film of a young woman practicing the gentle art of Self Breast Examination and commanded to examine ourselves in the shower from that day forward—you never knew when your boobs might do you in. Did boys get a similarly dark message in their sex-ed classes, about the lurking menace of prostate and testicular cancer? Not having been a boy, I don’t know, but somehow I doubt it.

How can issues of such life-and-death importance to women—more than half the population—be so murkily understood, and so conflictingly explained? Are medical authorities playing a guessing game with women’s health?

Big Fat Story: The New Breast Cancer Rules Fast-forward to adulthood. We women were told that, once we hit 40, our breasts would become even more dangerous than they had been all along, and that we should submit to annual mammograms, so that radiologists could peer at images of our soft tissue to check for cancers or suspicious blips that might turn into cancer. For women with dense, firm breasts (e.g. most young women, and some older women), many blips often appear whose significance or insignificance cannot be determined from the X-ray alone. A biopsy, in the majority of cases, reveals the blip to be benign. Yet in other cases, a biopsy reveals cancer, whose early detection and treatment can save a woman’s life. Mammograms may be uncomfortable, and biopsies may be dreaded, but most women do not question the utility of them. If mammograms help preserve our health and our lives, we want them.

For anyone who has not had a mammogram, here’s what’s involved: You position your breasts (one at a time) onto a clear platform. Another clear platform is cranked down from above until the breast is flattened between the two plates like a Fruit Roll-Up, or like the sci-fi Terminator monster when he’s smashed in the pounder at the end of the first Terminator movie. Men: To get a sense of how this feels, imagine that your testicle is on the slab. If men were told to regularly submit to this procedure, they likely would refuse, and a less painful method would have to be devised. But women, typically, are more heedful of the advice of medical authorities, and more eager to act in what they believe to be the best interests of their health.

But what is in the best interests of a woman’s health? Do the authorities who advise us even know? This week a national health panel, the United States Preventive Services Task Force, reversed the long-accepted medical wisdom that women should get annual mammograms from the age of 40 on. Instead, they announced, women who do not have exceptional risk factors for breast cancer should put off getting mammograms to the age of 50, and thereafter get them only every two years, not annually. What new scientific information can explain such a dramatic turnaround? In The New York Times, Gina Kolata reported that the new guidelines were “aimed at reducing harm from overtreatment.” She continued, “Over all, the report says, the modest benefit of mammograms—reducing the breast cancer death rate by 15 percent—must be weighed against the harms.”

What harms? Are there dangers associated with repeatedly exposing healthy tissue to direct radiation? Or are there other harms? If so, why haven’t we been told before now? Any woman who nervously asks a doctor or nurse about the risk of mammograms is told that the risk is minimal and is far outweighed by the advantages of early screening. But is this true? Certainly, anyone who has been saved by early detection of breast cancer would fiercely defend the advantages of screening. It’s magnificent that in the last 30 years, breast cancer has evolved from a miserable secret suffered in silence to a condition that women—and men, too—discuss openly and assertively, marching, wearing pink ribbons, and working to support advances toward a cure. Well-known women, from Betty Ford in the ’70s to Christina Applegate in this decade, have courageously shared their cancer diagnoses and survival stories with the public, demystifying the disease and making women less afraid to seek diagnosis and treatment.

And yet: Is it possible that, lately, well-intended women, desiring to be responsible and proactive, are exposing themselves to unnecessary medical procedures and stress? Who can tell us? And again, what are the concrete harms, if any, of mammography? Judith Graham, reporting on the panel’s reversal in The Chicago Tribune this week, wrote, “Mammograms help save lives, but they also can be unreliable, identifying benign growths as cancerous, missing other tumors that are malignant and sometimes leading to medical interventions of questionable benefit.” What quantification exists for these claims? A study in the Annals of Internal Medicine, also published Monday, noted, according to Graham, that a “40-year-old’s risk of being diagnosed with invasive breast cancer before her 50th birthday is only 1.44 percent. Most women vastly overestimate these risks and believe that starting screening younger is advisable.”

So should young women screen? The panel, passing the buck, advised women to take up the issue with their doctors. The panel also discounted the worth of Self Breast Exam—debunking the educational filmstrip my pre-teen pals and I absorbed so dutifully so long ago. Does this mean that we all should have just been enjoying our figures all along, not fearing them? The only consistent message from the scientific community to women is to be afraid. How can issues of such life-and-death importance to women—more than half the population—be so murkily understood, and so conflictingly explained? Are medical authorities playing a guessing game with women’s health?

This week, the experts tell us that women in their 40s now have permission to skip routine mammograms, though the American Cancer Society continues to recommend annual mammograms for women age 40 and over. But what will they say next week? And on what basis? The fact that the fundamental question—are mammograms necessary?—has no solid answer is disturbing. And equally disturbing is the anxiety our culture imposes on women, as they wait, as ever, for other people to tell them how to regard their bodies, themselves.

Liesl Schillinger is a New York-based writer and literary critic whose work has appeared in The New York Times, The New Yorker, New York magazine, The Washington Post, the New Republic, The London Independent on Sunday, and other publications here and abroad.