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The Great Mammogram Debate
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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.
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Paul Schrodt is a writer living in New York City. He has contributed to New York magazine, Radar, and Esquire.com.
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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.
cbeenthere
I know women read TDB, where are the comments and shared experiences?
Your article is correct in addressing the fear factor. I, myself, now 63, went through it in my forties, but I was not exposed to the lecture you were at 12, thank heavens. When will they get it right? After a review of my mammogram by a radiologist, and conferring doctor the same day as my mammogram was taken, I was immediately sent to a surgeon. Fortunately, for me, I was referred to Georgetown University, where my doctor chose to watch rather than biopsy. I am to this day grateful for this approach.
In my mother's day fibroids were considered a pre-cancerous condition, and she underwent an unnecessary hysterectomy. I too, had fibroids, but fortunately they were no longer treated by a hysterectomy.
One thing I am can do is to do is to make my nieces aware of family history, which is good, in hopes that it will inform the decisions they face.
Thanks for the article, you are correct about the fear and lack of knowledge of women's bodies, but where are the women who should be reading this?
I hope this does not turn into a political issue in regard to health care reform.
rchaynes
Thanks for this thoughtful article, Liesl. The most important takeaway here, in my opinion, is that we have been taught to view our bodies as a disease waiting to happen. I've always been appalled by this. In my 40s, I pushed back on anxious gynecologists and had a mammogram every two or three years. At 53, I still insist on every two years or so, following British rather than American guidelines. I also never do monthly breast exams -- mine are lumpy and I'd spend half my time at the doctor's office in a panic. What kind of way is that to live? Though terribly unscientific, there is also the possibility that the fear of breast cancer can help bring it on. And then all that exposure to x-rays and other scanning equipment -- can't that accumulate in such sensitive tissue?
In brief, women should not spend their lives in fear of their bodies and imminent disease. A reasonable amount of caution is important, of course, but if doctors had their way, we'd spend all of our time in their waiting rooms. Follow the money.
CarrieAnn
Yes, there is great harm from the repeated radiation of yearly mammograms. There are other methods of early breast cancer detection that are radiation-free and can find evidence of disease years earlier than mammograms -- specifically thermography and HALO, a procedure that examines nipple fluid. Yet the FDA hasn't approved these procedures. There's a big "why" that needs answered.
dooreen
My health classes were a lot different that the one described.
They were more like listening to a deodorant, tampon, and razer infomercials and an art class all in one.
We had to draw the female and male reproductive organs and label the parts and if we giggled, especially when drawing the opposite sex one, we would get a stern look from the gym teacher.
Bongenre
Testicles are extremely sensitive, and logically so.
As a citizen of the world, I have mistakenly elbowed many a ladies' bosom, and their reactions were invariably not compatible with the amount of pain you can inflict on a testicle with one finger. You're sort of full of shit, lady.
SusanSaid
You weren't paying attention and your lack of empathy and understanding diminishes you. The flesh of the breast is not meant to be flattened to a quarter of an inch and the act of doing so is unbelievably painful, as painful as having someone squeeze your testicles. You can't be much of a citizen of the world, or you would know women better and you wouldn't have made such a stupid remark. Please go make friends with some women and get your story straight.
SusanSaid
Did anyone think it was odd that a major study, designed to reduce medical costs, was aimed at women's health. Where are the studies to reduce costs of test given to men? I don't remember the exact numbers, but wasn't nearly twice as much money spent researching male impotency versus breast cancer? When we finally get practices in place to help PREVENT breast cancer, since the money devoted to breast cancer treatment has been sidelined to male impotence, some doofus decides that women don't need or deserve the amount of health care necessary for PREVENTATIVE MEDICINE either!
Which tests associated with male health cost more than the tests associated with women's and don't they deserve the same treatment?
Much of the debate over the current health plan is the insurance companies willingness to reduce health care to a set of actuarial tables weighing profits against health care - and this study panders to that kind of thinking but not at the expense of men, only women might die. Where is the similar study for men and believe me when that study hits the media, won't men have a fit!
I do smell the unmistakable scent of inequality - and we thought that was behind us.
Is this new study a bone the administration throws to the health care industry?
word2thewyz
Liesl raises a lot of thoughtful questions, but the answers to those questions aren't as difficult as some folks are making them out to be. Unfortunately, a lot of misinformation and confusion have gotten in the way. The recommendation wasn't that NO women under 40 should be screened. It was that they should not be screened "routinely," because no blanket statement can be accurately applied to all women in that age group. That's why women in that age group should individually consult their doctors. It was by no means passing the buck.
Now let's talk about what this was NOT. It was not a "major study." It was a recommendation by an independent panel who reviewed major studies from around the world. And the recommendation was not designed to reduce medical costs. It was designed to advise the public and health care professionals about what works, what doesn't and how the health risks of a service compare with the health benefits. And it's not a "bone" thrown to the health care industry, because most of the industry would like to make money by providing more mammograms.
Thank you.
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