New ACP Guideline Calls for Individualized Risk Assessment

A recent clinical guideline (http://www.acponline.org/college/pressroom/mam_guideline.htm?hp) by the American College of Physicians (ACP) rocked the boat of the standard approach to routine screening for breast cancer. According to the new ACP guideline, the risks of screening mammography for healthy women between the ages of 40 and 49 may outweigh the potential benefits. What does the ACP recommend? That physicians discuss the risks and benefits of annual mammograms with their patients and tailor the screening protocol to each patient's risk profile and needs.

It is not hard to realize why this guideline has caused such an uproar in the medical community. We have all heard the mantra: Baseline mammogram at 35 and then annual mammograms starting at the age of 40. While there is a lot to be said for the "better safe than sorry" approach, the ACP guideline dares to advocate the individualization of medical protocol as well as patient involvement in the decision-making processes regarding their health.

Mammograms have been around for over 30 years and to this day there are no widely accepted substitutes. Other breast imaging techniques (e.g. MRI, ultrasound) have been proposed as complementary to a mammogram, but have not been found either sensitive or specific enough to replace mammograms. For example, MRIs can detect cancers that a mammogram may miss, but they also have a higher rate of false positives. Ultrasounds may safely diagnose a breast mass as benign and spare the patient the need for a biopsy, but they have a higher rate of false negatives than mammograms.

It is a gray area, no doubt. Mammograms are far from perfect - they may miss up to 20% of cancers - but it seems they are all we've got and, unquestionably, they help save lives. The ACP guideline does not refute the value of mammograms as screening and diagnostic tools, but it does remind us of the multitude of drawbacks and side-effects: the numerous false-positives with the ensuing stress and unnecessary additional procedures (including unnecessary biopsies that carry a rare but real risk of infection); the detection and treatment of lesions that may never have become clinically significant; the various risks of radiation exposure.

"First do no harm" is the cornerstone of medical practice. It is far from easy to determine when a mammogram is indicated and when it is redundant. No statistical model to date can process the multitude of risk factors and come up with a definite answer for each and everyone of us. Which is basically why we have chosen to err on the safe side. Now the ACP guideline poses the question: How safe is it to err on the safe side?

So, ladies, take care of yourselves. Do not neglect you breast self-exams and annual clinical breast exams and mammograms. But if you are between the ages 40 and 49, talk to your doctor about this guideline and how it may affect your cancer screening plan. Be detailed and specific about your lifestyle choices, diet, medical history, family history, risk factors, fears, and concerns. Listen to your doctor with an open mind. Ask questions. And then some. Then go ahead and do what is best for you, for both your physical and emotional well-being.