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Some Frank Talk on Women’s Health Screenings
By Dr. Amy Crawford-Faucher

Dr. Amy Crawford-FaucherAs a family physician, I spend a lot of time with patients discussing, and often recommending, screening tests. Some of these tests are proven to save lives by picking up diseases such as cancer early enough to be curable. Others, despite a lot of press from support groups and maybe your doctor, deserve a little more thought.

When it comes to screening tests, a few things should be kept in mind. to be worthwhile – to you personally, to public health generally, and to you and your insurer’s bottom line—a good screening test must:

  1. test for common diseases,
  2. be able to pick up that disease early enough to make a difference in treatment (i.e., to make your life better),
  3. be affordable, and
  4. have more benefit than harm.

Doctors don’t talk nearly enough with our patients about the potential harms of screening tests. I don’t mean that a blood test or X-ray itself is harmful, but that we sometimes find things in those studies that lead to more testing (often biopsies or other so-called invasive tests) that end up not improving a patient’s health. Getting an abnormal test result is emotionally distressing and the additional testing that results can be expensive and sometimes painful.  Remember that nothing in health care is “free” (even if you don’t have to pay out of pocket for it).   I am certainly not recommending against screening, but some tests deserve a thorough discussion about when an individual should have the test or how often.

The “Slam Dunks”
This category includes tests that meet all the aforementioned requirements . Unfortunately, it is a short list.

  1. Testing for cervical cancer (i.e., PAP tests). This test can actually prevent cancer by catching abnormal cells before they become cancerous. Those precancerous changes are fairly easily treated. All of the medical groups who recommend screening tests agree on this one. We start testing patients at age 21 (not before!) and test every 3 years until age 30. Then it is every 3 to 5 years depending on which tests are used. Someone does not need a PAP test every year unless something abnormal is found.

Mostly beneficial but read the fine print!
The tests in this group might be surprising, especially:

  1. Breast cancer screening (i.e., mammograms). Medical experts generally agree that mammograms done between the ages of 50 and 75 years are beneficial. That is, they find potentially serious breast cancers early so they can be successfully treated. 

So the benefit of screening is early detection and treatment of early breast cancers. But what about potential harm? One problem with mammograms is that they are very good at finding abnormal-looking changes. This can be a problem because determining which funky-looking changes are cancer and which are not often require additional mammograms, ultrasounds, and sometimes biopsies. Seventy percent of the time, that abnormal finding turns out to be NOT cancer. The financial cost, emotional worry, and pain from these additional tests equals the harms of screening.

The controversy lies in starting screening earlier than 50. In a person’s 40s, the ratio of benefits to harms of screening is not as clear. Because breast cancer is less common in younger ages, these mammograms are more likely to find those noncancerous changes that still require the extra testing I mentioned. We also just don’t know yet (but we suspect) that some of those early breast cancers may never grow or spread to cause problems.

So what is a woman in her 40s to do? Even the medical experts don’t agree on when to start mammogram screening and how often to get it. For women at the usual level of risk, one group recommends yearly mammograms starting at 40, another at 45, and another at 50, with either yearly or every other year mammograms. Th decision should be based on the individual’s balancing of risk factors, such as a family history of some cancers, and the desire to avoid excess testing, against the benefits of finding a breast cancer very early. In my own family I have women who would rather find and treat every abnormality, even if it may not make them healthier, and some who would rather avoid the harms of extra testing and have about the same chance of finding a treatable breast cancer.  Any of these decisions are reasonable, and should be discussed with your doctor.

Dr. Amy Crawford-Faucher is a family physician and the program director for the Forbes Family Medicine Residency Program of Allegheny Health Network and a member of the board of directors for the Family Medicine Education Consortium.

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