Ashkenazi Jewish women are 13 times more likely than non-Jewish women to carry a genetic mutation that causes women in their 30s or 40s to be diagnosed with breast cancer.
This phenomenon puts one of every 40 Ashkenazi Jewish at increased risk of getting breast cancer.
For these and other at-risk women, new recommendations to change national mammography standards — starting screenings at age 50 instead of the previously recommended age 40 — simply do not apply.
“For many of us who were diagnosed, as I was, before the age of 40, the notion of being asked to wait until 50 to be screened by mammography for the first time seems preposterous,” said Rochelle Shoretz, founding director of Sharsheret, a Jewish nonprofit that provides resources and support to young, generally premenopausal Jewish women with breast cancer.
Based on an analysis of existing trials that looked at the impact of mammography on breast cancer deaths, the U.S. Preventive Services Task Force of the Department of Health and Human Services recommended that women between 50 and 74 get screened every two years instead of annually. Such a change would avoid unnecessary radiation exposure and false positives, the report said.
Doctors, breast cancer survivors and advocates erupted in debate over the new recommendations after they were announced in November.
“I certainly understand the angst that’s been generated by this report,” said Niecee Singer Schonberger, Sharsheret’s genetic counselor. “But the most important thing to remember is that these are guidelines are for women of average risk — not increased risk.”
A woman who carries the BRCA1 or BRCA2 genetic mutations has an 85 percent chance of developing breast cancer by age 70. An individual who learns from a genetic test that she has these mutations “should be screened every six months,” said Dr. Laura Esserman, a nationally known breast surgeon in San Francisco. “Because they tend to have aggressive cancers, screening at one-year intervals is not enough.”
Another risk factor for developing breast cancer is a family history of the disease. If a woman has a first-degree relative (mother, daughter, sister) diagnosed with breast cancer, especially early-onset, she is also at higher risk — even if she does not carry the BRCA1 or BRCA2 genes.
These women need to find out how old their relative was at diagnosis and start annual screenings five years before reaching that age.
“If you have a mother who had breast cancer at 37 or 44, rather than age 72, that screams and yells ‘risk factor,’ and you’ve got to have mammography between age 40 and 50,” said Dr. Richard Cohen, a medical oncologist at California Pacific Medical Center and a professor at UCSF.
One complicating factor is that many women in their 40s — and especially women in their 20s and 30s —have dense breasts, which makes mammography more difficult to interpret. The X-ray might miss some cancers because it can’t detect them, or a radiologist might see benign tissue and mistakenly identify it as cancerous — which leads to unnecessary treatment, anxiety and medical bills.
“The issue with women in their 40s is that the screening is not as effective” because breast density makes mammography less accurate, Esserman said. Younger women who need a mammogram because of their risk factors should get an MRI in place of a mammogram, or alternate between the two tests once or twice a year, she said.
Women who have no family history of breast cancer nor a genetic predisposition can adopt the Task Force’s recommendations and decrease the frequency of their mammograms — but first should talk to their doctor to determine a personalized screening schedule based upon their health and history, Sharsheret’s Shoretz said.
Just three weeks before the task force recommendations were released, Esserman co-authored an analysis in the Journal of the American Medical Association that suggested cancer screening is not the panacea people believe it to be.
Screening for prostate and breast cancer, she and her colleagues wrote, can have harmful and unintended consequences, such as false positives that can lead to unnecessary and aggressive treatment for patients.
“We have to understand that mammography actually does increase the chance of being diagnosed with a low-risk cancer, and it’s important that we use the right tools to help us understand the risks that each cancer poses so we don’t wind up overtreating,” Esserman said.
Esserman, a professor at UCSF Medical Center and director of the Carol Franc Buck Breast Care Center, also noted that mammograms often miss the most deadly, fast-growing cancers that flare up between screenings, but catch the slow-growing cancers that don’t always need immediate treatment because the tissue might simply be reabsorbed into the body and never evolve into a more aggressive cancer.
“We need to do a better job understanding who’s at risk for what kind of cancer so we can do a better job of developing the right screening tools,” she said.
She’s made it her mission to find those better tools. Next year, all five medical schools in the U.C. system will start tracking 150,000 breast cancer patients in one common database — the Athena Breast Health Network.
Doctors will track women for several decades and analyze their mammogram results as well as biopsy, cancer and blood specimens to allow large-scale comparative research to help tailor treatments and accelerate the search for better prevention, screening and treatment.
Another of Esserman’s projects is the Web site www.breasthealthdecisions.org, which will be available in a few months as a resource for primary care physicians and patients to learn more about their risks and options for treatment.
“Even though the tools we have are imperfect, we can start there and develop better ones,” Esserman said. “We should not settle for doing things as we’ve always done. We want to make it better.”