The following article is adapted from Carla Mills’ blog, which is available at www.maverickhealth.com/blog. Although written for women in general, it provides important insight for nurse practitioners (NPs).

Last fall, the US Preventive Task Force (USPTF) Services recommended that screening mammograms no longer be routinely required for women in their 40s and that breast selfexamination (BSE) no longer be advised. What! Is this just cost-cutting, or is it good medicine?

Mammogram Recommendations for Whom?
Before deciding how to react to these guidelines and whether to follow them or not, the first order of business is to put them in perspective in terms of your own personal and comprehensive health-care plan. It is my position that you—not doctors, task forces, organized medicine, or insurance companies—should be in charge of your health and health care.

Government agencies (like the USPTF), doctors, and insurance companies exist to serve you—not to dictate to you. To get the most out of these services, you must be the one in charge. This means taking on more responsibility for knowing your own circumstances. That’s how you will be able to determine where you fit into the new guidelines. Government agencies come up with recommendations for whole populations, but treatment decisions must be made by and for individuals.

Health Risk Screening in General
Cancer screenings and, in fact, all health screenings are designed to discover and treat diseases that may not yet be causing symptoms. The goal of screening is early detection to (hopefully) cure but at least to treat problems before they develop into chronic diseases or cause death.

Different people have different levels of risk for a long list of chronic diseases and cancers. Risks are the result of family history, personal lifestyle behaviors, and, to some extent, luck. I wrote my book A Nurse Practitioner’s Guide to Smart Health Choices specifically to help nonmedical readers determine their particular risk profile so that they are able to direct their health and health care intelligently. Different individuals have different risk tolerances, and your choice about what to do about these recommendations depends a lot on your own personal risk tolerance. You may love taking risks. Does jumping out of an airplane sound like fun to you? Or you may hate risk. Do you find stepping outside your own home so risky that you dread doing it? Most of us fall somewhere in between these two extremes, but our attitudes about risk determine how we choose to handle our health and health care. One size does not fit all.

The USPTF Mammogram Recommendation
The USPTF recommendation statement was directed at “women 40 years or older who are not at increased risk for breast cancer by virtue of a known underlying genetic mutation (i.e. a strong family history of breast cancer or known BRCA 1 or BRCA 2 genes from prior genetic testing) or a history of chest radiation.” The USPTF came to the following six conclusions.

1. For biennial screening mammography in women aged 40 to 49 years, there is moderate certainty that the net benefit is small. Although the USPSTF recognizes that the benefit of screening seems equivalent for women aged 40 to 49 years and 50 to 59 years, the incidence of breast cancer and the consequences differ. The USPSTF emphasizes the adverse consequences for most women—who will not develop breast cancer—and therefore uses the number needed to screen to save one life as its metric. By this metric, the USPTF concludes that there is moderate evidence that the net benefit is small for women aged 40 to 49 years.

2. For biennial screening mammography in women aged 50 to 74 years, there is moderate certainty that the net benefit is moderate.

3. For screening mammography in women aged 75 years or older, evidence is lacking, and the balance of benefits and harms cannot be determined.

4. For the teaching of BSE, there is moderate certainty that the harms outweigh the benefits.

5. For CBE (clinical breast exam) as a supplement to mammography, evidence is lacking, and the balance of benefits and harms cannot be determined.

6. For digital mammography and magnetic resonance imaging (MRI) as a replacement for mammography, the evidence is lacking, and the balance of benefits and harms cannot be determined.

What I Tell My Patients
1. My clinical concern and responsibility is taking care of individuals, not populations. A single case of breast cancer missed is one too many as far as I am concerned. Even though mammography is not the most perfect test in the world, particularly in women under age 50, the practice of combining screening with mammography, an annual CBE, and a monthly or bimonthly BSE is the best we’ve got at present in my opinion. I plan to continue to recommend a baseline mammogram between ages 35 and 40 and will subsequently determine frequency based on each woman’s particular risks and her financial ability to pay for the mammogram. As for the issue of “adverse consequences” raised by the task force (ie, anxiety surrounding testing or additional testing such as ultrasounds or biopsies if the mammogram is questionable), it is a non-issue in my opinion. A little anxiety surrounding screening or diagnostic testing pales in comparison to the anxiety associated with a diagnosis of breast cancer. If the mammogram is questionable, additional testing clarifies an individual’s breast status at any age.

2. For women aged 50 to 74 years, I’ll continue to recommend annual breast surveillance consisting of screening mammography, annual CBE, and a monthly or bimonthly BSE.

3. Breast cancer risk increases with age. For women aged 75 and older in good health, I will continue to recommend annual breast surveillance consisting of screening mammography, annual CBE, and a monthly or bimonthly BSE. Exceptions include women who are in poor health and would not be good candidates for breast cancer treatment or women who tell me that if they learned they had breast cancer they would not want any treatment.

4. I really don’t understand this recommendation. What possible “harms” can come from examining one’s own breasts for lumps, and who exactly would be harmed? Why anyone would recommend that women stop BSE is beyond me. My sister picked up her own breast cancer with BSE only a few months after her mammogram missed it. Because she caught it early, her treatment was less invasive and more likely to have resulted in a cure. I will continue to encourage and teach BSE to my patients.

5. For CBE (performed by your health professional at your physical exam), the USPTF says that it doesn’t know if it does any good or not. I haven’t picked up many breast cancers that way over the years, but I have picked up a few. In my practice, we recommend annual physical exams even though their “benefit” is also under question. The annual physical exam is an opportunity to do a very detailed exam of the whole body (not just a gynecological exam), check on whether health screenings are all up to date, and teach things like BSE and self skin exams, among other things.

6. Digital mammography and breast MRI are also question marks as far as the task force is concerned. At present, radiology centers are upgrading to digital, and it will be the new standard. Skilled radiologists reading the films—whether plain or digital—are still an essential component. In the last study I read, radiologists are still beating computers in reading digital mammograms. Breast MRIs are expensive and currently are used only for high-risk patients or as a follow-up to abnormal mammograms.

The Bottom Line
The best person to take care of you is you. If you’re lucky, you have a competent and understanding health professional in the form of an NP, physician, or physician assistant to help you and advocate for you. If you don’t—see if you can find one.