White Coat, Black Art

Canada's guidelines say most women in their 40s don't need a mammogram. This breast cancer survivor disagrees

Currently, the Canadian Task Force on Preventive Health Care (CTFPHC) doesn't recommend a mammogram for women aged 40 to 49 if they don't have any pre-existing factors that put them at risk of breast cancer. Some experts and breast cancer survivors worry that women are getting the wrong message.

Task force chair Dr. Brett Thombs defends the Canadian guidelines 'as among the best in the world'

Rebecca Hollingsworth was 44 years old when a mammogram discovered she had a tumour in her breast. (Dr. Brian Goldman/CBC)

Originally published on Dec 13, 2019.

Rebecca Hollingsworth credits self-exams and mammograms for detecting her breast cancer early enough to get effective treatment.

When she was 44 years old, she discovered her breasts felt different enough to raise an alarm. 

Hollingsworth, who lives in Ottawa, requested a mammogram, even though the current Canadian guidelines — released in late 2018 — don't recommend them for most women younger than 50 years old.

The mammogram found a three-centimetre tumour in her breast. A subsequent MRI found five more.

"I was devastated. I really, truly did not believe that this was going to happen to me," she told White Coat, Black Art host Dr. Brian Goldman.

I don't even want to think if I'd waited until I was 50 for my first mammogram … Would it have spread?- Rebecca Hollingsworth 

Currently, the Canadian Task Force on Preventive Health Care (CTFPHC) doesn't recommend a mammogram for women aged 40 to 49 if they don't have any pre-existing factors that put them at risk of breast cancer, such as if a family member had breast cancer, or if they had the BRCA gene.

Hollingsworth had none of these factors.

"I don't even want to think if I'd waited until I was 50 for my first mammogram … Would it have spread? It could be a completely different outcome."

The task force states that while most women see a "modest reduction in breast cancer mortality" with a mammogram, the benefit is lowest in women younger than 50.

Doctor, survivor dispute guidelines

Women in their 40s without increased risk factors can still request a mammogram, but need a referral from their doctor first.

Women aged 50 to 69 years old are recommended to get a mammogram every two to three years. After their first screening, they will receive a letter at regular intervals to remind them to schedule their next one.

Dr. Jean Seely, head of breast imaging at the Ottawa Hospital, says the guidelines don't reflect the reality she sees in her practice.

She says she often sees women in their 40s who found a lump, which could have been found at an earlier — and more treatable — stage with a mammogram.

Dr. Jean Seely (standing) with radiology technologists in an MRI suite at The Ottawa Hospital. Dr. Seely is raising funds for what would be Canada's first MRI devoted exclusively to breast imaging, (Dr. Brian Goldman/CBC)

"I think they shouldn't be listening to the task force ... because even delaying a diagnosis for three or four months can have an impact on their outcome — their survival."

Seely also pointed to a 2014 pan-Canadian study of 2.7 million women on mammogram screening that showed an average mortality reduction of 40 per cent, which was true of all age groups, including women in their 40s.

In the U.S., the American Cancer Society recommends annual mammograms for women aged 45 to 54, switching to every two years for women 55 and older.

In an email to White Coat, Black Art, the task force chair Dr. Brett Thombs defended the Canadian guidelines, describing them as "widely recognized as among the best in the world" by bodies including the American College of Physicians.

Thombs added that the guidelines "[do] not prescribe against or for screening for any women. Indeed, our mammography recommendations are conditional on women's values and preferences."

The guidelines are based on randomized controlled trials, which are considered the most accurate because the results are designed to be unbiased.

Technologist Erin Fowlie looks at images taken during a breast biopsy. (Dr. Brian Goldman/CBC)

Most provinces, including Ontario, follow the guidelines. But some deviate from them, including Nova Scotia, P.E.I. and B.C.

"The problem with not being in a provincial screening program is that you don't get the benefit of getting the invitation. You're not nudged to say, it's time to start thinking of being screened," Seely said.

The guidelines also say that women in their 40s are most susceptible to overdiagnosis and false positives compared to older women, leading to anxiety and undue stress.

Hollingsworth, who was treated by Seely, says "it's nothing compared to the anxiety that you have with a breast cancer diagnosis."

She also takes issue with the task force no longer recommending self-examinations since a 2011 update, which states it found a self-exam "has no impact on breast cancer mortality."

"It's so disturbing to me. I think that it's absolutely ludicrous that they would tell a woman not to do [a] breast self-exam."

'Start thinking about breast health'

According to Dr. Colin Mar, B.C.'s cancer agency has taken steps to help better inform women, recognizing that mammogram screening can be a complicated and confusing issue.

"We know we will find some cancers in the 40-year-old age group, and we wanted to allow that decision to be made," said Mar, medical director for B.C.'s breast cancer screening program.

Dr. Colin Mar, medical director for B.C.'s breast cancer screening program, helped develop an online breast cancer detection aid. (BC Cancer Society)

He echoed the task force's confidence in the randomized trials, but allowed that other observational studies could provide useful information — as long as their results are properly vetted.

"I think that anything new is worth looking at; it has to be evaluated with a critical eye," he said.

Mar also helped develop an online breast cancer detection aid, which asks a series of questions to calculate both your risk of getting breast cancer, and false positives.

I think any woman — even in their 30s — should start thinking about breast health.- Dr. Colin Mar

He says the tool, which is available to anyone in Canada, is used between 3,000 and 3,500 times per year in B.C. He credits this to a general awareness of the importance of breast health among women and their doctors.

"I think any woman — even in their 30s — should start thinking about breast health. And leading up through that decade to their 40s, hopefully that discussion and informing themselves will include talking to their doctor, and of course thinking about their family risk factors, as that might modify their own breast cancer risk," he said.

While the updated guidelines were intended to give women more choice by suggesting they and their doctor make a shared decision about screening, Hollingsworth isn't confident those discussions are routine.

"It's not something necessarily that your doctor is going to bring forward to you the day you hit 35, 40, 45, whatever it is. This is something that, for now anyway, is going to have to come from you."

Written by Jonathan Ore. Produced by Sujata Berry.


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