Navigating Breast Health

Breasts play a role in our sexual response, as I’ve described before. Our nipples are bundles of nerve endings that respond to touch. Some women (though not most) can reach orgasm through nipple stimulation alone. Others of us rely on breast and nipple fondling to put them “over the top” in experiencing orgasm during oral sex or vaginal intercourse. So while breast cancer isn’t central to my focus on women’s sexuality, it’s obviously connected—as the heel bone is to the ankle bone, the ankle bone to the shin bone. And because in my practice, I advise women on many aspects of their health, I pay attention to the discussion about mammograms and breast cancer diagnosis. It’s complicated, and it’s controversial right now. An article in the New York Times last month previewed a study published in JAA Internal Medicine. Dr. H. Gilbert Welch, of the Dartmouth Institute, concludes that three to fourteen 50-year-old women in 1,000 (that range tells you something of the current controversy about data) will be overdiagnosed and overtreated as a result of mammograms. Zero to three women in that same 1,000 will avoid a breast-cancer death. Dr. Welch encourages more study, but also concludes that mammograms are over-used and ineffective. That article prompted an almost immediate response from Dr. Elaine Schattner. Dr. Schattner takes issue with the notion that women are overly harmed by false positives. Mammogram technology is “more accurate and involves less radiation than ever before,” she says. Instead of doing more study, she suggests we focus on making high-quality screening facilities available to all women, get really good at accurately reading the images, and let women themselves decide how to manage the balance between risk and reward. In my own practice, I use the guidance from the American Congress of Obstetricians and Gynecologists, which calls for annual mammograms for best early detection. I balance that with my own knowledge of each woman’s history and risk factors, but it’s still complicated. I might have a patient whose mammogram comes back entirely negative—which is positive!—but still receive a recommendation for further imaging because of family history. The family history might be for cancer detected in a woman in her 80s or 90s. Cost factors in, too, both individually and collectively. As more of my patients have high-deductible health insurance, the decision about whether to have an MRI is more consequential. And, of course, tests that aren’t necessary or productive are part of what’s driving the cost of health care up for all of us. And yet! Given where we are with treatment, early detection remains one of our best assets in combating breast cancer. I’m reminded of an earlier paper that concluded that of the study subjects—women from 40 to 49 with stage I, II, or III invasive breast cancer—77 percent who died hadn’t had regular screenings. As a physician, I’m frustrated by the difficulty we have in sending consistent messages to women. I don’t want women to be afraid of breast cancer, but neither do I want them to be casual or skeptical about screening methods—like mammograms—that are relatively low risk and low cost. What about you? Are you confused by what you read about mammograms? Do you know what’s recommended for you? Do you follow those recommendations? Are you confident your health care provider is taking you—individually—into account? Have you had to navigate insurance guidance as well as medical guidance? The worst thing we can do is to throw up our hands and give in to the ambiguity. The best thing we can do is to encourage each other, speak up, demand common sense paths to follow, and work to make screening readily available.

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