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.

This Doctor Still Wants to See You

The new medical guidelines and what they mean for you.

Every year, you used to visit your ob/gyn for a Pap test and pelvic exam. Then you’d get your mammogram. Some ladies I know made it a “girlfriends date” and went out to lunch after their mammos.

It was like getting your healthcare seal of approval. All’s well with the world. See you next year.

Now the “guidelines” have changed. You’ve heard that you don’t need these tests every year. In fact, depending on your age and health status, you may not need them any more at all.

Wait, what? Who re-arranged the furniture? What does this mean?

And more to the point: What happens to the girlfriends date?

With a slew of new guidelines from the American Cancer Society and the American College of Obstetricians and Gynecologists (ACOG) and the US Preventive Services Task Force, it’s no wonder you’re confused. One year? Three years? Beginning at what age? Ending when?

These guidelines reflect new thinking and research, not the removal of a time-honored safety net. You won’t be at greater risk—you just may not need the same tests on the same schedule. Also, different professional groups have come to slightly different conclusions about how often these preventive tests should be administered.

So, while it’s helpful to be aware of these changes, it’s also critical to discuss them with your own healthcare provider. Because your healthcare situation is unique, and guidelines are one-size-fits-all, the schedule has to be tailored to fit your specific needs. You and your doctor are the best ones to make that decision.

Here’s what some of the discussion is about.

The value of an annual physical, which ACOG also refers to as a “well-woman visit,” is that your doctor can examine and assess your overall level of health and can check for changes or abnormalities. A regular visit also keeps intact the relationship between you and your doctor. After all, it’s important to trust this person when healthcare decisions need to be made.

During your annual physical, your provider may do a pelvic examination. Herein lies some confusion. A doctor may, and often will, do this exam without a Pap test. A pelvic exam allows the doctor to take a thorough look at your external genitalia and to digitally (yes, with a finger in your vagina or rectum) examine your cervix, uterus, and other internal organs.

In its new guidelines, ACOG recommends an annual pelvic examination in women over 21. But the guidelines also state that, while an annual pelvic exam “seems logical… No evidence supports or refutes the annual pelvic examination or speculum and bimanual examination for the asymptomatic, low-risk patient.”

Translation: in the absence of symptoms, the final decision is up to you and your doctor. Pelvic exams are also important if you have any pain, discharge, bleeding, or change in bowel or bladder function. Your doctor needs to know about any of these issues.

As for the Pap test—you probably know that it only screens for cervical cancer—it’s been a very effective tool in that regard. But many women don’t need screening for cervical cancer anymore—if they no longer have a cervix, if they’ve had several normal pap tests and don’t have a lot of sexual partners.

Be aware, however, that there are other cancers of the genitals and reproductive organs, and I’ve occasionally found them during a pelvic exam: You’d better believe I still recommend an annual physical that includes a pelvic exam for my patients.

The guidelines for mammograms are even more confusing. The American Cancer Society still recommends annual screening after age 40. However, the US Preventive Services Task Force recently revised its guidelines after analyzing data extensively, to screenings every two years for women over 50. Women over 74 no longer need mammograms, according to the Task Force.

Meanwhile, physicians routinely do manual breast exams in their offices. That’s the kneading, palpating exam the doc performs to check for changes and lumps. While ACOG and other organizations still recommend a clinical breast exam every one to three years, the US Preventive Services Task Force says that “current evidence is insufficient to assess the additional benefits and harms of clinical breast examinations….”

So, what’s a woman to do?

Again, talk with your doctor. It’s good to be informed about changing guidelines and protocols. These changes only mean that research is ongoing and the body of knowledge is increasing. But you have unique risk factors, heredity, health issues, fears, lifestyle choices, and preferences. The best way to make sense of the guidelines is to discuss them with your provider in light of your personal situation, and then come to a conclusion that you’re both comfortable with.