Bone Density Tests and Mammograms: Pros and Cons
November 16, 2021 1:35 PM   Subscribe

I tend to think the U.S. prescribes too many drugs and tests, compared to their peers in other industrialized countries. I also read Barbara Eichenreich's Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer, and found it largely convincing. I'm posting because I’m looking for articles, research studies and comparative information on testing practices in other industrialized countries for two medical "lady tests": Bone density and mammograms. Can you help?

(1) A few years ago my gyno suggested I take medicine to prevent osteoporosis. I can no longer recall the name of it, or the particulars of what I found, but I looked it up and, at least at that time, found little evidence of its worth, so I ignored her. Now she wants me to take a bone density test.

My main risk factor for osteoporosis is that I'm slight. But I'm well under 65, no woman in my family has suffered from it, I eat well, exercise and am reasonably, if not overly, active. What are the pros and cons of getting this now?

(2) For the second or third time, my gyno wants me to get a mammogram. Again, I have few risk factors and no breast cancer in the family. I also did a lot of reading about mammograms in the past, and knew, at one point, more than a dozen woman with false positives (including my mother), which is when I began to question their worth. Later, this was more than a decade ago, there was a widespread reassessment of their worth, and the conclusion was that mammogram xrays are not well suited to the task (all the false positives), that multiple x-rays can cause harm, as can biopsies. At that time, much of the EU raised their recommendations for the age of a first mammogram. The U.S., if I recall correctly, was too politicized to do so. What is current best practice (apolitical) scientific thinking on this? And what do you think of the notion of a "baseline" test?

Note: I am not looking for outlier anecdotes about people you know who were saved by one or both tests even though I'm glad for them. I'm looking for well analyzed scientific thought on any side.
posted by Puppetry for Privacy to Health & Fitness (13 answers total) 8 users marked this as a favorite
 
I have friends who have been working overseas for over a decade in India, China and now Malaysia and they are always talking about the extensive annual medical testing that is the standard over there. This definitely includes bloodwork, bone density tests and mammograms for women. It doesn't lead to more medications but rather a more intense focus on wellness in general. I think it's the concept of integrated healthcare referred to in this study.
posted by victoriab at 1:59 PM on November 16, 2021 [5 favorites]


I'm a person with lumpy breasts. I think it's worth understanding the difference between a "false positive" that just means "You need to come back here for some more imaging" and one that is "We said you had cancer when you didn't." My understanding of the process is that a basic mammogram can sometimes find important things but sometimes it also can just say "This thing needs more inspection" at which point you'd go in for an ultrasound or possibly a biopsy or more intensive mammogram (maybe?). The downside of this approach is that getting a callback that says "Hey we want to take a closer look at this" can be nervewracking. The one thing the US tends to get right about mammograms is that they are generally free if you are insured or have a Planned Parenthood nearby.

And I'm only mentioning this non-scientific feedback because you also asked what we thought of a baseline test. Generally speaking, it's not a bad idea to get some basic medical work (blood tests, mammograms, not sure what else) so that you know what you're like and how you're doing when you're just being you. As someone with lumpy breasts, since I know this about myself it can both be information to give to the mammogram tech so that they can do the test well and also information that can help deter false positives because it can be an "Oh we know you've got a cyst in that area because of your last test so we're not going to go all in on checking it out again unless it changes appearance"

It's worth knowing that mammograms are lower-energy x-rays than usual x-rays. The Wikipedia page for mammograms states that (for some non-US stats) "The Canadian Task Force on Preventive Health Care (2012) and the European Cancer Observatory (2011) recommend mammography every 2 to 3 years between ages 50 and 69." That article has a lot of good information about mortality stats vs screening stats.
posted by jessamyn at 2:03 PM on November 16, 2021 [16 favorites]


I don't know about bone density tests, but I just read this interesting review paper from 2018 about mammography from Current Oncology Screening for breast cancer in 2018—what should we be doing today? I didn't know until I read this paper that mammography was only invented in 1988! Which makes the changing guidelines around mammography make much more sense. It also notes that we just don't have as much data about mammography for women under 50.

The paper notes that, as jessamyn says, most false-positive mammogram readings only require more imaging, not biopsy or treatment. They also get into the question of overdiagnosis/overdetection/overtreatment - i.e. detecting and then treating cancers that truly are cancer but would have just sat around quietly and not have caused you any trouble, which is a bit more complicated both statistically and otherwise.

I am 43 and in the US and had been planning on waiting until 50 to start getting regular mammograms but that paper actually made me reconsider, and next time my PCP bugs me about it I'll probably go for it.
posted by mskyle at 2:14 PM on November 16, 2021 [1 favorite]


I waited until 45 to start having mammograms; my OB/GYN was supportive when I asked her about it. There is no history of breast cancer in my family. The doc explained that there are 5 different professional associations, all with different bases for their recommendations, and that the most stringent one, which recommends starting at 40, is the association of people who perform the test. Other groups advise waiting until 50 for people in my position. People with unknown medical histories, or with documented BC in their families, might want to start earlier.

I wasn't super keen on starting them, but at 45 something changed in my head and I have now got a couple on record. (I'm also super not great at doing self-exams, which my doc really recommended if I planned to wait to begin. I know that they are part of the picture and I just always forget.)

As someone who didn't grow up in the US, I think that preventative medicine is a major benefit of a universal health care system, and I think mammograms can fall into that category. But I was grateful that my doc was willing to discuss with me whether it was okay to wait a bit.
posted by Lawn Beaver at 2:19 PM on November 16, 2021 [1 favorite]


I'm in Denmark.
All women between 50 and 69 are offered mammograms every second year. If you are in a high risk group, it is every year.
People are only tested for osteoporosis if there are indications, typically if you break something and are in the age-group. I broke an ankle at 50, was tested, and since there were no indications, I haven't been tested since.

I've never been offered any sort of hormonal treatment or other medications.

My personal opinion is that I would take the mammograms as offered. Even if you have no known risk, there are so many unknowns. For years in Denmark we were way behind in breast cancer treatment, and one of the reasons was that we didn't scan people who were not in a known risk group, so many women discovered their cancer too late. I have lost friends and family to that and apart from the obvious fact that I miss them and wish they were still here, I would not wish a cancer diagnosis on my worst enemy.

As said, I haven't been offered any hormonal treatment, because doctors here suspect that a too generous use of hormone-treatment is an other factor in the excess mortality from breast cancer.
posted by mumimor at 2:43 PM on November 16, 2021


Best answer: The doc explained that there are 5 different professional associations, all with different bases for their recommendations, and that the most stringent one, which recommends starting at 40, is the association of people who perform the test. Other groups advise waiting until 50 for people in my position.

This is a really important point. The place to look for the least biased recommendations in the US is the US Preventative Services Task Force (USPSTF) who are not affiliated with any one professional organization. They also grade their recommendations based on the strength of the evidence behind them.

Another thing to think about is that screening recommendations are made because of population level outcomes; your doctor should work with you to determine if your individual circumstances might warrant a different subset or timing of the standard screenings.
posted by ocherdraco at 3:04 PM on November 16, 2021 [9 favorites]


Best answer: The Mammogram theater is the clearest explanation I know of the pros and cons of mammograms. It clarifies risks and benefits rather than recommending a course of action.

The problem with thinking about mammograms is that people assume that if cancer was found, the mammogram saved their lives when statistically it’s three times more likely that the person had treatment that was unnecessary.
posted by FencingGal at 3:44 PM on November 16, 2021 [3 favorites]


I had a baseline mammogram in my mid-20's (in the 1990s) which I don't think was particularly useful and was somewhat traumatizing because I didn't know what to expect. There were no electronic records at that time...so "sharing" the information with my future doctors meant lugging around a manila envelope of xrays to give them. I recently found and tossed them after never showing them to a single doctor, so I don't think MY baseline mammogram was particularly useful for a number of reasons.

I was one of the people upset when they suggested moving the recommended mammogram age from 40 to 45 and this was because I was just a few years out of treatment for an aggressive form of breast cancer that was diagnosed at age 44. I had skipped my exam for a few years and my OB/GYN was really riding me about it. I had no risk factors and was confident that I was way to young to become a statistic.

I know you don't want to hear individual stores and I understand that there are concerns about false positives, anxiety, biopsies that turn out to be unnecessary...but most of those things don't kill you. All of the justifications for moving the age out don't make sense to me if your main concern is making sure you catch something early enough that the treatment isn't worse than the cure. The Theater Link from FencingGal above is a really interesting visualization but it only talked about people that would die from breast cancer. Getting treatment later, when the cancer has spread, is far more toxic to your body and has lifelong effects. It's like only talking about who dies from Covid versus those people who recovered but will suffer with the lifelong debilitating side effects. Early detection is better for a number of reasons which aren't just tied to dying or not.
posted by victoriab at 4:06 PM on November 16, 2021 [1 favorite]


In addition to the USPSTF, Cochrane reviews are good meta-analyses of available evidence.

Mammography

I can't find one on bone density scans.
posted by basalganglia at 4:33 PM on November 16, 2021


In the UK there's a national screening programme for mammograms. People are invited every three years, between the ages of 50 and 71. You can find more information about the recommendations and evidence basis from the National Institute for Clinical Excellence (NICE). This page specifically sets out the benefits and harms, with links to relevant studies. In my opinion, NICE make good objective decisions at a population level based on the evidence available.
posted by plonkee at 4:34 PM on November 16, 2021 [2 favorites]


As in Denmark, bone density scans are not carried out as part of a screening programme in the UK. People with elevated risk of osteoporosis should be offered them.
posted by plonkee at 4:40 PM on November 16, 2021


Seconding plonkee's links - I too am in the UK, where the National Health Service looks really carefully at population-level screening programmes before opting to screen, given the costs associated with screening itself and of treatment resulting from screening. There is a nationwide mammography screening programme, but nothing for bone density as far as I know.

But what you're talking about is not population-level screening, it's tests suggested for you personally on the advice of a doctor. In your place I would gently push back and ask about the consequences of not doing these tests, and on what guidance they're basing their advice on. I'd probably ask what evidence they have seen that merely being slight might increase the risk of osteoporosis.
posted by altolinguistic at 12:18 PM on November 17, 2021


The guidelines saying women in their 40s shouldn’t be screened are very contentious.

Breast cancer screening guidelines based on flawed Canadian study, new paper says
A new paper calls into question a decades-old Canadian study that has informed breast cancer screening guidelines for women in their 40s around the world, which generally do not recommend a yearly mammogram.
….
According to the Canadian Cancer Society, while women aged 50 and older have higher rates of breast cancer diagnosis, there's a higher rate of mortality for women between 30 and 49.

Women in that age range consist of 17 per cent of all cancer deaths in Canada. That's compared to women aged 50-69, who represent just eight per cent of cancer deaths.
Also, it’s a good idea to get a baseline one done to find out if you have dense breasts. They are linked with increased risk of breast cancer and require different screening because dense breast tissue can hide cancer. There’s no way to know if you have dense breast tissue without a mammogram.
posted by hurdy gurdy girl at 12:55 AM on November 24, 2021


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