Why Mammogram Guidelines Would Have Missed Amy Robach’s Cancer

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Ida Mae Astute / ABC via Getty Images

Robach has her mammogram on ABC's Good Morning America show on October 1

Good Morning America host Amy Robach revealed on her show that a recent on-air mammogram had found she has breast cancer, but the diagnosis wouldn’t have been made if she followed certain federal guidelines for screening.

Robach is 40, and the U.S. Preventive Services Task Force, a group of independent experts convened by the government to review the risks and benefits of different screening practices, advised in 2009 that as a public health measure, the benefits of saving lives would outweigh the risks of screening if women started getting yearly checks beginning at age 50, rather than at age 40, as the American Cancer Society and other groups advise.

The task force based its conclusion on the potential costs, both economic and emotional, of uncertain mammogram results, which would lead to follow up tests including biopsies and procedures like lumpectomies and mastectomies, most of which, the studies they investigated showed, ended up being negative.

But maximizing public health and decreasing harm may be at odds with minimizing an individual woman’s risk of dying of breast cancer. And that’s the situation that “we see every day in my field,” says Dr. Larry Norton, a breast cancer expert at Memorial Sloan Kettering Cancer Center. “We see real human beings getting screening mammograms so their cancer is detected at stages when we have curative treatments,” Norton continues. “When people talk about the downsides of screening, it doesn’t compute in the minds of people who are actually in contact with human beings.”

MORE: GMA’s Amy Robach Reveals On-Air Test Led to Breast Cancer Diagnosis

Robach wrote on Good Morning America’s website that she has “very little family history” of the disease, and “considered it virtually impossible that I would have cancer.” She only agreed to get the mammogram, live on air, at the request of her producers and colleague Robin Roberts, herself a cancer survivor. Had she followed the USPSTF guidelines, which some doctors do, and upon which some insurers base reimbursement decisions, she might not have gotten a mammogram for another decade. “I don’t want to imagine what could have happened if she had her first mammogram at age 50,” says Norton of Robach’s case.

And that’s why, despite the public health advice, most doctors still recommend that their patients start getting regular mammograms when they turn 40. It’s not that they are being ornery, or stubborn to change, but that there’s a biological mandate to find potential tumors in younger women early. For one, the idea that the stage at which a cancer is detected, which has a lot to do with its size, determined a woman’s prognosis, are fading away. What truly matters is the biology of the tumor itself – understanding how it grows, what it feeds on, and whether it’s driven by genetic factors – is far more predictive of whether a woman will survive a breast cancer or not. “Younger women tend to get aggressive tumors that are quicker growing and not fed by estrogen,” says Dr. Jennifer Litton, a breast cancer specialist at MD Anderson Cancer Center. The concept of cancers growing slowly over years is more typical of older women who are past menopause than younger women in their 40s.

There’s also growing evidence that in breast cancer, tumors start to send out signals to other parts of the body to prime them for metastatic growths. “The lungs change before the first cancer [from the breast] gets there,” says Norton, “and the lungs become a fertile field so when the first cancer does get there, it’s ready to grow. And that’s a time dependent process, so the earlier you intervene, you can stop the process of metastasis.” And once a cancer has spread, it’s much more likely to be deadly.

MORE: Mammogram Guidelines: What You Need to Know

Why is the USPSTF conclusion so at odds with the breast cancer care that most doctors practice every day? Part of the problem may be that the studies the task force included involved older mammogram machines that did not provide the digital images that newer machines do, with better resolution and multiple views of the breast tissue to more accurately identify potential tumors.

The task force guidelines did not rule out mammograms for women under age 50; women with a family history of the disease, or other risk factors such as exposure to environmental estrogens, being on the pill or drinking alcohol, should talk to their doctors about starting screening earlier, the members said.

The decision about when to start screening, says Litton, should really be a personalized one, made by a woman and her doctor, after factoring in her medical history. And for now, that conversation is likely to be an involved and difficult one, but will hopefully become easier as better methods for detecting the first signs of breast tumors become available. “Screening is going to evolve, and we will have not just imaging but biologic tests such as biomarkers,” she says. “Wouldn’t it be great to have a blood test, or be able to spit into a cup and then know whether you have cancer, and you wouldn’t have to go through unnecessary biopsies?”

That day may be coming, but it’s not here yet. In the meantime, women like Robach have to make their own decisions about when to start screening. They also have to understand that the risk factors for cancer don’t always stand up and shout and make themselves obvious. Robach decided to undergo a double mastectomy to treat her disease, and wrote that “I got lucky by catching it early. I can only hope my story will…inspire every woman who hears it to get a mammogram, to take a self exam. No excuses. It is the difference between life and death.”

25 comments
RonniReiburn
RonniReiburn

If I had followed ANY guidelines I wouldn't be writing this comment.  I would be DEAD!   Nine years ago at the age of 37 and still menstruating (way before 50, and 3 years before current recommendation of 40 for baseline) I was diagnosed with Stage 2B, 2cm tumor with one sentinel lymph node involvement.   Tumor was ER+, PR+, and HER-2 -.  . The subsequent surgery for the removal of unclean margins and all lymph nodes detected no cancer metastasis.  Being in the pharmaceutical sales arena for my career helped me to be a self-advocate as I noticed common medical practices were not very proactive.  At 35, I advocated for a baseline mammogram due to my adoption and having no medical history to go by.  Of course the insurance companies originally said NO.  I fought back.  I cannot tell you how having the first one helped in my successful outcome due to knowing that it was recent.  (no lump detected from my monthly exams, 2 months prior)  I also advocated for a PET/CAT/MRI scans prior to surgery so I can know if any other areas were effected.  Had to fight for that to be paid too, but was willing to go bankrupt if I had to in order to save my life.  TOO MANY PEOPLE let others make decisions for them based on money.  Genetic test found that my cancer was not-hereditary.  What is so tragic is that those involved decision making policies for the masses aren't in the chemo suites.  Do you know how many women under the age of 40 was receiving chemo with me.  Too many, as well as those over the age of 40. One case is too many.  There was even a girl at the age of 19 in the room.  She is not an anomaly I am sad to say.  I am hearing more and more women under 35 are developing breast cancer, unfortunately their voices cannot be heard due to the mass media focusing on 40 and over.  This must and should stop.  Just like letting those wearing suits dictate what should be available to me in treating my particular illness based on cost figures.  Don't get me started on Obamacare or I'm sorry the now "Affordable Health Care" spin.  That's for another day

RuthGravitt
RuthGravitt

Thank you, Dr. Norton!  I am trying to get people to see the same thing about endometrial cancer--less screening is not always more.  The standard of care which says no screening is necessary because the symptom of abnormal bleeding usually shows up at the earliest stage, at which point a total hysterectomy is highly curative, shows no regard for the value of a woman's ovaries and uterus (which are highly useful to even a postmenopausal woman).  The standard of care needs to change to include risk stratification so that a woman with high risk can decide for herself whether the benefits of transvaginal ultrasound and endometrial biopsy outweigh the risks.

debinPDX
debinPDX

To the moderators: You need a cover-up for offensive comments on this site. Arshad Sherif was a total pig in his comments. What is the matter with people? She has breast cancer and you have not one ounce of compassion. You suck.

Arshad_Sherif_M.A._M.Ed. 11 days ago

A mammogram for Amy! It rhymes! But Amy Robach is the kind of hot blonde you want to see on TV getting a colonoscopy. One wonders whether she is comfortable allowing her male lover to use his male organ to give her one. We can only imagine how good it feels to do that to her. Surely this hot anchor on the hot career track in this intensely competitive world of broadcasting has had to allow her male bosses to do that kind of thing to her. Other women would do anything to get her job.


RuthGravitt
RuthGravitt

Alice's reasoning is excellent and applies to uterine cancer as well.  There needs to be risk stratification because less is not always more.

CynthiaBaileyMD
CynthiaBaileyMD

Mammograms are important, as is doing a monthly self breast exam.  Every woman needs to know, however, that even mammograms are not perfect.  I was just diagnosed with bilateral hereditary breast cancer at the age of 55 and am currently receiving chemotherapy http://www.drbaileyskincare.com/blog/dermatologists-advice-best-skin-care-chemotherapy/.  One of my cancerous tumors showed up on my mammogram, confirming that the small lump that I found on self exam was indeed a cancer.  The other tumor did not show up on my mammogram but it did show up on my breast exam and MRI.  Bottom line is that screening for breast cancer is important and complicated.  High risk women need to be identified and followed closely by their doctors.  All women need to learn how to do a good self breast exam, and then they need to do one every month.  

Sherry Payne Main
Sherry Payne Main

All women should get these! My daughter is 37 and had a hystorectomy. If you have one of those, then you should be screened!

Christy Weber's Chest
Christy Weber's Chest

Heather, you are an awesome mom!!! I found my (still at noninvasive!) lump at 43. It's because I always self check, and have found the other benign lumps, that I knew exactly what was there and what was new. It's critical to start self-checking early to know your body. You're doing your girl a huge favor.

Debra Serrano
Debra Serrano

i fought my former doctor for an exam, but she kept telling me that the insurance won't perform one until i was 35 or 40, despite the extreme family history. needless to say, when open enrollment came around, i changed my insurance from a public ins to a private one. the first day i met my new nurse practitioner, she immediately sent me downstairs for a mammogram. i am 42 now and get a mammogram every year without fail. be pro-active, it's your life.

Arshad_Sherif_M.A._M.Ed.
Arshad_Sherif_M.A._M.Ed.

A mammogram for Amy! It rhymes! But Amy Robach is the kind of hot blonde you want to see on TV getting a colonoscopy. One wonders whether she is comfortable allowing her male lover to use his male organ to give her one. We can only imagine how good it feels to do that to her. Surely this hot anchor on the hot career track in this intensely competitive world of broadcasting has had to allow her male bosses to do that kind of thing to her. Other women would do anything to get her job.

Mj Mckiernan
Mj Mckiernan

36!!! 14 years later... Don't think I'd be typing this.

Elisha Daniels
Elisha Daniels

I have been preaching early screening in the 7 years since my stage 3 breast cancer diagnosis that I accidentally found myself on the eve of my 40th birthday. Research & BCRF work saved my life. It will also save Amy's life!!!!

Donna O'Brien-Toepfer
Donna O'Brien-Toepfer

My daughter gets checked at 26 and my son had a lumpectomy at 26. You can never be too careful.

Donna O'Brien-Toepfer
Donna O'Brien-Toepfer

I was 37 and was TC I probably had it for 2 yrs which means I was 35, get checked! I had to get a mastectomy and chemo and December 29th I will be 10 yrs cancer free!

Pamela Dean-Dunlap
Pamela Dean-Dunlap

Cari Stewart Phipps might have something to say about waiting until age 50! Ugh.

Robert Bergmann
Robert Bergmann

Yes that's why beurocrats ahold not be involved in health care !!!!!!!!!

Diane Swanstrom
Diane Swanstrom

Who is this that is saying do not have a mammogram till age 40? Drug companies who sell chemo? I had them since 22 because of a tumor. Tumor removed and fine if I waited till 40 who knows what the outcome would of been. 65 now xx

Heather Willey Port
Heather Willey Port

PREACH IT!!!!!! I was 34 when diagnosed. I found my cancer on a self breast exam which I now hear from my daughter's pediatrician that they are not recommending girls perform anymore. ARGH! My daughter will be taught by me and will get her first breast MRI in her 20's. So scary!

Darlene Wagner Woodside
Darlene Wagner Woodside

If Amy had waited until she was 50 to be screened, she probably would not have been screened. The cancer may have already taken her life. Screening needs to be started early. I am a survivor.

Nina Comodo
Nina Comodo

It would have missed mine also. I was 38 when I was diagnosed. The guidelines should be lowered to age 30. Even women in their 20s get breast cancer.

Teresa Grow Filleman
Teresa Grow Filleman

It would have missed mine too...diagnosed at age 43. Thankfully I had a baseline mammogram at age 35!

CheriS
CheriS

I for am very pro-mammogram before 50. I was diagnosed with breast cancer when I was 47. Thankfully, mine was diagnosed so early I couldn't even feel a lump. I chose to have a double mastectomy due to family history and haven't regretted it one bit. After my surgery I was told the actual cancer was just 2mm. Because of that, I didn't need chemotherapy or radiation. Early detection is so important in saving the lives of women all across our country. I really think this guidance needs to be changed to 40 so more women can have the opportunity to live long lives.

DoNoHarmProject
DoNoHarmProject

This is an emotional topic and we should be sensitive to this reality. At the same time, it is important to recognize that the benefit of screening for breast cancer with mammography among average risk women in their 40s is unproven. In other words there may be a small benefit. It may also be, on balance, more harmful than beneficial. Wishing something to be so is not the same it being so - though these can feel the same. 

Let's also be clear on the recommendations of the USPSTF which does NOT make recommendations with respect to financial cost. See here for more: http://www.uspreventiveservicestaskforce.org/tftopicnom.htm

This serious topic deserves a more thoughtful, balanced discussion.


TrueAwareness
TrueAwareness

Does a touching story and the accompanied campaign for women to get mammograms erase the "inconvenient" fact that this medical test does more harm than good (read Rolf Hefti's e-book "The Mammogram Myth")?

lexafk
lexafk

I think you meant to say that she agreed to get the mammogram on air, not a mastectomy.