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Judy was nearing her 35th birthday. She was excited. Her husband was going to take her to Colorado for an exciting week of rock climbing, river rafting, and fishing. Then, she was sad. She wanted romantic walks in the foothills, expensive dinners with champagne and a night in the honeymoon suite. Men will just never learn.

It was time for her annual exam, and her gynecologist ordered a mammogram. She wondered why. She thought mammograms did not start until age 40. Her doctor told her that a baseline at 35 was necessary for comparison purposes when she turned 40. So she got her mammogram.

There has been so much confusion lately about when to start screening women with mammography. Three major organizations have three different recommendations:

The National Cancer Center Network (NCCN) recommends starting mammograms at age 40.
The American Cancer Society (ACS) recommends starting mammograms at age 45.
The United States Preventive Services Task Force (USPSTF) recommends starting mammograms at age 50.

The discussions center on risks and costs vs. benefits. The risks are the financial cost to the patient, insurance companies, and the government (Medicaid and Medicare). The risks are false positives whereby women have additional testing and biopsies for lesions that are not cancerous, which can lead to bleeding, infection, anxiety. The other risk is over-diagnosis, i.e. treating a breast cancer that would not otherwise need to be treated. We know there are many cancers that are indolent, i.e. do not need treatment because they will never cause any problems. Prostate cancer is perhaps the most studies but even in breast cancer, many DCIS do not need to be treated. We just do not know which DCIS do not need treatment and which DCIS do need treatment.

False positives are increased when screening is initiated, so whether women start at 40, 45 or 50, there will always be false positives. Finding cancers later in age will lead to more advanced cancers requiring more expensive treatment and a higher risk of dying from breast cancer. Finding cancer at age 42 and treating it successfully will lead to a longer life then finding it at 52 when it may be more advanced. This is a potential harm of not screening.

What is a girl to do?

Start your screening mammogram at age 40.

You do not need to get a “baseline” mammogram at age 35 as changes in your breast happen all the time and a 5-year-old baseline is not of benefit to the radiologist. If you have a family history of breast cancer, you should start screening mammograms ten years before the youngest person to be diagnosed with breast cancer.

Judy did not get her baseline mammogram for her 35th birthday. She’ll wait till she turns 40. As it turns out, Judy’s husband surprised her with a trip to Las Vegas. They stayed in the honeymoon suite at Caesar’s, ate dinner every night at a different special restaurant, they saw many shows and just had a grand time.