‘We can put an end to a lot of unnecessary suffering’

As the U.S. moves to begin mammograms at age 40, experts say Canada should do the same

Shira Farber was diagnosed with breast cancer two years ago. She first requested a mammogram 10 years ago when she went in for a checkup at age 40. Her request was denied.

“I had a wonderful family doctor, very thorough. I was scared of mammograms, so I remember feeling relieved when she told me that I didn’t need one before 50,” Farber said in an interview.

A mammography, a low-dose Xray of the breast, is the most reliable way to detect breast cancer early in women. Guidelines from The Canadian Task Force on Preventive Health Care say women should start getting mammograms at age 50 unless they have specific risk factors.

But some advocates have called for the guideline to be changed, so that women are advised to have mammograms starting at age 40 instead of 50. Last month, the U.S. Preventive Services Task Force, updated its proposed guidelines saying women should get mammograms every other year starting at age 40.

Farber did not push harder to get a mammogram until the age of 48, when she felt what she described as an abnormality in her right breast.

“I knew something was wrong. I don’t know if it would have made a difference if I could have gotten in earlier, but they discovered three large masses and they have been there for a long time.”

Farber had to wait six weeks to get a mammogram and an ultrasound.

A breast ultrasound is done to explore tissue found by a mammogram like a cyst filled with fluid or a solid tumour. It is not usually done to screen for breast cancer, because it may miss some early signs.

Once diagnosed, Farber quickly started treatment that included chemotherapy, radiation therapy, surgery and hormone drugs.

“It was pretty horrible. I lost my hair. I had trouble walking and could not work. I was in pain and could not take care of my children. (By allowing early screening) I really believe we can put an end to a lot of unnecessary suffering and death.”

She has been told by her surgical oncologist and by other experts that her treatment could have been less aggressive had the cancer been detected earlier.

Farber has been advocating for access to early breast cancer screening in Canada for a while now. She has given speeches at Parliament Hill, and at Queen’s Park, asking for the guideline for getting a mam

“They discovered three large masses and they have been there for a long time.

SHIRA FARBER

mogram to be 40, instead of 50. And she’s not alone.

Sherry Wilcox, 45, first asked for a mammogram a year ago when she felt a lump in her right breast. Her family physician said that it was likely a benign mass. When she pushed for a mammogram, she was told she did not need one, because the cancer, if she had it, would not show because of her age.

“I was outright refused,” she told the Star in an interview.

“She said I was too young because younger women typically have denser breasts, if I had cancer it would not show. I kind of pushed a bit more and she agreed to give me a requisition for an ultrasound, which then showed something suspicious. They didn’t think it was alarming and told me to come back in 16 weeks.”

Breasts that have more than 50 per cent glands and fibrous tissue are called dense breasts. Dense breasts make it harder for doctors to spot cancer because both cancer and dense breast tissue appear white on mammograms.

Wilcox demanded a mammogram at that point, thinking 16 weeks was too long to wait, and when she was finally screened weeks later, the radiology report showed that she had invasive ductal carcinoma, the most common type of breast cancer.

“I do not want to bash anyone but I do think that they erred in not giving me a mammogram on request. I think there is a lot of misinformation.”

Wilcox has also gone through chemotherapy and radiation treatment in the past year. She will finish chemo in October and will have breast reconstruction surgery after that.

“Canada’s guidelines are not the clearest,” Wilcox said, adding that she believes the usual rhetoric she’s heard in the medical community around shared decision-making and empowered decisions, does not reflect what’s actually happening.

“I actually had a physical lump. So the guidelines probably should have been thrown out the window,” Wilcox said.

“I’m frustrated, I can’t go back and change what happened to me, but I can try to help others who may not push back with a physician, because many of us do revere doctors, and will listen to everything they say.”

The Canadian Task Force will be reviewing and analyzing new evidence for an update, which they began working on this year, according to Dr. Guylene Theriault, the chair of the panel, but there is not yet a date for when the update will be available.

The evidence in the 2018 guideline showed a close balance between potential benefits and harms, Theriault said.

“For women in their 40s, it’s always an individual’s choice whether or not to get screened based on personal preferences and discussions with their health-care provider. With shared decision-making, women in their 40s should be able to have a mammography if they want one,” Theriault said.

Potential harms of screening for breast cancer include false-positive results, the need for additional imaging and biopsy, overdiagnosis and radiation exposure according to the U.S. and Canadian task forces.

The U.S. task force also noted that Black women are 40 per cent more likely to die of breast cancer than white women, making mammograms at 40 an especially important step — but also urged more research to better understand and combat the disparity.

Hannah Jensen, a spokeswoman for the Health Ministry in Ontario, told the Star the province is “exploring” lowering the breast cancer screening age to 40, but did not elaborate.

“I think (the U.S.’s proposed update) is a monumental first step in the right direction. Canada must update its own recommendations without question,” said Dr. Toni Zhong, an associate professor in the department of surgery at the University of Toronto.

“It will save thousands of women’s lives each year,” said Dr. Martin Yaffe, a breast cancer and imaging scientist with Sunnybrook Research Institute.

In some provinces of Canada, the screening program may not accept women aged 40 to 49 for a mammogram if they don’t show any symptoms and are not high risk.

Women between 50 and 74 years old can make an appointment at a screening centre without a doctor’s referral in all provinces and most territories, if they are at average risk for breast cancer.

“Many women, especially in Ontario, are being denied screening because of misinformation circulated by the Canadian Task Force on Preventive Health Care, suggesting less benefit and more harms associated with screening,” Yaffe said.

This notion has passed on to professional colleges and physicians as well as women and is dangerous according to Yaffe, who said on this basis some doctors are refusing to provide a requisition for screening to younger women.

One of those denied screening was 45-year-old Adina Isenberg. She asked her family doctor for a mammogram when she turned 40. Her doctor dismissed her request, she told the Star, despite risk factors like having a history of cancer in her family and her background. As Ashkenazi Jewish, she is at a higher risk for breast cancer at a young age, according to studies by the Centers for Disease Control and Prevention (CDC).

“My doctor was very dismissive, he said I was too young to worry about breast cancer citing the guidelines. Worse, when I had called his office asking for a mammogram referral, his assistant laughed at me and said ‘That’s not how it works, you need an appointment to determine whether you need one.’ ”

After she was reluctantly scheduled in for an appointment about a month later, she said, the doctor dismissed her request again.

When she pushed back, the doctor strongly discouraged her from getting screened elsewhere, stressing the risks of unnecessary mammograms.

“He said that was a mistake, and that the radiation from the mammogram would increase the likelihood of giving myself cancer.”

After more than three months of waiting and going to another doctor for a mammogram and ultrasound, Isenberg was finally diagnosed with triple-positive breast tumours.

Triple-positive breast tumours refers to cancer cells that test positive for estrogen receptors, progesterone receptors, and have higher than usual levels of the HER2 protein.

“I’m asking for the barriers to be removed so that younger women, can access the care they need,” she said.

Breast cancer is the most common cancer among Canadian women and the second leading cause of death from cancer in Canadian women, according to the Canadian Cancer Society (CCS).

“The provincial and territorial screening programs should act on the science and on the U.S. guidance and not wait for the Canadian Task Force,” Yaffe said.

Yaffe added that the screening should be done annually, not every second year, as suggested, at least for premenopausal women.

“It is extremely difficult to interpret for the family doctors who have to counsel their patients about the pros and cons of breast cancer screening,” Zhong said.

Zhong suggested that the task force is relying on outdated and weak evidence.

“Guidelines based on 30-year-old studies are questionable in their conclusions and irrelevant, since so much about breast cancer epidemiology, diagnosis and treatment have changed,” she explained.

There are several reasons why screening between the ages 40 and 49 is critical, according to experts.

“Cancers grow more rapidly in younger women so screening every second year would cause too many to be missed,” Yaffe explained, adding screening should also be readily available to women over age 74 who are in otherwise good health.

According to Zhong, nine per cent of all breast cancers occur in women younger than 45 years of age in the U.S., and statistics are probably similar in Canada.

“Breast cancer in younger women tends to be more aggressive and lead to more morbidity and more mortality than in older women. Therefore diagnosing younger women earlier is critical and gives them the best chance at survival.”