Check Up: Some guidance on when to start mammograms

It seems counterintuitive, but detecting breast cancer early is not automatically a good thing.

That dilemma is at the heart of the never-ending debate over starting mammography screening before age 50.

Now, a team led by obstetrician-gynecologist Margaret Polaneczky has developed an interactive online tool to help women in their 40s who are not at high risk of breast cancer decide when to start - and how often to get - mammograms.

The "decision aid," at http://bsd.med.cornell.edu, provides objective but individualized information based on the woman's own breast cancer risk and preferences.

"Women say to me, 'I'm confused. What's the right choice?' " said Polaneczky, a professor at Weill Medical College of Cornell University in Manhattan (and sister of Philadelphia Daily News columnist Ronnie Polaneczky). "We want to help women make the decision that is right for them, whatever that may be."

Decision aids are becoming more common as researchers, clinicians, and advocates seek to help patients weigh probable outcomes when there is no single best choice. The U.S. Agency for Healthcare Research and Quality offers such tools for osteoporosis treatment and prostate cancer screening and treatment.

The mammogram dilemma is particularly complex. Studies show that breast cancer awareness campaigns have led women to overestimate their personal risk as well as the effectiveness of mammography. In reality, the disease is relatively uncommon among women in their 40s, and most cancers that are detected then would not be life-threatening if caught after 50.

The issue came to a head in 2009, when the influential U.S. Preventive Services Task Force reviewed all available research and, in a reversal, advised against routine screening for women in their 40s at average risk. The panel concluded that the mortality benefit - three deaths averted per 1,000 women who were screened annually for a decade - was small compared to the harms of false alarms, unnecessary biopsies, and potential overtreatment. The panel stressed, however, that women should talk to their doctors and make an "informed" decision.

In her blog ("The Blog That Ate Manhattan"), Polaneczky complained that the panel was leaving doctors "to clean up the mess" of resulting confusion.

Recognizing that a decision aid would help, she set out to create one, getting a federal grant and enlisting other researchers at Cornell and Memorial Sloan Kettering Cancer Center.

After piloting the site with more than 150 women and their doctors at Cornell, the final product was launched last month. The user starts by answering 12 questions such as age and family breast cancer history that are used to calculate her five-year personal risk. Then a series of graphics - each using 1,000 tiny female icons on a screen - illustrate her risk and the likely impacts of mammography.

For example, one graphic shows how many women like her out of 1,000 will die of breast cancer over their lifetimes, depending on their screening schedule: 22 deaths for annual screening beginning at age 40, compared with 23 deaths for annual screening starting at 50.

The tool also asks questions that explore personal values and fears, and creates a summary that can be shared with a doctor.

After using the site, "the majority of my patients still want to get mammograms," Polaneczky said. "But they're clearer about what they're getting and why."

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