Two months after I turned 45, a little letter arrived in the post from my doctor's office, advising me it was time to schedule my first regular mammogram. The letter stated it would be free and that it was "a good way to detect breast cancer at an early stage".
I ignored the letter for a month, then dutifully called the number and scheduled my appointment. Today I presented myself at Breastscreen Aotearoa in Remuera. I am perhaps unusual in that I have a high threshold of pain but am at the same time very squeamish. I was dreading the experience because I'd heard other women complain that it was painful, but as I filled out the obligatory form, I noticed a slight squeamish feeling I hadn't anticipated, but which I was able to push out of my mind.
Fast forward to me standing before the screening apparatus. The first two scans squeezed each breast in turn from top to bottom and they were tolerable. The third was more awkward and the amount of compression far worse. I had to maintain a slightly bent position while standing, and, like with other X-rays, you're told not to breathe, though each time I was given very little time to decide if I wanted to hold my breath or simply pause after exhaling before taking another breath. The fourth scan did me in. The amount of compression was, as it turned out, unbearable. The technician stepped away. Hanging on to the bar provided for your left hand, I squeezed it for dear life and tried to hold my breath. She was able to take the X-ray. I remember telling her I felt faint and she suggested I try to sit down. You know how sometimes you are in the middle of a dream and you start waking up but you don't want to, because you want to see how the dream will resolve? That was my next memory, then I came to on the floor and realized I had, for probably the fifth or sixth time in my life, fainted.
Here is what I have learned since then:
The technician told me many people do faint, and a cursory Google search suggests my experience was not singular.
I am quite angry that no mention of this possibility was made. I could have been better prepared, for example by eating a heartier breakfast and asking if was possible to sit down for the procedure. Indeed I would say that that is best practice, at least for some women.
I have lodged a specific complaint about my experience, and I made the suggestion that the form you fill out should include a question or two about low blood pressure and tendency toward fainting.
There is no medical consensus about the best age to start performing routine mammography. In the aftermath, one of my friends commented that breasts at age 45 can still be too dense for mammography to be very helpful. In the US, the Preventive Services Task Force protocol is every two years for women aged 50 to 74, but the American College of Radiology and the American Cancer Society recommend yearly screens starting at age 40. In Canada and Europe, the recommendation is evidently for screens every two to three years for those between age 50 and 69. In New Zealand, screening is free for all women aged 45 to 69. The technician told me women can go yearly or every other year.
In fact, a landmark 2001 study, the Cochrane Collaboration, actually found that routine screening appears not to have an impact on total cancer mortality. For every one woman out of 2000 who might avoid dying of breast cancer, another 10 healthy women will receive unnecessary treatment, which can even include mastectomy, and more than 200 will experience psychological distress.
I am normally a person who demands to understand the rationale behind any drug or procedure a doctor wants to prescribe or perform on me, but I suppose I was as vulnerable as anyone to our pervasive fear of cancer. After all, even though non-Maori Kiwi women are more likely to die of heart disease and even though breast cancer isn't even in the top five causes of death for Maori women, it's not unfair to say that awareness of breast cancer, including the ubiquitous pink ribbons, has metastasized in recent years, as the Baby Boomers reach a vulnerable age and many much younger celebrities have been stricken with the disease. And certainly it would be the rare person who doesn't know at least one woman who has battled, and hopefully survived, this dreaded scourge.
Yet in order to provide the most effective public health services possible, New Zealand must get as much bang it can out of every buck it expends, and it seems we are long overdue to re-consider the value of routinely screening all women.
As the director of the Nordic Cochrane Centre wrote back in 2011, "The tides are plainly turning for mammography screening, and it is now essential that women be provided with information that allows them to make an informed choice about mammographic screening, rather than being pushed toward mammography as routine, while being told it is an unambiguously beneficial test."
My advice to anyone whose little letter lies in the future is to think twice about what might actually be best for you, and talk it over with your doctor so that you can make the informed choice the Cochrane Centre advocates. Here is a comprehensive list of risk factors (written for an American audience) you may want to think about.
Finally, to my surprise, breast self examination does not seem to be part of the conversation in New Zealand. I cannot recall any doctor or nurse here, not my GP nor the staff at Family Planning, ever doing a clinical exam on me, yet in the United States, it would be part of a routine physical or gynecological check-up. The American National Breast Cancer Foundation recommends monthly self-exams and I can recall receiving several handouts about how to perform one over the years. Just like with skin cancer, knowing our own bodies is one of our most important defenses.
Since I have no family history of breast cancer and have few risk factors, now that there is a baseline mammography for me, I think in the future I will get ultrasound scans every few years, even though the cost will come out of my own pocket.