What watching ESPN could teach us about mammograms.

How to fix health policy.
Nov. 18 2009 6:14 PM

My Own Private Screening

What watching ESPN could teach us about mammograms.

(Continued from Page 1)

But what if you're the one whose life is saved—doesn't that outweigh the dozens of fruitless biopsies and thousands of scans done on other women to save you? Now that's something to talk about. There: You now know pretty much everything the experts do in the debate over whether women under 50 should get mammograms.

Still, there's another way to discuss mammography, which is potentially more useful. When the people who know the most about the subject—like the folks at the National Cancer Institute, Centers for Disease Control, and American Cancer Society—disagree so strongly about mammograms, the lesson is that people handle risks in idiosyncratic ways. As a result, there is a growing but small movement to indentify precisely a given woman's risk of breast cancer and help her make the decision that's right for her alone.


Developed by a statistician at the National Cancer Institute, the so-called "Gail model" allows women to estimate their risk of breast cancer based on family history, age, menstrual history, and other personal factors. (You can calculate your risk of getting breast cancer here. It's helpfully delivered as a percent over five years and over a lifetime.) This allows higher-risk women to make more personalized decision. For example, a woman under 50 who has a sister or mother who's had breast cancer has the same overall risk as someone over 50 and thus would likely benefit from routine mammograms. Based on her risk profile, a woman might make a choice that adheres to her comfort level, without being at the mercy of arguing authorities. To better guide women, national organizations could band together and propose mammogram screening predicated on personal risk percentages, instead of only the blunt instrument of age.

Earlier this year, the American Society for Clinical Oncology proposed another personalized strategy. For women with a Gail score predicting a five-year breast cancer risk of more than 1.66 percent, the organization recommends considering the drug tamoxifen, which reduces breast cancer risk by about one-third to one-half—yet the guideline is widely ignored.

A third personalized strategy involves targeted genetic testing for the "BRCA" genes, which are responsible for one-tenth of all invasive breast cancers. A woman carrying the gene has an almost 60 percent chance of developing breast cancer during her life—and yet, no organization has yet developed guidelines on who should get tested. Though data are still sketchy, it is reasonable to assume that carriers would benefit more than the average woman from early mammograms or tamoxifen therapy.

Over time, medicine is bound to become more individualized. Unfortunately, national health organizations have failed to take the lead in such cancer screening, though the tools exist. But if people given the right statistical tools can manage a fantasy sports teams over a season, it stands to reason they can probably take charge of their personal health the same way.

Darshak Sanghavi, a pediatric cardiologist, is a fellow of the Brookings Institution and Slate’s health care columnist. Follow him on Twitter.


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