Tag: Cancer

Her Sister Died of a Brain Tumor. Now She Was Having Similar Symptoms.

Humanity has planted flags on the moon, yet a moonshot for brain cancer has yet to be realized.

I knocked and entered her room. Our patient had a few more questions about her surgery.

I introduced myself.

“This isn’t the same tall guy as before,” I recalled her joking.

“They only hire tall people,” I said.

Wearing masks in every hallway and patient room, though necessary in the time of Covid-19, had stolen the familiarity of a smile.

She was in her late 50s, wearing glasses and a light blue hospital gown, sitting up in bed. She had a full head of salt and pepper hair that was more salt than pepper really. Sprawled across her beige blankets were legal pads on which she had been taking notes.

On her right was a gingham-lined picnic basket brimming with treats, Coca-Cola and Otterbein’s Cookies, a local favorite, gifts from her co-workers.

A few weeks earlier, her life had been routine. As an information technology specialist, she had been working from home,. At some point she realized she had been experiencing weakness in her right leg, and then in her right arm.

“I noticed it late, I think, because I was sitting at my desk all the time,” she said.

Her handwriting had worsened precipitously over the previous few days. “I can’t write anymore,” she said, “and when I was lifting weights my arm felt heavy and weak.”

She had gone to the emergency room, where doctors performed a CT scan of her head. On the left side, at the top of her brain, they found a “hypodensity,” a dark area that would need further work-up. A subsequent M.R.I. scan of her brain provided more clarity.

A cystic mass was invading her left paracentral lobule, part of her primary motor cortex, a one-centimeter ribbon of brain tissue packed with the millions of neurons that allow us to voluntarily control our muscles.

I asked her if she had more questions about her surgery, which was scheduled for the next day. My attending had talked previously with her about the finding on her scan and options going forward.

“I’m just wondering what the mass is,” she said. “Hopefully you won’t find anything,” she followed up quickly.

“A scan is a representation,” I said. “We can only know for sure once we look at a piece of it under a microscope, after the surgery.”

Our concern was a tumor, but the mass could also be an infection, or an inflammatory process, or another disease, I explained. As we talked more, I learned more about the source of her anxiety.

Her sister had died of a glioblastoma a few years earlier, she told me. Glioblastoma is the most common tumor that arises from brain tissue, and one of the most lethal of human cancers. Three people in every 100,000 are diagnosed with this condition every year.

She recounted the story of her sister’s diagnosis and treatment, and the misery she had gone through. Her sister, too, had a mass on the left side of her brain, for which she had elected surgery. The surgery and mass had left her weak and unable to speak. After the diagnosis of glioblastoma was confirmed, she had undergone chemotherapy and radiation therapy, the standard of care, which can extend survival a few months. She died a year later, and had never regained her old self.

“Me and my sister have everything in common,” she said. “When I heard about this mass, I said, really, we have to have that in common too?”

I smiled at her efforts to add some humor to the situation.

“I read that glioblastoma is extremely rare, so it’s unlikely I have the same thing, right?” she asked.

I explained it was rare, but possible.

“My sister wasn’t the same after surgery,” she said. “Don’t take so much out that it causes problems.”

We talked a while longer before I left for the evening.

The next morning, the chief resident and I greeted her in her room.

“I’m ready,” she said.

Her nurses brought her down to the operating room, where the surgical nurses and technicians began their rhythms, making her comfortable on the operating table, moving equipment.

The anesthesiologist skillfully intubated her. He ferried her mind to the hinterlands.

We started by cutting a narrow furrow through her hair, as she had requested, preserving as much hair as possible. Cutting the hair before making an incision is a small part of brain surgery, but it remains our most visible maneuver. If she had what her sister had and we’d cut it all, her hair might never fully grow back in time. She would forever be marked by her disease. Cutting less mattered to her.

My attending, the chief resident and I cleaned her hair and scalp, and then, using the surgical drapes, created a window where we would work.

I made an incision down to her skull with a scalpel, and we instinctively stemmed any bleeding. After folding her scalp back and exposing her skull, I made several burr holes with a drill, then connected these using a different kind of drill to complete our craniotomy, removing a disc of skull. My chief resident and I then cut and drew back the dura, the pearly lining that protects the brain. We were now staring directly at her brain.

Using surface electrodes, and tiny jolt of electricity, we determined the boundaries of her motor cortex, the no-go zone. Compromising any part of this ribbon would result in paralysis.

My attending and chief resident started dissecting between both brain hemispheres. They met the mass from its flank. It was aberrant, alien.

We sent the first piece of it to the pathologist for analysis.

They methodically resected the mass, working from within the abnormal tissue itself; better to damage the mass than to harm healthy brain tissue. They peeled it away from her brain, bit by bit. It was deliberate work.

The phone rang, interrupting the sound of buzzing electrocautery forceps and whirring suction tips. It was the pathologist.

“The specimen is consistent with glioblastoma,” her voice rang on speakerphone, to a change of tenor in the room.

Like her sister, I thought to myself.

Two years earlier, I had seen Damien Chazelle’s “First Man,” a biopic of Neil Armstrong. There was a moment in the film when the astronaut stood at the rim of a baby crater on the moon. He had spent 10 minutes at that crater, but what he did there remains a mystery. The filmmakers had suggested he left a bracelet there, a bracelet that had belonged to his daughter Karen, who had died seven years earlier, in 1962, at age 2.

Karen had succumbed to what is believed to have been diffuse intrinsic pontine glioma, a rare childhood cancer of the brainstem that shares some similarities to glioblastoma. His daughter had undergone radiation therapy, which reduces symptoms from the tumor, but only for a short while. It remains the only available treatment for this devastating disease, which today, as then, is almost universally fatal.

Humanity has planted flags on the moon, yet a moonshot for brain cancer has yet to be realized.

Diagnosis known, we gradually stopped removing more tumor. The more tumor you remove, the longer the average survival, meager though it may be. But the quest for surgical perfection sometimes comes with a cost. In the brain, where critical human functions are packed into mere millimeters of tissue, removing more tumor and possibly damaging healthy tissue risks the loss of strength, speech, vision, memory and more. In glioblastoma, tumor cells that have traveled centimeters away from the bulk of the tumor, far out of reach of any forceps, almost guarantee the cancer’s recurrence. Surgical perfection is imperfect. She wanted to preserve her strength.

We sutured the dura closed, and then plated her bone back on. With care, we closed the layers of her skin. In a short while, she was extubated, and we brought her up to our neurological intensive care unit to recover.

“I have seven years on my sister, and a lot of young people are dying these days, so I’m trying to be pragmatic,” she had said to me the day before. Bargaining.

Forty years ago, the median survival time for glioblastoma was four-and-a-half months. Since then, researchers have characterized the genetics of glioblastoma and studied various vaccines, chemotherapies, immunotherapies, cell therapies, new imaging modalities, targeted radiation therapies and innovative forms of drug delivery to treat the disease. Many steps.

The median survival time today is about 15 months. Only a small percentage of patients survive more than five years.

Defeatism is a common feeling among neurosurgeons, but you maintain resolve, for your patients, and for yourself. The next morning, our patient was in good spirits, recovering well, with good strength. We delicately shared the diagnosis with her.

“Just my luck,” she said with a smile. She seemed to be expecting it.

Some cancers in siblings can be explained by genetics. But that’s not the case for glioblastoma. As for her sister, and many others, it really was just bad luck.

Our surgical team, along with our colleagues in neuro-oncology and radiation oncology, recommended the standard treatment of chemotherapy and radiation therapy. But she declined treatment multiple times and chose palliative care.

“I don’t want to drag it out,” she said.

She died peacefully four months later, surrounded by her family, listening to “The Sound of Music,” her favorite musical.

His Comfort Is Not My Responsibility

A young woman with a prosthetic leg hopes to make the world a more empathetic place. If only she didn’t have to do it on first dates.

Rob and I had been talking on Bumble for about a month. We matched while he was apartment hunting in New York City. He was handsome, funny and well-educated, with roots in Boston. He could do his job from almost anywhere and said he was moving to New York just because, and I liked that. We stayed in touch.

After he arrived and moved into his new place, we switched over from app messaging to texting, the crucial next step. Those first few days of texting, we were deciding among restaurant recommendations in the East Village.

“Trust me,” he wrote. “I’m settling in as fast as I can!” And then, finally: “Let’s try one of these places early next week?”

“That’d be fun!” I wrote.

And just like that, I was torn over what to say next. I still don’t know how soon I am supposed to bring up the thing — if I’m supposed to bring it up at all. If I should wait until we meet to say anything, or if I should say nothing. Because maybe he already knew. But I had no way of knowing if he already knew. I would have to ask.

That’s what runs through my head when I’m on dating apps as a young woman with one leg. You would think that my photos would give it away. If guys actually scrolled through all four of them. After a few years on these apps, I am still in shock over how many guys miss this detail in my photos. Is “detail” even the right word? Having one leg is definitely something, but is it bigger or smaller than a detail?

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I’m 25 and a third-year medical student, but I’ve been dealing with this in one way or another for most of my life. When I was 6, my mother noticed that my right knee was suddenly larger than my left. She thought it might be an infection, but no. It turned out to be an aggressive osteosarcoma (bone cancer) that led to many months of chemotherapy and ultimately to an above-knee amputation of my right leg.

That is one story of my life, but it’s hardly my only story.

I decided that I would be direct with Rob. It made me uncomfortable to meet without knowing if he knew about my prosthesis. So, at 8:32 p.m., in the middle of our texting, I wrote: “Just so there are no surprises, you know that I wear a prosthesis on one of my legs, right?”

Twenty minutes later, there was still no response. My next move was to open up Bumble, and that’s when I saw that our chat history had been wiped clean, replaced with: “Rob ended the chat.”

I fumbled with my phone and texted him the first words that came to mind: “That was really harsh.”

“I’m sorry,” he wrote.

We never spoke again.

Did I cry? No. Did it sting? Yes.

My dating app profiles are carefully curated with photos. My first and second only show my face. That counts for a lot in the world of dating apps. My third is bolder: It shows me kneeling. A careful observer will notice my prosthesis. My fourth photo leaves no question: I am standing with the prosthesis on full display.

I never know how many photos a guy has scrolled through before we match and start talking. I have heard that after a guy makes a match, some are more diligent about looking through all the woman’s photos. Maybe that explains why I match with guys who never start conversations or delete me within minutes.

I learned from a young age that, as an amputee, my dating pool would be smaller. In college, I enjoyed going out every weekend dancing with friends. Often, a guy would start conversations on a dark, crowded dance floor and sometimes get me a drink. Then we would walk upstairs to a lighted room to talk, where he would glance down and see my legs below my skirt and find an excuse to wander off.

One guy who didn’t wander off later told me that our mutual friend had given him a heads-up before introducing us, saying, “You know she has one leg, though, right?”

I was not asked to date parties. I couldn’t wear heels going out because of my prosthetic ankle adjustment. And I had to watch what I drank so that I could safely walk up and down the stairs of house parties. It all had to be planned in my head, every time.

I don’t have a plan for explaining over dating apps how I lost my leg. In fact, telling guys how I lost my leg is the last thing I want to do on a dating app. Sometimes I’ll say, “I had bone cancer as a young girl.” Keeping it simple.

I cringe at the responses: “Oh damn.” “I am so sorry.” “You must be so strong.”

On dating apps, I don’t want to be thought of as being that kind of strong. I don’t want to talk about chemotherapy; I really have to be in the mood for that. On apps, I just want to know if we can go out to dinner or grab a drink on Friday night.

When I think about Rob, I know I dodged a bullet, but I also wonder about what would have happened if we had met, if I had not mentioned my leg. Friends are quick to say that he was not meant for me, and they’re right. Yet might something good have come from us having met? Perhaps.

I doubt Rob has ever gone out with an amputee before. I imagine that guys who don’t have amputees in their lives have their own thoughts about what dating one is like. Many have preconceived ideas about women who look like I do — seeing us as potential friends, but not potential girlfriends.

If I hadn’t mentioned the leg, Rob and I would have met for dinner. When I arrived, I might have caught him off guard with my walking limp, as he made note of my prosthesis. He might not have been into it then. But he would have had no choice but to talk with me, to engage with me, at least for a while, as an actual person. And my hope would be that from that night on, whenever Rob saw other amputee women, he would no longer be able to escape into baseless misconceptions and generalizations about who we are.

He would have a face to put to it. Perhaps he would remember me and think of the night we met, and maybe he would think of how little it all mattered then. Even if he were to drop things with me afterward, just to be able to humanize the abstraction would have been valuable. Doesn’t change happen one person at a time? After all, in my life, there have been many Robs.

Rob doesn’t know, and will never know, that I walk around with an above-knee prosthesis for 16 hours a day as a medical student. He doesn’t know that I swim twice a week, that I’m part of an adaptive rock-climbing group, that I ski on one leg and go out dancing on weekends.

He doesn’t know that I’m a summer camp counselor for young amputees, or that I plan limb loss education events around the country. He doesn’t know that showing my prosthesis in public doesn’t bother me, that I proactively take care of my body, and that I travel independently.

Since that episode, I haven’t mentioned my leg during conversations on dating apps. I have no desire to slap a warning sign on myself. I don’t want to spend my time thinking about how to make other guys more comfortable with meeting me. I do not wish to do that at all.

Recently, I remembered a different Rob I met years ago, an investment banker I dated for a bit. On our second date, we sat at Morgenstern’s eating ice cream. He glanced at my leg, I glanced at him, and he said, “You don’t need to tell me anything about it. That’s up to you.”

I kissed him that night. He called things off a few weeks later because he said I deserved so much better — a typical line, I suppose, from the kind of guy who tries but ultimately can’t move forward.

But he was right. I did, and do, deserve better.

Yet I think fondly back on that night for the reminder: I do not owe anyone my story. Being comfortable around my body will always be his responsibility, not mine. And when it comes to opening his heart beyond his fears and preconceptions? That responsibility, too, belongs to him.

Alexandra Capellini is a third-year student at the Icahn School of Medicine in New York City.

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Music Therapy: Why Doctors Use it to Help Patients Cope

Music therapy is increasingly used to help patients cope with stress and promote healing.

“Focus on the sound of the instrument,” Andrew Rossetti, a licensed music therapist and researcher said as he strummed hypnotic chords on a Spanish-style classical guitar. “Close your eyes. Think of a place where you feel safe and comfortable.”

Music therapy was the last thing that Julia Justo, a graphic artist who immigrated to New York from Argentina, expected when she went to Mount Sinai Beth Israel Union Square Clinic for treatment for cancer in 2016. But it quickly calmed her fears about the radiation therapy she needed to go through, which was causing her severe anxiety.

“I felt the difference right away, I was much more relaxed,” she said.

Ms. Justo, who has been free of cancer for over four years, continued to visit the hospital every week before the onset of the pandemic to work with Mr. Rossetti, whose gentle guitar riffs and visualization exercises helped her deal with ongoing challenges, like getting a good night’s sleep. Nowadays they keep in touch mostly by email.

The healing power of music — lauded by philosophers from Aristotle and Pythagoras to Pete Seeger — is now being validated by medical research. It is used in targeted treatments for asthma, autism, depression and more, including brain disorders such as Parkinson’s disease, Alzheimer’s disease, epilepsy and stroke.

Live music has made its way into some surprising venues, including oncology waiting rooms to calm patients as they wait for radiation and chemotherapy. It also greets newborns in some neonatal intensive care units and comforts the dying in hospice.

While musical therapies are rarely stand-alone treatments, they are increasingly used as adjuncts to other forms of medical treatment. They help people cope with their stress and mobilize their body’s own capacity to heal.

“Patients in hospitals are always having things done to them,” Mr. Rossetti explained. “With music therapy, we are giving them resources that they can use to self-regulate, to feel grounded and calmer. We are enabling them to actively participate in their own care.”

The Healing Power of Music

“A Song for Wayne,” performed by Edie Elkan and written as she played at the bedside of a student who was dying.

Even in the coronavirus pandemic, Mr. Rossetti has continued to perform live music for patients. He says that he’s seen increases in acute anxiety since the onset of the pandemic, making musical interventions, if anything, even more impactful than they were before the crisis.

Mount Sinai has also recently expanded its music therapy program to include work with the medical staff, many of whom are suffering from post-traumatic stress from months of dealing with Covid, with live performances offered during their lunch hour.

It’s not just a mood booster. A growing body of research suggests that music played in a therapeutic setting has measurable medical benefits.

“Those who undergo the therapy seem to need less anxiety medicine, and sometimes surprisingly get along without it,” said Dr. Jerry T. Liu, assistant professor of radiation oncology at the Icahn School of Medicine at Mount Sinai.

A review of 400 research papers conducted by Daniel J. Levitin at McGill University in 2013 concluded that “listening to music was more effective than prescription drugs in reducing anxiety prior to surgery.”

“Music takes patients to a familiar home base within themselves. It relaxes them without side effects,” said Dr. Manjeet Chadha, the director of radiation oncology at Mount Sinai Downtown in New York.

It can also help people deal with longstanding phobias. Mr. Rossetti remembers one patient who had been pinned under concrete rubble at Ground Zero on 9/11. The woman, who years later was being treated for breast cancer, was terrified by the thermoplastic restraining device placed over her chest during radiation and which reawakened her feelings of being entrapped.

“Daily music therapy helped her to process the trauma and her huge fear of claustrophobia and successfully complete the treatment,” Mr. Rossetti recalled.

Some hospitals have introduced prerecorded programs that patients can listen to with headphones. At Mount Sinai Beth Israel, the music is generally performed live using a wide array of instruments including drums, pianos and flutes, with the performers being careful to maintain appropriate social distance.

“We modify what we play according to the patient’s breath and heart rate,” said Joanne Loewy, the founding director of the hospital’s Louis Armstrong Center for Music & Medicine. “Our goal is to anchor the person, to keep their mind connected to the body as they go through these challenging treatments.”

Edie Elkan plays the harp as part of the music therapy program at Robert Wood Johnson Hospital in New Jersey.
Edie Elkan plays the harp as part of the music therapy program at Robert Wood Johnson Hospital in New Jersey.Edie Elkan

Dr. Loewy has pioneered techniques that use several unusual instruments like a Gato Box, which simulates the rhythms of the mother’s heartbeat, and an Ocean Disc, which mimics the whooshing sounds in the womb to help premature babies and their parents relax during their stay in noisy neonatal intensive care units.

Dr. Dave Bosanquet, a vascular surgeon at the Royal Gwent Hospital in Newport, Wales, says that music has become much more common in operating rooms in England in recent years with the spread of bluetooth speakers. Prerecorded music not only helps surgical patients relax, he says, it also helps surgeons focus on their task. He recommends classical music, which “evokes mental vigilance” and lacks distracting lyrics, but cautions that it “should only be played during low or average stress procedures” and not during complex operations, which demand a sharper focus.

Music has also been used successfully to support recovery after surgery. A study published in The Lancet in 2015 reported that music reduced postoperative pain and anxiety and lessened the need for anti-anxiety drugs. Curiously, they also found that music was effective even when patients were under general anesthesia.

None of this surprises Edie Elkan, a 75-year-old harpist who argues there are few places in the health care system that would not benefit from the addition of music. The first time she played her instrument in a hospital was for her husband when he was on life support after undergoing emergency surgery.

“The hospital said that I couldn’t go into the room with my harp, but I insisted,” she said. As she played the harp for him, his vital signs, which had been dangerously low, returned to normal. “The hospital staff swung the door open and said, ‘You need to play for everyone.’”

Ms. Elkan took these instructions to heart. After she searched for two years for a hospital that would pay for the program, the Robert Wood Johnson University Hospital in Hamilton, N.J., signed on, allowing her to set up a music school on their premises and play for patients at all stages in their hospitalization.

Ms. Elkan and her students have played for over a hundred thousand patients in 11 hospitals that have hosted them since her organization, Bedside Harp, was started in 2002.

In the months since the pandemic began, the harp players have been serenading patients at the entrance to the hospital, as well as holding special therapeutic sessions for the staff outdoors. They hope to resume playing indoors later this spring.

For some patients being greeted at the hospital door by ethereal harp music can be a shocking experience.

Recently, one woman in her mid-70s turned back questioningly to the driver when she stepped out of the van to a medley of familiar tunes like “Beauty and the Beast” and “Over the Rainbow” being played by a harpist, Susan Rosenstein. “That’s her job,” the driver responded, “to put a smile on your face.”

While Ms. Elkan says that it is hard to scientifically assess the impact — “How do you put a number on the value of someone smiling who has not smiled in six months?”— studies suggest that harp therapy helps calm stress and put both patients and hospital staff members at ease.

Ms. Elkan is quick to point out that she is not doing music therapy, whose practitioners need to complete a five-year course of study during which they are trained in psychology and aspects of medicine.

“Music therapists have specific clinical objectives,” she said. “We work intuitively — there’s no goal but to calm, soothe and give people hope.”

“When we come onto a unit, we remind people to exhale,” Ms. Elkan said. “Everyone is kind of holding their breath, especially in the E.R. and the I.C.U. When we come in, we dial down the stress level several decibels.”

Ms. Elkan’s harp can do more than just soothe emotions, says Ted Taylor, who directs pastoral care at the hospital. It can offer spiritual comfort to people who are at a uniquely vulnerable moment in their lives.

“There is something mysterious that we can’t quantify,” Mr. Taylor, a Quaker, said. “I call it soul medicine. Her harp can touch that deep place that connects all of us as human beings.”

Breast Cancer Centers Urge Annual Scans, Counter to U.S. Guidelines

A panel recommends biennial screenings, starting at 50, but a new study took issue with the way hundreds of centers are telling women 40 and up to come in yearly. Some experts contend that frequent mammograms can “do more harm than good.”

My last breast cancer screening was “b.c.” — before Covid — just a few weeks before the mysterious new disease was detected in China. The timing was perfect: Everything was normal, and by the time we went into lockdown, my to-do list no longer included a mammogram.

But by November 2020, exactly one year after that scan, I started getting barraged by phone calls and text messages telling me I was due for another one.

“MAMMO MATTERS,” screamed one in all capital letters. “Breast cancer does not take a break during pandemics, and neither should you.” I was well aware that national health guidelines recommend a mammogram only every other year for women at average risk for breast cancer. But there has been a cacophony of advice in recent years as different groups recast their recommendations, often contradicting one another. So the messages were unnerving.

It turns out my imaging center is not alone in badgering women to have mammograms more frequently than the U.S. Preventive Services Task Force deems optimal. A recent study found that hundreds of breast centers tell women who are not at elevated risk of cancer to have a routine scan every year, and to start at 40.

The task force, however, recommends regular mammograms every two years starting at 50. Its guidelines do recommend that women in their 40s discuss mammography with their doctors, evaluate the risks and benefits and come to an individual decision. (The panel’s recommendations extend to age 74; it has said there is not enough evidence to make recommendations past that age.)

The new study, published in JAMA Internal Medicine on March 15, was accompanied by a rather scathing editorial that said extra screening can do “more harm than good.”

“I don’t think breast cancer centers that have clear financial benefits from increasing mammography should be the ones that are giving out patient advice, particularly when it conflicts with the patient’s primary care provider’s advice and the task force’s advice,” said Dr. Rita F. Redberg, editor in chief of JAMA Internal Medicine, who co-wrote the editorial along with Dr. Anand R. Habib and Dr. Deborah Grady.

The American College of Radiology took umbrage, shooting back that it was “outrageous” to assert that breast cancer centers were promoting mammograms for financial reasons, and that the radiologists’ had a different set of guidelines.

When the pandemic started, both routine screenings and appointments triggered by troubling symptoms like the discovery of a lump were delayed as facilities shut down. Even when they reopened, many patients were reluctant to go in.

But Dr. Dana Smetherman, who chairs the American College of Radiology’s breast imaging commission, said the breast centers’ recommendations for more frequent screening predate the pandemic.

“What this study is telling us is that the experts in breast cancer in the U.S. do not support these recommendations,” Dr. Smetherman said in an interview, referring to the U.S. task force’s guidelines.

Indeed: Both the college of radiology and the American Society of Breast Surgeons recommend annual mammograms starting at age 40 (Dr. Redberg’s institution, the University of California, San Francisco, also recommends that schedule).

The American Cancer Society scaled back its recommendations recently, however, endorsing yearly scans starting at age 45, with the option of switching to every other year at age 54. The American College of Obstetricians and Gynecologists recommends women at average risk start mammography at 40, but “every one or two years.”

The debate over screening frequency for breast cancer — the second leading cause of cancer death for women after lung cancer — dates back to 2009. That is when the U.S. Preventive Services Task Force, an independent expert panel that reviews the evidence and provides guidance to doctors and insurers, rolled back its mammography recommendations for women who were deemed at average risk for breast cancer.

Screening can actually be harmful, especially for younger women, the panel found. False positive findings can trigger unnecessary procedures like biopsies, or lead to what experts call over-diagnosis — the aggressive treatment of slow-growing tumors that might never become life-threatening, but cannot be distinguished from fast-growing tumors.

When women had mammograms every other year, the harms of false positives and unnecessary treatment were reduced, the panel determined, while it found the life-saving benefits remained relatively unchanged.

But some experts believe the panel overstated the harms of more frequent screenings. The appropriate schedule for screenings can vary from doctor to doctor, and patient to patient, and has become quite confusing.

“Many women may not even be aware of the guidelines, or that there may be any downside to mammography, and that they have the option to begin screening at age 45 or 50,” Dr. Jennifer L. Marti, an assistant professor of surgery at Weill Cornell Medicine who led the new study, said in an interview. “In almost every other country, women start at 50.”

While many women might assume that “the pros of breast cancer screening outweigh the harms,” Dr. Marti said, that is not always the case for women who aren’t at elevated risk.

Dr. Marti and her co-authors, Mark Lee and Neal Patel, two Weill Cornell researchers, decided to examine the recommendations posted on the websites of some 606 breast cancer centers in the United States. They found that 376 centers — over half — made recommendations that differed from those of the U.S. task force, saying women at average risk for breast cancer should start imaging at age 40.

And 347 centers said women should not only start at 40, but continue annually.

More rigorous screening may be appropriate for some high risk groups, like Ashkenazi Jewish women, who are more likely to carry mutations that put them at risk for breast and ovarian cancer, and Black women, who were likely underrepresented in mammography screening trials, Dr. Marti said.

Women who want help assessing their individual risk to make screening decisions can use an online tool developed by Dr. Margaret Polaneczky, a gynecologist from Weill Cornell Medicine, and Elena Elkin, a research scientist at Memorial Sloan Kettering Cancer Center, Dr. Marti suggested.

As for myself, I’ve been on a two-year plan for a while. I do regular breast self-examinations, and have clinical breast exams too. So even though I felt a smidgen of irrational guilt after receiving the text messages, I politely asked a receptionist to please stop calling. I promised I’d be in touch.