Rethinking Mammograms - What the Breast Cancer Experts Now Recommend. The Risks, the Benefits, and Who Gains the Most From Regular Screening

"I'm admitting that American medicine has overpromised when it comes to screening.  The advantages to screening have been exaggerated."

-Dr. Otis Brawley, chief medical officer of the American Cancer Society, on Oct. 21, 2009-

Dr. Brawley's comment, which appeared in the New York Times (read the article here), was in response to a groundbreaking essay by Laura Esserman, Yiway Shieh, & Ian Thompson that appeared in the Oct. 21, 2009 issue of JAMA:  Rethinking Screening for Breast Cancer and Prostate Cancer.  

"It's just not true to say that 'if you get a mammogram, all will be well.'  A recent study indicates that most stage II and III breast cancers actually turn up clinically, between normal planned screens.

A central problem with the screenings for both of these cancers seems to be that they have increased the burden of low-risk cancers without reducing the burden of more aggressive cancers.

We are not saying that screening is bad. It's what you do with the information that makes it good or bad. We need to refocus and figure out how to tailor screening.

I think people like the simple message that screening is good and are uncomfortable with complexity. I understand that. However, cancer is a complicated disease.

We need to expand our messages to say, among other things, that many screen-detected cancers are slow growing and may not need treatment."

-Dr. Laura Esserman, University of California, San Francisco School of Medicine, lead author of the JAMA "Rethinking Screening for Breast Cancer and Prostate Cancer"-

If Mammograms Aren't Perfect, What Are We Supposed to Do Now?

OK, so mammography isn't the wonderful screening tool we all thought it was.  It can pick up slow-growing-non-life-threatening-insignificant cancers, while sometimes missing the fast-growing-aggressive ones.  Although, mammograms do save lives, they can result in unnecessary biopsies, unnecessary treatment, unnecessary fears, and at the same time, they sometimes give us undeserved peace-of-mind when we hear our latest mammogram is just fine. 

Not to mention the large Norwegian study published last year that found about 22% of mammogram-diagnosed cancers might have disappeared without treatment.

What's a woman to do?  Well, thank goodness for Denise Grady, a medical writer for the New York Times, who interviewed several breast cancer experts to find out what exactly we should do--now that we know there's a "dark side" to mammograms.

I recommend everyone read Denise's article, "Quandary With Mammograms:  Get a Screening, or Just Skip It?"  that was published on November 3, 2009.  Click here for the article.

Most importantly--when we go in for our next mammogram, we need to have our EYES WIDE OPEN!  We need to know what mammograms do well, what they miss, which women benefit most, and what are the real risks of screening and biopsy. 

We also need to push for a better way to distinguish the aggressive cancers from the low-risk cancers.

The Breast Cancer Experts' Advice on Mammograms--Compliments of Denise Grady

Dr. Laura Esserman, breast surgeon from UC San Francisco:

1. In terms of growth & aggressiveness, breast cancers are: slow, medium, or fast, and mammograms don't do an equal job of diagnosing all three.
2. Mammograms are good at finding the slow ones--which probably don't need treatment.  
3. Mammograms might not catch the aggressive ones before they begin to spread.  A recent study showed most Stage II & III breast cancers turn up clinically between screenings.
4. Mammograms are good at picking the "medium" ones--and those are the women who benefit most from mammography.
5. Women over 70-75 can stop being screened--no studies have shown that it helps this age group.  Most of the cancers in this age group are likely to be the slow-growing-non-life-threatening variety.
6. There's no evidence of benefit for screening women from age 40-50 unless they have a strong family history of breast cancer or the BRCA gene.
7. Know your risks.  Be proactive.  If you have a high risk, talk to your doctor about taking tamoxifen or raloxifene, which can lower your risk.  Other risk factors include: taking hormones for menopausal symptoms, having a history of biopsies, no pregnancies before 30, a mother or sister with breast cancer, and of course, aging.
8. For the National Cancer Institute Breast Cancer calculator click here.  Dr. Susan Love advises: the calculator is not so good for determining individual risk!
9. Women from age 50-60 benefit most from mammograms--and screening can reduce the risk of cancer by 20-30%.
10. If you are in the over 50 age group--find out if you have dense breasts.  Most doctors don't mention this, and it should be on the radiologist's report.  No one ever told me--I had to ask.  Having dense breast tissue is a double risk.  It's hard to find cancers on mammograms--like finding a polar bear in a blizzard--and for unknown reasons, cancers are more likely to occur in dense breasts.
11. If you have dense breast tissue you might consider an ultrasound. However, even though it does a better job of picking up small hidden breast cancers--it increases the biopsy rate.  A very recent article in BMC Cancer 2009, 9:335doi:10.1186/1471-2407-9-335 looked at ultrasounds for dense breasts. "Early detection of breast cancer: benefits and risks of supplemental breast ultrasound in asymptomatic women with mammographically dense breast tissue. A systematic review"   Click here for the article.  Positive note: Exercise has been found to lower density.

Dr. Susan Love, a breast surgeon & researcher in Santa Monica, CA:

1. "I really don't think we should be routinely screening women under 50.  There's no data to show it works."
2. Women who are 50-70 years old need to find out if they have dense breasts.  If they're dense she recommends yearly mammograms.  Click here to read Dr. Susan Love's advice about dense breasts.
3. If you don't have dense breasts, you can have less frequent mammograms.
4. European countries screen every other year, and their breast cancer rates are not higher than the U.S.

Dr. Larry Norton, deputy physician-in-chief for the breast cancer program at Memorial Sloan-Kettering Cancer Center:

1. Even though mammography isn't perfect, it shouldn't be abandoned. 
2. According to Norton, "If an individual woman wants to reduce her odds of dying of breast cancer by at least 24 %, she should follow the current guidelines."
3. Norton disagrees that 1 in 3 cancers found by mammography aren't fatal--he says, "There's no way to be sure."
4. Finding tumors when they are small, which mammograms can do, increases the odds that a woman can avoid mastectomy and chemotherapy.

Dr. Silvia C. Formenti, the chairwoman of radiation oncology at New York University, Langone Medical Center:

1. "Screening does not pay off the way we expected."
2. All women should have a doctor do a manual exam for lumps & abnormalities.  Experienced doctors can feel lumps as small as 1 centimeter, and even with those as large as 5 centimeters, it's possible to only have a lumpectomy, and perhaps no chemotherapy.
3. Her biggest concern is that mammography will find tumors in older women (over age 70), and these tumors are likely to be not life-threatening.  "The diagnosis turns them into cancer patients and erodes their peace of mind forever.  The psychological cost of becoming a cancer patient is underrated."
4. Best times for screenings:  the 50-60 age group--and women over 60 may still benefit, even though the evidence isn't as strong.
5. It was misleading and "a giant misconception" that  groups like the American Cancer Society led us to believe that screening prevents cancer.

How to Improve Screening--What Drs. Esserman, Shieh, & Thompson Recommend

4-Point Plan to Improve Screening.  From Medscape Medical News "Rethink" of Cancer Screening Triggers Comments and Controversy.

1. More powerful markers that identify and differentiate cancers with significant risk from those with minimal risk are needed.
2. The treatment burden for minimal-risk disease must be reduced. Methods currently exist to identify low- and high-risk cancers in both the breast and prostate, they emphasize. For instance, in prostate cancer, low-volume lesions with low Gleason scores have a low-risk for death. Minimal-risk disease should not be called cancer; it should be called indolent lesions of epithelial origin (IDLE), they say.
3. Improved tools to support informed decisions are needed. "Information about risks of screening and biopsy should be shared with patients before screening," they write. Currently, an estimated one third of PSA tests take place without even the most basic doctor–patient discussion, as reported by Medscape Oncology.
4. A greater emphasis on prevention, including the use of proven cancer preventive agents, such as finasteride for preventing prostate cancer and tamoxifen and raloxifene for preventing breast cancer, is needed.

The Risks and Benefits of Breast Cancer Screening

According to Esserman, Shieh, & Thompson:

Although evidence indicates that breast cancer screening saves lives, 838 women, aged 50 to 70 years, must undergo screening for 6 years to avert 1 death. However, this 1 life saved generates "thousands of screens, hundreds of biopsies, and many cancers treated as if they were life-threatening when they were not."

To Read More on the Subject:

1. Medscape's excellent article by Nick Mulcahy, "Rethink" of Cancer Screening Triggers Comments & Controversy, click here

2. Dr. John McDougall's October 2009 newsletter:  The American Cancer Society Reverses Its Strong Position on Mammograms and PSA Testing  McDougall's reminder: The truth is breast and prostate cancer are caused by the rich Western diet full of beef, chicken, cheese, milk, and oils, and contaminated with powerful environmental cancer-causing chemicals. A sizable share of that $20 billion must be spent on advertising, education, and subsidy programs to bring about monumental changes in our eating.

3.  Dr. Susan Love on the breast density/breast cancer connection and what to do about it.  Click here.

4.  My previous post: Archives of Internal Medicine Study Asks: Can Cancer Disappear Naturally? Lessons to Learn - Diet & Exercise May Help  click here

Comments

[JK]

From one of the NY times articles...

Dr. Formenti said she was concerned about finding tumors in older people that would probably not kill them. But the diagnosis turns them into cancer patients and erodes their peace of mind forever.

“We take away the innocence of being healthy and not having to worry about cancer,” she said. “The psychological cost of becoming a cancer patient is underrated.”

As someone who got "screened" for something that she shouldn't have been screened, I totally agree... I have information about something that I will just worry... I've almost got it in perspective, but it's taken a couple of weeks for me to figure it out, and feel like I understand it. Someone who is older, and not trained to think in "research" ways may not be able to get past the worry.

I hope that we can gain a better understanding of markers to distinguish dangerous cancers from slow growing, most likely non-fatal ones.

[The Healthy Librarian]

Thanks for emphasizing Dr. Formenti's point. It's no small matter when one's peace of mind is shattered, and when one starts thinking of themselves as a sick person, rather than a healthy one.