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Is This the End of Mammograms to Screen for Breast Cancer?

A new panel from Switzerland says it should be.

by
Theodore Dalrymple

Bio

June 2, 2014 - 4:00 pm
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Internet discussions usually descend into abuse within a few postings. Whether this is because people these days are less polite and restrained than they used to be, or because the internet allows them to publish their first reactions without the time to cool off that older means of communication entailed, I do not know; but the fact is that those who take part in such discussions seem to confuse insult with argument and are seldom able to keep to the point for very long.

Doctors, if the internet discussions that follow articles that appear in the New England Journal of Medicine are anything to go by, are better than average. Often, indeed, though not always, they employ rational argument. Perhaps there is something to be said after all for a long and rigorous education.

Not long ago there appeared an article in the NEJM throwing doubt on the wisdom and even the ethics of screening by mammography for early cancer of the breast. A Swiss commission examined the evidence for the benefits and found none, or some so slight that it hardly counted. The best estimate they could come up with was that mammography saved one life from breast cancer per 1000 women aged 50 who underwent screening, but that the all-cause death rate in the screened and unscreened was practically the same. Not only did many screened women undergo unnecessary operations and much radiotherapy for false positive results, but those who offered the screening were little more honest than second-hand car salesmen, in effect preying on the women’s complete misunderstanding of the supposed benefits of screening. Women believe that even with screening they are twenty times more likely to die of the disease than in fact they are; and they overestimate the benefits of screening by eighty times.

In the circumstances, then, the Swiss panel suggested that screening by mammography should be stopped forthwith.

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Top Rated Comments   
This distinction isn't black and white. The first question is how fast is the tumor growing. The second is what's the woman's age and what other conditions and risk factors does she have? A 70 year old with a slow-growing malignant tumor and serious heart disease is a totally different story from a 20 year old, otherwise healthy, with a fast growing tumor.

Specialists also know a lot about what different kinds of cancer cells look like and how they respond to different kinds of tests -- that's what biopsies (they cut out a tiny bit of the cancer, often with a hollow needle) are for. And they can grow your cells and see how fast they multiply.

We're all going to die of something. "Do everything you can, doctor" is not the best thing for everyone with cancer. At age 70, 'watch and wait' may give a lot more good life.

Because any detectable tumor (for mammography that would be around 1 mm diameter but otherwise several times larger) has already doubled in size many times since it started out as one very sick cell, the age of the victim is one clue: A tumor at age 60 is more likely indolent than one at age 20 since the latter has probably had only 8 years or so to grow.

Did you know that nearly all men age 90 have prostate cancer? True ... but these tumors are so indolent that a 90-year old will almost certainly die of something else without having trouble with the cancer.

A tumor is a group of cells that aren't under normal body controls for excess growth. Our bodies have search-and-destroy workers that kill cells that don't look right. But sometimes a cell comes along that can fool or otherwise protect itself against those defenses so it can divide without limit. That's a tumor.

Many tumors, however, cannot send out colonists to start trouble in other places. Those that can are called cancers, that is, they are malignant.

Even cancer cells aren't all alike and there is no complete catalog of the ways a cell can be cancerous. Cancers large enough to be detected are COLONIES of cells that may be enough different that they cannot all be killed by any current treatment. So you get treatment, the initial tumor goes away, and then -- maybe -- one day it comes back. Now it's mostly cells grown from those that survived the initial treatment -- much harder to kill.

See why there's a need for a lot more research? Cancer cells are all abnormal. That abnormality means they have weaknesses. But current knowledge is not even close to being sufficient to use those weaknesses to kill all the cells every time.
12 weeks ago
12 weeks ago Link To Comment
All Comments   (30)
All Comments   (30)
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As I understand it, Thermography is far better than a mammogram & detects at a much earlier stage, WITHOUT radiation & getting your breasts smashed painfully flat. NATURALLY, it is NOT covered by medical insurance, so (like SO MANY healthy lifestyle choices) we have to pay the full cost ourselves!!
10 weeks ago
10 weeks ago Link To Comment
Current Am Cancer Soc data put lifetime risk of developing breast cancer at 12.3%. That is one out of every eight women. Women never outgrow the risk of breast cancer. Current median age at diagnosis is 61.
12 weeks ago
12 weeks ago Link To Comment
Mammography does nothing to detect Inflammatory Breast Cancer, which is almost always Stage IV before it is detected. My neighbor didn't even know she had it, there were no lumps, etc., only fatigue and a feeling of heaviness, like her breasts were bloated. Her doc sent her for a mammogram which showed nothing, so he told her not to worry about it. Eventually she happened upon a doc who knew what to look for and found that she had IBC that had spread to her lungs and liver. Even with treatment she was dead in a year.

I agree that a lot of mammograms are useless, especially for women with NO family history for breast cancer. I deal with this be telling my doc that I'll humor her by getting a mammogram every other year, instead of every year.
12 weeks ago
12 weeks ago Link To Comment
" I deal with this be telling my doc that I'll humor her by getting a mammogram every other year, instead of every year."

Why do you see need to humor your doctor? Who's in charge?

12 weeks ago
12 weeks ago Link To Comment
From your tone, I'd say the ignorant are in charge, or you think they should be.
12 weeks ago
12 weeks ago Link To Comment
DG:
So what? You think there are panaceas out there, and everything else is useless? Your agreement that "a lot of mammograms are useless" shows you simply do not understand that screening tests show most people do NOT have the screened-for abnormality. By your thinking, taking blood pressure on all patients is a waste of time... why are you checking? Most BPs are normal! But I'll humor you and let you check it.

Your neighbor had IBC in both breasts, "like her breasts(plural) were bloated"? Most unusual, and unusual things are harder to diagnose.She very possibly had lung/liver metastases ("fatigue" as a symptom) when she went to her 1st doc; that happens with IBC.

I would not have you as a patient. You think you are as medically educated, and have given as much thought to patient care, as a conscientious physician, by the sound of it.
12 weeks ago
12 weeks ago Link To Comment
Dalrymple is a shrink whom I normally respect very much. I have not read the NEJM paper nor the Swiss study, taking Dalrymple's representations as fact.I am a cancer doc.
1) He wrote, "mammography saved one life from breast cancer per 1000 women aged 50 who underwent screening". Aged 50? That cannot be true. 50-55 maybe, but no one reports data by single year of age--the numbers are too small.Screening is not intervening; it is discovering abnormalities to be intervened upon, in many but hardly all cases. Do you wish to reduce police (detection) patrols because they don't prevent sufficient crime? That was not the Giuliani approach in NYC that lowered crime rates so profoundly.
2) "Not only did many screened women undergo unnecessary operations and much radiotherapy for false positive results." No one gets radiotherapy based on false or true mammogram results; NO ONE. Operations for screening results are not "unnecessary". That lesion X turned out not to be invasive cancer did not make its excision unnecessary-one must excise it to show that. The sensitivity of mammograms is high; the specificity is not.
3) That all-cause mortality was not seriously impacted by excision of very early breast lesions after mammography is hardly surprising. Most early breast cancers (Stage zero, stage 1) become potentially lethal only after multiple years, and breast cancer is only one cause in the all-cause mortality pool. Treating breast cancer does not prevent strokes or rupture of aneurysms,after all. And our duty in medicine is to do more than merely keep people (women, though men get breast cancer too) alive.

The Chicken Littles commenting all see profiteering plots at places where they too work and profit. And then we get the usual and useless anecdotes about Mrs Chichen and her mamms.

The same shoddy thinking has been leveled at PSA screening for prostate cancer. "Many will never kill the old gents in their lifetimes; only some will." Who will that be? To prevent those deaths means we must treat them all. And those that don't spread can make peeing tediously difficult unless TURPs are done to prevent or treat urinary obstruct
12 weeks ago
12 weeks ago Link To Comment
Well said Doc.

I am a practicing Radiologist. I no longer include mammography in my practice. Mostly because it has become, as it should be, a sub specialty. Partly I became skeptical because I thought that some of us were becoming too aggressive in pursuit of questionable lesions to support a large population based screening program.

For example, giving a Bi-rads category 3 after a diagnostic workup which should not happen. She has already undergone too much anxiety to wait 6 more months for an answer.

Large scale population screening needs to have low trade off in cost, bother, and anxiety to the population in return for benefit. Mammography, screening and diagnostic, tomosynthesis, Breast MRI, directed biopsies, are powerful tools. They just need at this point, a review.

I agree that overall mortality data is not a complete picture. Screening mammogram is just that. Perhaps because we can see so much now many women and primary care docs have backed off because it was more than they could handle in daily life.

Always, the radiologist, and yourself, deal with "incidentalomas", the 3mm nodule in the lung, the thing in the liver or adrenal gland, not clearly benign, thyroid nodules, renal "complex cysts". You know about all of this and we work together to solve these problems.

These are seen when the patient shows up for pneumonia or whatever and are found anyway. So we deal with those because they cannot be ignored.

A screening population based exam is a different endeavor. We are looking for findings not referred by acute illness. It is welcome that maybe with new data, we can refine screening guidelines to achieve better outcome.

12 weeks ago
12 weeks ago Link To Comment
Yearly mammograms are the biggest money making medical scam in our healthcare system. I work in radiology and I'll tell you that over 99% of mammograms are negative. If you have a strong history of breast cancer in your family and you're experiencing symptoms or changes, fine, go in for a mammogram. Otherwise save your time and money. We're laughing all the way to the bank.
12 weeks ago
12 weeks ago Link To Comment
The studies that seemed to show that screening mammography saved lives were done in the 80's -- early, if I recall. By around 2000, criticism of the study methods -- basically study design flaws that meant you couldn't really draw any conclusion about benefits -- was out there and there have been a very few doctors since then who advised accordingly.

It is a serious indictment of the medical profession that most doctors, the American Cancer Society, and the breast cancer-specific organizations hopped on the 'mammography saves lives' bandwagon. There's never been proof of that.

Screening mammography DOES detect cancers at an earlier (smaller) stage and that often leads to easier treatment and a better looking result because (if surgery is used) less needs to be removed. The reason this DOES NOT mean a higher survival rate is that many tumors that are going to spread do that while they're still too small to be detected. It's not the cancer in the breast that's the killer, it's the metastases in other places in the body.

The bottom line seems to be that mammography DOES NOT save lives. It MAY slightly reduce the death rate due to breast cancer but if it does, then at the same time it increases the rate from other things. It could be that the radiation required to do all those x-rays CAUSES enough other damage (including new cancers) to cancel out the lives saved from an original cancer.

At the same time the other things that influence breast cancer rates haven't been given enough attention: Estrogen is a risk factor. While birth control pills have benefits (pregnancy has risks) minimizing the number of years they're taken makes sense. Fat cells produce estrogen and weight gain is a risk factor for breast cancer. Breastfeeding is protective; I think at least the first two breast fed babies add to the protection.

A second error -- monumental in my opinion -- is that we spend around ten times as much money doing screening for breast cancer as we do on research. This disease is NOT well understood and treatment is still at the level of using bombs and flamethrowers to handle a village with a bad attitude.

What I believe women should do is seek out a 'women's medicine' specialist (gyn or ob) for their routine care who can talk about the points above more or less along those lines and fill in the gaps. There isn't a single right answer but your specialist should be keeping up with the science: If he (or she) is stuck on "mammography saves lives" I'd strongly suggest finding a new specialist.

No single right answer? Well, no. Age matters, risk factors matter. A science-oriented guy who did a ton of reading back when the most important person in his life was dealing with this isn't a substitute for a medical specialist who keeps up with the science and knows you.

It's good that the truth is finally starting to show up in public.

12 weeks ago
12 weeks ago Link To Comment
Statistics are tricky. I don't like them, but I mostly understand them. However I've seen some very prominent and otherwise intelligent people completely unable to cope with them. A lot of that is at work here.

There is another side, which is that if we have something that *might* help, is it *ever* really advisable not to even try? That's just a big thing to swallow, whatever the numbers say.

BTW, the case of the colonoscopy if very similar, it is very hard to justify all the kerfuffle about it if you look at all the numbers.

With a little luck science will get us out of this in a few more years, some better noninvasive tests would clear up the mathematical and moral dilemmas.

BTW2 my cousin recently underwent a double mastectomy and the even worse reconstructive surgery based on such a diagnosis, and of course one never knows but I think she drastically overreacted, based on what I know of such things. Just the pain of even a "successful" intervention also needs to be weighed.
12 weeks ago
12 weeks ago Link To Comment
An honest representation of the misdiagnosis rate would be helpful. If these statistics were presented we would be arguing over whether one life was worth thousands upon thousands of false alarms. My wife went thru these false alarms for years (she's what they call fibrous). Yet, the diagnostics never changed and the false alarm treatment dollars piled up.
12 weeks ago
12 weeks ago Link To Comment
Then there's the shoe on the other foot; my mom had her usual mastectomy. Then a month later saw the doc. The mamo came back negative, but the doctor found a lump manually, and did a biopsy. Cancer.
12 weeks ago
12 weeks ago Link To Comment
Well, my first wife died of breast cancer. She was first treated at age 25 with lumpectomy and radiation. She presented again when 42 with a massive seizure. This was from a completely different type of breast cancer according to the pathologists. So, she had two different tumors of two separate types. The first could be easily felt. The second was so small, they didn't even remove it because they treated her with chemotherapy. It had already metastasized, though, and she suffered through 3 years of gradual decline.
Over her life, she had at least 50 mammograms without ever having a positive result. That, to me, is the very definition of useless.
FWIW.
12 weeks ago
12 weeks ago Link To Comment
With any luck, the question will be moot. Those evil Israelis, while Hamas and and Abbas are busy doing their death dance, and the rest of the neighborhood is blowing each other up, have developed a new non-invasive blood tat to detect breast cancer. Yup -- there those Jews go again, controlling the world!

http://israel21c.org/health/israelis-develop-first-blood-test-for-breast-cancer/
12 weeks ago
12 weeks ago Link To Comment
They make some awesome machine tools and servo drives, too. In my book, they are ahead of even the Germans and Japanese in those two areas. They do some amazing stuff.
If the Ayrabs finally decide to go to Allah collectively, they should just shoot a nuke at Israel. There is no evidence that the Ayrab one will work, while I guarantee the Israeli one will put an end to their troubles.
Ditto the Chinese and Japanese. (Of course Israel and Japan have nukes, silly!)
12 weeks ago
12 weeks ago Link To Comment
Thanks.

As one of the commentators writes...

"...imagine how much more could be accomplished if scientists were not distracted by the social and moral failures of their neighbors pointing rockets."
12 weeks ago
12 weeks ago Link To Comment
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