Mammograms: Value Still Questioned

Another study has come out questioning the real value of mammograms. I won't copy the whole piece, but will quote the most important part, which best explains why mammograms may not be as helpful as one might logically think. More is not always better, and early detection doesn't ensure a better outcome.
October 24, 2011, 4:01 pm
Mammogram’s Role as Savior Is Tested
By TARA PARKER-POPE
Stuart Bradford

Has the power of the mammogram been oversold?

At a time when medical experts are rethinking screening guidelines for prostate and cervical cancer, many doctors say it’s also time to set the record straight about mammography screening for breast cancer. While most agree that mammograms have a place in women’s health care, many doctors say widespread “Pink Ribbon” campaigns and patient testimonials have imbued the mammogram with a kind of magic it doesn’t have. Some patients are so committed to annual screenings they even begin to believe that regular mammograms actually prevent breast cancer, said Dr. Susan Love, a prominent women’s health advocate. And women who skip a mammogram often beat themselves up for it.

A new analysis published Monday in Archives of Internal Medicine offers a stark reality check about the value of mammography screening. Despite numerous testimonials from women who believe “a mammogram saved my life,” the truth is that most women who find breast cancer as a result of regular screening have not had their lives saved by the test, conclude two Dartmouth researchers, Dr. H. Gilbert Welch and Brittney A. Frankel...

Dr. Welch says it’s important to remember that of the 138,000 women found to have breast cancer each year as a result of mammography screening, 120,000 to 134,000 are not helped by the test...

How is it possible that finding cancer early isn’t always better? One way to look at it is to think of four different categories of breast cancer found during screening tests. First, there are slow-growing cancers that would be found and successfully treated with or without screening. Then there are aggressive cancers, so-called bad cancers, that are deadly whether they are found early by screening, or late because of a lump or other symptoms. Women with cancers in either of these groups are not helped by screening.

Then there are innocuous cancers that would never have amounted to anything, but they still are treated once they show up as dots on a mammogram. Women with these cancers are subject to overdiagnosis — meaning they are treated unnecessarily and harmed by screening.

Finally, there is a fraction of cancers that are deadly but, when found at just the right moment, can have their courses changed by treatment. Women with these cancers are helped by mammograms. Clinical trial data suggests that 1 woman per 1,000 healthy women screened over 10 years falls into this category, although experts say that number is probably even smaller today because of advances in breast cancer treatments.

“Of all the women who have a screening test who have breast cancer detected, and eventually survive the cancer, the vast majority would have survived anyway,” Dr. Begg said. “It only saved the lives of a very small fraction of them.”..

Dr. Love, a clinical professor of surgery at the David Geffen School of Medicine at the University of California, Los Angeles, says the scientific understanding of cancer has changed in the years since mammography screening was adopted. As a result, she would like to see less emphasis on screening and more focus on cancer prevention and treatment for the most aggressive cancers, particularly those that affect younger women. Roughly 15 percent to 20 percent of breast cancers are deadly.

More needs to be done on the causes of all these cancers, but with funding so tight it's difficult to see how this is going to happen.
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Mammograms, the controversy continues

From last week's New York Times

An expert in breast cancer. Dr. Marisa Weiss, was diagnosed with breast cancer herself. This, is one of many anecdotal stories of early diagnosis leading to successful treatment after a mammogram. These stories abound and fuel the debate over the recently revised guidelines for mammography. The new guidelines stipulate that women with no risk factors do not need regular mammograms until age 50, and then every other year. I've done a few posts on the topic, here and here.

Dr. Marisa Weiss scheduled her mammogram this spring, just as she does every year. ..
Dr. Weiss, who soon learned that she had an invasive Stage 1 cancer in her left breast, is not just any physician. A radiation oncologist and a specialist in breast cancer, she founded a popular Web site, breastcancer.org, for women seeking comprehensive information about the disease, and she considers herself a woman with a mission...
A year ago, when a federal task force issued new guidelines relaxing the recommendations for mammography screening, Dr. Weiss was one of their fiercest critics. Mammograms aren’t perfect, she said at the time, but they save lives. Now she says one may have saved hers...
If Dr. Weiss had followed them, she might have skipped this year’s scan, giving the tumor more time to grow undetected; and if she had not had a trail of scans from her 40s, doctors would not have been able to compare the images and notice the tumor’s subtle emergence. (In fact, her risk is above average, because of her dense breast tissue and a family history. But she noted, “Most women who get breast cancer don’t have a family history — that’s a huge myth.”)...
Dr. Brawley says that on balance, mammography saves lives. But he notes that it misses some cancers, and that radiation from the scans will actually cause some cancers to develop.
In addition, some women will be called back repeatedly for additional procedures, scans and biopsies that ultimately rule out cancer but can be painful and anxiety-provoking. Mammograms also find some cancers that grow very slowly but look the same as any other cancerous tumor, leading to aggressive but unnecessary treatment..

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The article goes on to say that the decision is still a personal one and though some primary care physicians have reduced the number of referrals for mammograms, the new guidelines have not had a big impact on mammogram scheduling nor insurance coverage. Of note, is that Dr. Weiss would have been in a higher risk group anyway, and would have received mammograms as per the previous recommendations.

The trend is disturbing to Dr. Weiss, who says she fears that radical changes in the way women live — earlier puberty, rising obesity and alcohol consumption, environmental pollution, long-term use of oral contraceptives, later childbearing and less breast-feeding — could lead to more breast cancer emerging at younger ages.

Dr. Weiss goes on to say,

“The thing is: every woman is at risk. And every woman needs to do everything she can to protect herself.”

Coincidentally, I went to see my OB/Gyn physician for a checkup, and she was diagnosed with breast cancer over a year ago. The cancer showed up 2 months after her mammogram when she noticed an asymmetric nipple and dimpling. So her mammogram missed it. There are no easy answers here, and I certainly hope we can get some insight and funding to find out the cause of increasing breast cancer rates.


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Benefits of Mammograms after 50 less than previously thought

I will simply link to the local news story that covered the article published in the New England Journal of Medicine concerning the benefits of mammograms in women over the age of 50 years of age. The data on this topic is difficult to wade through, so I'm leaving the article as is. There is suspicion on both sides of the mammogram controversy. Many women feel that mammograms are being targeted and denigrated so that the insurance companies won't have to pay for them. On the other side, there are people who feel that there are definite harms in interfacing too much with the medical system and welcome the scrutiny these and other screening procedures (PSA for example) are getting.

September 22, 2010 (WLS) -- New research suggests mammograms may not be as helpful for women over fifty as many experts have said.

According to a large study conducted in Norway, mammograms reduce the risk of dying from breast cancer by 10 percent.

Only a third of that reduction is due to the screening itself. The rest is because of better treatment and greater awareness of the disease.

According to these findings, 2,500 women would have to be regularly screened over a 10-year period to save one life..."

http://abclocal.go.com/wls/story?section=news/health&id=7683998

Risk/Benefit Ratio of Mammograms Being Questioned

In an article from the NYTimes titled "Benefits of Mammograms Under Debate in Britain" the author discusses the controversy raging over information pamphlets handed out to patients on the benefits of mammograms in the UK. (http://www.nytimes.com/2009/03/31/health/31mamm.html?ref=health&pagewanted=print) A group of advocates and experts complain that the pamphlets are not truthful and exaggerate the benefits of mammograms and understate the risks.
"What women are not told... is that for every woman whose life is saved by breast cancer screening, up to 10 healthy women are given diagnoses — and, often, surgery — for a cancer that is so slow-growing it would never have threatened a woman’s life...."

Mammograms have been accepted as such a basic tenet of preventative care for women over the age of 40 in the U.S. , that questioning the benefit is startling to many here. I touched on this topic when discussing the newly questioned benefit of PSA testing. (http://ksparrowmd.blogspot.com/2009/03/prostate-screening-test-psa-may-not.html)

I've personally refused mammograms over the years and have encountered only astonishment and disbelief that I would avoid such a life saving exam. From reading I had done, I wasn't convinced that for a person like myself, with zero risk factors, the benefit would outweigh the risk, and now the data seem to support that stance. Indeed, Dr. Peter C. Gotzsche the author of the Cochrane analysis study states, "It may be reasonable to attend breast cancer screening with mammography, but it may also be reasonable not to attend.” And Dr. Lisa Schwartz from Dartmouth says “You’re not crazy if you don’t get screened, and you’re not crazy if you do get screened”...People can make their own decision, and we don’t need to coerce people into doing this (mammography.)"

I will be fascinated to watch the reaction to this issue by HMO's like Kaiser. Will they change their policies?
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