Discord on Mammography Roils the ACS

Yazmin

by Ralph W. Moss, Ph.D.

There appears to be discord at the top of the American Cancer Society (ACS) over the promotion of breast cancer screening. According to a front-page article in the New York Times, the ACS intends to abandon its rigid advocacy of mammography screening of the age 40+ female population. The Times states that in early 2010 the ACS will modify its long-held position. The stated reason is that screening mammography does not actually save many lives, since it mainly detects innocuous tumors that will never become life threatening. Meanwhile, it fails to detect most of the dangerous tumors. But a press release from the ACS soon afterward directly contradicted its own medical director's stated positions.

The failure of mammographic screening has been widely discussed for years and so the "news" was that the ACS was going to finally acknowledge this reality. "The American Cancer Society, which has long been a staunch defender of most cancer screening," wrote Times science reporter, Gina Kolata, "is now saying that the benefits of detecting many cancers, especially breast and prostate, have been overstated" (Kolata 2009).

Breast cancer thus turns out to be much like prostate cancer. In prostate cancer, the use of the prostate specific antigen (PSA) blood test has created an "epidemic" of new cancers, most of which would never have progressed to become life-threatening conditions. Doctors have been busy "curing" artifacts of the testing process itself. Widescale PSA screening turned many otherwise healthy men into traumatized cancer patients. Anxiety over one's PSA level became a disease in its own right called "PSA-itis," to quote the distinguished Toronto oncologist, Ian F. Tannock, MD (Lofters 2002). Meanwhile, deadly forms of prostate cancers-which are rapid growing and prone to metastasize-are less likely to be detected through PSA screening in time to make a survival difference.

Criticism of Mammography

There have been similar criticisms of mammography over the years. One thinks of the efforts of John Bailar, MD, PhD, a former editor of the Journal of the National Cancer Institute, who, starting in 1976, vigorously disputed the efficacy of mammography. One also thinks of Samuel Epstein, MD, of the University of Illinois, who pointed out the danger of the radiation involved in repeated mammograms. I myself wrote critically about mammography in my book The Cancer Industry (1980) and in a more recent Moss Report on the topic (see below).

A lucid discussion of the uncertainty of cancer screening has been made by H. Gilbert Welch, MD, and colleagues at the VA Outcomes Group and the Dartmouth Institute for Health Policy and Clinical Research, White River Junction, VT. Welch is the author of a provocative book, Should I Be Tested for Cancer? Maybe Not and Here's Why (2005) as well as numerous articles. For example, Dr. Welch wrote in 2009 in the British Medical Journal:

"Overdiagnosis of cancer occurs when the cancer grows so slowly that the patient dies of other causes before it produces symptoms or when the cancer remains dormant (or regresses). Because doctors don't know which patients are overdiagnosed, we tend to treat them all. Overdiagnosis therefore results in unnecessary treatment" (Welch 2009).

This week, the ACS dam appeared to be breaking, as a result of a recent article in the Journal of the American Medical Association, reiterating many of Welch's points. The lead author was Laura J. Esserman, MD, a breast surgeon at the University of California, San Francisco. According to the Times, the ACS was "spurred in part by an analysis published Wednesday in The Journal of the American Medical Association." This JAMA article shows that there has been a "40 percent increase in breast cancer diagnoses and a near doubling of early stage cancers, but just a 10 percent decline in cancers that have spread beyond the breast to the lymph nodes or elsewhere in the body" (Kolata 2009).

This contradicts the very purpose of mammography screening, which is to find breast tumors in an early and curable stage, before they become deadly. If that were indeed happening, then the statistical increase in early-stage breast cancer should be accompanied by an equivalent decrease in the number of late-stage tumors. Instead, there was only a 10 percent decrease in late-stage cancers. So the net effect has been to greatly increase the number of breast cancer cases, finding innocuous pseudo-malignancies, without significantly impacting the death rate.

As the JAMA paper put it, mass screening increased "the burden of low-risk cancers without significantly reducing the burden of more aggressively growing cancers and therefore not resulting in the anticipated reduction in cancer mortality" (Esserman 2009). Or, to quote the Times, there was a "real risk of over-treating many small cancers while missing cancers that are deadly."

TO BE CONCLUDED, WITH REFERENCES, NEXT WEEK

Our Report on Mammography

We have a special 36-page report on "Mammography, Biopsy and the Detection of Breast Cancer." Here is what one reviewer, Samuel Epstein, MD, professor emeritus of Environmental and Occupational Medicine at the University of Illinois School of Public Health, said about this report:

"A characteristically thoughtful and incisive work that not only exposes the very real dangers of breast cancer screening...but also lays bare the astonishing lack of scientific evidence underpinning current screening recommendations. This is an outstanding and important work by an outstanding and important author."

To order our report, please click here or go to:
http://www.cancerdecisions.com/mrstore/index.php?main_page=product_info&cPath=2&products_id=511
(Listed under "Current Topics")

 

--Ralph W. Moss, Ph.D.

AnneW

I read that earlier today. Thanks for posting it. This is bound to stir up some discussion, just as when the World Health Organization stated a few years ago that clinical self breast exam did not improve overall survival.

Anne

carol1949

The whole issue is certainly worthy of notice. 

For me, since at least 2 mammograms and one ultrasound missed my tumor until it was 6.5 cm, I don't have a lot of confidence in them.  My gynocologist found it on a routine yearly exam and yes I went yearly.  I had so many cysts, when I felt my breast, I thought I was finding just another cyst.  The tumor was actually between 2 cysts.

My oncologist told me it is like looking for a cotton ball in a cloud!

TenderIsOurMight

Just to stir the pot even more, why not use mammograms in tandem with breast MRI as a screening tool if you wish to lower late stage tumor pickup (those aggressive tumors which spread quickly and are missed on mammograms). 

Cost, excellence in interpretation, and willingness to take on potential liability certainly accompany breast MRI's and mammograms. Might their joint use at a single setting actually lower the risk of liability given mammograms missing of 10 to 25% of cancers (density issues, lesion not seen by reader, masked calcification's), and MRI's imperfection of detecting breast calcification's (see below).

 The question remains (even in light of mammogram and MRI false positives):  As a screening tool for breast cancer, would breast MRI/mammogram result in an achievable goal: that of finding all breast cancers early enough, but especially the aggressive ones, and thereby decreasing late stage tumors in a statistical manner, and above the 10% reduction afforded by mammograms alone. We already recognize the value of  PET/CT combinations in breast cancer. How about a large prospective study on MRI/mammograms as breast screening?

 Food for thought, and guaranteed to make many eyes roll.

Tender

http://www.ajronline.org/cgi/content/abstract/186/6/1723

carol1949

We will just keep stirring and sharing ideas!

I finally did have a Pet scan as well as MRI w/ contrast and then 2 more of those during chemo.  They are not fun and probably cost more than insurances will want to pay.  As for the Pet scan.... it can't be good to be injected with nuclear glucose!  The tanks have danger written all over them.  The person who did mine said, "Oh, Yeh, this stuff is real safe", rather sarcastically, but not trying to be sarcastic to me directly.  Incidentally, when he finished, he said, :You can Relax and have a good weekend.  I think that was his way of telling me it was clear.

I would like to see more thermography and also the radiologist who gave me my last mammo said he would like to see it used more as well!  Once again... most insurances won't pay for it.

Yazmin

carol1949:

If you are ER+, PR+, HER-, I would not be surprised that you can, indeed, relax: my understanding is that those are the tumors that are least likely to recur......which makes the issue of avoiding (whenever possible) toxic "screening" even more pressing.