Ny Times article slamming mammography screening

gardengumby - I totally agree with you about Dr. Welch --- totally absord and I doubt he would treat his family member that way. A routine mammogram found my very deep IDC not felt on PE and like you it already spread to my nodes. I regret not catching it sooner with my hx of moderate dense fibrocystic breasts and previous large fibroadenoma removed.  No other screening options were offered and I did not know that breast density was an issue. My aunt died of breast cancer and mother had early stage breast cancer while I was the youngest dx at age 49.  Strong family hx of other cancers too. I am so tired of fighting with Drs to get an MRI or US on alternating years.  Now I will ask my PCP for a US script at next mammogram to determine exactly what is in my breasts regarding calcifications, density status, etc because right now it is a big secret.  I feel I am entitled to this information.  Until they can come up with better screening options the mammogram is the best we have but we must be aware it is not perfect. No I don't believe it is a government plot - - but money and funding is certainly behind alot of medical advances.

voraciousreader - Ditto the 6th thought too!!!  All the more reason for us to speak out and be the squeaky wheel until they give us something better.........

Dragonfly1. According to the data... Improvements in treatments should give both of you a shot at a very long life. Part of the study said that back in the 70's and 80's because there were less treatments, screening and earliest diagnosis was paramount. Thankfully, we have more treatments now and that's why they believe women are living longer. This does not negate the need for a cure.

Here is the NY Times editorial regarding the controversy:

More Questions About Mammograms

Two years ago, a group of outside experts who advise the federal government raised a furor when it suggested that mammography screening to detect breast cancer early, when it is theoretically most treatable, should be scaled back. Now a new analysis published in the Archives of Internal Medicine, a journal of the American Medical Association, has found that while some women have their lives saved by mammograms, a vast majority found to have tumors do not benefit - probably because they have slow-growing cancers that would never have killed them or could have been treated at a later stage, or they have aggressive cancers that are deadly even if detected early.       

The analysis, by two researchers at Dartmouth, used a variety of data sources to estimate the probability that a woman with breast cancer detected by mammography would have her life saved because of the screening. For the baseline case of a 50-year-old woman, only 3 percent to 13 percent escaped death from breast cancer thanks to early detection by mammography. As described by Tara Parker-Pope in Science Times, that translates into 4,000 to 18,000 women being helped by the test, a small portion of the 230,000 women diagnosed with invasive breast cancer annually in the U.S. and a minuscule fraction of the 39 million American women who undergo mammograms each year.       

Several thousand lives saved per year is not inconsequential. But the new analysis inevitably raises questions as to whether the $5 billion spent annually on mammography screening and the millions more spent urging women to get screened might better be used for other purposes. Women will face a difficult choice. Fewer than 1 in 1,000 healthy women screened over a decade will have a cancer found at just the right moment for successful treatment. The rest will undergo a decade's worth of radiation for no medical benefit or, worse yet, undergo unnecessary treatments that can be harmful to eliminate tumors that would never have killed them.       

Off topic a bit....but recalling the Autism controversy where Dr. Wakefield's data was discredited:

http://en.wikipedia.org/wiki/Andrew_Wakefield

it took the medical establishment many years to come to it's conclusion!  I am not saying here that what we have here is on that level.  What I will say is that, sadly in the journey to research treatments and the prevention of Autism, time and money was lost because of this one study.

With THIS controversy regarding screening mammograms, no doubt, many fine people, doing EXCELLENT research need to come to some consensus so that TIME and MONEY will not be lost in finding treatments, prevention and a cure.  With the cacophony of different opinions, the clock is ticking louder and louder with each life lost....  We all deserve a better answer.  Thank goodness Breast Cancer Awareness month is almost over.....

Pitanga...I don't think we have any disagreements with regard to mammograms being a valuable tool, nor do we disagree that for our younger sisters, we need an even better tool AND we need a cure for EVERYBODY.  However, what the younger sisters need to know is that THERE IS A CONTROVERSY over how effective SCREENING mammograms are for them and that they need to be VIGILANT in getting the BEST possible care.  The bottom line is that until THIS controversy is settled, the status quo is potentially not helping us find a better way of screening.  There are very hungry researchers and inventors out there that are scraping by that need an infusion of money to fund the next great discovery that may one day lead to a cure.  Again, the British get it and are willing to examine the controversy and I applaud them.

Pitanga...I do not disagree with you.  All I am referring to is that more women need to be educated that there is a controversy.  A very REAL controversy and all of our lives depend on this controversy being settled once and for all.  And to answer your question regarding European women being recommended for SCREENING mammograms beginning at 50 (BTW..and then every 2 to 3 years)...that is NOT part of the controversy!  Dr. Welch's data suggests that for women between the ages of 50 and 69, SCREENING mammograms are the MOST effective. 

Please try to get his book.  He gives a very long explanation of what "over treatment" and "over diagnosis" are.  It isn't as simple as you think and cannot be explained in a sentence.  I think that is why the British are commencing the task force.  To fully understand the data once and for all.

pitanga, o.k., I thought we were thinking along the same lines.  Now that you mention it, all SCREENING is "just in case," with perhaps a little more vigilance among the high risk patients.  The fact that so many slip thru' the cracks on mammo means we need:

BETTER, CHEAPER, and NON-AGE LIMITED screening methods. 

It's not like the under-40's never get B/C, and some with few or no risk factors.  In dealing with the unknown randomness of B/C, how can we really leave any group out?  (I know this is where the sticky cost part comes in.)

From the National Cancer Institute, here's the controversy in a nutshell:

Harms of Screening

Additional Interventions
False Sense of Security
Radiation Exposure
Anxiety
Overdiagnosis

Mammography screening may be effective in reducing breast cancer mortality in certain populations. As with any medical intervention, it has limitations, which can pose potential harm to women who participate. These limitations are best described as false-negatives (related to the sensitivity of the test), false-positives (related to the specificity), overdiagnosis (true positives that will not become clinically significant), and radiation risk.

Additional Interventions

The specificity of mammography (refer to the Mammography section of this summary for more information) affects the number of "unnecessary" interventions due to false-positive results. Even though breast cancer is the most common noncutaneous cancer in women, only a very small fraction (0.1%-0.5%, depending on age) actually have the disease when they are screened. Therefore, even though the specificity of mammography is approximately 90%, most abnormal tests are false-positives.[1] Women with abnormal screening test results have additional procedures performed to determine whether the mammographic finding is cancer. These procedures include additional mammographic imaging (e.g., magnification of the area of concern), ultrasound, and tissue sampling (by fine-needle aspiration, core biopsy, or excisional biopsy). A study of breast cancer screening in 2,400 women enrolled in a health maintenance organization found that over a 10-year period, 88 cancers were diagnosed, 58 of which were identified on mammography. During that period, one-third of the women had an abnormal mammogram result that required additional testing, including 539 additional mammograms, 186 ultrasound examinations, and 188 biopsies. The actuarial cumulative biopsy rate (the rate of true positives) due to mammographic findings was approximately 1 in 4 (23.6%). The positive predictive value (PPV) of an abnormal screening mammogram in this population was 6.3% for women aged 40 to 49 years, 6.6% for women aged 50 to 59 years, and 7.8% for women aged 60 to 69 years.[2] A subsequent analysis and modeling of data from the same cohort of women, all of whom were continuously enrolled in the Harvard Pilgrim Health Care plan from July 1983 through June 1995, estimated that the risk of having at least one false-positive mammogram was 7.4% (95% confidence interval [CI], 6.4%-8.5%) at the first mammogram, 26.0% (95% CI, 24.0%-28.2%) by the fifth mammogram, and 43.1% (95% CI, 36.6%-53.6%) by the ninth mammogram.[3] Cumulative risk of at least one false-positive by the ninth mammogram varied from 5% to 100%, depending on four patient variables and three radiologic variables. Patient variables independently associated with increased chance of a false-positive result included younger age, higher number of previous breast biopsies, family history of breast cancer, and current estrogen use. Radiologic variables included longer time between screenings, failure to compare the current and previous mammograms, and the individual radiologist's tendency to interpret mammograms as abnormal, which ranged from 2.6% to 24.4% across 93 radiologists in the study. Overall, the largest risk factor for having a false-positive mammogram was the individual radiologist's tendency to read mammograms as abnormal. The authors noted that CIs for estimates of false-positives beyond five mammograms were wide because of the relatively small numbers of women in the analysis with more than five mammograms.

By reviewing Medicare claims following mammographic screening in 23,172 women older than 65 years, one study [4] found that 85 per 1,000 had follow-up testing and 23 per 1,000 had biopsies. The cancer detection rate was 7 per 1,000, so the PPV for an abnormal mammogram was 8%. For women older than 70 years, the PPV was 14%. An audit of mammograms done in 1998 at a single institution revealed that 14.7% of examinations resulted in a recommendation for additional testing (Breast Imaging Reporting and Data System category 0), 1.8% resulted in a recommendation for biopsy (categories 4 and 5), and 5.7% resulted in a recommendation for short-term interval mammography (category 3). Cancer was diagnosed in 1 out of 30 of the cases referred for additional testing.[5]

False Sense of Security

The sensitivity of mammography (refer to the Mammography section of this summary for more information) ranges from 70% to 90%, depending on a woman's age and the density of her breasts, which is affected by her genetic predisposition, hormone status, and diet. Assuming an average sensitivity of 80%, mammograms will miss approximately 20% of the breast cancers that are present at the time of screening (false-negatives). If a woman does not seek medical attention for a breast symptom or if her physician is reluctant to evaluate that symptom because she has a "normal" mammogram, she may suffer adverse consequences. Whereas the medical community has been carefully educated that a negative diagnostic mammogram should not deter work-up of a palpable lump, the medical and lay communities should be made aware that a negative screening mammogram misses one in five cancers.

Radiation Exposure

Because radiation exposure is a known risk factor for the development of breast cancer, it is ironic that ionizing radiation is our best screening tool. The major predictors of risk are young age at the time of radiation exposure and the radiation dose. For women older than 40 years, the benefits of annual mammograms may outweigh any potential risk of radiation exposure due to mammography.[6] It is speculated that certain subpopulations of women may have an inherited susceptibility to ionizing radiation damage,[7,8] but mammography has never been shown to be harmful in these, or any, subgroups. In the United States, the mean glandular dose for screening mammography is 1 mGy to 2 mGy (100-200 mrad) per view or 2 mGy to 4 mGy (200-400 mrad) per standard two-view exam.[9,10]

Anxiety

Because large numbers of women have false-positive tests, the issue of psychological distress-which may be provoked by the additional testing-has been studied. A telephone survey of 308 women performed 3 months after screening mammography revealed that about one-fourth of the 68 women with a "suspicious" result were still experiencing worry that affected their mood or functioning, even though subsequent testing had ruled out a cancer diagnosis.[11] Several studies,[12-14] however, show that the anxiety following evaluation of a false-positive test leads to increased participation in future screening examinations.[15]

Overdiagnosis

Overdiagnosed disease is a neoplasm that would never become clinically apparent prior to a patient's death without screening. An example is a tumor that is found by mammographic screening that would never be evident otherwise.

Autopsy studies have found tumors in people who died of causes unrelated to the tumors. The studies indicate that lesions exist that fulfill the histologic criteria of cancer but that were not clinically apparent in the woman's lifetime. An overview of seven autopsy studies documents a median prevalence of 1.3% for undiagnosed invasive breast cancer (range, 0%-1.8%) and 8.9% for undiagnosed ductal carcinoma in situ (range, 0%-14.7%).[16,17] Finding such cancers by mammography would be overdiagnosis. Because cancers that will progress cannot be distinguished with certainty from those that will not, these tumors are often treated (with surgery and possibly with radiation, chemotherapy, and hormonal therapy). This treatment would constitute overtreatment because it would not confer a benefit to the woman.

It is difficult to determine the proportion of screen-detected cancers that are overdiagnosed. A widely accepted estimation method is to compare breast cancer incidence over time in a screened population with that of an unscreened population. Randomized screening trials are the most credible, but the period of screening versus control is limited in all the trials. If a woman complies with not being screened during the study period but gets screened afterwards, then a breast cancer that would have been found had the woman been assigned to screening would likely be found shortly thereafter. (Most of the women in the control group in the Swedish trials were assigned to receive a control mammogram at the end of the study period.) Such delayed screening will also find overdiagnosed cancers; the cumulative incidence of cancers will be similar in the two groups, irrespective of the magnitude of overdiagnosis.

Population-based studies suffer from the same problem as randomized trials, although to a lesser extent. However, the population-based studies have their own problems. Unbiased estimates would only be possible if the screened and nonscreened populations were the same except for screening, but the populations may differ in time, in geography, in culture, and by the use of postmenopausal hormone therapy. In addition, investigators differ in their assessments of overdiagnosis regarding how and whether to adjust for characteristics such as lead-time bias.[18,19] As a consequence, the magnitude of overdiagnosis due to mammographic screening is controversial, with estimates ranging from 7% to 50%.[18-21]

Several observational population-based comparisons consider breast cancer incidence before and after adoption of screening.[22-26] If there were no overdiagnosis-and other aspects of screening were unchanged-there would be a rise in incidence followed by a decrease to below the prescreening level, and the cumulative incidence would be similar. Such results have not been observed. Breast cancer incidence rates increase at the initiation of screening without a compensatory drop in later years. For example, in Sweden, the age-specific incidence rates doubled between 1986 and 2002 for all age groups participating in screening.[22] Another study in 11 rural Swedish counties showed a persistent increase in breast cancer incidence following the advent of screening.[23] A population-based study from Norway and Sweden showed increases in invasive breast cancer incidence of 54% in Norway and 45% in Sweden in women aged 50 to 69 years, following the introduction of nationwide screening programs. No corresponding decline in incidence in women older than age 69 years was ever seen.[27] Similar findings suggestive of overdiagnosis have been reported from the United Kingdom [24] and the United States.[25,26]

References

1. Kerlikowske K, Grady D, Barclay J, et al.: Positive predictive value of screening mammography by age and family history of breast cancer. JAMA 270 (20): 2444-50, 1993.  [PUBMED Abstract]
   
   
2. Elmore JG, Barton MB, Moceri VM, et al.: Ten-year risk of false positive screening mammograms and clinical breast examinations. N Engl J Med 338 (16): 1089-96, 1998.  [PUBMED Abstract]
   
   
3. Christiansen CL, Wang F, Barton MB, et al.: Predicting the cumulative risk of false-positive mammograms. J Natl Cancer Inst 92 (20): 1657-66, 2000.  [PUBMED Abstract]
   
   
4. Welch HG, Fisher ES: Diagnostic testing following screening mammography in the elderly. J Natl Cancer Inst 90 (18): 1389-92, 1998.  [PUBMED Abstract]
   
   
5. Rosen EL, Baker JA, Soo MS: Malignant lesions initially subjected to short-term mammographic follow-up. Radiology 223 (1): 221-8, 2002.  [PUBMED Abstract]
   
   
6. Feig SA, Ehrlich SM: Estimation of radiation risk from screening mammography: recent trends and comparison with expected benefits. Radiology 174 (3 Pt 1): 638-47, 1990.  [PUBMED Abstract]
   
   
7. Helzlsouer KJ, Harris EL, Parshad R, et al.: Familial clustering of breast cancer: possible interaction between DNA repair proficiency and radiation exposure in the development of breast cancer. Int J Cancer 64 (1): 14-7, 1995.  [PUBMED Abstract]
   
   
8. Swift M, Morrell D, Massey RB, et al.: Incidence of cancer in 161 families affected by ataxia-telangiectasia. N Engl J Med 325 (26): 1831-6, 1991.  [PUBMED Abstract]
   
   
9. Kopans DB: Mammography and radiation risk. In: Janower ML, Linton OW, eds.: Radiation Risk: a Primer. Reston, Va: American College of Radiology, 1996, pp 21-22.
   
   
10. Suleiman OH, Spelic DC, McCrohan JL, et al.: Mammography in the 1990s: the United States and Canada. Radiology 210 (2): 345-51, 1999.  [PUBMED Abstract]
    
    
11. Lerman C, Trock B, Rimer BK, et al.: Psychological side effects of breast cancer screening. Health Psychol 10 (4): 259-67, 1991.  [PUBMED Abstract]
    
    
12. Gram IT, Lund E, Slenker SE: Quality of life following a false positive mammogram. Br J Cancer 62 (6): 1018-22, 1990.  [PUBMED Abstract]
    
    
13. Burman ML, Taplin SH, Herta DF, et al.: Effect of false-positive mammograms on interval breast cancer screening in a health maintenance organization. Ann Intern Med 131 (1): 1-6, 1999.  [PUBMED Abstract]
    
    
14. Pisano ED, Earp J, Schell M, et al.: Screening behavior of women after a false-positive mammogram. Radiology 208 (1): 245-9, 1998.  [PUBMED Abstract]
    
    
15. Brewer NT, Salz T, Lillie SE: Systematic review: the long-term effects of false-positive mammograms. Ann Intern Med 146 (7): 502-10, 2007.  [PUBMED Abstract]
    
    
16. Welch HG, Black WC: Using autopsy series to estimate the disease "reservoir" for ductal carcinoma in situ of the breast: how much more breast cancer can we find? Ann Intern Med 127 (11): 1023-8, 1997.  [PUBMED Abstract]
    
    
17. Black WC, Welch HG: Advances in diagnostic imaging and overestimations of disease prevalence and the benefits of therapy. N Engl J Med 328 (17): 1237-43, 1993.  [PUBMED Abstract]
    
    
18. Duffy SW, Lynge E, Jonsson H, et al.: Complexities in the estimation of overdiagnosis in breast cancer screening. Br J Cancer 99 (7): 1176-8, 2008.  [PUBMED Abstract]
    
    
19. Gøtzsche PC, Jørgensen KJ, Maehlen J, et al.: Estimation of lead time and overdiagnosis in breast cancer screening. Br J Cancer 100 (1): 219; author reply 220, 2009.  [PUBMED Abstract]
    
    
20. Gøtzsche PC, Nielsen M: Screening for breast cancer with mammography. Cochrane Database Syst Rev (4): CD001877, 2006.  [PUBMED Abstract]
    
    
21. Zackrisson S, Andersson I, Janzon L, et al.: Rate of over-diagnosis of breast cancer 15 years after end of Malmö mammographic screening trial: follow-up study. BMJ 332 (7543): 689-92, 2006.  [PUBMED Abstract]
    
    
22. Hemminki K, Rawal R, Bermejo JL: Mammographic screening is dramatically changing age-incidence data for breast cancer. J Clin Oncol 22 (22): 4652-3, 2004.  [PUBMED Abstract]
    
    
23. Jonsson H, Johansson R, Lenner P: Increased incidence of invasive breast cancer after the introduction of service screening with mammography in Sweden. Int J Cancer 117 (5): 842-7, 2005.  [PUBMED Abstract]
    
    
24. Johnson A, Shekhdar J: Breast cancer incidence: what do the figures mean? J Eval Clin Pract 11 (1): 27-31, 2005.  [PUBMED Abstract]
    
    
25. White E, Lee CY, Kristal AR: Evaluation of the increase in breast cancer incidence in relation to mammography use. J Natl Cancer Inst 82 (19): 1546-52, 1990.  [PUBMED Abstract]
    
    
26. Feuer EJ, Wun LM: How much of the recent rise in breast cancer incidence can be explained by increases in mammography utilization? A dynamic population model approach. Am J Epidemiol 136 (12): 1423-36, 1992.  [PUBMED Abstract]
    
    
27. Zahl PH, Strand BH, Maehlen J: Incidence of breast cancer in Norway and Sweden during introduction of nationwide screening: prospective cohort study. BMJ 328 (7445): 921-4, 2004.  [PUBMED Abstract]
    
    

No argument from me there.  But women need to arm themselves with this information so they can make an informed decision with whatever information is out there.  I think once we have a civilized discussion in the medical community about what is NOT working...then we can move on to the next step sooner rather than later...

One other thing...speaking of statistics....I was once pregnant with twins.  Unfortunately, one was in the uterus and the other was in one of my tubes.  It was a disaster that nearly cost me my life.  The doctor told me that the incidence of that occurring was one in 40,000.  He said of 5 or 10 doctors, one might see that occur in their professional life.  And yet, that happened to me!  When my husband was diagnosed with his rare metabolic muscular dystrophy, fewer than 500 people in the WORLD were diagnosed with it.  When I was told I had a rare breast cancer and that there were several thousand women diagnosed with it each year, I laughed...to me that was A LOT of people.  Statistics blow when you are on the losing side....I hear ya.  I wish you well...and all of our sisters, as well.

voracious - in regards to the high numbers of women choosing to get a BX when it is not "necessary".  Of course, necessary is in the eye of the beholder, but I personally changed doctors because of the pressure my 1st surgeon was putting on me to have a BX.  So based only upon my own experience, I would bet that a certain number of women choosing the BX route is due to the scare tactics of some of the doctors in the field.

You can google Joan hamburg Larry Norton and listen to the podcast from October 20th. See what you think.