Angry About This Article - Have They Minimized BC Issues?

 Of course if you are the one who believes your life has been saved you think everyone should be screened as a mammogram has saved YOUR life. But you might be one of those whose cancer was so slow growing that treatment was unnecessary. Unfortunately we don't know. Wouldn't it be better to NOT have to go through the worry of having cancer and the treatment? But this means that our current use of mammograms as a screening tool has to change. Perhaps yearly mammograms are not necessary for every woman. In England, women over 50 are recommended to have a screening mammogram every three years. Their cancer rates/mortality are not worse than the US despite higher screening levels in the US. Mammograms as a screening tool is poor at best. Unfortunately we have come to rely on them as a way to "save" us. Catch it early and you'll be fine - that magic 98% survival rate. Though many of us now know this is not true.

I think this article was trying to show the points I have made here. Perhaps the version of the article in your paper was abbreviated in some way. I thought it was a truthful account in my paper.

I think that what the article was trying to say - perhaps clumsily - is that there are instances when screening cannot predict the course of a particular kind of breast cancer and, because it can't, overtreatment is the result.  I'm thinking, specifically, of DCIS.  Not all DCIS will become invasive, but some does and doctors just don't know how to predict which woman's DCIS will become harmful and which woman's won't.  So, because they don't know, and because most women who are told they have DCIS don't want to take the chance, once DCIS has been identified, treatment is recommended even when it's not known if it's really needed.

In addition, mammograms as a screening tool do not have a good track record; a mammogram is only 70% accurate.  Some malignancies do look benign on a mammogram and some benign conditions do look malignant.  A mammogram can't sort it out; it can only tell you if there is something there, not what that something is.  Moreover, a mammogram can't "see" through dense breast tissue, so if you have dense breasts, a mammogram may not pick up a developing malignancy.  That's what happened to me; 10 years of annual mammograms did not pick up my breast cancer at all.  My last "all clear" mammogram prior to my finding the lump was five months earlier and my diagnostic mammogram didn't "see" it either.  It took an ultrasound and a biopsy to make a diagnosis.

So, no, regular screening will not help everyone and I do believe that - given a number of factors including family history, etc... - there is truth in the statement that regular mammographic screening is not necessary for EVERY woman.  But, since we don't know which women need it and which women may not - and since we don't have anything better to offer by way of screening - then regular mammograms are all we have.

Blessings, I used to get just as angry about these sorts of articles - and over the past few years I've seen lots of articles like this - but I'm starting to have a different perspective.  I still get angry at much of what they are saying, but I also now better understand the issue that is leading to the types of concerns that are voiced in these articles.  

You posted about this article in the DCIS forum and I responded there, so I will copy and paste my comments here:

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These sorts of studies and articles pop up every 6 months or so.  They are always the same, measuring lives saved against those who undergo what may be unnecessary treatment and needless angst. 

I have several issues with these types of arguments/articles/studies:

- They arbitrarily put a value on a "life saved".  Who's to say that 1 life saved is not worth 3 who may undergo unnecessary treatment?  Or 10 who may undergo unnecessary treatment?  Or 20?  Who gets to decide what the right equation is?

- If you can't possibly know if the treatment is "unnecessary", then is it really unnecessary?  Currently medical science doesn't have the ability to determine, with any degree of certainly, which cases of DCIS or early stage invasive cancer may never be harmful, and which cases truly need to be treated.  So we are all treated. The suggestion of these types of studies seems to be that it would be better if none of us were ever screened so that our cancers wouldn't be found and as a result, we would all avoid treatment. Sure, a few of us will die but most of us will have avoided an unnecessary treatment, so it's all good in the end.  Seriously???

- There seems to be a belief that the only valid endpoint of treatment is "a life saved". What's never factored into the discussion is that early detection often means that women are able to avoid more toxic treatments that present greater health risks and have more side effects, treatments such as chemo and Herceptin. I suspect that my diagnosis, even if not caught until years later, most likely would still not have been life threatening. But if my cancer hadn't been caught until years later, there is no question in my mind that I'd have needed to have chemo. Not needing chemo was a really big deal for me. Since "unnecessary treatment" is such a big part of these arguments, shouldn't the avoidance of treatment also be part of the argument and a valid endpoint of early detection?

- There is a big push to find the cure for breast cancer. At this point in time, the only truly curable breast cancer is DCIS. So shouldn't the objective therefore be to try to detect all breast cancer while it's still DCIS, so that it can be adequately treated and therefore cured? How is it that the detection of DCIS has now turned into a bad thing?

Okay, so now I will answer the last question.  "How is it that the detection of DCIS has now turned into a bad thing?"  The longer I'm on the board, the more I understand and appreciate this issue. I believe that DCIS should be treated but I'm surprised at the amount of over-treatment that I see. Emotionally, a diagnosis of DCIS is just as much of a shock as a diagnosis of invasive cancer.  But DCIS is not invasive cancer and unfortunately that's not always factored into the treatment decisions. DCIS is breast cancer and it does need to be removed (although some doctors now disagree); as a result sometimes a MX is necessary and often rads is necessary.  But DCIS is a low risk diagnosis and patients and doctors don't always weigh the risks from the treatments against the risks from the disease. SNBs with lumpectomies. Tamoxifen after BMXs. Rads for small, grade 1 tumors with wide margins. BMXs even when the patient isn't high risk and has no other breast problems. "Over-treatment" is subjective of course, and there are emotional and non-medical concerns that are often factored into treatment decisions, but a starting point should be a simple medical/health benefit vs. risk assessment. And so often that's just not done. 

I see so many women who have DCIS diagnoses that could be put behind them in a matter of months, who instead opt for treatments that affect them for the rest of their lives. I feel terrible when I see someone suffering the side effects of a treatment that they really didn't need to have. The longer I've been here, the more I've seen this happen, and the more I'm beginning to understand the medical community's dilemma about DCIS.  I get angry with doctors or 'experts' who say that DCIS is not breast cancer.  I get frustrated when I see DCIS being downplayed or when someone with a diagnosis of DCIS is not taken seriously. I really dislike studies and articles like the one above that question the value of early detection and/or that argue that DCIS doesn't need to be treated. Yet more and more, I'm beginning to understand it.  There are two sides to DCIS, and to the issue of early detection. It took me a long time but I finally am starting to see both sides.  

Unfortunately, this report seems to be part of a wider political agenda in the UK to cut government spending, in this instance on the cost of screening. The reporting in the British media has been appalling (sensationalist partial information and half-truths), and my fear is that women will not attend screening for fear of going through unnecessary treatment. But as we all know, until such time as the medical technology can accurately predict which DCIS will progress and which will not, "over-treatment" is a risk that most of us would prefer to take.

Athena, I'm afraid that in the UK, almost everything in healthcare comes down to government spending and, at present, we are dealing with a government which wants to dismantle our universal healthcare system because of its political ideology.



Of course there are other forms of screening, but in the UK, mammography is the technique used by the national screening programme; ultrasound and very rarely MRI would only be used for women and men presenting with a palpable lump, i.e. not people attending screening. (In my case, however, only a mammogram picked up my sizeable tumour, which was not visible on u/s.) The benefits of screening in the UK in terms of the number of lives saved are, therefore, down to mammography. And until there is a more accurate technology available, "over-treatment" is the unfortunate consequence. But given that there is no such technology, what is the point of telling women they MAY have gone through treatment they didn't need? What purpose does that serve? Because we cannot know who has been over-treated and who has had their life saved.



As I said, in the UK, the media reporting of the study's conclusions has not been helpful, balanced or informative and may in fact have given the impression that screening is just not worth the risk.



If the report is merely looking at the efficacy of mammography, then shouldn't it have compared it to other imaging and diagnostic techniques? It didn't; it just looked at the existing screening programme, using data which was, in some cases, 20-30 years old.



The study doesn't refer to high risk women because they would already be monitored. Many people who seemingly have no risk develop BC and the aim of screening is to identify tumours which might otherwise go undetected in the general female population above the age of 50.



Current technology and treatments clearly do not have all the answers, but that's all we have to go on right now and reports pointing out the flaws are only helpful if there is then funding to research and develop improved technologies.



And you don't have to tell me about the 25% (although I thought it was nearer 30%); I will be one of them.

In fact, the report shows that screening DOES save lives, but that for each life saved, 4 women MAY be over-treated. So I don't agree that the screening programme is a "misleading public service campaign".



Ultrasound is used when there is a palpable lump; where there is no such lump, it really would be like looking for a needle in a haystack. MRIs are rarely used because of the high incidence of false positives, much higher than that in mammography.



Again, it's the misleading reporting of the study which doesn't make its conclusions clear to an ill-informed public.



The screening programme isn't looking for a needle in a haystack and the number of women over 50 who develop BC despite seemingly having no risk and whose cancer is detected by screening bears this out.

Well said, Molly! And I love the postman and the credit card analogy!!! ;o)