Study regarding value of mammograms

The Breastcancer.org team includes medical writers and experts from across the field -- medical oncologists, breast surgeons, radiation oncologists, and many more experts in breast cancer risk reduction, treatment, and recovery. Breastcancer.org has long stated that mammograms are not perfect, and the best approach is to use all the tools at your disposal – breast self-exam, regular clinical exams in the doctor’s office, and annual mammograms starting at age 40. For more information, visit our mammography pages:

Breastcancer.org Mammogram Recommendations

Mammography: Benefits, Risks, What You Need to Know

What annoys me about these studies is when they talk about the ineffectiveness of mammos, CBE, SBE, etc, without presenting a viable, easily implemented alternative.

Until the alternative comes along and can be widely used, all we have are mammograms (over 40) and clinical breast exam/self exams. I fully support developing better routine diagnostic methods, but I don't think it should be at the expense of what we already have. 

and....this debate really IS about money.  Because if people like you or I said, "Let's fund finding better ways of screening for breast cancer" we'd be laughed at when our politicians ask where would the money come from? Then we'd be opening a hornet's nest full of trouble because monies earmarked for free screening mammos would theoretically be reduced at the expense of finding better tools to detect breast cancer...

I'm also one of those wishful thinkers that believes that in my daughter's future, screening mammos will be passé.  I think genetic testing and better and even more better blood tests will discover breast and other types of cancers and will be able to tell us who and what kind of treatments will be needed...

What the study compared was mammos vs clinical exams. Basically, it seems to me is that what this challenges is the notion that 'early detection' (at least the early detection that mammo aids with) is important. Essentially what it says is this:

Average Patient A is diagnosed by mammogram; a 1CM tumor is found at age 43, average patient undergoes standard care and lives 15 years.

Average Patient B is diagnosed by clinical exam; a 2 CM tumor is found at age 45, average patient undergoes standard care and lives 13 years.

So the difference is that mammograms find tumors less than 2 cm that can't be felt by a clinical exam, but it doesn't help the long term survival rate. Both patient A and B live 15 years from the time that their cancer was 1CM.

This is reasonable - the long term survival rates between 1cm and 2cm (what can be more often detected by touch) are just not that great. The dividing line for early detection is really about finding the cancer before has traveled to distant locations in the body (and the difference between mammos and clinical exams is unlikely to make much of a difference in this respect).

So within the narrow parameters defined by this study, it may very well be the case that the survival outcomes for mammos and clinical detection for women who show up each year to have either on are no different for invasive cancers (which is what the study looked at).

This begs the question: What about those things outside of the parameters defined by the study? What about the fact that it may be the case that a woman will be more likely to pay attention to her breasts if she has been alerted to the fact that she has atypical cells that will more likely become breast cancer - is she more likely then to be sure to show up for her yearly screening? What about the fact that finding a lump that is 1CM instead of 2.5 CM might mean that a woman can have a lumpectomy rather than a MX - regardless of the fact that it doesn't affect her prognosis? What about all of those non-invasive cancers that are way more often picked up by mammograms that can not be 'felt' yet? These are not even included in the study and many times they can just be removed by extensional biopsy.

A research study can only be as good as its design. This study was designed to answer a tightly defined question:

Do yearly mammograms affect the long term survival rates for invasive breast cancer vs those women who have yearly clinical breast exams instead? The answer is no (according to the study).

The follow up question SHOULD BE : Does this mean that there is no benefit to yearly mammograms in the general population?

The answer to this question is that this study can not answer that question because it was not designed to. It may be that yearly mammograms make treatments less invasive, it may be that the prevention of having DCIS or LCIS from ever becoming invasive has an enormous effect on survival rates. It may be that in the real world where women often miss a yearly exam here or there, it becomes much more important to find a cancer at 1 cm. We simply can not know because the study did not address those questions. 

Ziggy...you are aware that in many countries outside of the US, patients 50-69 are "invited" for screening every 2 to 3 years... The recommendation made in 2009 by the US task force would have been in line with other developed countries, but instead was rebuked and has led to this contentious debate...

ziggypop, you touched on something I'm confused about. I've read that the distant recurrence is 20-30%. Not thrilled about those stats, especially since I'm probably on the high side of those, but that also indicates that 70-80% of patients will not get a distant recurrence. Ergo, they will survive BC and eventually die of something else. Unless those are only the stats only for 5/10 year survival rates and more women will recur and die at 15/20/25 years out?

But anyway, if 70-80% will avoid a distant recurrence in either the short or long term, how were those women diagnosed? I would guess a substantial number were diagnosed by mammograms.

Although...out of the tiny number of women I know IRL who have had BC, my mom was the only one diagnosed by mammogram. I found my lump accidently, my mom's best friend found her lump accidently (even though she was mammogram age), I believe my grandmother found her lump herself (don't know if accidently or by self-exam, she was mammogram age too) and I don't know how my great aunt found hers. Interesting.

But by the time a tumor grows and becomes big enough to be felt, it is more likely that the cancer has moved into the nodes, right? I realize that tumors are missed on imaging and even women that were diligent about their mammos still end up with cancer that has spread. But though who are diagnosed with invasive cancer, Stage 1 or 2b and node negative, how many of those found their tumor through mammograms vs. feeling it themselves?

I absolutely agree with you on clinical exams. It wasn't until after my diagnosis until I realized how woefully inadequate the clinical exams I had been getting all my life were. Then again, the really fantastic surgeon who did my mom's lumpectomy never felt it--she had to have a wire placed to track it during surgery. Some early stage masses will never be able to be felt.

I have never heard anyone with invasive cancer say...I wish mine was found at a later stage!

wyo - If the 'battle' rages on (rather than simply a discussion), it is because you seem to attempt to relate anything that you can to health care reform so that you can express your misgivings about the ACA - but in this context that seems particularily strange given that the ACA strengthens coverage for mamograms - 

"Q: Does the Affordable Care Act restrict my ability to get a mammogram?

A: No. In fact, the law requires insurers to cover mammography, with no cost-sharing, every one to two years for women starting at age 40. Medicare fully pays for mammograms once every 12 months with no upper age limit.

FULL QUESTION

Is it true that now that ObamaCare or Affordable Care has been enacted, yearly mammograms for women over 70 will not be covered by Medicare or Obamacare. Surely not. Awful rumor going round.

_________________________

Does Obamacare limit the number of times women get a mammogram and at what age?

FULL ANSWER

Several readers have asked us questions, such as those listed above, about whether the Affordable Care Act would limit their ability to get a mammogram, or if insurance or Medicare wouldn’t cover mammograms under the law. One reader wrote that a doctor told her cousin she couldn’t get a mammogram under Obamacare once she turned 74. If so, that doctor is misinforming his or her patients.

The Affordable Care Act actually improves coverage of mammograms for Medicare beneficiaries and an unknown number of women on private insurance, depending on what their insurance covered previously. The law requires Medicare to cover a yearly mammography screening at no cost to women starting at age 40. For private insurance plans, the law also requires coverage of mammograms, with no cost-sharing, every one to two years for women starting at age 40.

For seniors, this is a step up in benefits: Before the health care law, mammograms were also covered, but with 20 percent cost-sharing. For private plans, coverage varied, but under the ACA, women get free mammograms as part of required preventive coverage. That’s for non-grandfathered plans starting on or after Sept. 23, 2010. “We know it’s a big change,” said Mona Shah, associate director of federal relations for the American Cancer Society Cancer Action Network. “We know based on research that even a small cost-sharing can be a deterrent to getting screened.”

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Now it is the case, and always has been that the federal government essentially decides what will or won't be covered by medicare - that has always been the case & healthcare reform doesn't change it. What the ACA DOES DO is set some minimum standards for what private insurance companies must cover - it can't PREVENT them from covering things. Thus far it has made sure that women can get mammos at no additional cost every year to two years after age 40 - some insurance companies did that in the past - some didn't.  So it is really hard to understand your point in this regard. Are you saying that private insurance should NOT cover mammos? Or that there is some kind of push by the government to have mammos not be covered? Why would they want mammos to not be covered if they actually end up lessening the long term treatments & cost to the government - that doesn't make sense. Women who end up getting cancer cost the government a lot of money - as medicare is available to every low income woman to cover breast cancer related costs. This is one of the areas where government interests/taxpayers interests and patients interests are all in alignment. Better preventative services (if they work) save everybody something - money and or health. 

The immediate danger here is that women will begin to believe that mammograms are unimportant and simply stop having them.  Certainly, we cannot tell which tumors "need" to be identified promptly, and which can be left to their own devices for a couple of years, but I'm pretty sure nobody out there wants to be diagnosed later rather than sooner.

When I refer to politicians and funding, I am NOT referring to the rationing of health care dollars.  I refer to what Dr. Otis Brawley (chief medical officer and executive vice president of The American Cancer Society) means by the rationing of health care dollars.  In his book, How We Do Harm, he discusses RATIONAL health care spending, and that is money spent on evidence based therapies AND devoting money to research that will find better ways of screening and  better treatments that will ultimately save more lives.

Here is a link to this amazing one hour speech that he delivered to medical writers at their annual meeting.  He was met by a standing ovation!  Included in the link is also a great primer BEFORE you watch the video.  Oh, and his book?  Let's put it this way, after reading the book, I would be honored if I was a patient of his!

http://www.kaiserhealthnews.org/stories/2012/may/0...

I believe that I am in the overkill category. I really wish I had never been diagnosed with LCIS. The lesion that showed up on my mammogram & prompted the first biopsy was benign sclerosing adenosis/calcifications. Now I'm caught up in high-risk screening including annual mris which I am guessing I will have difficulty getting approved as I transition to private insurance. I am being pushed to take an AI which I believe will worsen other health conditions. I have to deal with frequent screening anxiety. i just had another biopsy which I felt was borderline unnecessary and proved to be benign. Am I high risk? Yes, but the vast majority of women with LCIS do not go on to develop breast cancer. I don't know, but I think I wish I had just been left to take my chances with an annual diagnostic mammogram. I know I can refuse things but it is very difficult to unring the bell.

ziggy...the Canadian study IS what it IS...no more or less than what it states.  However it appears in these last few years since the 2009 Task Force recommendations, IMHO that with each new mammography study that has since reached the masses, there has been a battle drawn between those who claim population based screening mammos save lives, vs. the camp that says, mammos save lives but not as many as we, collectively are led to believe.  Research.  Are we re- searching for the best evidence so we can come up with new facts that will lead to better screening methods that will ultimately lead to saving more lives? I'm not so sure!  What I think needs to happen is that there must be a huge shift in how we collectively think that just might get us on the road to finding better treatments....I think as Dr. Brawley said, we need to first understand and APPRECIATE the limitations of screening mammography.  I also think we need to move away from the idea that if we catch finding breast cancers early, we stand a greater chance at being cured.  Once everyone understands these ideas, then maybe there might be some agreement on how to get on the road to finding better screening tools.  I don't think that day is around the corner.  Why do I say this?  Because my cousin who was recently diagnosed with breast cancer and her sister, who are both highly educated, seem relieved that my cousin's nasty but small tumor was found early on an MRI that wasn't seen on a mammogram 3 months before!  Where do I begin to tell them that there will be no relief until decades from now when she dies from something else?  How do I explain to her what truly makes her lucky is she will have access to effective treatments that didn't exist for other women with similar diagnoses a mere decade ago?

I'm sick and tired of all of the controversy and the lack of enlightenment. Dr. Brawley also says more doesn't necessarily mean better.  I think if all of us open our minds to the possibility that many women will NOT be harmed by having a screening mammo every other year, which was recommended in the 2009 Task Force AND we begin to believe that just MAYBE that screening mammo that we took just a few months ago that was "clean" means nothing more or less than it was "clean" at that moment in time, AND then begin to reshape in our collective conscience, that there might be little meaning to the phrase "Catching breast cancer EARLY saves many lives...or saved my life"....then MAYBE we can get on to the journey that really matters and that is funding the research that will give us better tools that DO lead to truly diagnosing breast cancer at the earliest possible moment when it can be beaten.  Now that would be something! A real cure!

"The first published results at the end of the study period were a
surprise to most everyone. There were actually more deaths in the 40 to
49 age study in the mammogram group than in the control group, but the
numbers were small and the results not significant."

The fact that women underwent a physical exam before being assigned to one group vs. the other really has me questioning whether there might have been some unintended bias in the group placement.  If someone had a palpable lump or anything that appeared concerning, wouldn't there be an inclination to assign that woman to the mammogram arm of the study?  The mortality rates of those who were diagnosed in the first year are higher for the mammogram group, and that's illogical unless there was bias in the group assignments.  

If there was bias, and if more women with a serious diagnosis were placed in the mammo group up front, that could explain why in the end there was no significant difference in the mortality rates.

There is just something about this study that doesn't sit right with me.  It's not the conclusion itself but just the way the data comes together.  As I said in my earlier post, if survival rates are so different after 25 years, I just have a problem seeing how that could not be reflected (although quite possibly to a much lesser extent) in the mortality rates. I know that the survival and mortality numbers aren't comparable (survival being measured against the group who were diagnosed with breast cancer; mortality being measured 'per 10,000' women, against all the women in each arm of the study) but over such a long period of time, I would expect to see the results become more similar.

my doctor flat out refused to give me a mammo because here in Canada we start screening at 50.  Because I had zero risk factors she basically told me I was being my usual hypochondriac self in asking for one at my physical in 2010.  She said that the risks of radiation exposure outweighed the benefits for me.  Well lo and behold I found a lump exactly 8 months later - do I wish I had that mammo? absolutely.  Firstly because my tumor was just over 2cm and had LVI I had to have rads even with a msx - if I had found it sooner I probably could have avoided rads.  So much for radiation exposure my doctor was concerned about - had 25 all in a row thank you very much!

I later spoke to a rads onc and she said the exposure we get is equal to an airport scanner - and if you are concerned about that then get a u/s or thermo screen (I think that's what its called)

my tumor wasn't caught this way but I still believe in screening