Over diagnosis of IDC

hyphencollins · October 2015

With the changes in the mammogram recommendations, I've been hearing a lot in the media about how mammograms lead to overdiagnosis of invasive cancer (not just DCIS and not false positives). I'm having difficulty understanding this... an invasive cancer that won't kill you? I'm wondering if this is about cancers that may be so indolent that someone would die of another cause first? While I can kind of understand this concept in the case of an indolent cancer in a very elderly person, I guess I don't understand this concept in general, especially for those who have the possibility of many years left... Can someone help break this down to me? I really keep hearing this in news stories explaining the rationale for the changes but nobody is really explaining exactly what this means! Thanks!

cloudynight · October 2015

The basic hypothesis goes like this: Screening mammography catches a lot of small cancers, but doesn't really affect the number of larger cancers, or affect the number of women who die of metastatic breast cancer. (Here's an example of a study attempting to prove this: Breast Cancer Screening, Incidence, and Mortality Across US Counties, Harding et al. Mobile link: http://archinte.jamanetwork.com/Mobile/article.asp...) Therefore, there must be some mechanism by which catching those small cancers doesn't affect the mortality rate.

cloudynight · October 2015

Oops, hit post too soon.

A main person driving this idea is H. Gilbert Welch, whose career seems to be built around arguing that overdiagnosis (of other cancers too, not just breast cancer) is rampant. Look for his name in a lot of these overdiagnosis stories; he's almost always there, or a second or third author on the linked papers.

The oncologists I've bounced this off react with GREAT ROLLING OF EYES. So, two sides to every story.

I think it's also a compelling news story because it's got the dog-bites-man surprise factor that modern editors like. What if everything you know is wrong!?!?!11?

grammakathy · October 2015

Cloudy night - thank you for the explanation!

peggy_j · October 2015

It really bugs me that their measurement is mortality rate. Because my tumor was caught when it was small, I didn't have to do chemo. Doesn't that count for something? It does for me--fewer short-term and long-term SEs, better overall prognosis and oh, hey Mr Insurance Company Man, you just saved six-figures by my not needing chemo.

I also hate the trend that DCIS is not a "real" cancer even though--surprise--sometimes it turns into invasive cancer and we can't predict which ones will or will not turn into IDC. My tumor had both IDC and DCIS, so in my case, the DCIS turned so quickly into IDC, it was never detected as "just DCIS." I suspect that no one is tracking cases like mine because the DCIS gets ignored once they find IDC.

arg!

ChiSandy · October 2015

The kicker is that we can’t predict which DCIS will turn invasive, and which invasives will never metastasize--only which of the hormone-positive ones of the latter have a lesser chance of recurring and for which chemo would be riskier than the cancer. And we certainly can’t do that without at least a needle biopsy. As to the chance that someone my age (64+) would die in 20-25 years whether or not of breast cancer, would you rather go to bed one night at 85-90, after a full and relatively painless life, and not wake up, or go through years of recurrences and metastases and all the suffering that entails and finally die at that same age? Not all “mortalities” are qualitatively equal, even if quantitatively so. Statistics are mere numbers to crunch--they don’t have feelings, hopes, fears and loved ones.

NJ-Jen · October 2015

it also fails to take into account anything else about the person like previous health or density of breasts. Not a fan.

Tomboy · October 2015

That's a good point, Peggy. I am surprised the insurance companies aren't fighting it.

farmerlucy · October 2015

I don't understand that comment either. I had ALH and ADH at biopsy, more ALH and ADH at mx along with IDC - no DCIS/LCIS was found. Now that you think of it that is kind of interesting. I asked my onc if it can go straight to IDC she said we'd don't know. In my ignorance I figure all my blue ribbon screening would "catch it" at stage 0. HA!

marijen · October 2015

Chisandy there's a good variable to the die after 25 years look forward, it is there will be plenty of new treatments available in that 25 years, maybe even in 2016. So to keep the cancer down in the meantime is a good idea in my opinion.

Cubbie2015 · October 2015

Peggy_j, that's the same thing that frustrates me. I understand that treating earlier isn't improving the mortality rate, but where is the consideration for morbidity? The earlier we catch cancer, the less drastic the treatments have to be, and the fewer long term side effects patients have, and as a bonus, the less it costs to treat. I sure wish my cancer had been caught while it was still DCIS.

ChiSandy · October 2015

Marijen said: "Chisandy there's a good variable to the die after 25 years look forward, it is there will be plenty of new treatments available in that 25 years, maybe even in 2016. So to keep the cancer down in the meantime is a good idea in my opinion.“

Exactly! Which is why, if we are vigilant and keep beating that cancer down, we’re likelier to die of some other "natural cause” characteristic of old age (hopefully an “easier” death with less pain and suffering in the years leading up to it).

marijen · October 2015

So there you have it, no matter what we do we have to die eventually. Have you seen the Netflix show with Jane Fonda and Lily Tomlin? Two women about 70ish. What fun and heartache they have. It's called Frankie and Grace or something,,, so much for my memory. I marathoned it in two days. Hilarious.

peggy_j · November 2015

This whole argument really ticks me off. The more I think of it, the angrier I feel. There are so many cancers that are tough to catch early. Ovarian cancer, for example, isn't necessarily more aggressive but since there are no good screening tools, it's usually not caught until Stage 3, so the prognosis is worse.

And the worst part is that this argument deflects attention away from what really matters in Public Health--finding a cure, understanding the causes and...prevention!

arg!!!!!

SummerAngel · November 2015

Peggy_j, my left-side tumor was much larger than yours, but I didn't need chemo, either. It's because the grade and negative nodes. Also, of course, the Oncotype score. The point is that early detection isn't working to save lives like they thought it would. Early detection did work for colon cancer and cervical cancer, so the thought was that it would work for breast cancer. That's not proving to be true on a population basis. So for people like me, who had a tumor growing for a much longer period of time than you did, detecting it earlier would not have changed the outcome. This is what the data is showing.

Over diagnosis of IDC

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