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Mammograms: Are they really necesary?

Mammograms: Antiquated diagnostic tests that should be replaced

     Spring is here and soon there will be runs and walks everywhere to raise money for breast cancer. This sea of pink campaign is extremely successful and yet a larger portion of the funds collected go for screening rather than treatment. This would be a good idea if the screening really worked, but the fact is that, depending on whose statistics you read, for every life saved, anywhere between three and ten women are over treated.

A recent review published in the The Lancet medical journal demonstrated that although screening saves lives, it also picks up cases in many women that would never have caused a problem.

The independent review, commissioned by the charity, Cancer Research UK (CRUK) and Britain’s Department of Health, follows fierce international debate about the benefits of routine screening and recent research that shows it does more harm than good. One of the sponsors of the review is Sir Mike Richards, the Department of Health’s national cancer director and one of the sponsors of the review.

One of the problems of screening is that is done on women that are too young. They usually have thicker breast tissue and when this appears on the mammogram as an area of increased density, a biopsy is scheduled. Most of these biopsies are negative for breast cancer but the ones that are positive are usually cancers that are benign, represent zero risk, and should be left alone.

A huge number of these are over treated and many women will actually have healthy breasts removed because of their fear of breast cancer.

Just like the PSA test, the proponents of screening just want to keep the status quo and not look into newer and better methods of diagnosing all the different types of breast cancer and this attitude is causing unnecessary radiation, surgery and chemotherapy to many healthy women.

According to a survey of randomized clinical trials involving 600,000 women around the world, for every 2000 women screened annually over ten years, one life is prolonged but 10 healthy women are given diagnoses of breast cancer and are unnecessarily treated, often with therapies that have life-threatening side effects. (Tamoxifen, for instance carries small risks of stroke, blood clots, uterine cancer and a large risk of reduced bone density; radiation and chemotherapy weaken the heart; surgery, of course has its risks and downsides.

Many of these women are told they have something called ductal carcinoma in situ (D.C.I.S.), or “Stage Zero” cancer, in which abnormal cells are found in the lining of the milk-producing ducts. Before universal screening, D.C.I.S. was rare. Now D.C.I.S., and the less common lobular carcinoma in situ account for 25% of all new breast cancer cases, some 60,000 a year. In situ cancers are more prevalent among women in their 40’s. By 2020, according to the National Institutes of Health’s estimate, more than one million American women will be living with a D.C.I.S. diagnosis.

With a 10 years 100% survival rate, all these women become cancer survivors, and get to wear their pink ribbons. But the fact is they never had and do not have cancer. They have less than a 5% chance of developing any kind of cancer and that is the average risk of any 62 year old women for developing breast cancer. Treating these women is the same as having a diagnosis of high cholesterol and then getting heart surgery. Both make as much sense.

Since the mapping of the human genome, we have actually found four distinctive types of breast cancers. They have different causes and they respond to different types of treatment. Two related subtypes, luminal A and luminal B, involve tumours that feed on estrogen; they may respond to a five year course of pills like tamoxifen or aromatase inhibitors, which block cells’’ access to that hormone or reduce its levels. In addition, a third type of cancer, called HER2-positive, produces too much of a protein called human epidermal growth factor receptor 2; it may be treated with a targeted immunotherapy called Herceptin. The final type, basal-like cancer (often called “triple negative” because its growth is not fueled by the most common biomarkers for breast cancer –estrogen, progesterone and HER2),is the most aggressive, accounting for up to 20% of breast cancers. It is more prevalent among young and African-American women.

We should be focusing on specific genetic tests for these true cancers and not lumping them all together with the non-cancerous D.C.I.S. Remember the last two letters stand for “in situ”. This is a Latin term meaning something that stays in its place. A cancer can only be defined as a cancer if it spreads and any growth that stays “in situ” is not a cancerous growth.

Recently, in another study, a panel of experts led by University College of London professor Sir Michael Marmot concluded that screening prevents about 1300 deaths a year in Britain but can also lead to 4000 women having treatment for a condition that would never have ever bothered them.

This means that according to their study, for every death that was prevented, three women were over-diagnosed and treated. This was less than the whole world study which showed that for every one death prevented, 10 women were over-diagnosed.

The review panel called for improved information, in health leaflets for instance, to give women a clearer picture of both the benefits and potential harm before they undergo a mammogram.

In Britain, breast cancer is the most common form of cancer affecting one in eight at some point in their lives. Right now their country’s screening program invites women aged 50 to 70 for a mammogram every 3 years and this is being expanded to ages 47 and 73.

According to KRUK, early diagnosis and better treatments have improved the survival rates to 77% in 2007 from 41% in 1971. But how many of those survivors were screened with D.C.I.DS., “Zero Stage” cancer, and have been used to pad the statistics for breast screening and survival rates.

Many people are intimidated by their physicians. They tell us we must do something and we do it without question. However, just as I advise the men to ask the serious questions about their prostate, so should you women also ask the serious questions. Do not accept a diagnosis of breast cancer without the very detailed information of which type and sub-type it may be. If it must be treated, ask if there are new treatments specifically designed for that type of breast cancer and demand that your physician provide all the information.

After all, if you have non-invasive D.C.I.S. you have the right to refuse treatment and the right to ask why your physician wants to treat something that cannot go anywhere and is benign and non-invasive.

If this actually was your diagnosis, the fact is that without the mammogram, you would never know and live a normal healthy level to its full expectancy and your breasts would still be intact.

 

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