Value of Mammograms?
This is an interesting and controversial article about the benefits of mammography. Certainly, we have all been aware that they are imperfect but they are the best universal screening tool that we currently have. My personal experience seems a good example: in 1993, my first breast cancer never showed on a mammogram. The lump was palpable, but not visualized on film. However, in 2005, a mammogram did find my second very small breast cancer. Personally, I am convinced they are worth the annual squeeze.
Benefits of Mammogram Under Debate in Britain
By RONI CARYN RABIN
Published: NYT March 30, 2009
The conventional wisdom about breast cancer screening is coming under sharp attack in Britain, and health officials there are taking notice.
They have promised to rewrite informational fliers about mammography after advocates and experts complained in a letter to The Times of London that none of the handouts "comes close to telling the truth" — overstating the benefits of screening and leaving out critical information about the harms.
What women are not told, the letter said, is that for every woman whose life is saved by breast cancer screening, up to 10 healthy women are given diagnoses — and, often, surgery — for a cancer that is so slow-growing it would never have threatened a woman's life.
"The culture is just that mammography is such a very sensible thing to do, so you chug along and have it done," said one of the signers, Hazel Thornton, in a telephone interview. Mrs. Thornton, 75, said she became disenchanted with routine screening more than 15 years ago, after a mammogram identified ductal carcinoma in situ, a noninvasive breast cancer that often does not progress. She had a lumpectomy, but was offered such a confusing array of treatment options that she realized doctors knew little about how aggressively to treat this kind of cancer.
"You don't know about all the uncertainty until you're one of the unlucky ones, and it happens to you," she said. The idea that mammography may do more harm than good may be alien to many American women. The prevention message has emphasized that screening protects women from breast cancer, and one survey of 479 women found that only 7 percent were aware that some cancers grow so slowly that even without treatment they will not affect a woman's health.
A 2006 analysis by the Nordic Cochrane Center collaborative, an independent research and information center based in Copenhagen, found that for every 2,000 women age 50 to 70 who are screened for 10 years, one woman will be saved from dying of breast cancer, while 10 will have their lives disrupted unnecessarily by overtreatment. The figures were cited in the letter to The Times.
Julietta Patnick, the director of cancer screening programs for the British National Health Service, said the patient handout was being revised and added that information about overdiagnosis might be added. But in a telephone interview, she dismissed the Cochrane figures as inaccurate. British studies, she said, show that the ratio of lives saved to lives unnecessarily disrupted is more like one to one. "We know, from statistics, that there are cancers diagnosed through screening that wouldn't otherwise have been diagnosed — because the woman dies of something else first, because she might get run over by a bus, or she might have a heart attack, or she might live to 90 and it would just sit there, and she wouldn't have died of breast cancer," Ms. Patnick said.
But the problem is, "You don't know who that woman is," she continued. "You just know that statistically, she exists." Experts agree that under a microscope, slow-growing cancers look no different from more aggressive ones, so it is impossible to know which ones can be left untouched. The author of the Cochrane analysis, Dr. Peter C. Gotzsche, another signer of the British letter, has written an alternative version of a patient handout for women considering mammography. It starts off by saying, "It may be reasonable to attend breast cancer screening with mammography, but it may also be reasonable not to attend."
Women in the United States are screened much more rigorously than women in Britain, with annual mammography starting at 40. British women start at 50, and get a mammogram once every three years. Dr. Ned Calonge, chairman of the United States Preventive Services Task Force, says mammography has been oversold to American women. "The expectation of women is that 'If I get screened, I won't get breast cancer,' " he said. "I hear that women will say: 'How can I have breast cancer? I always get my mammogram.' " In fact, Dr. Calonge went on, early detection may not make a difference in survival for many women. "Some women would have the same outcomes, whether the cancer is detected clinically or by mammography," he said. "And there are women whose cancer is so aggressive we cannot detect it early enough to make a difference in mortality."
An expert panel that reviewed the evidence on annual mammography for the task force in 2002 downgraded the recommendation for annual screens to "recommended" from "strongly recommended." That review raised some of the same concerns mentioned by the critics in Britain: the high incidence of false-positive scares that cause anxiety yet turn out to be nothing serious, and the potential overtreatment of ductal carcinoma in situ and other "indolent" cancers. The panel also expressed concern about the potential for harm from exposure to radiation during the scans.
Mammography is more effective in older women. But even among women 50 and over, the panel concluded, only one death would be prevented after 14 years of observing more than 800 women who had undergone screening. "That's a hefty number of women" who must be screened to derive a benefit, Dr. Calonge said. Similarly, studies about prostate screening for men concluded this month that the P.S.A. blood tests save few lives while leading to unnecessary treatment with potentially serious complications.
Despite the task force's reservations, most medical societies endorse annual mammography, as does the American Cancer Society. Robert Smith, director of cancer screening for the society, says he believes overdiagnosis is minimal at best, and only 10 percent of invasive cancers found through mammography are harmless and will never be life-threatening. "I think this is another example of, 'Here is something your doctor knows and isn't telling you,' " Dr. Smith said. "This is a debate between people who see the glass half full or the glass half empty."
Breast cancer screening is a good part of a preventive health care plan," he continued. "It's not perfect."