Mammography Debate:

The Great American Mammography Debate

By Dr. Ralph Moss
from CancerDecisions.com

On Monday, November 16 [2009], the United States Preventive Services Task Force (USPSTF) revised its previous position and came out against annual screening mammograms. The new recommendations included the following points:

  • Women age 40-49 do not need to get routine mammograms.
  • Postmenopausal women need only get mammograms once every two years, instead of every year, as presently recommended.
  • Women over the age of 74 do not need mammograms at all.
  • Physicians should stop teaching women to perform breast self-examinations.

These recommendations pertain to the routine screening of the general population and do not apply to the small percentage of women who are known to be at heightened risk of breast cancer.

When you consider how central mammography (and breast self-examination) have been to the "war on cancer" you realize how drastic a change this would be. The USPSTF is a very influential and prestigious group, made up of independent experts in prevention and primary care, appointed by the federal Department of Health and Human Services. Yet, immediately, the report became a political football. Some Republicans attacked this as the first sign of healthcare rationing while most Democrats have backed away from the findings as if it were overripe Limburger cheese.

HHS Secretary Kathleen Sebelius said that the report (which her office had commissioned) had caused "a great deal of confusion and worry" among American women. "My message to women is simple. Mammograms have always been an important life-saving tool in the fight against breast cancer and they still are today. Keep doing what you have been doing for years – talk to your doctor about your individual history, ask questions, and make the decision that is right for you."

Another prominent Democratic politician, Debbie Wasserman Schultz (D-FL) went on the attack:

"I am very concerned that these guidelines conflict with many of the well-established recommendations from the American Medical Association, the National Comprehensive Cancer Network, the American Cancer Society, and Susan G. Komen for the Cure. This conflicting information will inevitably lead to confusion among providers and women, resulting in fewer women getting screened for breast cancer," she said in a statement.

So I doubt if these recommendations will be implemented anytime soon. Indeed, I think this controversy throws a light on the much-discussed topic of health-care reform. There appears to be no mass constituency in the US for cool-headed, rational science, when such findings conflict with the fundamental interests of a large portion of the medical establishment. Mammography is now as American as apple pie.

The co-chair of the USPSTF said that the recommendations were aimed at reducing the harm caused by over-screening. But the very notion of "over-screening" gets short shrift from the cancer establishment, especially from the American Cancer Society (ACS). They have built their reputation on finding all "cancers" as early as possible, especially through mammography and BSE. This would be too radical a shift for their members.

But, as Robert Aronowitz, MD, of the University of Pennsylvania points out in an op-ed in the New York Times, such recommendations are nothing new. They are the same as most thoughtful experts have been making since the 1970s. "You need to screen 1,900 women in their 40s for 10 years in order to prevent one death from breast cancer," said Aronowitz, "and in the process you will have generated more than 1,000 false-positive screens and all the overtreatment they entail."

The backlash against the report began immediately. According to a statement by Otis Brawley, MD, chief medical officer of the ACS:

"The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40." He claimed that ACS has examined the same data as the USPSTF, and had also looked at additional data that the panel did not consider. Generously, he said that "sensible people" could differ over their interpretation of the data.

The National Cancer Institute (NCI) valiantly tried to defend the panel's decision. In its Cancer Bulletin, it soberly evaluated the new recommendations and commented:

"When compared with screening from ages 50 to 69, beginning screening every other year at age 40 produced a small additional reduction in mortality but increased the number of false-positive results by more than 50 percent" (Cancer Bulletin 2009).

Unless you have gone through one of these false positive scares you can hardly imagine what it entails. You are called by the doctor's office and told, usually in a very cryptic way, that there is something wrong with your mammogram and you urgently need to come back for further testing-a repeat mammogram, an MRI or a biopsy. This entails more visits to the doctor's office. Because you may need to arrange transportation and childcare, your friends and family members may get involved. The dreaded "C word" gets whispered abroad. Then comes a period of waiting for the results, which may seem endless. Figure on a few days of lost time and wages. The whole business, multiplied millions of times, puts an economic strain on the medical system.

If you are lucky, the needle biopsy proves negative and you are left to heal your emotional and physical wounds. But sometimes the biopsy detects an abnormality. In rare instances this will be breast cancer. Or it may be ductal carcinoma in situ (DCIS), an amorphous category that sounds like cancer but may not be. What is the medical significance of DCIS? Will it surprise you to learn that, after decades of detecting and treating this condition, nobody seems to know? As the new USPSTF report states:

"Studies on overdiagnosis might also include long-term follow-up of women with probable missed cases of DCIS on the basis of microcalcifications that were missed in an earlier mammogram. Such studies could provide the percentage of these women who develop invasive breast cancer over the next 10 or more years" (Nelson 2009).

In other words, nobody knows how many of these DCIS lesions actually progress to invasive cancer. Since nobody really knows what DCIS means, nobody knows how best to treat it. Again, quoting the USPSTF report says:

"Although the standard treatments women receive for ductal carcinoma in situ (DCIS) include surgical approaches as well as radiation and hormonal therapy, considerable debate exists about the optimal treatment strategy for this condition" (Nelson 2009).

According to breastcancer.org, DCIS is not cancer and isn't life-threatening. But DCIS is routinely treated as if it were full-blown cancer, possibly entailing a mastectomy (surgical removal of the breast). Meanwhile, thanks to mammography, DCIS's growth has been astonishing. In 1983, there were 4,900 US cases of DCIS. By 2008, that number had increased to 67,770 (Nelson 2009). The over-treatment of DCIS has also swollen the ranks of "breast cancer survivors" and mightily improved the cure rate from the disease-because doctors are now "curing" a non-cancerous condition that in all likelihood would not have progressed to cancer.

The American organization that has been most firmly associated with screening mammography is the ACS. Apparently, the JAMA article momentarily tipped the scale in the debate against mammography. Although the ACS gives lip service to evidence-based medicine, in this case the evidence tilts away from mammography and towards skepticism. The new ACS chief medical officer, Otis W. Brawley, MD, told the Times, he was ready to embrace the factual approach. "I'm admitting that American medicine has over-promised when it comes to screening. The advantages to screening have been exaggerated" (Kolata 2009).

Dr. Brawley is a well-regarded medical oncologist who took over the top administrative position at the ACS two years ago. It took a lot of courage for him to try to adjust ACS's positions to the facts on the ground. Before coming to ACS, Dr. Brawley had expressed personal reservations about cancer screening, especially the use of the PSA test for prostate cancer. In 2000, he told a patients' Web site:

"I have never had a PSA and do not desire one. I have had relatives with the disease. I just do not believe it saves that many lives.... I am aware of 23 different organizations of experts in screening around the world who have considered the question and all have chosen not to make the blanket statement that screening saves lives and men should be screened. Most actually recommend men not get the test because it is not proven effective" (www.psa-rising.com).

So, if anything, Dr. Brawley could be considered a skeptic regarding cancer screening. But he also told the Times, "We don't want people to panic" over the new mammography position. But apparently the idea of scaling back mammography did lead to panic within ACS. Less than a day after publication of the Times article, the ACS put out a press release: "American Cancer Society Stands By Its Screening Guidelines."

Stands by its guidelines? How was that possible, when just hours before its medical director had directly contradicted those guidelines? Were they attempting to deny the accuracy of the Times report? One day it is revising its guidelines, and the next day standing by them? Here is an excerpt from the press release. Read it carefully:

"Today's New York Times...indicates that the American Cancer Society is changing its guidance on cancer screening to emphasize the risk of over-treatment from screening for breast, prostate, and other cancers. While the advantages of screening for some cancers have been overstated, there are advantages, especially in the case of breast, colon and cervical cancers. Mammography is effective - mammograms work and women should continue get them."

Notice that the press release does not say that the Times article was wrong or that Dr. Brawley had been misquoted. It simply falls back on the time worn argument that "mammograms work." It claims that breast is like colon and cervical cancer, not like discredited prostate cancer screening. It thus totally ignores the powerful arguments of Welch, Esserman and many others. It cites some studies of its own "proving" that mammography is effective, but just ignores the more recent and (in my opinion) more powerful arguments in JAMA and elsewhere.

Notice too how the ACS release associates mammography with colon and cervical cancer screening, rather than with prostate cancer screening. That is convenient, because there is little debate over the efficacy of colonoscopies for colon cancer or Pap smear (and HPV virus) screening for cervical cancer. The whole point of the recent JAMA article, however, was that mammography more closely resembles the faulty PSA screening program in its failure to significantly increase actual survival.

Although the ACS has now backtracked, I suspect that this reversal is only temporary. Dr. Brawley's previous skepticism about screening is well known. As long as he remains medical officer, he will probably push for clarity on this question. The mammography recommendations are now looking like the fringe position, while the position of the erstwhile skeptics has become mainstream. ACS cannot hold back this trend and sooner or later, it will have to modify its outdated position. That will be a victory for evidence-based medicine.

I hope, however, that ACS will make this revision in the context of a sweeping public review of its method of debating scientific issues, including its high-handed tendency to crush opponents, rather than engage in reasonable dialogue. For instance, we have seen in the past how ACS abandoned its notorious 'quackbuster' position regarding complementary and alternative medicine without making a clean sweep of its disgraceful history in that regard. ACS should admit that it (and not "American medicine" in general) was mainly responsible for the mammography recommendation and for various reasons got that wrong, long after many others had pointed out its errors. This may hurt in the short run, but it would be incredibly salutary for the long-term health of the organization. Or would such honesty be asking too much from a multi-billion organization?

CancerDecisions.com is directed by Ralph W. Moss, Ph.D. Dr. Moss is the author of eleven acclaimed books including Antioxidants Against Cancer, Herbs Against Cancer, Questioning Chemotherapy, and Cancer Therapy. He consults for thousands of clients through his Moss Reports service. The Moss Reports specializes in educating cancer patients about the most promising alternative treatments for their condition.

References:

Esserman L, Shieh Y, Thompson I. Rethinking Screening for Breast Cancer and Prostate Cancer. JAMA. 2009;302:1685-1692).

Bailar JC, III. Mammography: a contrary view. Annals of Internal Medicine. 1976;84:77-84.

Bailar JC, III. Screening for early breast cancer: pros and cons. Cancer. 1976;39:2783-2795.

Bailar JC, III. Mammographic screening: a reappraisal of benefits and risks. Clinical Obstetrics and Gynecology. 1976;21:1-14.

Epstein SS, Bertell R, Seaman B. Dangers and unreliability of mammography: breast examination is a safe, effective, and practical alternative. Int J Health Serv. 2001;31:605-615.

Kolata, Gina. Cancer society, in shift, has concerns on screening. New York Times, Oct. 20, 2009, page A1.

Lofters A, Juffs HG, Pond GR, Tannock IF. "PSA-itis": knowledge of serum prostate specific antigen and other causes of anxiety in men with metaststic prostate cancer. J. Urol. 2002;168(6):2516-2520.

Welch HG. Overdiagnosis and mammography screening. BMJ. 2009;339:b1425.





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