Great American Mammography Debate
Dr. Ralph Moss
Monday, November 16 , the United States Preventive Services
Task Force (USPSTF) revised its previous position and came out against
annual screening mammograms. The new recommendations included the
age 40-49 do not need to get routine mammograms.
women need only get mammograms once every two years, instead of
every year, as presently recommended.
over the age of 74 do not need mammograms at all.
should stop teaching women to perform breast self-examinations.
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.
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
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."
prominent Democratic politician, Debbie Wasserman Schultz (D-FL)
went on the attack:
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.
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
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.
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."
backlash against the report began immediately. According to a statement
by Otis Brawley, MD, chief medical officer of the ACS:
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.
National Cancer Institute (NCI) valiantly tried to defend the panel's
decision. In its Cancer Bulletin, it soberly evaluated the new recommendations
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).
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
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
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).
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
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).
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.
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
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:
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).
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."
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:
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."
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.
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
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.
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?
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.
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