Do mammograms really work? Mixed messages on screening for breast cancer

Are mammograms useless? That’s just one of the turn-your-world-upside-down questions raised in a provocative and personal New York Times Magazine piece about the fight against breast cancer, published online Thursday and set to hit newsstands this weekend.

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In “Our Feel-Good War on Breast Cancer,” Peggy Orenstein—thoughtful writer and translator of marketing strategies, known for her takedown of princess culture in 2011’s “Cinderella Ate My Daughter”—turns her analytic eye on pink-ribbon mania, the possible over-diagnosis of breast cancer, and yes, the idea that the sacred mammogram may be barely making a dent in the fight against the disease.

Orenstein, herself a breast-cancer survivor, begins by pointing to a recent three-decade study. It found that, while mammography does reduce, by a slight margin, the number of women who develop late-stage cancer, it is is far more likely to result in overdiagnosis and unnecessary treatment, including the use of potentially toxic drugs.

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“And yet, mammography remains an unquestioned pillar of the pink-ribbon awareness movement,” she writes. “Just about everywhere I go—the supermarket, the dry cleaner, the gym, the gas pump, the movie theater, the airport, the florist, the bank, the mall—I see posters proclaiming that ‘early detection is the best protection’ and ‘mammograms save lives.’ But how many lives, exactly, are being ‘saved,’ under what circumstances and at what cost?”

In 1996, Orenstein wrote about her belief that a mammogram had saved her own life. The screening had caught her tumor when she was 35, and her treatment was a lumpectomy and six weeks of radiation. So she was angry when, one week after her diagnosis, the National Institutes of Health made the controversial decision to not recommend universal screening for women in their 40s. Now, 16 years and one recurrence later, Orenstein says she’s had a change of heart.

“How much had my mammogram really mattered? Would the outcome have been the same had I bumped into the cancer on my own years later? It’s hard to argue with a good result. After all, I am alive and grateful to be here,” she writes. “But I’ve watched friends whose breast cancers were detected ‘early’ die anyway. I’ve sweated out what blessedly turned out to be false alarms with many others.”

Among the issues raised and revelations presented in her piece, blending a clear first-person narrative with interviews, studies and statistics, are:

Mammograms may not make much difference. Yes, there has been about a 25 percent drop in breast-cancer death rates since 1990. But some researchers point to treatment—not mammograms—as being mainly responsible for the decline. Evidence comes from a study of three pairs of European countries: In each pair, mammograms were introduced in one country 10 to 15 years earlier than in the other. Yet mortality rates are virtually identical, indicating mammography hadn’t made a difference. Further, mammograms, are not so great at detecting the most lethal forms of disease—a “triple negative,” for example—at a treatable phase. Aggressive tumors also tend to progress too quickly, cropping up between screenings.

Unnecessary treatments can be harmful. “According to a survey of randomized clinical trials involving 600,000 women around the world, for every 2,000 women screened annually over 10 years, 1 life is prolonged but 10 healthy women are given diagnoses of breast cancer and unnecessarily treated, often with therapies that themselves have life-threatening side effects,” Orenstein reports. Those treatments include Tamoxifen, which carries risks of stroke, blood clots and uterine cancer, while radiation and chemotherapy weaken the heart.

Newer diagnosis is on the rise. Many women today are told they have ductal carcinoma in situ (D.C.I.S.), or “Stage Zero” cancer, in which abnormal cells are found in the lining of the breast’s milk ducts. The diagnosis of D.C.I.S., in fact, now accounts for about a quarter of new breast-cancer cases, totaling some 60,000 a year. These are oftentimes the women we see celebrated at pink-ribbon events as “triumphs of early detection.” But D.C.I.S. does not spread; “in situ” means “in place.” The only danger is if it develops into an invasive cancer, and right now, there’s no way to know that, which is one of the major things in this fight that needs to change, say researchers. In the mean time, says Laura Esserman, director of the Carol Franc Buck Breast Care Center at the University of California, San Francisco: “D.C.I.S. is not cancer. It’s a risk factor. …We don’t do heart surgery when someone comes in with high cholesterol. What are we doing to these people?”

Preemptive mastectomies are on the rise, and not because of medical advice. According to Todd Tuttle, chief of the division of surgical oncology at the University of Minnesota and lead author of a study on the topic, there was a 188 percent jump between 1998 and 2005 among women given new diagnoses of D.C.I.S. in one breast who opted to have both breasts removed just in case. “You could attribute the rise in mastectomies to a better understanding of genetics or better reconstruction techniques,” Tuttle said, “but those are available in Europe, and you don’t see that mastectomy craze there. There is so much ‘awareness’ about breast cancer in the U.S. I’ve called it breast-cancer overawareness. It’s everywhere. There are pink garbage trucks. Women are petrified.”

Fund-raising efforts raise questions. The Susan J. Komen foundation trademarked the phrase “for the cure.” But only 16 percent of the $472 million raised in 2011, the most recent year for which financial reports are available, went toward research. “At $75 million, that’s still enough to give credence to the claim that Komen has been involved in every major breast-cancer breakthrough for the past 29 years,” Orenstein writes. “Still, the sum is dwarfed by the $231 million the foundation spent on education and screening.” 

Critics find Komen misleading. Though Komen acknowledges the debate over screening on its Web site, the foundation has been repeatedly accused of overstating mammography’s benefits while dismissing its risks, the piece states. Further, says Gayle Sulik, a sociologist and founder of the Breast Cancer Consortium, of the foundation’s goals, “If the goal is eradication of breast cancer, how close are we to that? Not very close at all. If the agenda is awareness, what is it making us aware of? That breast cancer exists? That it’s important? ‘Awareness’ has become narrowed until it just means ‘visibility.’ And that’s where the movement has failed. That’s where it’s lost its momentum to move further.”

Self-exams, Orenstein reports, are passé. “There’s no reason for anyone—let alone young girls—to perform monthly self-exams,” she explains. “Many breast-cancer organizations stopped pushing it more than a decade ago, when a 12-year randomized study involving more than 266,000 Chinese women, published in The Journal of the National Cancer Institute, found no difference in the number of cancers discovered, the stage of disease or mortality rates between women who were given intensive instruction in monthly self-exams and women who were not, though the former group was subject to more biopsies.”

Girls may be unnecessarily frightened. Finally, Orenstein worried about the move toward educating girls “to be aware of their breasts as precancerous organs.” A 20-year-old woman has about a .06 percent chance of developing breast cancer in the next decade—roughly the same as for a man in his 70s. “And no one is telling him to ‘check your boobies,’” she notes. “It’s tricky,” offers breast surgeon Susan Love, president of the Dr. Susan Love Research Foundation. While you don’t want anyone to ignore the risks, she says, “I don’t think it empowers girls. It scares them.”

Neither the American Cancer Society nor the Susan G. Komen foundation responded to requests for comment from Yahoo! Shine about the New York Times Magazine story.

Many of the ideas raised in the story—questioning mammograms especially—represent a huge change of pace from what has been drilled into women by healthcare professionals for years, and feedback on the story has so far been mixed.

“The author completely ignores diagnostic breast ultrasound, which is painless, noninvasive, and uses no radiation," writes one annoyed reader on the magazine's website. "Ultrasound can reliably diagnose benign cysts, benign solid fibroadenomas, and small cancers.”

Another takes umbrage to the mere idea of questioning mammograms. "There is absolutely no argument and no disagreement among physicians that mammograms save lives," said the reader. "Make no mistake, if mammograms were discontinued, deaths from breast cancer would go up. For any physician to allege otherwise would be malpractice."

Yet another commenter is offended to the story's negative outlook. “While it is good to bring up the issue of questionable success of screening not only in breast cancer, but also in many other diseases, I think that the tone of this article is needlessly bleak,” wrote one reader, in Boston. “Herceptin and tamoxifen/raloxifene are among our greatest successes in the arena of cancer treatment, and have revolutionized our approach to other cancers. The cancers treated by these drugs are among the few that were once lethal and now eminently treatable and survivable. This should not be lost on anyone.”

Many others, though, agreed with Orenstein. "More lives aren't being saved because the "war on cancer" has basically been turned into a pink-ribbon profit-making exercise," said one. Another declared, "This is such an important article. I really hope we can start basing health care on research and logic. Too many young women are getting mastectomies and double mastectomies out of fear rather than good medical protocol."

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