Mixed Messages

02.13.14

Mammogram Wars

A new study raising questions about the screening method has launched yet another debate around breast cancer. Haven’t we heard all this before?

The mammogram debates have been dredged up again, thanks to an update of a study conducted in the 1980s. The new report shows that regular mammograms do not save lives, a finding that was criticized the first time around. Once again, many breast-cancer specialists say this new study will not change advice nor impact insurance reimbursement. But they did provide fodder for daytime talk shows and a slew of news articles, perhaps infuriating women more than anything else. Haven’t we heard this all before?

You have. Last time it was a ten-year follow-up. Now it’s 25 years out. Between 1980 and 1985, some 90,000 Canadian women, ages 40 to 49, were randomly divided into groups in which one set would have a mammogram every year and the other not at all. The screening part lasted five years and then doctors continued to trace women to monitor death rates. The first results, reported years ago, ignited fierce debates, prompting other teams of researchers to launch their own studies. For the most part, they found mammograms saved lives. And so, doctors advised women to get an exam every year, starting at age 40.

The new findings, published this week in The British Medical Journal, are based on the same Canadian women 25 years later. The upshot: same findings as before. Annual mammograms don’t save lives. “This is one page in a huge book called The History and Findings in Breast Cancer. It’s not even a chapter. It’s one page,” said Dr. Otis Brawley, Chief Medical Officer of the American Cancer Society. “ I change policy and I change recommendations based on an assessment of the entire literature. Every study has limitations and every study has flaws. The truth is that we should be telling women that we have at least eight clinical trials. If you look at those eight trials, the overwhelming majority tell us that mammograms saves lives.”

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Courtesy of Randi Epstein

The Canadian scientists estimated that for women in their 40s, mammograms had no effect on death rates. The U.S. Preventive Services Task Force, an influential group, found a 15 percent reduction, he said.

The real issue, as Dr. Brawley explained, is to ensure four things: 1. That mammograms are read by specialists, which would minimize the rate of false alarms. 2. That screening centers follow up with women who need further tests, so they aren’t lost in the system. 3. That women are seen in the same breast center, so doctors can compare the recent film to prior ones. (Often a change from one exam to the next is more telling that an incidental finding.) 4. That women understand the limitations of the test.

Mammograms are not cure-alls. “Women need to make an informed decision on whether or not to be screened,” says Jay R. Harris, M.D., Professor and Chair, Department of Radiation Oncology at the Dana-Farber Cancer Institute, Brigham and Women's Hospital Harvard Medical School. “A woman needs to recognize that there is a definite but modest benefit in terms of avoiding breast cancer mortality, but this needs to be balanced against the real risks of extra biopsies, over diagnosis, and worry."

Like any screening exam, they need to be done on a lot of healthy people to catch the rare cancer. Because most people do not have breast cancer, it is sometimes hard to prove their overall worth in large trials. If you are the one woman whose cancer was found at a curable stage through mammogram, you are certainly going to see the benefits of annual screening. If you are like most women, going for the test—and sometimes needing extra tests to confirm questionable findings—you may think it’s all a big waste of time and money.

After the initial Canadian studies, a group of U.S. cancer experts claimed the results were based on archaic mammogram machines that would not have picked up cancer as well as the machines used in the U.S. These film-based imaging machines are certainly not as good at picking up cancers as the computerized machines used today. Yet, that is part of the current debate. These ever-so-little wisps of white on the screen can indicate a potentially aggressive cancer, a slow-growing cancer, or nothing at all. Are we finding too much? Are we seeing little that could nothing at all? Are we putting women through too many tests to prove they had nothing in the first place?

About two years ago, my mammogram showed a suspicious shadow, so the doctor did an ultrasound. As she brushed the wand across my breast, I could see an oval bubble on the television screen. She suspected it wasn’t cancer, but wanted to be sure. One pain-free skinny needle sucked out some of the cells and within a few days, I got the pathology report confirming the doctor’s hunch. Fibroadenoma. A small benign growth. Granted the way she presented the news (“we’re 98 percent sure this is nothing,”) made the experience as mundane as a getting a physical exam.

The new study, which got everyone talking about false positives and needless anxiety, exasperated Lilli Roth, a 48-year-old mother of two and ten-year breast cancer survivor. “I find it insulting that doctors would think that if you get a false positive, women are going to freak out. It’s a disservice to all of us to say that we are too frail, that we can’t deal with uncertainty.”

Dr. Susan Drossman, a breast radiologist in private practice in New York City who is affiliated with Mt. Sinai School of Medicine said her patients were angry, not worried. The most aggressive breast cancers, she added, are found in women between the ages of 40 and 50. The least aggressive ones are found in elderly women. “I wish they would take this stupid argument and flip-flop it,” she said, “and say, stop coming when you are 75.”

Drossman, like other doctors, said she doesn’t think it will change a thing. In 2009, she said the U.S. Preventive Services Task Force said that screening should be every two years, should start at age 50 instead of 40, and that self-breast exams were pointless. That didn’t change a thing. So this one study won’t either.

Randi Hutter Epstein is the author of Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank.