• Cancer Survivor or Victim of Overdiagnosis?

    The New York Times Articles
    By: H. Gilbert Welch
    Written: November 21, 2012

    FOR decades women have been told that one of the most important things they can do to protect their health is to have regular mammograms. But over the past few years, it’s become increasingly clear that these screenings are not all they’re cracked up to be. The latest piece of evidence appears in a study in Wednesday’s New England Journal of Medicine, conducted by the oncologist Archie Bleyer and me.

    The study looks at the big picture, the effect of three decades of mammography screening in the United States. After correcting for underlying trends and the use of hormone replacement therapy, we found that the introduction of screening has been associated with about 1.5 million additional women receiving a diagnosis of early stage breast cancer.

    That would be a good thing if it meant that 1.5 million fewer women had gotten a diagnosis of late-stage breast cancer. Then we could say that screening had advanced the time of diagnosis and provided the opportunity of reduced mortality for 1.5 million women.

    But instead, we found that there were only around 0.1 million fewer women with a diagnosis of late-stage breast cancer. This discrepancy means there was a lot of overdiagnosis: more than a million women who were told they had early stage cancer — most of whom underwent surgery, chemotherapy or radiation — for a “cancer” that was never going to make them sick. Although it’s impossible to know which women these are, that’s some pretty serious harm.

    But even more damaging is what these data suggest about the benefit of screening. If it does not advance the time of diagnosis of late-stage cancer, it won’t reduce mortality. In fact, we found no change in the number of women with life-threatening metastatic breast cancer.

    The harm of overdiagnosis shouldn’t come as a surprise. Six years ago, a long-term follow-up of a randomized trial showed that about one-quarter of cancers detected by screening were overdiagnosed. And this study reflected mammograms as used in the 1980s. Newer digital mammograms detect a lot more abnormalities, and the estimates of overdiagnosis have risen commensurately: now somewhere between a third and half of screen-detected cancers.

    The news on the benefits of screening isn’t any better. Some of the original trials from back in the ’80s suggested that mammography reduced breast cancer mortality by as much as 25 percent. This figure became the conventional wisdom. In the last two years, however, three investigations in Europe came to a radically different conclusion: mammography has either a limited impact on breast cancer mortality (reducing it by less than 10 percent) or none at all.

    Feeling depressed? Don’t be. There’s good news here, too: breast cancer mortality has fallen substantially in the United States and Europe. But it’s not about screening. It’s about treatment. Our therapies for breast cancer are simply better than they were 30 years ago.

    As treatment improves, the benefit of screening diminishes. Think about it: because we can treat most patients who develop pneumonia, there’s little benefit to trying to detect pneumonia early. That’s why we don’t screen for pneumonia.

    So here is what we now know: the mortality benefit of mammography is much smaller, and the harm of overdiagnosis much larger, than has been previously recognized.

    But to be honest, that general message has been around for more than a decade. Why isn’t it getting more traction?

    The reason is that no other medical test has been as aggressively promoted as mammograms — efforts that have gone beyond persuasion to guilt and even coercion (“I can’t be your doctor if you don’t get one”). And proponents have used the most misleading screening statistic there is: survival rates. A recent Komen foundation campaign typifies the approach: “Early detection saves lives. The five-year survival rate for breast cancer when caught early is 98 percent. When it’s not? It decreases to 23 percent.”

    Survival rates always go up with early diagnosis: people who get a diagnosis earlier in life will live longer with their diagnosis, even if it doesn’t change their time of death by one iota. And diagnosing cancer in people whose “cancer” was never destined to kill them will inflate survival rates — even if the number of deaths stays exactly the same. In short, tell everyone they have cancer, and survival will skyrocket.

    Screening proponents have also encouraged the public to believe two things that are patently untrue. First, that every woman who has a cancer diagnosed by mammography has had her life saved (consider those “Mammograms save lives. I’m the proof” T-shirts for breast cancer survivors). The truth is, those survivors are much more likely to have been victims of overdiagnosis. Second, that a woman who died from breast cancer “could have been saved” had her cancer been detected early. The truth is, a few breast cancers are destined to kill no matter what we do.

    What motivates proponents to use these tactics? Largely, it’s sincere faith in the virtue of early diagnosis, the belief that screening must be good for women. And 30 years ago, when we started down this road, they may have been right. In light of what we know now, it is wrong to continue down it. Let’s offer the proponents amnesty and move forward.

    What should be done? First and foremost, tell the truth: woman really do have a choice. While no one can dismiss the possibility that screening may help a tiny number of women, there’s no doubt that it leads many, many more to be treated for breast cancer unnecessarily. Women have to decide for themselves about the benefit and harms.

    But health care providers can also do better. They can look less hard for tiny cancers and precancers and put more effort into differentiating between consequential and inconsequential cancers. We must redesign screening protocols to reduce overdiagnosis or stop population-wide screening completely. Screening could be targeted instead to those at the highest risk of dying from breast cancer — women with strong family histories or genetic predispositions to the disease. These are the women who are most likely to benefit and least likely to be overdiagnosed.

    One final plea: Can we please stop using screening mammography as measure of how well our health care system is performing? That’s beginning to look like a cruel joke: cruel because it leads doctors to harass women into compliance; a joke because no one can argue this is either a public health imperative or a valid measure of the quality of care.

    Breast cancer is arguably the most important cancer for a nonsmoking woman to care about. Diagnostic mammography — when a woman with a breast lump gets a mammogram to learn if it’s something to worry about — is an important tool. No one argues about this. Pre-emptive mammography screening, on the other hand, is, at best, is a very mixed bag — it most likely causes more health problems than it solves.

    H. Gilbert Welch is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and an author of “Overdiagnosed: Making People Sick in the Pursuit of Health.”

  • Mammography: Are There Pros, or is It Just a Con?

    By Johnnie Ham, MD, MBA

    Original Article at Mercola.com

    Many women are completely unaware that the science backing the use of mammograms is sketchy at best. As was revealed in a 2011 meta-analysis by the Cochrane Database of Systemic Reviews, mammography breast cancer screening led to 30 percent overdiagnosis and overtreatment, which equates to an absolute risk increase of 0.5 percent.

    There’s also the risk of getting a false negative, meaning that a life-threatening cancer is missed.

    Unfortunately, even though some high-profile people agree that mammography has limitations as well as dangers, others prefer to ignore the science and continue to campaign for annual screenings without so much as a hint at the risks involved.

    Now, they’ve unrolled “new and improved” 3D TOMOSYNTHESIS mammogram, which still requiring mechanical compression, and delivers 30 percent more radiation!

    In order to make better informed decisions, I provide my patients with all of their screening options, their strengths and weaknesses, and I reinforce that they have a right to utilize those options. Some of the options may include; self and clinical breast exams, thermography, ultrasound and/or MRI. My role as a doctor is to diagnose and treat, but I am also an educator. I want my patients’ focus to be on prevention to improve their health and well-being.

    The Industry of Cancer

    Breast cancer has become big business, starting with the multi-billion dollar goliath, mammography. No other medical screening has been as aggressively promoted. My passion is providing integrative primary care as an MD for hundreds of patients. I also have over 23 combined years of military experience as an OB/GYN, trauma surgeon, experimental test pilot, and master army aviator.

    My training prepared me to navigate through challenging, and sometimes life threatening situations. Unfortunately, most women do not have the training I received, yet they could certainly use some of it to help navigate through the fear based methods of the breast cancer industry.

    The tide of thought on mammography’s benefits is rapidly changing as evidenced by recently published studies in the Archives of Internal Medicine,1 the Lancet Review,2 the British Medical Journal3 and the Nordic Cochrane Center;4 and the fact that the US Preventative Services Task Force5 and the Canadian Task Force on Preventative Health Care.6

    Why are Nearly All Health Care Professionals Not Following Current Mammogram Recommendations?

    Nearly every woman age 40 and older continues to be told by their primary care physician, their gynecologist, the media, self-proclaimed advocacy groups, and even their medical insurance carrier, “get your annual mammogram!” despite the fact that nearly every recent authoritative study concludes that women should know all of the facts before agreeing to a mammogram screening. Yet nearly all health care professionals insist on mammograms. If a woman dare refuse, she may be chastised or worse, threatened. These efforts have gone beyond persuasion to guilt and even coercion, “I can’t be your doctor if you don’t get a mammogram.” Women need to stop this runaway train, not only for their sake, but for the sake of their daughters.

    In November 2012, the New England Journal of Medicine published a study by Dr Archie Bleyer, MD from The Oregon Health Sciences Center, and his co-author, Dr H. Gilbert Welch, M.D., M.P.H., from Dartmouth, challenging the validity of mammogram screenings and concluded that mammograms have little to no influence in the reduction of the number of women who ultimately die of breast cancer.7

    Thirty years of US government data studied found that as many as 1/3 of cancers detected by mammography may not have been life threatening, and that over 1 million women have been over-diagnosed; leading to unnecessary treatments involving disfiguring surgeries; radiation and chemotherapy. They also showed that mammogram screenings have increased from about 30 percent of women 40 and older in 1985, to about 70 percent of women screened, proving how effective we have been at convincing women they need to get a mammogram.

    I have witnessed this strategy for decades and I have seen the profound psychological effect it has had on many of my patients. This paradigm has seriously misled women regarding the actual effectiveness, and the benefits vs. potential dangers of mammograms. They also have women confused about the erroneous belief that mammography is their only tool. Some women actually believe mammograms can prevent cancer, or do not realize they have the right to say, no!

    Most women comply with the current “gold standard” in fear of the ravages of breast cancer, convinced their annual mammogram will save their life through early detection. It is nearly impossible for them to negate decades of slick marketing, annual reminders from radiology imaging centers and the exploitation of October’s Breast Cancer Awareness month blitz. All of these efforts beautifully packaged, tied up with a pretty pink ribbon.

    I take my oath to do no harm very seriously. After many years of research, clinical practice; and due to my wife’s personal experience with mammography, I cannot in good conscience recommend mammograms. I inform my patients that mammograms are considered the current “gold standard”, but I also make certain they know the facts about the screening and that there are other screen tools available.

    Facts and Persisting Concerns: Mammograms

    More women are refusing mammograms. This is reflected in the dramatic decline of 4.3 percent in 2010. Previously, mammography use had increased annually by 1 percent between 2005 and 2009. Mammograms:

    1. Are incorrect 80 percent of the time (providing a false negative or false positive)
    2. Require repeated ionized radiation that can cause cancer
    3. Use compression, which can damage breast tissue or potentially spread cancer
    4. Are not effective for up to 50 percent of women (women with dense breasts or implants)
    5. Can lead to over-diagnosis and over-treatment of non-invasive cancers
    6. Can lead to the disturbing practice of “preventative” double mastectomies

    What is Mammography Industries Solution?

    The “new and improved” 3D TOMOSYNTHESIS mammogram, still requiring mechanical compression, and 30 percent more radiation! We know all levels of ionizing radiation can cause cancer but, astonishingly, radiologists still want you to have your traditional mammogram screening first, followed by tomosynthesis mammogram for those with dense breasts or an area of suspicion. When my local Radiology Community approached me in an effort to disprove my concerns, I posed one simple question: Can you show me, one well-designed study that proves screening mammography has improved ultimate survival rates? I am still waiting for their answer.

    We cannot prove that screening mammography improves the ultimate survival rate. A quick look at the SEER data would suggest treatment has improved, by a decline in the death rate since 1998 of 1.9 percent.8 For every 1,000 women in this country, today 125 will ultimately be diagnosed with breast cancer. Of those 125, over 40 will be over-diagnosed, and receive treatment they never needed, and suffer the potential psychological consequences of a cancer diagnosis. That leaves about 80, of which 28 will die of breast cancer. The decline since 1998 in the death rate means that for our 28 women who would have otherwise died from breast cancer, 2 more out of 1000 women diagnosed with breast cancer survived due to over a decade of treatment advances.

    But, we really don’t know what actually saved those 2 women, of the 125 diagnosed with breast cancer for every 1,000 women in our group. If we attribute anything to lifestyle changes we have emphasized recently (which has been shown repeatedly to work), then either we wipe out any improved survival rate from decades of treatment advances, or worse, we cause death to some of those 40 women who were over-diagnosed!

    If You Have Dense Breasts it is Even Worse

    Breast density laws have now been passed in California,9 Connecticut, New York, Virginia and Texas making it mandatory for radiologists to inform their patients, who have dense breast tissue (40 to 50 percent of women) that mammograms are basically useless for them. Dense breast tissue and cancer both appear white on an X-ray, making it nearly impossible for a radiologist to detect cancer in these women. It’s like trying to find a snowflake in a blizzard. A law is now being considered at a Federal level as well.

    Some radiologists already provide density information to their patients, and encourage them to utilize other options like thermography, ultrasound and/or MRI. I believe it reasonable for a woman to trust that her radiologist is not withholding vital density information. Unfortunately, many have kept this potentially lifesaving data from women for decades, and our government agencies have failed to protect them from this unethical practice.

    I know it is extremely difficult to navigate through all of the contradicting information and study findings. It would better serve women if efforts, money and resources were utilized on educating women on cancer prevention, being that 95 percent of disease is lifestyle related. Yet 40,000 women continue to die of breast cancer each year. The only way to reduce this number is through utilizing preventative therapies.

    Basic Cancer Prevention Strategies

    As mentioned above, many women are completely unaware that the science backing the use of mammograms is sorely lacking, and that more women are being harmed by regular mammograms than are saved by them. Many also do not realize that the “new and improved” 3D tomosynthesis mammogram actually delivers even MORE ionizing radiation than the older version. This is not a step forward…

    Please understand that there are other screening options, each with their own strengths and weaknesses, and you have a right to utilize those options. Also remember that in order to truly avoid breast cancer, you need to focus your attention on prevention.

    A few simple, yet great options to assist in your efforts to avoid breast cancer are: making sure you are getting enough vitamin D, K2 and iodine; that you utilize lymphatic massage; use stress management techniques, exercise often, and balance your hormones naturally. It is also wise to eat a Mediterranean diet consisting of organic foods. Avoid processed and GMO foods; and toxic environments.

    In my practice, I recommend breast thermography, even for young women to get a baseline, but also combine the imaging not only with a review of the findings, but more importantly, as a venue to educate women on breast health. It is far more effective to prevent breast cancer, than it is to wait until it is there and then treat it. We are all different so make sure you consult with your doctor and do your own research before utilizing any of these suggestions.

    The advice I give all of my patients is to be your own health advocate, do your own research and always ask questions before agreeing to any therapy or treatment, screening and/or procedure.

    About the Author:

    Dr. Johnnie Ham, MD, former Lieutenant Colonel of the US Army Medical Corps, is the Medical Director of Coastal Prestige Medical Services, Pismo Beach, CA. Coastal Prestige Physicians offer top-notch comprehensive healthcare, with an emphasis on evidence-based primary care and preventive health for all ages.