• From the ED: Breast Cancer Mammograms: Overrated – and Over-diagnosing Women

    Posted on June 23, 2014
    by Caitlin C.
    Posted at:  Breast Cancer Action

    Editor’s Note: You may have seen Karuna’s article back in April of this year when it was published in The Guardian. The piece generated a lot of discussion – over 1,000 people shared it on their Facebook page and over 150 people commented on the article itself. Many of you who have been through several iterations of these debates are used to the controversy that arises from publicly challenging routine mammography screening. What’s new this time around is the growing agreement that the benefits of routine mammography screening have long been overstated, and the harms long underestimated. Ten years ago, our challenge to the conventional position that “early detection saves lives” and “early detection is your best protection” was highly unpopular. Our independent position was a hard truth for many to hear even though it was grounded in evidence because it went against the grain of pretty much every mainstream breast cancer organization—many of which were and still are heavily invested (both in terms of funders and core values) in the “early detection saves lives” philosophy. We’ve reached a tipping point recently and now increasingly we hear more discussion about this issue and less unquestioned acceptance of the earlier screening messages.Karuna-Jaggar-headshot-2014-150x150

    By Karuna Jaggar, Executive Director

    How will we ever hope to make desperately needed progress in the breast cancer epidemic when the mainstream breast cancer movement continues to push an outdated and scientifically debunked agenda? The evidence has been mounting that the time has come to radically re-think the tenets of the breast cancer awareness movement because it is clear that the fundamental philosophy behind “early detection” is flawed. [Read More…]

  • Mammography controversy needs greater participation to inform decisions

    Wednesday 7 May 2014 – 2am PST

    Doctors at the World Congress on the Menopause in Cancun, Mexico, have called for any decision to participate in mammography to be a based on an informed choice and consideration of all factors, rather than just be an automatic process.

    A major session at the World Congress on the Menopause has debated the benefits and risks associated with regular mammography. The potential benefit of mammography is earlier detection of breast cancer, but increasing evidence has shown that mammography also uncovers some cancers which would not go onto cause any problem, and many doctors believe that this over diagnosis can cause real harm through unnecessary treatment. The debate in the scientific press has led to confusion in the minds of many women, who hope for a definitive answer on whether or not they should undergo regular mammography.

    Now two prominent doctors from opposing sides of the debate have agreed that women need to be more involved in making decisions on whether or not mammography is right for them.

    Dr Eugenio Paci presented work from the EUROSCREEN working group, showing that over diagnosis is at the lower end of the estimates, indicating that mammography saves lives. This work indicates that screening 1000 women saves up to 7 lives, with only 4 over diagnosis. Professor Robin Bell presented an analysis showing that up to 40% of invasive breast cancer cases identified in women invited for mammography may be over diagnosed, and says that the total number of deaths in screened patients does not drop when measured against non-screened patients, indicating that screening has few benefits. [Read More…]

  • Abolishing Mammography Screening Programs? A View from the Swiss Medical Board

    Nikola Biller-Andorno, M.D., Ph.D., and Peter Jüni, M.D.

    April 16, 2014DOI: 10.1056/NEJMp1401875

    In January 2013, the Swiss Medical Board, an independent health technology assessment initiative under the auspices of the Conference of Health Ministers of the Swiss Cantons, the Swiss Medical Association, and the Swiss Academy of Medical Sciences, was mandated to prepare a review of mammography screening. The two of us, a medical ethicist and a clinical epidemiologist, were members of the expert panel that appraised the evidence and its implications. The other members were a clinical pharmacologist, an oncologic surgeon, a nurse scientist, a lawyer, and a health economist. As we embarked on the project, we were aware of the controversies that have surrounded mammography screening for the past 10 to 15 years. When we reviewed the available evidence and contemplated its implications in detail, however, we became increasingly concerned.

    First, we noticed that the ongoing debate was based on a series of reanalyses of the same, predominantly outdated trials. The first trial started more than 50 years ago in New York City and the last trial in 1991 in the United Kingdom. None of these trials were initiated in the era of modern breast-cancer treatment, which has dramatically improved the prognosis of women with breast cancer. Could the modest benefit of mammography screening in terms of breast-cancer mortality that was shown in trials initiated between 1963 and 1991 still be detected in a trial conducted today? [Read More…]

  • Are the Harms of Mammography Underestimated?

    April 08, 2014

    By Kristen Fischer

    More controversy has emerged surrounding mammograms ever since a new report in JAMA recommended that the test be performed based on a woman’s risk and preferences.
    Dr. Lydia Pace and Dr. Nancy Keating both of Brigham and Women’s Hospital in Boston, conducted a systematic review of data spanning 50 years. They examined about 450 studies from 1960 through the present to look for evidence on the benefits and harms of the diagnostic test.

    According to their report, annual mammograms lower mortality from breast cancer by about 19 percent, though the benefits vary based on a woman’s risk and age. Approximately 1,904 women in their 40s would have to undergo a mammogram to prevent one death, while the same would be true for 377 women in their 60s. The disease is more common as a woman ages. At 40, the risk for breast cancer in the next 10 years is 1.5 percent, but that rises to 2.3 percent by age 50, and 3.5 percent by age 60. [Read More…]

  • More Doubts About Mammograms’ Value Are Raised in Large Study

    By Melinda Beck
    Updated April 1, 2014
    Article from The Wall Street Journal

    Nearly 20% of breast cancers diagnosed by mammogram would never cause problems if left alone, according to a new report. Melinda Beck and the study’s lead author Dr. Nancy Keating join the News Hub. Photo: AP.
     

    A large study published Tuesday adds to the growing body of research concluding that screening mammograms save relatively few lives from breast cancer while discovering many cancers that wouldn’t have caused problems if left alone.

    “The more we screen for cancer, the more we find it. But we could have saved some of these women the angst of being told they have cancer,” said Nancy Keating, a researcher at Harvard Medical School and senior author of the study, which examined decades of screening data.

    Other recent studies also have found that mammograms often lead to unnecessary treatment, including a British Medical Journal study in February that followed 90,000 Canadian women over 25 years. But to date, that message hasn’t resulted in fewer mammograms or changes in treatment—largely because scientists still can’t tell which breast cancers can be safely left alone.

    “The challenge is, we can’t tell which are the aggressive cancers,” said Dr. Keating.

    Growing doubts about the benefits of mammograms prompted the U.S. Preventive Services Task Force to change its recommendations in 2009. Since then, it has urged women to get mammograms every other year starting at age 50, rather than annually at 40. The American Cancer Society and other cancer advocacy groups continue to recommend annual screenings starting at 40.

    Many health-care policies encourage more screening. Several states now require doctors to tell women if they have dense breasts, which can make mammograms less accurate, and to discuss more high-tech options. A growing number of doctors are rated—and compensated—on the percentage of their patients who are up to date on screenings. And the Affordable Care Act requires insurers to make mammograms free to women without copays or deductibles.

    About 225,000 cases of breast cancer are diagnosed in the U.S. each year, and about 40,000 people die of it, according to the American Cancer Society.

    The latest study, published in the Journal of the American Medical Association, took an especially long view of the data, examining randomized trials and observational studies on mammograms back to the 1960s to calculate the benefits and harms for women at various ages. Researchers concluded that annual mammograms reduced the overall death rate from breast cancer by about 19%. But they also discovered that about 19% of the breast cancers found when women undergo 10 years of annual mammograms are “over-diagnosed”—that is, they never would have caused problems if left alone.

    Younger women had the least benefit, researchers found. They estimate that for every 10,000 women in their 40s who undergo annual mammograms for 10 years, 190 will be diagnosed with breast cancer. But only five of those women would avoid dying of breast cancer as a result of the screening. Of the remainder, about 25 would die despite being treated, and 36 would be treated unnecessarily because the cancer wouldn’t have become life-threatening.

    For women in their 50s, 10 breast-cancerdeaths would be averted for every 10,000 women screened annually for 10 years. For women in their 60s, 42 breast-cancer deaths would be averted. But as many as 137 women in their 50s, and 194 in their 60s would be diagnosed and treated unnecessarily.

    The conclusion that some cancers are overtreated is controversial, and critics note that it is based on statistical estimates alone. Scientists can’t ethically watch to see whether some breast cancers progress and some don’t. Even precancerous changes, known as ductal carcinoma in situ, can become invasive cancers, so those are almost always treated aggressively.

    Treatment typically involves a combination of surgery, radiation, chemotherapy and hormone therapy, with side effects that can last for years.

    Still, many breast-cancer survivors say they are simply grateful that their cancer was treatable. And some experts stress that even if screening spurs some unnecessary treatments, it saves lives. “Over a decade or so, we prevent between 10,000 and 11,000 deaths,” said Richard Wender, chief cancer control officer at the American Cancer Society. “The overwhelming odds for any one women to benefit are quite low, but overall, from a population perspective, it’s one of our best tools in the war on cancer.”

    Scientists are working on ways to distinguish between breast cancers that are slow-growing and those that are fast-moving and lethal, and to better predict which women are at high risk for aggressive cancers so that screening and treatment can be more targeted.

    In the meantime, many cancer experts urge women and their doctors to weigh their individual risks and preferences.

    “There isn’t a one-size-fits-all on mammograms,” said Dr. Keating, who said she discusses all the pros and cons with her primary-care patients at Brigham and Women’s Hospital.

    “I have a lot of patients who say, ‘I’m comfortable waiting,’ ” she said.

  • FAIL: Another Mammography Study Finds They Don’t Save Lives

  • Vast Study Casts Doubts on Value of Mammograms

     

    study-imageOne of the largest and most meticulous studies of mammography ever done, involving 90,000 women and lasting a quarter-century, has added powerful new doubts about the value of the screening test for women of any age.

    It found that the death rates from breast cancer and from all causes were the same in women who got mammograms and those who did not. And the screening had harms: One in five cancers found with mammography and treated was not a threat to the woman’s health and did not need treatment such as chemotherapy, surgery or radiation.

    The study, published Tuesday in The British Medical Journal, is one of the few rigorous evaluations of mammograms conducted in the modern era of more effective breast cancer treatments. It randomly assigned Canadian women to have regular mammograms and breast exams by trained nurses or to have breast exams alone.

    Researchers sought to determine whether there was any advantage to finding breast cancers when they were too small to feel. The answer is no, the researchers report.

    The study seems likely to lead to an even deeper polarization between those who believe that regular mammography saves lives, including many breast cancer patients and advocates for them, and a growing number of researchers who say the evidence is lacking or, at the very least, murky.

    “It will make women uncomfortable, and they should be uncomfortable,” said Dr. Russell P. Harris, a screening expert and professor of medicine at the University of North Carolina, Chapel Hill, who was not involved in the study. “The decision to have a mammogram should not be a slam dunk.”

    The findings will not lead to any immediate change in guidelines for mammography, and many advocates and experts will almost certainly dispute the idea that mammograms are on balance useless, or even harmful.

    Dr. Richard C. Wender, chief of cancer control for the American Cancer Society, said the society had convened an expert panel that was reviewing all studies on mammography, including the Canadian one, and would issue revised guidelines later this year. He added that combined data from clinical trials of mammography showed it reduces the death rate from breast cancer by at least 15 percent for women in their 40s and by at least 20 percent for older women.

    That means that one woman in 1,000 who starts screening in her 40s, two who start in their 50s and three who start in their 60s will avoid a breast cancer death, Dr. Harris said.

    Dr. Wender added that while improved treatments clearly helped lower the breast cancer death rate, so did mammography, by catching cancers early

    But an editorial accompanying the new study said that earlier studies that found mammograms helped women were done before the routine use of drugs like tamoxifen that sharply reduced the breast cancer death rate. In addition, many studies did not use the gold-standard methods of the clinical trial, randomly assigning women to be screened or not, noted the editorial’s author, Dr. Mette Kalager, and other experts.

    Dr. Kalager, an epidemiologist and screening researcher at the University of Oslo and the Harvard School of Public Health, said there was a reason the results were unlike those of earlier studies. With better treatments, like tamoxifen, it was less important to find cancers early. Also, she said, women in the Canadian study were aware of breast cancer and its dangers, unlike women in earlier studies who were more likely to ignore lumps.

    “It might be possible that mammography screening would work if you don’t have any awareness of the disease,” she said.

    The Canadian study reached the same conclusion about the lack of a benefit from mammograms after 11 to 16 years of follow-up, but some experts predicted that as time went on the advantages would emerge.

    That did not happen, but with more time the researchers could, for the first time, calculate the extent of overdiagnosis, finding cancers that would never have killed the women but that led to treatments that included surgery, chemotherapy and radiation.

    Many cancers, researchers now recognize, grow slowly, or not at all, and do not require treatment. Some cancers even shrink or disappear on their own. But once cancer is detected, it is impossible to know if it is dangerous, so doctors treat them all.

    If the researchers also included a precancerous condition called ductal carcinoma in situ, the overdiagnosis rate would be closer to one in three cancers, said Dr. Anthony B. Miller of the University of Toronto, the lead author of the paper. Ductal carcinoma in situ, or D.C.I.S., is found only with mammography, is confined to the milk duct and may or may not break out into the breast. But it is usually treated with surgery, including mastectomy, or removal of the breast.

    Mammography’s benefits have long been debated, but no nations except Switzerland have suggested the screening be halted. In a recent report, the Swiss Medical Board, an expert panel established by regional ministers of public health, advised that no new mammography programs be started in that country and that those in existence have a limited, though unspecified, duration. Ten of 26 Swiss cantons, or districts, have regular mammography screening programs.

    Dr. Peter Juni, a member of the Swiss Medical Board until recently, said one concern was that mammography was not reducing the overall death rate from the disease, but increasing overdiagnosis and leading to false positives and needless biopsies.

    “The mammography story is just not such an easy story,” said Dr. Juni, a clinical epidemiologist at the University of Bern.

    Even experts like Dr. H. Gilbert Welch, a professor of medicine at Dartmouth, who have questioned mammography’s benefits were surprised by Switzerland’s steps to reconsider its widespread use.

    “Wow, times they are a-changin’,” Dr. Welch said.

    In the United States, about 37 million mammograms are performed annually at a cost of about $100 per mammogram. Nearly three-quarters of women age 40 and over say they had a mammogram in the past year. More than 90 percent of women ages 50 to 69 in several European countries have had at least one mammogram.

    Dr. Kalager, whose editorial accompanying the study was titled “Too Much Mammography,” compared mammography to prostate-specific antigen screening for prostate cancer, using data from pooled analyses of clinical trials. It turned out that the two screening tests were almost identical in their overdiagnosis rate and had almost the same slight reduction in breast or prostate deaths.

    “I was very surprised,” Dr. Kalager said. She had assumed that the evidence for mammography must be stronger since most countries support mammography screening and most discourage PSA screening.

     

     

  • For Women, a More Complicated Choice on Mammograms

  • Special report: The end of traditional mammography?

    July 19, 2013

    by Carol Ko , Staff Writer

    This first appeared in the July 2013 issue of DOTmed Business News

    It’s no secret that getting a mammogram is a nerve-wracking experience for many women. Although some studies suggest women at higher risk for breast cancer are more likely to get regular screens, others show that the most fearful women are the least likely to be screened.

    To that end, many imaging centers are working to try to put women at ease by making their mammography screening more than just a test. “We want to make sure they’re the most important person at that given moment,” explains Barbara Marshall of Battlefield Imaging.

    The facility, based in Ringgold Georgia, is designed to convey a spa-like feeling, complete with oversized furniture, flat screen TVs and a nutrition café. Even the center’s mammography machines supplied by Siemens contribute to the atmosphere, coming in different colors like pink and green, and equipped with mood lighting designed to soothe the patient. “It’s been the talk of the community,” says Marshall. “The patients are surprised when they see it, they say, this is beautiful.”

    But even as doctors are trying to encourage more of the population to get screened regularly, others are questioning whether routine annual screenings for certain women are necessary at all. [Read More…]