Cancer Society, in Shift, Has Concerns on Screenings
The American Cancer Society is finally recognizing that the benefits of mammography have been exaggerated, as it misses some tumors that prove deadly, while other tumors it finds that are not dangerous are treated as if they were deadly. This story is from the New York Times
Cancer Society, in Shift, Has Concerns on Screenings
By GINA KOLATA
Published: October 20, 2009The American Cancer Society, which has long been a staunch defender of most cancer screening, is now saying that the benefits of detecting many cancers, especially breast and prostate, have been overstated.
It is quietly working on a message, to put on its Web site early next year, to emphasize that screening for breast and prostate cancer and certain other cancers can come with a real risk of overtreating many small cancers while missing cancers that are deadly.
“We don’t want people to panic,” said Dr. Otis Brawley, chief medical officer of the cancer society. “But I’m admitting that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated.”
The cancer society’s decision to reconsider its message about the risks as well as potential benefits of screening was spurred in part by an analysis published Wednesday in The Journal of the American Medical Association, Dr. Brawley said.
In it, researchers report a 40 percent increase in breast cancer diagnoses and a near doubling of early stage cancers, but just a 10 percent decline in cancers that have spread beyond the breast to the lymph nodes or elsewhere in the body. With prostate cancer, the situation is similar, the researchers report.
If breast and prostate cancer screening really fulfilled their promise, the researchers note, cancers that once were found late, when they were often incurable, would now be found early, when they could be cured. A large increase in early cancers would be balanced by a commensurate decline in late-stage cancers. That is what happened with screening for colon and cervical cancers. But not with breast and prostate cancer.
Still, the researchers and others say, they do not think all screening will — or should — go away. Instead, they say that when people make a decision about being screened, they should understand what is known about the risks and benefits.
For now, those risks are not emphasized in the cancer society’s mammogram message which states that a mammogram is “one of the best things a woman can do to protect her health.”
The new analysis — by Dr. Laura Esserman, a professor of surgery and radiology at the University of California, San Francisco, and director of the Carol Frank Buck Breast Care Center there, and Dr. Ian Thompson, professor and chairman of the department of urology at The University of Texas Health Science Center, San Antonio — finds that prostate cancer screening and breast cancer screening are not so different.
Both have a problem that runs counter to everything people have been told about cancer: They are finding cancers that do not need to be found because they would never spread and kill or even be noticed if left alone. That has led to a huge increase in cancer diagnoses because, without screening, those innocuous cancers would go undetected.
At the same time, both screening tests are not making much of a dent in the number of cancers that are deadly. That may be because many lethal breast cancers grow so fast they spring up between mammograms. And the deadly prostate ones have already spread at the time of cancer screening. The dilemma for breast and prostate screening is that it is not usually clear which tumors need aggressive treatment and which can be left alone. And one reason that is not clear, some say, is that studying it has not been much of a priority.
“The issue here is, as we look at cancer medicine over the last 35 or 40 years, we have always worked to treat cancer or to find cancer early,” Dr. Brawley said. “And we never sat back and actually thought, ‘Are we treating the cancers that need to be treated?’ ”
The very idea that some cancers are not dangerous and some might actually go away on their own can be hard to swallow, researchers say.
“It is so counterintuitive that it raises debate every time it comes up and every time it has been observed,” said Dr. Barnett Kramer, associate director for disease prevention at the National Institutes of Health.
It was first raised as a theoretical possibility in the 1970s, Dr. Kramer said. Then it was documented in a rare pediatric cancer, but was dismissed as something peculiar to that cancer. Then it was discovered in common cancers as well, but it is still not always accepted or appreciated, he said.
But finding those insignificant cancers is the reason the breast and prostate cancer rates soared when screening was introduced, Dr. Kramer said. And those cancers, he said, are the reason screening has the problem called overdiagnosis — labeling innocuous tumors cancer and treating them as though they could be lethal when in fact they are not dangerous.
“Overdiagnosis is pure, unadulterated harm,” he said.
Dr. Peter Albertsen, chief and program director of the urology division at the University of Connecticut Health Center, said that had not been an easy message to get across. “Politically, it’s almost unacceptable,” Dr. Albertsen said. “If you question overdiagnosis in breast cancer, you are against women. If you question overdiagnosis in prostate cancer, you are against men.”
This concern of Dr. Albertsen is a red herring. Who says questioning overdiagnosis in breast cancer is against women? Presumably those would be his colleagues, because informed feminists already know about that problem. ABC News ran a report, which I wrote up here, and an editorial questioning the wisdom of standard mammography guidelines in 2007.
Naturally there are concerns about confusing women, discouraging more women from complying with the mammography recommendations. If women decline mammograms after becoming more informed, this is not a problem for women, though it may cut into the profits of mammographers. Their diagnostic technique has been so oversold, even the American Cancer Society now has to come clean about it. The question Dr. Brawley poses, are we treating the cancers that need to be treated, is crucial. Evidently, in far too many cases, the answer is no. If mammography finds a great many innocuous tumors that do not need to be treated, without significantly decreasing the incidence of late stage deadly tumors, it would seem inescapable that a better diagnostic method is required, because mammography is not doing what it claims to do. It is causing untold unnecessary grief, while rarely detecting deadly tumors in time to save the woman, especially before menopause.
Overdiagnosis is also a problem with less invasive diagnostic methods, such as thermography and MRI, so the issue of determining which tumors require treatment is not going to go away. It would seem answering that question, and taking steps to prevent exposure to toxins that cause breast cancer, would do far more to help women than searching for the elusive cure, or getting more women to blindly go along with the program of yearly mammograms starting at age 40. The report questioning those guidelines which I cited above does mention that
The new report suggests women may be harmed by radiation from testing, particularly the earlier and more frequently they are screened.
The more mammograms a woman has, the greater chance she has of getting a false positive.
If the controversy confuses women enough to encourage becoming better informed about the risks and limitations of mammography, that would be a vast improvement over the blind faith women are expected to have in modern medicine, which has been disastrous for women on so many fronts, from counterproductive birthing techniques to hormone replacement therapy. Medicine makes plenty of mistakes; no branch of science is immune to errors, hubris, overstating benefits, or understating risks, and medicine is certainly no exception.
November 17th, 2009 at 1:26 am
The US Preventive Services Task Force has greater misgivings than the American Cancer Society, finally recognizing that USA is not standing alone in recommending yearly mammograms starting at age 40 for any good reason. The task force, in line with the rest of the world, is now recommending mammography start at age 50. This story is from the New York Times
The backlash is predictably fierce. Some are indeed claiming the new guidelines are motivated by political considerations, since there is so much hoopla about how much health insurance reform will cost. Others cite women who developed breast cancer in their forties, which was diagnosed by mammography which may have saved their lives. What is overlooked by that argument is that there are other ways to find breast tumors and in any event, there is no way to prove that the tumor would not have been found in time anyway, or that it would have been deadly. Other concerns are cited in this article from Reuters
Are these not scare tactics by those with conflicts of interest? If these recommendations are not supported by science, why is it no other country recommends mammography until age 50 or menopause? Are they all inconsistent with current science, or were the current recommendations unsound? Mammography is a crude and dangerous diagnostic procedure. Naturally those who make money from it, or who feel their reputations may be sullied by having recommended a dangerous and counterproductive screening method, are up in arms about their overzealous overprotective methodology being challenged. Yes, some women in their forties may have been saved by mammography, but these new guidelines do not apply to women considered at high risk. If there was no risk to mammography, the overkill approach would not be a big deal. However, the risks are real, and there are better ways to find breast cancer. These other ways, such as MRI, ultrasound, thermography, self-examination do not solve the problem of treating cancers that would be better left alone, but at least they are far less likely to cause the cancer they are looking for. Bottom line, it would help women far more to eliminate the causes of breast cancer than to keep the focus on early detection. This planet has become extremely toxic, thanks to the recklessness of industry and science, and many toxins gravitate toward fatty tissues such as the breast. If industry and science were forced to clean up their act, there might not be any need for mammography, which is best used as a means to confirm a tumor, not as a primary diagnostic method.