October is National Breast Cancer Awareness Month and the sea of pink has reached tidal-wave proportions. Every conceivable product from yogurt to running shoes to breakfast cereal now sports the ubiquitous pink ribbon. This month some NFL players will wear pink cleats, still more will don helmets festooned with pink ribbons, and legions of supporters are participating in walks, runs and bike rides to raise money for breast cancer causes. The collective spirit has been awakened; the American public wants progress on breast cancer!
But besides being a great marketing tool for selling “things,” what, ultimately, is the purpose of National Breast Cancer Awareness Month? The concept was introduced in 1985 by AstraZeneca, the giant international pharmaceutical company that makes the breast cancer drugs tamoxifen and Arimidex. The company’s aim was to promote regular mammograms as the most effective weapon in fighting breast cancer. It has since enlisted the support of such venerable groups as the American Cancer Society, the American College of Radiology, the National Cancer Institute and the Center for Disease Control, among others in this campaign.
This mission to promote mammography—helped by a massive media onslaught that features the likes of Rachael Ray and Dr. Phil—gets more ambitious every year. And the calls for women, from age 40 until they can no longer hobble to an imaging center, to get yearly screenings get more urgent as well.
Here is the American Cancer Society’s current clarion call for screening:
“Current evidence supporting mammograms is even stronger than in the past. Recent evidence has confirmed that mammograms offer substantial benefit for women starting in their 40s. Women can feel confident about the benefits associated with regular mammograms for finding cancer early.”
Wait a minute. Is this really true? In April, I wrote in HealthBeat that researchers at the Nordic Cochrane Centre in Denmark and elsewhere had raised serious questions about the benefits of mammography, especially in women under 50 and over 70. The researchers found that:
“For every 2,000 women [age 50-69] invited for screening throughout 10 years, one will have her life prolonged. In addition, 10 healthy women who would not have been diagnosed if there had not been screening, will be diagnosed as breast cancer patients and will be treated unnecessarily. It is thus not clear whether screening does more good than harm.”
In July, researchers from this same center published another study in the British Medical Journal that attempted to determine the level of “over-diagnosis” (the detection of cancers that will not cause death or symptoms) that can be attributed to wide-scale screening mammography programs. The researchers studied programs in the United Kingdom, Canada, Australia, Sweden, and Norway. Their findings: one in three breast cancers were “over-diagnosed” in publicly organized mammography screening programs.
What this means is that one out of three cancer diagnoses turned out to be lesions that either went away on their own or otherwise never progressed. In some cases, patients would have died of something else before their symptoms progressed.
Meanwhile, the women who received these diagnoses likely went on to have surgery to remove the lesion or the entire breast, radiation and chemotherapy. This seems a substantial cost—both in terms of a woman’s psychological and physical health and in terms of health care dollars—for questionable gains.
In February, two dozen researchers, physicians and patient advocates signed a letter published in the Times of London, imploring the NHS to rewrite its information pamphlet to include the risks of over-diagnosis and over-treatment that women face with mammography. The model is a pamphlet written by Peter C. Gotzsche, the director of the Nordic Cochrane Center and other professionals that also appears in the British Medical Journal.
In this country, the breast cancer establishment has chosen not to integrate these findings into their literature or their recommendations. Their argument is that in the absence of any prevention strategies, although early detection doesn’t prevent or cure disease, it is still the best weapon women have in the battle against breast cancer. That may be so, but why not give women—and providers—enough information to make informed choices about mammography? Why continue to push yearly mammograms for all women over 40 (even those in their 70s and 80s) without also giving them up-to-date information about the risks associated with the procedure?
H. Gilbert Welch, professor of medicine at Dartmouth Institute for Health Policy and Clinical Research, writing in an editorial in the British Medical Journal looks at the “credits” and “debits” a 50-year-old woman considering yearly mammography should consider: (figures are per 1000 women)
–1 in 1,000 women annually screened for 10 years will avoid dying from breast cancer.
–2 to 10 women will be over-diagnosed and treated needlessly
–10 to 15 women will be told they have breast cancer earlier than they would otherwise have been told, but this will not affect their prognosis.
–100 to 500 women will have at least one "false alarm" (about half of these women will undergo a biopsy)
Welch adds, “Mammography is one of medicine’s ‘close calls’—a delicate balance between benefits and harms—where different people in the same situation might reasonably make different choices. Mammography undoubtedly helps some women but hurts others. No right answer exists, instead it is a personal choice.”
We all know there is enormous profit in diagnosing more breast cancer—even at the very earliest stages these lesions are currently treated with the full armament of chemotherapy, surgery and radiation. There is also profit in developing new drugs and imaging technologies—like digital mammography—that are more sensitive but also more likely to find pseudodisease. And yes, AstraZeneca does have the final say in what the National Breast Cancer Awareness Month campaign promotes.
In her blog, Breast Cancer Advocate, Laura Nikolaides notes that 40,000 women die of breast cancer each year—despite the push for yearly mammograms. Many of them were diagnosed with the fast-growing, aggressive tumors that are not found with regular screening and are most common in younger women.
“The truth is that mammography and early detection are not the cures for breast cancer that everybody thought they would be, but we can’t seem to get off this train. Pink marketing and promotion of early detection have taken on a life of their own, way out of proportion to the actual benefit. What’s the harm? The harm is that we’ve lost our focus for finding the real answers. We continue to fail those 40,000 women every year.”
Next October, let’s get off the mammography train. Let’s think about devoting the considerable resources of National Breast Cancer Awareness Month to promoting more research on preventing breast cancer, on finding root causes of the disease—including environmental factors that might contribute to a rise in breast cancer rates, and improving access to services for poor women struggling with cancer. Finally, with the clear problems associated with mammography, let’s direct resources toward finding new technologies that can differentiate between fast-growing, aggressive tumors (the kind often not detected by routine screening) and those that will ultimately prove harmless. Let's stop pretending that mammography prevents or cures cancer.