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.
Scientists at the University of California at San Francisco report that healthy diets rich in fruits and vegetables are associated with decreased risk of developing deadly pancreatic cancer. Pancreatic cancer is far from being as common as breast or lung cancer, but their analysis and treatment are particularly difficult. Find a ratification categorically that simple changes in our daily diet can provide reliable protection against pancreatic cancer, he could be one of the most practical ways to reduce the occurrence of the dreaded disease of prostate cancer.
Bravo Naomi, well said!
It would be wonderful if the American media would report the findings about mammography and overdiagnosis that were published in the BMJ over the summer. As far as I can tell it’s been pretty much ignored.
The American Cancer Society has recognized that the PSA test causes massive overdiagnosis, and they have stopped promoting it. Yet their uncritical push for screening mammography continues. How many more women must suffer unnecessarily before they accept the facts? Women are generally terribly misinformed about mammography – informed consent is not possible under these circumstances. Why so few people in the US care about this is quite beyond me.
I read mammography from 1984 to 1997. Many times, I have had to break the news to a woman that she has an abnormal mammogram and will need a biopsy. I have performed many “needle localizations” as well as “Ultrasound guided core biopsies”. I have also, on a few occasions been able to postpone/cancel a breast biopsy because the alleged “lesion” was simply not there (skin calcification, not in the same quadrant on two views, etc.) My mother is a breast cancer survivor, I have 3 daughters and my wife gets regular mammograms.
Mammography has always been a mediocre to poor test, and it is better now than it used to be. Mammography has both a very high false positive rate and a significant false negative rate. . Unfortunately, it is still the best test we have for detecting breast cancer early. (MRI may be more accurate, but will multiply costs by a factor of 10)
An atmosphere of hysteria has grown up around mammography/breast cancer, promoted by many people; some who have a financial interest and some who are just “pro-woman”, like Oprah, or politicians who wished to be perceived as such. This atmosphere of hysteria has prevented rational discussion of the costs (high) and benefits (relatively low) of mammography. It also guides physicians to do ever more to never “miss” or “undertreat” breast cancer. No wonder the false positive rate is so high – in any case where there is a doubt, physicians err on the side of doing more, not less. From a malpractice perspective, it was the most dangerous thing I did, although I did invasive procedures involving the liver, lung, kidney, etc
A whole Federal and State bureaucracy has grown up around mammography, which has completely separate and much more stringent record keeping and reporting requirements than any other disease – including lung cancer which kills more women. Our group has a whole separate mammography record keeping department devoted to making sure that women get the follow mammograms. We do this for no other disease.
Despite what some people say, there is NOT a lot of money to be made in mammography, for most who perform mammography it is a “loss leader” and is far less profitable than CT, MRI, US, etc. Reimbursements barely cover the costs, which include extensive record keeping, multiple inspections, etc., etc. For those of you who doubt me – over the years, multiple “Imaging Centers” have sprung up in my area offering CT, MRI US, etc. I am unaware of a single investor owned “Imaging Center” that offers mammography.
Several years ago after I read my last mammogram I celebrated. This October, I will not be marching, running, wearing pink or doing anything else to re-inforce the hysteria surrounding Breast Cancer and mammography. I would like to see a better test(s) and better treatment(s) for Breast Cancer, but do not think that “drinking the Kool Aid” served by the various Oprahs of this world is the best way to do it.
oops 1984 to 2007
At the risk of becoming a bore, I would like to point out another example of the kind of thinking that seems to be inherent in discussions of breast cancer.
I watched the House Committee on Energy & Commerce – Breast Cancer Legislation – Part 1 and 2 (on C-Span). A bill is being introduced that would deal with a number of issues related to breast cancer (including mandating coverage for screening mammography starting at age 40.) One part of the bill dealt with the so called “drive by mastectomy” by forbidding insurance companies from discharging patients “too early” after mastectomy.
Of course insurance companies save money if patients are discharged earlier after ANY surgery (or in fact any admission surgical or not). But now we have legislation specifically forbidding early discharge after breast surgery. Apparently a “too early” discharge after surgery to the brain, lung, colon (or for CHF or pneumonia) is OK, but NOT after mastectomy. Unfortunately, this kind of thinking seems to be only too common with respect to breast cancer.
but introducing a bill is far different than passing it. for the moment the only law I’m aware of mandates an inpatient stay in maternity cases — extra long for c-sections. try to make sense of that as America’s top health priority
I’ve long been suspicious of all the “pink ribbon” and “walk for the cure” stuff. I wondered where does all the money go?
Mostly it goes to the “cancer industry” and also cosmetics, athletic shoes and a lot of other stuff that has nothing to do with understanding causes and prevention of cancer. It’s one of the cleverest marketing schemes ever.
I resent using fear; in this case the fear of illness and death to sell products.
Happy breast cancer awareness month!
While the benefits of mammography screening alone are not ‘as advertised’, bear in mind that many breast cancer specialists, while agreeing it is not so effective, will point out that it has become an important ‘pillar’ in the rise of the multidisciplinary breast centre, which are undoubtedly important in driving up standards of care. Here’s an article I wrote for Cancer World that covers the key points (more or less).
http://www.cancerworld.org/CancerWorld/getStaticModFile.aspx?id=1933
The problem I have with the BMJ and other studies on mammogram impact is that the only outcome of interest is death. I would love to see more data on stage at diagnosis and treatment regimens undergone in women diagnosed in the screened vs non-screened groups. One might argue that the lack of a difference in death rates between the groups could be due to the fact that there is increasingly effective treatment of cancers diagnosed at a later stage. However, these treatments may be more disfiguring (ie, mastectomy vs lumpectomy), and use of chemotherapy or additional radiation. Thus, there may be a price paid for the additional years afforded by treatment. I’ve been searching for a well-done study that addresses this issue, but have not found it. If you know of one, please let me know.
Margaret, if you go to http://www.screening.dk/folder_uk.pdf, you will find references to research that documents that women who participate in mammography screening are at least 20% more likely to lose the entire breast than those who are not screened (from a Cochrane review). The idea that screening mammography results in less extensive treatment is a myth.
The pamphlet has a “references” section at the end that lists many excellent sources of information about this issue.
Dear Naomi:
I was surprised to see a link to this blog with its independent analysis of screening from the American Journal of Roentgenology Women’s Imaging Online website. (This is one of the two major U.S. radiology journals). Thank you to the editor for presenting this alternative viewpoint. As a radiologist, I have studied this issue for several years and agree that the screening “hysteria” (you can also call it brainwashing) and push for Uptake is increasing while informed decision-making and a professional push for Insight is stagnant at least in the U.S. Gigerenzer et al just published in the JNCI Sept. 2009 that only 2% of European women know the absolute risk reduction is 1 in 1000 for regular screening over 10 years. The most common response was 50 times this benefit. The performance was even worse in England. What is most disturbing about the hysteria is that over half of women think that screening prevents breast cancer (see references in my articles at biomedcentral.com or linked on pubmed).
Is it ethical for radiologists or the expert panel at the American Cancer Society (ACS) to sit by while this (egregious?) misunderstanding exists? Thankfully, consumer organizations like the National Breast Cancer Coalition (StopBreastCancer.org) are fighting what they call “pinkwashing” by trying to educate women on the myths of mammography and breast cancer. On a positive note, some radiologists are starting to acknowledge overdiagnosis. Ginny C is right to ask why the ACS ignores the problem. Besides the BMJ articles, recent work by Zahl et al in another well respected medical journal, Arch Intern Med 2008; 168:2311-2316 shows that many breast cancers might go away on their own. This throws a big wrench in earlier detection theory.
My research showed that we must find 21-27 screening cancers to save the equivalent of one life, which partially reflects overdiagnosis. (Remember this the next time a celebrity has screen-detected breast cancer.) Radiologists can do a much better explaining their support for mammography instead of deferring to the ACS or ignoring the literature. For instance, why do experts promote annual screening when there is no evidence from the screening trials that this is better than the longer intervals used in Europe? In addition, the most recent screening trial in England for women starting at age 40 found a statistically non-significant relative risk reduction of 17%.
Thanks to Legacy Flyer for his mammography service. Reading mammograms is not easy and breast radiologists are highly skilled, but I need to point out the screening professional (not including technical) reimbursement at Medicare rates is over $1000 an hour (25 mammograms times $40 with CAD). The 25 million screening mammograms a year translate into one billion dollars in radiologist revenue at Medicare reimbursement (without recalls).
Recall rates could be dramatically reduced if something like Mammography Courts were established since there is no question radiologists are pressured to favor recall (in a feedback loop from the hysteria). This creates a tremendous economic inefficiency in the optimal screening trade-off between true-positive exams and false-positive exams with excess costs and anxiety for women. U.S. recall rates are 2-3 times those in Europe. Given all the MQSA regulations, I have yet to see this proposal advocated by the radiology profession.
I hope by next year some progress occurs with informed decision-making. Woloshin et al have a new book called Know Your Chances that is a good primer on understanding the marketing and overpromotion. Thank you for your excellent analysis.
Posted by: John D. Keen, MD MBA |
The New York Times had an article about a shift on cancer testing by the American Cancer Society (Oct 20):
http://www.nytimes.com/2009/10/21/health/21cancer.html
It appears that my prayers may have been answered. Thank you Naomi and Dr. Keen for helping to bring this important issue to the fore. Cheers!
I think companies like Diagenic should get more attention.
http://www.diagenic.com/site.php?id=bc
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