Mammograms are Lousy, Women Deserve Better
Dec 13, 2011 | Leslie Kollar | Health Musings
image by: Joseph Moon
Putting special interest groups aside, don’t we owe it to ourselves to raise our voices and our pink ribbons in support of the development of even better methods and means of screening for breast cancer for the women we love?
The Canadian Task Force on Preventative Health Care released their new recommended guidelines which suggest routine screening for women not at high risk beginning at age 50 - previously age 40 - every two to three years - previously every two years - and includes screening every two to three years for women age 70 - 74 - previously no screening after age 70, as well as recommending against teaching breast self exams (BSE).
The language of these recommendations closely reflects those submitted in 2009 in the United States by the US Preventative Services Task Force which further suggested that women not at high risk under the age of 50 consult with their physicians regarding screening mammography. It should be noted however, that although these recommendations came out in 2009, the American Cancer Society still suggests annual mammogram screening beginning at age 40 along with breast self exams (BSE).
According to Dr. Cornelia Baines, professor emeriti, Dalla Lana School of Public Health at the University of Toronto, "Women are afraid of breast cancer and have faith in mammography. Doctors fear litigation if they fail to recommend screening for a woman who subsequently develops breast cancer. And even when doctors are informed about expert guidelines, many tend to ignore them. Politicians, especially in the U.S. are loathe to provoke the ladies with pink ribbons. Last but not least are very real but usually ignored conflicts of interest."
Almost everyone you know has been touched in some way or another by breast cancer, a friend, relative or acquaintance having fought the battle and won, or succumbed to this terrible disease. For years we have heard the mantra of the cancer institutions "mammograms save lives, every woman should have an annual mammogram . . ." Runs, walks, campaigns awash in pink, shoes, shirts, hats, ribbons - pink symbols of the battle against breast cancer.
But in that battle mammography is clearly not the perfect weapon of choice. Here's why:
False negatives are mammograms that appear normal but breast cancer is present. Screening mammograms may miss as much as 20% of breast cancers present at the time of screening. The National Cancer Institute (NCI) puts false negatives of screening mammograms at 40% for women aged 40 - 49. One reason for this is that women under the age of 50 have more dense breasts leading to more difficult accurate detection of the presence of cancer. And, the National Institute of Health (NIH) admits that mammograms miss 10% of malignant tumors in women aged 50 plus, hardly an accurate test. False negatives can lead to delays in treatment and a false sense of security.
False positives are mammograms that radiologists interpret as abnormal but no cancer is actually present. False positives create tremendous anxiety in the patient and lead to further testing in the form of diagnostic mammograms (more radiation exposure), ultrasound, needle biopsy and even surgical biopsy. These treatments are time consuming, can be physically uncomfortable and quite costly.
A mammogram may identify ductal carcinoma in situ (DCIS) - that needs treatment, as well as some DCIS that will not need treatment or will never threaten a woman's life - overdiagnosis. Doctors cannot distinguish between cases of DCIS that do and do not need treatment so all are treated - overtreatment.
Mammograms expose women to radiation, which if done annually over the course of times leads to enough exposure to increase the incidence of breast cancer due to radiation - the degree to which that incidence increases is a subject of debate. A Dutch study of 8,500 women exposed to radiation from mammograms and chest x rays before the age of 20 or those who had 5 or more exposures were 2.5 times more likely to develop breast cancer. According to researchers, "Findings suggest that low dose radiation may increase the risk of breast cancer in young women at high risk."
Although proponents claim that "mammograms save lives" the question is do they?
In 2009, the Nordic Cochrane Centre, an independent research group that conducts extensive and thorough reviews of the medical literature, assessed the potential benefits and harms of mammography. They concluded that for every 2000 women that are screened regularly for ten years, one will have her life prolonged. Ten healthy women will be unnecessarily treated for breast cancer, either by having a lumpectomy, mastectomy, chemotherapy, or radiotherapy. Also, 200 healthy women will experience a false alarm, leading to substantial psychological and emotional strain. In their analysis, the Cochrane group stated that it is "not clear whether screening does more good than harm."
Mammography is far from the perfect test - but it is the best we have - so what now?
The issue is not the newly (if you are in Canada) published guidelines as they relate to mammograms, the issue should be looking for alternative, more effective, ways of diagnosing breast cancer with more accuracy and less risk to the patient. Instead of sitting back and accepting that the mammogram is the only way (especially if you are a radiologist, hospital, radiology center with a financial investment in current mammography equipment) perhaps some of the fundraising efforts that go on all around the country and world for that matter should funnel into research for alternatives.
Are there alternatives?
There are several that are either currently being used, or are being developed - some better than others. Unfortunately, at this juncture, none appear to be better than mammography.
A thermograph is a picture of the heat (and cold) levels in your body. Since cancer has a very high metabolism, it is slightly hotter than the normal tissues surrounding it. State-of-the-art breast thermography uses ultra-sensitive infrared cameras and sophisticated computers to detect, analyze, and produce high-resolution diagnostic images of these temperature and vascular changes without the use of radiation. Breast thermography will detect abnormalities which may not always be cancerous and there is some debate as to the accuracy of thermography.
In 2010 the University of California Los Angeles released their findings in a pilot study using saliva testing as an indicator in the presence of breast cancer. "In summary, we conclude that saliva is a novel avenue for tumor marker research in breast cancer and deserves further study. Saliva can be obtained non-invasively, sparing the patient unpleasant needles from blood drawing procedures. We do not expect a fluid-based tumor marker test to replace the standard screening physical exam and mammogram. However, we can envision at least one possible scenario where a new salivary test may potentially enhance our ability to detect breast cancer early, when it is still curable with existing treatment methods. The salivary avenue of research may prove to be just as useful as studies searching for biomarkers in the blood."
Although not currently used as a predictor, these preliminary studies show promise as a diagnostic breast cancer tool.
Blood tests are currently available to determine the presence of the BRCA1 and BRCA2 genes which are human genes that belong to a class of genes known as tumor suppressors. Mutation of these genes has been linked to hereditary breast and ovarian cancer. A woman's risk of developing breast and/or ovarian cancer is greatly increased if she inherits a harmful BRCA1 or BRCA2 mutation. The company DiaGenic has a blood test called BCtect which claims to detect gene changes which are indicators of early stage breast cancer in both pre and post menopausal women.
Digital mammography is currently in use and does expose women to radiation however the proponents claim that the amount of radiation is less than that of a regular mammogram. The digital mammogram is still an x-ray of sorts which is digitally enhanced to show finer detail.
Ultrasound is currently used after the initial identification of something suspicious on a mammogram, it is not used on its own as a screening test for breast cancer. If an abnormality is seen on mammography or felt by physical exam, ultrasound is the best way to find out if the abnormality is solid (such as a benign fibroadenoma or cancer) or fluid-filled (such as a benign cyst). It cannot determine whether a solid lump is cancerous, nor can it detect calcifications. It is however, non invasive and without the pain associated with biopsy. Ultrasound may also be recommended for younger women with more dense breasts to evaluate a suspicious finding by a physician's physical exam.
Other options include Breast Tomosynthesis - 3d views, MBI Molecular Breast Imaging, AMAS Anti Malignan Anitbody Serum tests, NMP66 blood test, and CTLM Computed Tomography Laser Mammography using optical imaging without radiation.
The Bottom Line
Although mammography is the issue here, we should remember that there are other factors that influence the risk of breast cancer, some we cannot change such as heredity, family history, the presence of certain genetic factors, but there are those we can such as lifestyle choices, diet and exercise. "Every woman should see her doctor to have a breast cancer risk assessment, as the new guidelines apply only to women facing average risk. Women with a family history of breast cancer, or other important risk factors, may need earlier, more frequent or additional screening. And every woman should be "breast aware," and report any change in the appearance or feel of her breasts to her doctor." Ellen Warner is an oncologist at Sunnybrook Health Sciences Centre and a professor of medicine at the University of Toronto.
I am not suggesting that women stop having mammograms. On the contrary, mammograms are an important part of our health screening, if and only if it is because they are the best that we have rightnow. But special interest groups aside, don't we owe it to ourselves to raise our voices and our pink ribbons in support of the development of even better methods and means of screening the women we love for breast cancer?
Leslie Kollar has over 20 years of experience in the health care field in both the U.S. and Canada. She has worked professionally in medical offices and hospital administration, using her BA in Communications/Public Relations and MBA in Marketing. She has also seen the other side of the health care coin as a 16 year cancer survivor. As a survivor she is passionate that each and every person is and should be responsible for their own health - and with this passion she hopes to inspire, inform and educate through HealthWorldNet. Leslie can be reached at LK Communications [email protected]
Your Path to Meaningful Connections in the World of Health and Medicine
Connect, Collaborate, and Engage!
Coming Soon - Stitches, the innovative chat app from the creators of HWN. Join meaningful conversations on health and medical topics. Share text, images, and videos seamlessly. Connect directly within HWN's topic pages and articles.