A Researcher Says The Best Strategy To Impact Breast Cancer Is To Stop Mammography, And No One Cares?

The announcement today from Canada that women should severely curtail their use of screening mammograms for the early detection of breast cancer and discontinue regular clinical examinations and self-breast examinations was interesting in and of its own. But the editorial that accompanied that announcement-from a long-time avowed skeptic of the benefits of screening mammograms-took the debate to a new level. Whether that level was higher or lower is a matter of personal interpretation, but in the editorial was the statement that abandoning breast cancer screening is the most effective way we have to reduce the risks of breast cancer. The statement, highlighted in an accompanying press release (http://www.eurekalert.org/pub_releases/2011-11/cmaj-nbc111611.php) was, in short a stunner.


What is even more amazing is that there hasn’t been much reaction to that statement. And keep in mind that just two days earlier, the medical journal The Lancet published a letter from an international  group of experts in breast cancer screening who raised the issue of an organized anti-mammography campaign orchestrated in part by the head of the Nordic Cochrane Centre, headed by none other than the physician who wrote the editorial. But from where I sit-a place that is usually the epicenter of these discussions-there has in fact been very little reaction. No media, no frantic calls, no running to man the barricades. Essentially, nothing.


I find that hard to understand for a story with this degree of impact. Maybe we are all just worn out from the screening debates, after several years of indecision about the benefits of mammograms, the frequency of pap tests, and the big debate recently about whether or not prostate cancer screening really saves lives.


For me and others I know, there is increasing concern that the value of screening for the prevention and early detection of cancer will get lost in the morass of conflicting comments, and that we might be at risk of turning off the public to the benefits of screening for cancer, and perhaps lives will be lost in the process. And that would be shameful. [more]


When I started medical school in the late 1960’s, we were told by our professors about the number of cancers that were found on autopsy that were not detected during life and were “incidental” to the death of the patient. Prostate cancer was particularly common as men aged. Thyroid cancers were also common as “incidentalomas”, and there were breast cancers as well as other cancers that never came to a diagnosis during a patient’s life.


From a cancer point of view, we had the “early warning signs of cancer,” which unfortunately were the “late signs of cancer.” Blood in the stool, a cough that wouldn’t go away, and a bleeding lesion on the skin were on the list.


So, it wasn’t much of a leap for all of us to truly believe that if we could find a cancer before we could feel the cancer, we would be much better off.


As time went on, that is exactly what happened. Research in the 1960’s showed that an x-ray of the breast could detect a cancer before we could feel it. Before that, a woman would present to the doctor after she felt a lump or perhaps the doctor would feel the lump on a physical examination. We would tell the woman we “caught the cancer early,” usually after she went to surgery and woke up without her breast. More often than not, the lesion was fairly large and had spread to the lymph nodes. “We got it all” was a common refrain, but in fact we learned that frequently we did not. The cancer had spread, and disability and death was the outcome for too many women.


Fast forward to today, and where do we stand?


The mammography debates go on and on: does mammography really make a difference, or is it the improvements in breast awareness and self-detection and treatment that account for the significant reductions in deaths from breast cancer that we have seen since the early 1990’s? When do you start getting a mammogram? At age 40 as the American Cancer Society recommends, or at age 50 as recommended by the USPSTF? Do you get a mammogram every year, every other year, or every 3 years?


So now back to the history lesson:


Before we had screening, we had nothing. We would sit and scratch our heads, telling ourselves that if we could find cancer before it found our patients, wouldn’t that be terrific? It was axiomatic that if we found a cancer early, there was no question we would help our patients.


Well, our prayers were answered. We developed and improved screening mammography. We continue to move the threshold of detection to smaller and smaller cancers, and I have no doubt that we will continue to move that threshold even lower still.


But what we didn’t consider was that in some cases treatments would improve, saving lives that could not have been saved before. We developed adjuvant treatments for breast cancer that reduced deaths from that disease, especially for women who had lymph node involvement–which we learned was in fact not a step along the way for the spread of breast cancer but in fact a signal that cancer cells had spread elsewhere in the body.


We also relearned some biologic truths: just because we found a cancer, that didn’t mean that that particular cancer was destined to cause harm to a person during their lifetime. We are now able to routinely find cancers that our professors were previously only able to see on autopsy.


So where does that leave us today?


First, our science moves on. We have better detection methods, and we also have better treatment methods. We have some glimmers that we can define which cancers may be aggressive and which may be more indolent (especially for breast cancer and unfortunately not to clearly for prostate cancer). We have drugs that have dramatically reduced the risk of death from some forms of breast cancer, particularly HER-2 positive breast cancers where research shows that treated early deaths decline about 50%.


Forty-five years ago we sat around and wondered how we could find cancer early and save lives. Today we sit around and argue about whether finding cancer early makes a difference.


So who is right?The people who believe that they have never seen a screening test they didn’t like? Or the people who say screening for certain cancers at best has been oversold and at worst doesn’t work?


Actually there is a little truth for everyone.


We now find cancers we never dreamed of finding back in 1970. And our research suggests that not every one of those cancers is a killer. Our treatments for certain cancers–especially adjuvant therapies for breast and colorectal cancer–are saving lives. And, yes, we are overtreating people who would never have been bothered by their cancer.


The problem is we frequently can’t tell what made a difference in a particular person’s life once they have been diagnosed with a cancer detected through screening. We can’t tell a woman with breast cancer whether or not her particular cancer is a killer or just an incidental event in her life that will have no impact if left alone.


What does the American Cancer Society believe?


We still believe that mammography saves lives, as does the United States Preventive Services Task Force, incidentally. We also believe that mammography allows treatments that are less disfiguring and equally effective to what women used to go through, which was mutilating.


However, we also believe that mammography is not the only thing that saves lives. Treatments have improved, and lives have been saved. Women are more aware, although I am not certain that that awareness leads to finding smaller cancers in the breast.


Our science has moved on, and sometimes that creates as much confusion as it does clarity.


The biggest lessons for patients is the need to understand the benefits and risks of the screening tests we are offered. We really need to become educated and to be our own advocates. We need to understand–and our health professionals need to help us understand–the nuances of the tests we are offered.


Many of us would like to live in an “all or nothing” world. Either screening works or it doesn’t. Uncertainties are viewed with suspicion.


But real life is not so convenient. And it’s up to us to understand that dogma doesn’t get us where we need to be, especially when it comes to our health and in particular regarding the early detection and prevention of cancer.


And then we end up with the editorial published today suggesting that no screening for breast cancer is the best screening. And I say that such a position may not take us back to the 1960’s, but not far from that. We will have more women having more mastectomies because the cancers are larger. And more women will have chest wall invasion, and more women will have lymph node involvement and our use of radiation and post-operative adjuvant chemotherapy will not get us back to baseline. Not to mention that the decline in breast cancer death rates in the United States that we have seen year over year since the early 1990’s would likely stop at some point over the next 10 years.


I am not a Luddite. At least I hope I am not. But this is one journey I do not want to take back to the future- -for my wife, my family, my friends, my colleagues or anyone else for that matter. It is a future I and others have seen, and we don’t want to or need to revisit that past. It was awful then and it would be awful now.


Right now I will admit to feeling very worn down by the constant barrage of anti-screening statements that I have seen. But saying that no screening is the answer to breast cancer is a new level I never thought we would reach. And to not see a peep of criticism raised is perhaps more disconcerting than the statement itself. Allowing such thoughts to go unchallenged is not acceptable. It demeans the other side of the argument, and suggests in fact there is no other side.


So we will continue to wander in in the morass of conflicting recommendations enhanced by illogical rhetoric. Instead of having rational discussions of the benefits and risks of cancer screening, we will have the populace turning off to breast cancer early detection entirely. And over a decade from now, in my personal opinion, we will see the impact of our choices. And I do not believe it will be a pretty picture.


The sad part is that by ignoring all of the science, we will have only ourselves to blame.


J. Leonard Lichtenfeld's Biography

Dr. Len

J. Leonard Lichtenfeld, MD, MACP: Dr. Lichtenfeld currently serves as Deputy Chief Medical Officer for the American Cancer Society in the Society's Office of the Chief Medical Officer located at the Society's Corporate Center in Atlanta. Dr. Lichtenfeld joined the Society in 2001 as a medical editor, and in 2002 assumed responsibility for managing the Society's then newly created Cancer Control Science Department which included the prevention and early detection of cancer, emerging cancer science and trends, health equity, quality of life for cancer patients, the science of cancer communications and the role of nutrition and physical activity in cancer prevention and cancer care.  In 2014, Dr. Lichtenfeld assumed his current role in the Office of the Chief Medical Officer where he provides extensive support to a number of Society colleagues and activities. As a result of his over four decades of experience in cancer care, Dr. Lichtenfeld is frequently quoted in the print and electronic media regarding the Society's positions on a number of important issues related to cancer. He has testified regularly in legislative and regulatory hearings, and participated on numerous panels regarding cancer care, research, advocacy and related topics. He has served on a number of advisory committees and boards for organizations that collaborate with the Society to reduce the burden of cancer nationally and worldwide. He is well known for his blog (www.cancer.org/drlen) which first appeared in 2005 and which continues to address many topics related to cancer research and treatment. A board certified medical oncologist and internist who was a practicing physician for over 19 years, Dr. Lichtenfeld has long been engaged in health care policy on a local, state, and national level.  He is active in several state and national medical organizations and has a long-standing interest in professional legislative and regulatory issues related to health care including physician payment, medical care delivery systems, and health information technology. Dr. Lichtenfeld is a graduate of the University of Pennsylvania and Hahnemann Medical College (now Drexel University College of Medicine) in Philadelphia.  His postgraduate training was at Temple University Hospital in Philadelphia, Johns Hopkins University School of Medicine and the National Cancer Institute in Baltimore. He is a member of Alpha Omega Alpha, the national honor medical society.  Dr. Lichtenfeld has received several awards in recognition of his efforts on behalf of his colleagues and his professional activities.  He has been designated a Master of the American College of Physicians in acknowledgement of his contributions to internal medicine.  Dr. Lichtenfeld is married, and resides in Atlanta and Thomasville, Georgia.

6 thoughts on “A Researcher Says The Best Strategy To Impact Breast Cancer Is To Stop Mammography, And No One Cares?

  1. Len,
    I share your concerns. My impression is that the media has accepted and highlighted studies, mainly old and without due criticism (non-political, I mean about the science of the meta-analyses). Meanwhile most newspapers have ignored, near-systematically, papers that show a benefit in younger woman. I worry that in a few years we’ll see an upsurge of Stage III and IV cases. Very sad, because most (not all) of those late-stage (and presently incurable) cases could be prevented.

  2. Donald A. Berry, chairman of the department of biostatistics at M.D. Anderson Cancer Center feels that it’s possible that we all have cells that are cancerous and that grow a bit before being dumped by the body. Screening tests may pick up minute tumors that would not progress and might even go away if left alone (pseudodisease).

    But since it is not known for sure whether they will develop into fatal cancers, doctors tend to treat them with the same methods that they use to treat clearly invasive cancers. Screening is finding cancers that did not need to be found. So maybe cancer is not always the right word for them.

    This was brought out in an essay by New York Times’ Gina Kolata. Some experts say the word "cancer" is used for far too many conditions that are very different in their prognoses. Take stage 0 breast cancer.

    Stage 0 was almost never detected before the advent of mammography screening. With widespread screening, this particular diagnosis now accounts for about 20% of all breast cancers. That is, if it is actually is cancer. If it is confined to a milk duct, has not spread into the rest of the breast, and may never spread if left alone, it may even go away.

    It also could also break free and enter the breast tissue. But for now, it is hard to know in many cases whether it makes any difference to treat D.C.I.S. right away or to wait to see if it spreads, treating it then.

    Two years ago, an expert panel at the National Institutes of Health said the condition should be renamed. Get rid of the word carcinoma, the panel said. A carcinoma is invasive; D.C.I.S. has not invaded the breast. If those cells do invade, they are no longer D.C.I.S. Then they are cancer. So call the condition something else, perhaps “high-grade dysplasia.”

    The very existence of spontaneous remissions represents a threat to some in the cancer industry. But such anomalies can pave the way to a better understanding of the causes of cancer which can then lead to rational therapies.

    Spontaneous remissions represent an important clue as to how the body can defend itself against cancer. Researchers should think "outside the box" at this important phenomenon rather than see it as a threat to their conventional thinking and appreciate the insight it may provide to rational approaches to cancer diagnosis and its treatment.

  3. Dr. Lichtenfeld, I strongly suspect the reasons that the reactions to this editorial haven’t been there is because no one is taking this guy seriously. I certainly didn’t. It’s not like he did some big study or even cites the science in a serious way. I’s just one man’s backward opinion that a journal published during the furies of the legitimate debate, probably in part to highlight in everyone’s mind just what you say: we don’t really want to go back to the bad old days.

  4. Dr. Len, have you ever considered that the lack of reaction to the editorial that accompanied the recommendation from the Canadian equivalent of the US Preventative Services Task Force provoked very little reaction because it’s correct? It is correct because screening mammography does not prevent deaths. It finds "too much" cancer. Screening mammography finds abnormal cells that look like cancer, but don’t act like cancer. They would never grow, or spread and may disappear by themselves. But the unfortunate woman finds these meaningless cell changes because of screening mammo is then put through the cancer mill for nothing. And the cancer mill means mutilation, radiation (which can damage the heart and lungs), chemotherapy and takin drugs that eliminate estrogen from the body.

    And it’s disingenuous to say that screening mammo results in fewer mastectomies. You know very well that what was pointed out in the editorial that accompanied the recommendation was correct. Screened women are far more likely to lose a breast than unscreened women because of overdiagnosis.

    It will be a great day when the ACS admits that it was wrong about screening mammo. And I rejoice because that day is coming. Not because I like pointing out that people are wrong, but because I don’t want women to suffer from being treated for "cancers" that are actually meaningless.

  5. I had a Mammogram every year and in 2009 I was diagnosed with not 1 but 2 kinds of breast cancer. One was ductal and the other lobular, Her 2+ and stage 2. I had a double masectomy and chemotherapy. Had it not been for my regular mammogram I would not be here today to type this.

    So I believe firmly that screening mammograms do save lives ! And I believe that every woman deserves to have health coverage for this.

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