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Breast-cancer screening: Frequency hasn’t declined, but the conversation is changing

The conversation about mammograms has undergone a significant shift in recent years as women express frustration and anger about our continuous “feel-good” war on breast cancer.

Earlier this month, a study published in the journal Cancer reported that the percentage of women getting annual mammograms has not changed since 2009, the year the United States Preventive Services Task Force (USPSTF) recommended, amid huge controversy, that routine screening start at age 50 rather than age 40 and that it be done every two years rather than annually.

Using results from national surveys of almost 28,000 U.S. women, the Cancer study found that mammography-screening rates actually increased slightly from 2008 to 2011, from 51.9 percent to 53.6 percent. 

For women aged 40 to 49, the rates rose from 46.2 percent in 2008 to 47.5 percent in 2011.

“[The USPSTF] recommendations — which are recommendations from one of the most prominent national bodies out there — have not been widely adopted,” the study’s lead author, Dr. Lydia Pace of Brigham and Women’s Hospital in Boston told Huffington Post reporter Catherine Pearson. “We have not seen the decrease you would expect if these recommendations had been widely adopted.”

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It’s not clear why women have rejected the new recommendations, although, as Pearson points out, it may be because old health habits are difficult to break — for physicians as well as women. (A small, but significant, percentage of men, however, have adopted the equally controversial USPSTF’s recommendations against routine PSA screening for prostate cancer.)

A changing conversation

Yet, on a purely anecdotal basis, I’ve noticed that the conversation about mammograms and breast cancer has undergone a significant shift in recent years. Many more women are expressing frustration and anger about our continuous “feel-good” war on breast cancer.

One of those women is writer Peggy Orenstein (“Cinderella Ate My Daughter”) who published a thoughtful and thought-provoking article Sunday in the New York Times. In 1996, at the age of 35, she went for a “base line” mammogram, which revealed, she said, “an odd, bicycle-spoke-like pattern on the film — not even a lump.”

Orenstein underwent a lumpectomy and six week of radiation. “I considered myself a loud-and-proud example of the benefits of early detection,” she writes.

No longer.

“Sixteen years later, my thinking has changed,” she acknowledges in the Times article.

“As study after study revealed the limits of screening — and the dangers of overtreatment — a thought niggled at my consciousness. How much had my mammogram really mattered? Would the outcome have been the same had I bumped into the cancer on my own years later? It’s hard to argue with a good result. After all, I am alive and grateful to be here. But I’ve watched friends whose breast cancers were detected ‘early’ die anyway. I’ve sweated out what blessedly turned out to be false alarms with many others.”

A paradigm shift

One of the problems, Orenstein explains, is that women have been sold a too-simple bill of goods about breast cancer:

Even as American women embraced mammography, researchers’ understanding of breast cancer — including the role of early detection — was shifting. The disease, it has become clear, does not always behave in a uniform way. It’s not even one disease. There are at least four genetically distinct breast cancers. They may have different causes and definitely respond differently to treatment. …

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[The] early mammography trials were conducted before variations in cancer were recognized — before Herceptin, before hormonal therapy, even before the widespread use of chemotherapy. Improved treatment has offset some of the advantage of screening, though how much remains contentious. There has been about a 25 percent drop in breast-cancer death rates since 1990, and some researchers argue that treatment — not mammograms — may be chiefly responsible for that decline. They point to a study of three pairs of European countries with similar health care services and levels of risk: In each pair, mammograms were introduced in one country 10 to 15 years earlier than in the other. Yet the mortality data are virtually identical. Mammography didn’t seem to affect outcomes. In the United States, some researchers credit screening with a death-rate reduction of 15 percent — which holds steady even when screening is reduced to every other year. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and co-author of last November’s New England Journal of Medicine study of screening-induced overtreatment, estimates that only 3 to 13 percent of women whose cancer was detected by mammograms actually benefited from the test.

If Welch is right, the test helps between 4,000 and 18,000 women annually. Not an insignificant number, particularly if one of them is you, yet perhaps less than expected given the 138,000 whose cancer has been diagnosed each year through screening. Why didn’t early detection work for more of them? Mammograms, it turns out, are not so great at detecting the most lethal forms of disease — like triple negative — at a treatable phase. …

At the other end of the spectrum, mammography readily finds tumors that could be equally treatable if found later by a woman or her doctor; it also finds those that are so slow-moving they might never metastasize. As improbable as it sounds, studies have suggested that about a quarter of screening-detected cancers might have gone away on their own. For an individual woman in her 50s, then, annual mammograms may catch breast cancer, but they reduce the risk of dying of the disease over the next 10 years by only .07 percentage points — from .53 percent to .46 percent. Reductions for women in their 40s are even smaller, from .35 percent to .3 percent.

Orenstein, like many other breast cancer advocates, would like to see our emphasis — and funding — switch from breast cancer “awareness” to finding both preventions and cures for metastatic cancer:

Women are now well aware of breast cancer. So what’s next? Eradicating the disease (or at least substantially reducing its incidence and devastation) may be less a matter of raising more money than allocating it more wisely. When I asked scientists and advocates how at least some of that awareness money could be spent differently, their answers were broad and varied. Many brought up the meager funding for work on prevention. In February, for instance, a Congressional panel made up of advocates, scientists and government officials called for increasing the share of resources spent studying environmental links to breast cancer. They defined the term liberally to include behaviors like alcohol consumption, exposure to chemicals, radiation and socioeconomic disparities.

Needed: a different kind of awareness

Last summer, nine months after receiving a clear mammography result, Orenstein found a small, firm lump under the scar from her previous breast cancer surgery. “Just like that,” she writes, “I passed again through the invisible membrane that separates the healthy from the ill.”

She opted for a single-breast mastectomy and tamoxifen treatment. With this round of the disease, however, she has a different “awareness” message for women:

It has been four decades since the former first lady Betty Ford went public with her breast-cancer diagnosis, shattering the stigma of the disease. It has been three decades since the founding of Komen. Two decades since the introduction of the pink ribbon. Yet all that well-meaning awareness has ultimately made women less conscious of the facts: obscuring the limits of screening, conflating risk with disease, compromising our decisions about health care, celebrating “cancer survivors” who may have never required treating. And ultimately, it has come at the expense of those whose lives are most at risk.”

You can read Orenstein’s article on the New York Times website.