On Monday, ABC’s Amy Robach announced that she had been diagnosed with breast cancer and would be undergoing a double mastectomy as part of her treatment.
What was remarkable about this diagnosis was that the 40-year-old reporter had received her first mammogram a month earlier during a live broadcast of “Good Morning America” to promote the annual (and controversial) Breast Cancer Awareness Month.
Robach said her doctor told her the mammogram saved her life.
“I can only hope my story will…inspire every woman who hears it to get a mammogram, to take a self exam,” she said. “No excuses. It is the difference between life and death.”
The media almost universally reported the Robach story with that theme: that the benefits from mammography screening — even for women as young as Robach — outweigh the harms.
But, of course, there’s another side to this breast cancer story, one that’s much more complicated, as several health experts and media watchers have pointed out this week.
‘Not all breast cancers are the same’
Did the mammogram save [Robach’s] life, as one doctor was quoted as saying? The answer, of course, is we don’t know. While mammography is capable of finding about 26% of cancers at a point where it makes a life-saving difference in the outcome, it also finds many lesions which would never have gone on to be life-threatening and others which will still be life-threatening in spite of early detection and rigorous screening.
The problem is not the mammogram as a detection tool, but the natural history of the disease, which brings us to the crucial point…not all breast cancers are the same. Before a treatment is prescribed or chosen, it is critical that a woman or man knows what kind of breast cancer they have of the roughly 5-7 kinds we can now recognize. There are probably many more kinds that we just don’t know about or know how to recognize yet. The behavior of the cancer is dictated not as much by when it is found as by what kind it is and how that kind usually behaves. This information informs the decisions about treatment.
‘A misleading overstatement’
Gayle Sulik, a social science researcher, author (“Pink Ribbon Blues: How Breast Cancer Culture Undermines Women’s Health”) and founder of the Breast Cancer Consortium, agrees. Here’s some of what she wrote Thursday on her “Pink Ribbon Blues” blog at the Psychology Today website:
Stories about Amy Robach’s on-air mammogram and public reveal mirror breast cancer’s false narrative that “Every cancer is curable as long as you catch it in time.” Epitomized by the phrase, “That mammogram just saved your life,” the idea that early detection via screening is the key to survival is a misleading overstatement, one that reverberates in an awareness inspired echo chamber especially during the month of October.
Professors Steven Woloshin, MD, and Lisa M. Schwartz, MD, of the Department of Veterans Affairs Medical Center and the Dartmouth Institute for Health Policy and Clinical Practice, published an essay in British Medical Journal criticizing advertisements (notably those from the wealthiest breast cancer charity in the world, Susan G. Komen [for the cure]) that play into the false narrative by exaggerating and distorting medical information to sell wholesale mammography screening. Yet, the mammogram “get screened now” mantra resounds even though Komen’s chief scientific advisor Dr. Eric Winer admitted that “We have oversold mammography to the American public.”
The body of evidence does not support universal screening; it supports individualized informed decision making based on specific benefits and harms. The 2009 recommendation from the United States Preventive Services Task Force against universal screening mammography for women aged 40 to 49 recognized the limitations of this popular diagnostic tool in reducing deaths from breast cancer. The updated systematic review of randomized, controlled trials with 10 or more years of follow-up also found evidence of harm from universal screening, as it leads to overdiagnosis and overtreatment. This admission and change in recommendations continually sets off a flurry of disagreements among doctors and professional associations alike. Yet the evidence continues to mount that universal mammography screening overpromises and underdelivers.
In particular, screening has increased the number of cases of “indolent/precancerous” tumors which, according to a working group of the National Cancer Institute, tend to be potentially clinically insignificant. Instead of finding the aggressive cancers that are the most life threatening, one in five breast cancer diagnoses fall into the stage zero/precancer category. Treating these conditions has not led to a decrease in late stage disease as would be expected if they were all early indicators of invasive cancer. The working group sees this flaw in screening as an opportunity for improvement.
“Going forward, the ability to design better screening programs will depend on the ability to better characterize the biology of the disease detected and to use disease dynamics (behavior over time) and molecular diagnostics that determine whether cancer will be aggressive or indolent to avoid overtreatment. . . . Physicians, patients, and the general public must recognize that overdiagnosis is common and occurs more frequently with screening.”
Media’s ‘unhealthy advocacy’
Minnesota-based health-news watchdog Gary Schwitzer sees an additional problem with Robach’s announcement, one that has to do with journalism ethics. Here’s part of what he wrote on his Health News Review blog this week:
I believe it is unethical for network television journalists to use their celebrity status to talk about their own health care decisions and to suggest what other people should do.
I’ve written about some journalists’ unhealthy advocacy of various screening tests for years. I thought it was wrong and I wrote about it when:
ABC reporter Bill Weir had a full-body CT scan which he said saved his life (a claim he later corrected/retracted)
NBC’s Andrea Mitchell followed her own breast cancer diagnosis and treatment by giving advice on the air to other women
NBC’s George Lewis followed his own prostate cancer diagnosis and treatment by recommending PSA testing
CBS’s Harry Smith followed colleague Katie Couric’s example from when she was at NBC and had a colonoscopy on the air, endorsing the practice while not mentioning other colon cancer screening options which many people might prefer and which the evidence supports.
NBC’s Matt Lauer & Al Roker last week had digital rectal exams on the air to promote prostate cancer screening and failed to discuss guidelines which don’t recommend such screening.
(Anyone see an NBC pattern here?)
There are countless other examples — especially on local TV news. And there are some in print. But the national television platform is still influential — and is used, in my opinion, unethically when it delivers an advocacy, opinion-based message on what should be a highly-individualized, evidence-based, shared decision-making discussion between patient and doctor.
Time to ‘tone down the hype’
None of these writers are against mammography screening, but only against the promotion of screening without, as Schwitzer notes, an evidence-based discussion that includes information about the procedure’s limitations and potential harms. And that’s where much of the media continues to come up short.
“We all need to help tone down the hype that mammograms are the be-all/end-all life-saving tool and stop fueling mass fear that a questionable mammogram is a potential death sentence,” writes Love. “The real question that we should be debating is why we are still doing so many mastectomies and why, after thirty years of breast cancer awareness-building and the availability of early detection methods, major surgery is still a frequently utilized treatment by women because the medical profession still doesn’t have better answers!”
All three commentaries can be read through the links above.