imported_womens-health

A Breast Cancer Controversy: To Screen or Not to Screen?

By Erica Heilman
For years, the National Cancer Institute and the American Cancer Society have recommended that women over forty receive regular mammograms so that tumors may be detected in their earlier, more treatable stages.

But these recommendations have come under the sharp scrutiny of two Danish researchers who say that the current standards are "unjustified". Their findings, published in the British medical journal the Lancet, were critical of methods used in several large screening trials in the U.K., North America and Sweden. Since then even more data has come out on both sides.

What is a woman to think?


Below, Amy Langer, Executive Director of the National Alliance of Breast Cancer Organizations, explains why many international public health and breast cancer experts have dismissed the Lancet findings, and continue to strongly recommend regular mammograms for women forty and older.

To begin, what is the National Alliance of Breast Cancer Organizations, or NABCO?
NABCO is a 16-year-old non-profit organization that is the nation's leading information and education resource about breast cancer.

Could you first describe why breast cancer screening is important?
Breast cancer is the most common form of cancer in women in the United States. Women have a one in nine chance of being diagnosed in their lifetimes, and particularly at age 50, the risk starts climbing.

Mammograms find breast cancers at small sizes, before they can even be felt by women and their doctors. The smaller the size of a breast cancer found, the easier it is to treat it successfully.

In the vast majority of cases, breast cancer detected early is treated without losing the breast, and with drug therapy that reduces the chances that breast cancer will return. When breast cancer is detected by a mammogram - when two small too be felt - the chance for successful treatment is extremely high - over 90 percent. In fact, breast cancers these days are being reported at about half the size they were as recently as a decade ago.

And what are the current breast cancer screening recommendations?
The national consensus screening recommendation -- which is an opinion of the National Cancer Institute, every major government agency, the American Cancer Society, the American Medical Association and literally dozens of other leading medical and women's health organizations -- is that women should have regular screening mammograms -- that is, before any signs or symptoms of breast cancer -- starting at age forty.

What is the controversy about?
What's going on right now is an extension of confusion that all of us had hoped was resolved, and is effectively an academic controversy over methodology. There's been some disagreement about maturing results of worldwide breast cancer screening studies.
The data that the Danish team is discussing and reanalyzing are from studies around the world that have been completed for a long time. Most of them started over thirty years ago.

All the trials were a little different in design. Methodology did differ from trial to trial somewhat, and some of the screening methods were different. They were similar enough, however, so that it was statistically appropriate to pool their results.

The data that came out of these trials was sufficiently compelling to convince all of the leading academic, government and professional organizations that regular mammograms were an appropriate and beneficial public-health recommendation for women in the United States. And women listened and started getting them.


What has happened as a result of these recommendations?
Recent studies over the last couple years indicate that up to three-quarters of age-eligible insured women are getting mammograms. And the mammograms are finding breast cancers at an earlier stage and at smaller sizes.

So which are the studies that women need to be most concerned with?
What's more important than what happened in a 1972 study is what's going on in the clinic every day. We have recent studies from major cancer centers and data in our national cancer databases that show what's known as a 'downward stage shift', or the diminishing, earlier stage at which breast cancer is being diagnosed.

In the real world, breast cancers are getting smaller, and that means not only are they easier to treat and increasingly survivable, but there are far more treatment options for women managing their disease.

But some argue that mammograms can lead to treatment of tumors that may not pose a threat to a woman's life. Is over-treatment a problem?
The way I usually answer that question is to say yes and no. When you look at the breast, you find a lot of things. Among the things that we find with screening mammography are very early, preinvasive breast cancers - most commonly ductal carcinoma in situ (DCIS). And we don't know enough about the natural history of preinvasive breast cancers to know which we can leave alone and which need to be removed...the kind of breast cancer that can travel and kill. This can put women and their doctors in the difficult position of not understanding what is best to do.

On the flip side, for breast cancers that we do know for certain are life-threatening, we're finding them earlier and treating the disease more successfully.

So the answer lies in thorough education about preinvasive cancer during the screening process?
Education is essential. But to some extent, I think that you can get lost in what's really important if you allow yourself to get bogged down with presenting a woman with every nuance of how preinvasive breast cancer could behave. Women are mostly interested in, "What's important for me? What makes sense for me? And what should I do?"
I think it is important for women to realize that if they have breast cancer, finding it early is still the best bet for successful treatment. If along the way there are some quandaries, extra biopsies, or suspicious lesions and preinvasive disease, well, that is the price that is paid. But I think it is a price worth paying.

Why must a governing body make these recommendations? Why shouldn't a woman decide alone with her doctor whether to get screened, and when?
Because we cannot be experts in everything. As women who juggle and multitask constantly, we need to rely on someone to be a resident expert. And that someone should be the most qualified body and group that has reviewed data, understands health tradeoffs, has a high degree of ethical responsibility and is made up of experts committed to patient empowerment through providing all appropriate information.

You can't find that in one body anywhere. So one of the things that I think is most convincing about screening mammography as an issue, is that an extremely diverse group of expert organizations have either recommended -- if that's their business, like the American Cancer Society or the NCI -- or have supported -- like NABCO and other nonprofits have done - ongoing screening, for women forty and older, with regular mammograms.


What do you suggest to women who are confused by this recent controversy?
I don't think that this debate needs to turn women into researchers or scientists or academic police. I think we need to rely on experts. And, of course, discuss the issue with our own doctors.

But I'm not shy, and as a well-known voice for women's astonishing, often under-represented ability to make decisions about their own health, this is not one I think should be left to flipping a coin. The data is here, it's solid. Until someone can show us something new or prove otherwise, we are all comfortable that mammography -- regular screening mammography -- makes sense.

Ms. Amy Langer is the Executive Director of the National Alliance of Breast Cancer Organizations

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