No sooner had I posted my Tuesday blog on the role of tamoxifen in the adjuvant treatment of women with breast cancer than the New England Journal of Medicine comes out with an article detailing the benefits of screening and adjuvant treatment. In my opinion, this is a very important if not momentous article summarizing the real advances in the treatment of breast cancer that have been made over the past 30 years.
Let’s try to put this in perspective (it may be worthwhile to go back to my posting of 10/12/05, where I talk about the real measure of progress in the treatment of breast cancer).
In the past, I used to give talks to doctors and occasionally patient groups about the treatment of breast cancer. What confounded me and my audience during those talks was the fact that despite our best efforts to provide mammography and adjuvant treatment to women with breast cancer, we didn’t see any decrease in the rate of death from the disease going back, many, many years. The death rate remained flat on the graph, meaning no improvement despite all of the advances we thought we were making.
Couple that observation with the stinging criticism some experts and the American Cancer Society (along with other reputable groups with an interest in breast cancer) were subjected to claiming that there was no real change in mortality as a result of breast cancer early detection screening with mammograms.
Well respected experts said that we were seeing what is called lead time bias, not real changes in the disease process when we claimed that mammograms were saving lives. In simpler terms, we could diagnose a cancer early, but in fact the end result remained the same: women still died from the disease at the same time they would have otherwise. Basically, the critics claimed, we didn’t change the date of death despite all of our treatments and “early” diagnoses.
There were others (and they remain) who were very vocal critics of the whole concept of mammography based on their various analyses of the clinical trials that suggested mammograms reduced deaths from breast cancer. The studies weren’t well done, they claimed. There were errors in the interpretation of the studies. We had been duped by our own enthusiasm, according to the critics.
But something started to change around the early 1990’s. Despite a rising incidence of breast cancer, the rate of death did indeed start to decline. And that has continued to the present day. The American Cancer Society has predicted a continuing decline in the rate of death from breast cancer, so long as women continue to get mammograms and have access to appropriate adjuvant therapy.
The arguments began to shift. More people were convinced that mammography was beneficial in reducing deaths from breast cancer, while others said it was the benefits of new adjuvant treatment programs with hormone agents and chemotherapy. It was interesting to hear these discussions (disputes, if you would). From my point of view, it made no difference which was responsible. What was important was that change was happening, and the cure rates for women detected with localized breast cancer were climbing to levels that never would have been dreamed of 20 or 30 years ago. Women were being treated with smaller cancers, and fewer of them had lymph node involvement at the time of diagnosis. These are the factors that have a real impact on survival from this disease.
Now we have an elegant research paper that tries to estimate the impact of mammography and adjuvant treatment on the rates of death from breast cancer. They start from point zero, which was the case 30 years ago when we didn’t have widespread available mammography, and adjuvant chemotherapy was a research interest only (I recall participating in some of the early group trials of adjuvant therapy in breast cancer. I have often wondered what happened to the women we treated in those early programs, and whether or not they were helped. They were certainly brave pioneers in uncharted waters at the time).
The paper uses some very fancy statistical models, and a novel level of cooperation between different groups to develop their models. But all agreed that the impact of screening and treatment had been significant and that the benefit of mammograms and adjuvant treatment reduced the rate of death from breast cancer from about 25 to 38% from 1975 to 2000.
To my colleagues who have been at the forefront of this revolution, our admiration. To organizations such as the American Cancer Society, the National Cancer Institute, and many others who funded the research and promoted the benefits, our thanks. And to the women who participated in the trials that made this happen, we couldn’t have done it without your help and understanding.
There is, once again, a core message that cannot be overstated: If you are a woman age 40 or over, and are at average risk (without a family history or some other indication of increased risk for breast cancer), you need to get a mammogram every 12 months.
None of this research, and none of these advances mean a thing if you don’t do everything you need to do to find the cancer early. And the best way we know of doing that is a regular, annual mammogram.
If you are a woman, there are no longer any excuses to not take care of yourself.