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.
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.