Breast cancer screening has lead to an over-diagnosis of breast cancer.
Ramona Bates talks about a recent study in the BMJ, showing that there was a “52% over diagnosis of breast cancer in a populations of women who are offered organized mammography screening,” amounting to, “one in three breast cancers being over diagnosed.”
When it comes to cancer screening, it’s hard to accept the consequences of over-diagnosis. But that risk is real. As I recently wrote, “Mammograms detect a number of slow-growing tumors that will never be harmful. But because doctors cannot be sure of which cancers are dangerous, every woman with a suspicious finding is subjected to a biopsy or breast surgery. For every life saved from breast cancer, 10 more lives will be affected by the ensuing procedures.”
Dr. Bates further comments, “Each ‘unnecessary’ surgery for one of the over-diagnosed cancers puts the patient at risk for complications. Not to mention the increased cost to the healthcare system of each country.”
The answer is that we need better screening tests. Something more specific than mammography. And also, an understanding by patients that there are consequences to consider when undergoing cancer screening.
Update:
Orac over at Respectful Insolence also provides his typically thorough take on the issue.
Related posts:
- Is the test that finds the most cancers the best?
- Breast cancer screening: Orac’s take
- Is clinical breast examination, added to mammography, worthwhile?
- "The great majority of women in the United States should not be getting MRI scans for breast cancer screening"
- Will patients accept the new, evidence-based, breast cancer screening guidelines?
- "The best test isn’t necessarily the one that finds the most cancer"
- A 10-year old girl with breast cancer, how much media coverage should she receive?
{ 26 comments }
What’s the difference between this situation and the issue of prostate cancer screening?
Cancer is a scary word. But breast cancer is not a death sentence and every day there are more breast cancer survivors due to advances in treatments and drug therapy
As a breast cancer survivor diagnosed at age 38 I have to say that there is not a woman out there who doesn’t know that “there are consequences to consider when undergoing cancer screening.” But they also know the consequences of not undergoing screening are too often death.
Great post: my thoughts exactly. I also understand the comments that you have been getting. I am a breast cancer surgeon, in practice for over 15 years. Women don’t want breast cancer; but if they have it, no matter how it is discovered, they want it GONE.
Yes, let’s work to get better, more specific, screening for breast cancer. But, in the meantime, let’s work as hard as possible to discover the CAUSES of breast cancer and use the knowledge we NOW HAVE to prevent it.
Dr. Kathleen T. Ruddy
Founder and President
Breast Health & Healing
breasthealthandhealing.org
I don’t get it. The terminology used here confuses me. Are we trying to say that “cancer” is overdiagnosed? That doesn’t make any sense. Is it rather that we are identifying too many suspicious lesions that ultimately end up being benign? Cancer is cancer. There’s no “overtreating” of cancer. It’s a surgical disease. I certainly wouldnt want my wife/mother/sister’s DCIS being managed by “watchful waiting”.
I’m surprised to hear that last comment coming from a physician. Overdiagnosis is a pretty simply concept and it’s not the same as overtreatment (obviously). It refers to the diagnosis of cancer that will ultimately cause no morbidity or mortality. Sure, if your wife is diagnosed with DCIS, she’s getting a lumpectomy. Without screening, though, she may never have been diagnosed with cancer in the first place. Hence, overdiagnosis. You should read Respectful Insolence’s blog to get up to speed on the topic. Cancer is cancer? Are you serious?
Anonymous Genius-
I appreciate your condescending imperative to run to Orac’s blog. I did read it. Hopefully I am now “up to speed”. It seems the estimable Orac had some problems with the article as well.
No one knows how often DCIS progresses to invasive cancer. Sure, some people are probably walking around with a focal area of DCIS that hasn’t changed in 30 years and they dont even know it. But once identified, wouldn’t most women want it removed, knowing that they harbor a pre-malignant lesion that may or may not progress into the number 2 leading cancer killer of women in this country? Breast cancer is breast cancer, seriously. The problem isn’t one of screening or diagnosis; it’s a lack of understanding we currently have for the biology of breast cancer which limits our ability to make predictions on future behavior of individualized tumors. The more we identify, the more data we will have for study.
I understand the terminology, at face value. I just think a word like “overdiagnosis” is inappropriate in the setting of breast cancer. We know prostate cancer is often a slow growing, indolent disease that affects men at the end of the actuarial tables anyway. The idea of “overdiagnosis” makes sense there.
You’re still missing the point. It’s the exact same thing as prostate cancer. Overdiagnosis is detecting disease that won’t kill you over your lifetime. We’re finding that some breast cancers can behave just like indolent prostate cancers – they smolder and do nothing for decades or they regress spontaneously as your body’s immune system fights it. You’re under the misperception that all breast cancers (with the exception of DCIS) are fatal if untreated and we’re discovering that this isn’t necessarily the case. You talk about more data to understand breast cancer biology – this is what it’s showing. Breast cancer is not breast cancer. There are aggressive tumors which metastasize early and spread rapidly, and tumors that sit dormant for years and years and never metastasize. There are so many misperceptions regarding breast cancer out there perpetuated by the media and resulting in unrealistic expectations by the general public (i.e. malpractice suits) that it pains me to see a colleague in the medical profession falling into the same traps.
Buckeye surgeon – some of the studies of autopsies of women who died of other causes show as much as 30% of women having breast cancer. So if we ever get a test accurate enough to detect them all, you’ll have 1/3 of women getting cancer diagnosis, getting treatment and suffering the side effect of treatment. There are some that may die as side effect of treatment. When the number of women is large enough, you may get a situation of women who die from treatment than from cancer. Also, keep in mind that treatment doesn’t make a difference in all cases. Some cases are so aggressive that they’ll kill anyway; some are sufficiently slow-growing that are curable even when detected later; and some you’d not know you had within your lifetime. Screening only helps with a small subset of cancers and studies are conflicting as to how high a percentage that is.
@Aftercancer – I am sorry about your diagnosis. In all fairness, though, you don’t know and can never know which group of cancers yours is — if it would have ever progressed in your lifetime had it remained undetected, if it had still been curable were it detected later e.g. at a regular exam or if screening indeed helped. Nobody can say that. I invite you to read a personal story of Dr Cornelia Baines. This is one woman, a doctor, whose cancer was missed on mammograms and discovered 8 years later and yet she is grateful for the delay. In her story she talks about screening and different possible outcomes of screening both good and bad.
And yes, I know all about cancer too (though not breast). My never-smoking mother from never-smoking (actually vehemently anti-smoking) family has lung cancer. But guess what – I know that there is no screening for it, so I have no intention of doing anything.
Also, have you ever heard of the history with neuroblastoma screening in Japan, when screening increased the number of detected cancers by serveral times, yet the incidence of advanced cancers diagnosed later hasn’t changed.
Interesting blog since my wife had breast cancer and we are completing surgical treatment at the Mayo Clinic. Let me ask you all what you would do if you or your wife was diagnosed with biopsy proven DCIS. It easy to to say what someone you are not related to should do but what would YOU do when you have to live everyday of your life with this diagnosis?
Re: TrenchDoc
Precisely! At this point in time there is no way to know which of the diagnosed breast cancers is “indolent” and not likely to kill . . . or, deadly and ought to be treated aggressively.
I had a patient in my practice who was diagnosed with DCIS only. She elected mastectomy. All margins were entirely free of disease. Her lymph nodes were negative. She died of metastatic breast cancer three years later WITHOUT any evidence of return of breast cancer either in her original mastectomy wound or chest wall or in the opposite breast. Who would have guessed that this would be her outcome? Most patients with DCIS do well, as do most patients with breast cancer. But unless and until we have better ways to understand the precise biologic behavior of each individual breast cancer, we must take them all seriously – and treat them fully while we wait for scientists to catch up with the news that not all of these breast cancer are lethal.
All the best. Dr. Ruddy
Breast Health & Healing
I’m not a doctor, but from what I’m reading from most of you is that a woman who keeps her head in the sand and fingers crossed will have the same outcome as one who is dilligent about her mamos.
Ann Marie:
No not really. If 30% of the overall diagnosed breast cancers will never harm the patient, then putting your head in the sand and taking your chances means that a patient might be one of the 70% of women with a potentially lethal breast cancer.
Problem is: we have no way of knowing, at the present time, who falls into the lucky 30% group and who falls into the unlucky (and dangerous) 70% group.
As a woman, as the daughter of a mother who was diagnosed with breast cancer at the age of 43, as a female breast surgeon, and as the Founder and President of the Breast Health & Healing Foundation, I would like to propose the following conservative Solution:
Take the diagnosis of breast cancer with a degree of urgency – for the time being; and INSIST that researchers move as quickly as possible to discover methods to distinguish the indolent (relatively harmless) form of breast cancer from the one that kills.
I have my wife screened once a year just to be safe. Women must take this seriously, I have already lost a good friend to breast cancer and it is no game
I had my first mammagram at age 49…
I accepted my doctor’s recommendation without doing my own research.
My mammogram resulted in a call-back and a day of further investigation…repeat mammograms, ultrasound, CBE and finally, the ordeal of biopsies.
Now for the worst bit by miles…an overnight wait to get the pathology results.
I didn’t sleep at all…it felt like my life was in suspended animation.
After the all clear, a false positive, the relief was enormous.
A reprieve from my death sentence.
It felt like a cancer scare….a year later, it still feels like a health scare and I still feel anxious and focused on cancer.
I read everything I could get my hands on….and last week, I took myself off the Breastscreen Registry.
It was a difficult decision, but I feel that I’ve made the best decision having regard to the evidence currently on the table.
I think we assume that all cancer screening is a good thing, but that’s just too simplistic an argument.
DB
What would you have done if the biopsy had been positive? You are a classic “glass half empty” person. Of course do what your research and heart tell you to do. BUT if, God forbid, you do develop breast cancer please don’t sue your doctor for a delay in diagnosis.
Best of luck and health in the future.
My point is that women should be fully informed as to the risks of mammograms.
I was never told that false positives are very common and so totally unprepared for what followed….
I now have the information I need to make an informed decision and I didn’t get it from my doctor.
We all take chances in life – screening has risks and choosing not to screen has risks…and that is why we need risk information.
We can then make a decision based on our risk profile and considering the risks of testing.
I think it is unwise to assume all screening is a good thing for all people.
I’d suggest anyone interested in the topic look at the research published by the Nordic Cochrane Institute.
I think having blind faith in these tests is very unwise.
Of course, we can’t make decisions for each other, the decision to screen or not is entirely up to the individual.
http://www.bmj.com/cgi/content/full/338/jan27_2/b86?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=%22Mammograms%22&searchid=1&FIRSTINDEX=0&sortspec=date&resourcetype=HWCIT
The sad thing is that you guys apparently have no clue as to what its like when you learn that part of your body has betrayed you be it DCIS or prostate cancer. Check out the discussion groups. We hope you never have to join us but if you do you will realize the idiocy of these anti screening approaches.
http://community.breastcancer.org/forum/68
Gosh I wish it were more politically correct to spread this word. I never knew that mammograms were controversial until I received a diagnosis of DCIS. Strangely, I don’t feel like some awful cancer has invaded my body, rather, I feel angry as all heck at the medical establishment that pushes screening and then neglects to tell us that some “cancers” may never become harmful at all. I want to scream every time I see a newspaper article re: breast cancer awareness that says something like “Mary found a lump three months after a normal mammogram. Therefore, everyone should get mammograms.” If you have ever taken a course in logic, you know that the above statement fails the final.
And here’s the other dirty little secret. Many stage 1 cancers can be successfully removed by a lumpectomy. With DCIS, however, the lower (less dangerous) the grade, the more likely it is to be spread out, therefore necessitating a mastectomy. That’s right, women get their breasts removed for something with a low probability of ever harming them. So are we finding too much cancer? I don’t know. Are we finding too many abnormalities that we are quick to call cancer? Absolutely.
Are more and more indolent breast and prostate cancers being uncovered by mammograms and PSA tests — undoubtedly. Are some folks jumpiing to treatment prematurely — no doubt. 1. Solution one — ignorance and not testing. Fight to save lives only once the cancer metasticizes
2. Learn about cancer, check the odds, get screened, learn about the state of your body, and weigh YOUR OWN odds based on existing data and YOUR specific indicators.
Its your choice. 2 is tougher UNLESS your cancer invades your body. ITS YOUR CHOICE. Ignorance may be bliss and a little knowledge may be dangerour ITS YOUR CHOICE.
Lee, I agree with you, but doctors do not give women a choice based on their specific indicators. Healthy women with no family history, good diets and regular exercise habits are told that they must have mastectomies for DCIS. If I know that I have DCIS, meaning a higher chance of breast cancer, I’ll stay off of junk food for the rest of my life, stop taking birth control pills, etc. Seems to me that the surgery plus reconstruction are more harmful than the DCIS, but doctors won’t concede that. If you know of such a doctor who will, please publicize the name.
MK: with all due respect you don’t know what you are talking about. Unfortunately I know and I hope you never have to know. Having been diagnosed with DCIS just about a year ago — I had a lot of decisions to make. The first decision of course was whether or not to accept that I had cancer, albeit stage 0 non invasive. Reading papers, seeing the charts and graphs, discussing, etc, left little doubt I had cancer (albeit non invasive at that point) and that there was a rather large likelihood that it could become invasive (although not in the majority of case, definitely in a substantial number of cases). Hence I decided to try to get cured rather than take the chance of metasticizing cancer. No one told me to have mastectomy — if anything they didn’t think it was a good idea. I had two partial mastectomies– i.e. lumpectomies but there is no lump in DCIS as it’s distributed within the ducts. The margins weren’t great and although the standard statement is that lumpectomy plus radiation plus hormonal treatment has the same mortality rate as mastectomy it is also clear that the reoccurrence rate is smallest with mx — since you have no breast. I consulted with 3 surgeons and two oncologists and one radiation therapist and no one told me to have a mastectomy. But guess what, I and many women in my situation chose a mastectomy to minimize the chances of recurrence and avoid radiation and chemical/hormonal. (Some even get a prophylactic mx — I chose not to). As I said it was my choice and it’s your choice by I believe it’s essential to uncover if you have it so that you know that you need to make a choice. Not knowing is a choice as well. Check out the hundreds of women discussing/describing what it is to have DCIS at
http://community.breastcancer.org/forum/68
I would add that the prostate cancer situation doesn’t seem all that different. However, i think that a stronger argument for active surveillance and monitoring can probably be made for those whose prostate biopsies show low grade cancer. There is probably more time to take action and more indications of when things are getting worse. However the anti PSA test arguments are the same as the anti mammogram arguments and often made by the same so called experts such as Dr. Welch.
Lee, you might want to look at the materials here http://consensus.nih.gov/2009/dcisstatement.htm to see what the experts in DCIS are saying. Two things stand out: first, the experts agree that medical research needs to find a way to identify those women who can go without surgery for DCIS and second, they suggest removing “carcinoma” from the name to reduce the anxiety that women experience upon a DCIS diagnosis.
Seen it, been there. Hiding the fact that DCIS is (non invasive) cancer and potentially will become invasive is not the solution in my opinion. Check out the NCCN 2009 report on breast cancer. No knowing and not considering action is not a solution, IMHO.
Even if the word carcenoma is removed, the NIH consensus statement also notes that
“Mastectomy and local excision with radiotherapy are both effective local therapeutic approaches in patients who have DCIS. A randomized controlled trial comparing mastectomy with local excision and radiation has not been done, but current data demonstrate that long-term survival is similar with either approach. Although survival rates are similar, there is a higher local recurrence risk for DCIS with local excision and radiation therapy (12%, half of whom have invasive cancer) than in patients who choose mastectomy (about 1%).” So the question isn’t whether to treat it but how and that becomes a personal decision — mastectomy and minimum chance of recurrence, no need for radiation or lumpectomy and radiation plus hormonal treatment and increased chance of recurrence (which can then be treated by mastectomy),
Incidentally, Dr. Morrow at MSKCC has just come out with a study showing women are being “scared” into mastectomy nor are they being mislead by their MDs.
Surgeon recommendations and receipt of mastectomy for treatment of breast cancer.
Morrow M, Jagsi R, Alderman AK, Griggs JJ, Hawley ST, Hamilton AS, Graff JJ, Katz SJ.
JAMA. 2009 Oct 14;302(14):1551-6.
PMID: 19826024 [PubMed - in process]
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