Why the fear of cancer undermines the new mammography guidelines

Fear is such a powerful emotion, humans will do almost anything to relieve it. The most effective way to control fear is to manage whatever it is we’re afraid of. Night lights against the monsters under the bed; locks on the doors and a handgun under the pillow to fend off intruders; annual mammograms and PSAs to keep us from dying of cancer. Although all these things may relieve fear subjectively, they may have little or no objective efficacy against the source of our fears. Fear of death — especially a painful, lingering, degrading one — is a primal human fear.

This is why cancer is so terrifying, and why any news about scientists’ and doctors’ successes in diagnosing and treating it (ie, controlling it) is held in such high regard. Anything we can do to reduce our chances of dying from cancer or getting it in the first place is a powerful balm to this deepest of fears. though the subtleties of science can make it difficult for non-scientists to grasp some of the nuances. One of the earlier discoveries about cancer is that it generally responds better to treatment sooner in its natural history rather than later. From this has flowed the logical assumption that “early detection saves lives.”

What fantastic news! All you need to do to not die of cancer is have it detected early enough! As a practical matter, this has been the message heard by patients through the years as they troop through my office for mammograms, pap smears, PSAs, rectal exams, colonoscopy referrals, and complete skin checks. Unfortunately, this reassuring scenario is seriously flawed.

First, there is no effective screening for some cancers (leukemia, lymphoma, pancreatic, liver, primary brain tumors; the list is long). Second, some tumors are rapidly growing, springing up between regularly scheduled screenings. Third, even some cancers detected “early” will fail to respond to treatment. Finally and most importantly, the screening process itself is not harmless. Mammograms involve radiation. Frequent skin exams often involve numerous biopsies, which can bleed, scar, or become infected. Colonoscopy comes with its own myriad of complications including perforation, infection, bleeding, and anesthesia-related problems like aspiration. PSA’s and pap smears can detect lesions that were destined to regress spontaneously, meaning that all subsequent treatment risks come with no real benefits at all. And yet when someone is diagnosed with cancer the first thing everyone does is try to figure out “why?”

Lung cancer? Must have smoked. (Not always.) Breast cancer? Must not have gotten mammograms. Manifestly false, given the number of rapidly growing tumors diagnosed between screenings. Prostate cancer? Didn’t want to bend over and take it like a man, a sentiment as grossly unjust as it is inaccurate.

This is why the introduction of the new USPTF mammography recommendations to change from 40 to 50 the age for beginning asymptomatic screening in average-risk women is so threatening. These new guidelines are a nuanced expression of the complexities of screening, and a slap in the face to the safe, secure — and wrong — perception of mammography as a talisman against breast cancer. The dangers of screening are real, and go far beyond “a little anxiety,” as the guidelines’ detractors point out with such derision. Unnecessary surgery — biopsies of abnormalities found on premature mammographies — is a big deal, far beyond the financial costs everyone seems so eager to add up.

Yet the fear of cancer is so great, and the (false) promise of “peace of mind” from mammography and other screenings is so powerful, that not only do we continue to seek this comfort even when it’s shown not to be true, but we vilify those who dare to threaten our fragile safety net against the terror of cancer. Although this response is understandable, it is still a shame.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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