After sitting through a presentation by a general surgeon about treatment of small breast cancers (the vast majority of his patients do great), I was stunned to hear him opine, “Every woman needs a mammogram every year starting at age 40.” Really. That’s what he said.
I’ve had my doubts. I’ve diagnosed women with breast cancers less than a year after their last mammogram because the tumors grew so damn quickly. Mammography didn’t save them.
Now we have new research (linked above) looking at 16 million women (a pretty decent sample size by any reckoning) showing that the more you screen, the more cancers you find WITH NO DIFFERENCE IN HOW MANY WOMEN DIE of their disease.
To put it into the vernacular, overdiagnosis is a thing.
A real thing, with real drawbacks. Time; money; pain; anxiety. I steamed when the surgeon mentioned above responded to my concerns with the definitive statement, “There is no downside to mammography.” Wrong in so many ways.
Ah, but what to do about it? Especially with the juggernaut already running full speed ahead, fueled by millions of pink ribbons and tacky tee shirts. It’s now a performance measure. Women without mammograms are costing me money. So far I’ve been able to take a deep breath and ignore the increasingly strident calls from various insurance companies crying, “Screen! Screen! Screen!”
Why is this drive so powerful?
There’s the default assumption that knowledge is power. Sometimes it is, but sometimes it isn’t. Despite the reality of fast-growing fatal cancers, the normal mammogram (or breast MRI for the “high risk”, a designation surprisingly easy to fudge) provides reassurance. For now. Year after year we irradiate breasts looking for ever tinier lesions, every last one of which must be treated because “cancer!”
Then there’s the cognitive error which blocks women who have been successfully treated for a small cancer from believing this research. The cognitive dissonance created by, “I went through hell getting treated for breast cancer, and you’re telling me it didn’t make any difference!?!” is strong indeed.
I wonder if we are perhaps one step closer to being able to do a truly randomized breast cancer study: enroll a series of women with small (< 1 cm) breast cancers and randomize them to standard treatment (surgery, radiation, adjuvant chemo) or observation only. Maybe we’re ready to look at the biology of breast cancer more closely. Maybe all breast cancer, like most prostate cancer, isn’t fatal after all.
If we really want to lower deaths from breast cancer, how about re-directing the massive time, effort, and funding away from “mammograms for everyone” toward developing better treatments for those wickedly fast-growing tumors that actually kill.
Think about it.