Posted by: notdeaddinosaur | July 7, 2015

Mammography Doesn’t Save Lives

Preventive care doesn’t save money and now it turns out mammograms don’t even save lives.

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.

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Responses

  1. I’ve known for a long time that some cancers are way more aggressive than others. Older women are less likely, imho, to have aggressive tumors.

    Good luck with this one. And any patient not screened who dies have a small tumor is likely to ….you know where this goes.

    Btw, I had a Ct scan yesterday. Something showed up on the chest xray taken in the er. Hope I’m not like my dad…his thoracic aneurysm killed him. Time foe a shower and off to Peter’s. We have tickets for Paul Stuckey and Peter Yarrow at Longwood tonight. Lu. Give my love to Bill.

    >

  2. Every woman who’s been through surgery for DCIS, and every one of her friends & relatives, is convinced that mammography saved her life by finding this “cancer” early. It’s going to be very hard to convince them that a) they didn’t have cancer, b) they didn’t need surgery, and c) ithis unnecessary fear and unnecessary treatment was triggered by unnecessary mammography.

  3. There is a great couple of articles debating the pros and cons of mammography in a recent Cleveland Clinic Journal:

    http://www.ccjm.org/?id=105745&tx_ttnews%5Btt_news%5D=397145&cHash=236ab771bf5dfa75eab0517c13473324

    http://www.ccjm.org/?id=105745&tx_ttnews%5Btt_news%5D=397105&cHash=f9a9d45f6de9b50fac6f6f2d9f0f3796

  4. I’m one of those women whose tumor was wickedly aggressive and grew massively between mammograms. I walked barefoot through the glass shards of hell known as AC&T, surgery and radiation. It’s not something I’d want to do again. In my journey i have met many women diagnosed with DCIS who insisted that “everything possible be done” without understanding that DCIS isn’t cancer yet. One of them is suffering from treatment induced MML. They problem seems to be with “isn’t cancer yet”. Cancer is a big ugly word and seeing the word malignant on a piece of paper with your name on it is terrifying. Even knowing what I know, I’m not sure that if I had a mammogram on my remaining breast that showed DCIS I wouldn’t be demanding that they do a mastectomy. Cancer is a fire breathing beast.

  5. Brava, Dottoressa!

  6. Totally anecdotal. Ironically, with my mother’s cousin (62 year old) who lives in Germany, the mammograms introduced a false sense of security that likely led to a delay in cancer diagnosis. She had a mammogram one year that found something that was removed and turned out to be a benign cyst. Next mammogram was clean. Then at one point she noticed a tumor, but because she’s had a cyst before she figured it’s probably the same and blissfully ignored it until the next mammogram. It turned out to be an invasive tumor that spread to her lymph nodes. Would it have made a difference if she went to a doctor the moment she noticed a tumor – maybe, maybe not, but without the false sense of security that she had because of the benign cyst she had before, who knows, maybe cancer hadn’t spread to her lymph nodes by then. She needed to have two surgeries and they didn’t get everything the first time around, so at the very least she’d have been spared one.
    She went though surgeries, radiation, chemo and had every side effect in the book from each. Then, on top of it she couldn’t tolerate hormonal therapy which I guess puts her at higher risk of recurrence. But… the worst thing is that she’s been fighting atypical pneumonia now for 2 years now. They could find no pathogens in the lungs, but she has inflammation – maybe from radiation, maybe because she had an undiagnosed infection that the body fought off eventually but not before her immune system going into overdrive (her doctors’ explanation, not mine). She’s been on prednisone for it, got diabetes because of it which she finds very difficult to treat since her sugar skyrockets a few hours after she takes prednisone, but then falls rapidly towards the evening and to dangerously low level because of diabetes medication.. . She got better for a time, almost went off prednisone, but then the lungs trouble started again. She is now taking prednisone again, and also insulin (though once a day instead of normal twice a day since she only has sugar issues for the first half of the day), but still feels miserably.

    Anyway, I can understand going through all of it for an invasive tumor that she had, but for those who are “overdiagnosed”, it’d be a lot worse.

    Personally, I choose not to do mammograms. Yes, maybe I am forgoing a chance of having my life saved, but it just doesn’t worth it for me, not with the risk of going through the treatment because of overdiagnosis.

  7. Don’t you know that if all our patients get the appropriate preventive treatment: mammograms, colonoscopy, PSA, exams, labs and everything else no one will ever get sick or die?
    Seriously, I’ve seen lots of women over the years with breast cancer who said, “but I got my mammogram every year like I’m supposed to, how can I have breast cancer?”
    Luckily most of the time the cancer is very early and easily treated. Often, the previous mammograms will show the cancer in retrospect, the mass just was not interpreted as cancer.


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