Breast Cancer Screenings Debated by Medical Experts

At a breast cancer screening convention in Barcelona on Friday, March 26, medical experts debated how to implement breast cancer screening programs across Europe. The debate centered around who should be screened for breast cancer, the frequency of breast cancer screenings, and the age that breast cancer screenings should begin.

Some medical experts at the convention want to implement the same guidelines issued by the U.S. Preventive Services Task Force (USPSTF) in the Annals of Internal Medicine in 2009, stating that routine mammograms aren't necessary for women of average cancer risk in their 40s, and that women between 50 and 74 years old don't need to undergo mammograms more often than every other year.

In most women, tumors are slow-growing, and that likelihood increases with age. So there is little risk by extending the time between mammograms, some researchers say. Even for the minority of women with aggressive, tumors, annual screening seems to make little difference in survival odds. U.S. researchers last year estimated five lives saved per thousand women screened. (Maria Cheng, AP)

The USPSTF also recommended that physicians abstain from teaching women how to examine their breasts for signs of cancer because of a lack of evidence that it is of any benefit and recommended scaling back screening programs to begin at age 50 instead of 40. (About $3.3 billion was spent on mammograms in the last 12 months, according to the American College of Radiology.) The American Cancer Society and some other experts rejected these guidelines. (Shirley Wang, Wall Street Journal)

Difference Between Screening Mammogram vs. Diagnostic Mammogram

According to Cecilia Brennecke, M.D at BreastCancer.Org, "A routine or screening mammogram consists of four views-two views of each breast. The technologist takes the pictures, checks them for quality, and then you leave. With a diagnostic mammogram, you start with four standard views, and then supplement them with additional views, a physical exam, and ultrasound and MRI as needed. So a diagnostic mammogram is for women who are having a problem such as a lump or unusual nipple discharge or pain.

A diagnostic mammogram is generally read by the radiologist right after it has been done; ideally the woman does not leave the radiology facility until she has an answer about what is causing her breast problem. Usually the outcome is that everything is fine, but there is a higher incidence of finding cancer in that situation than in a screening situation."

Problems From Over Screening

"The over-diagnosis problem has been down played because people really want to believe screening works," said Karsten Jorgensen of the Nordic Cochrane Centre in Copenhagen, who has published several papers on the issue. "There is a lot of over treatment happening, and it is time to re-evaluate whether the benefits really outweigh the harms." (Maria Cheng, AP)

Professor Michael Baum, an international authority on breast cancer, said for each woman whose life is saved, ten healthy ones needlessly receive mastectomies and other treatment. He said: 'I believe the benefits have been exaggerated by political spin.' Previous studies have shown breast cancer screening programs in countries including Britain, Canada, Denmark and Sweden can lead to unnecessary treatment." (Daily Mail, UK)

According to the American Cancer Society the risks of breast cancer screening tests include the following:

Finding breast cancer may not improve health or help a woman live longer.

Screening may not help you if you have fast-growing breast cancer or if it has already spread to other places in your body. Also, some breast cancers found on a screening mammogram may never cause symptoms or become life-threatening. When such cancers are found, treatment would not help you live longer and may instead cause serious treatment-related side effects. At this time, it is not possible to be sure which breast cancers found by screening will cause symptoms and which breast cancers will not.

False-negative test results can occur.

Screening test results may appear to be normal even though breast cancer is present. A woman who receives a false-negative test result (one that shows there is no cancer when there really is) may delay seeking medical care even if she has symptoms.

One in 5 cancers may be missed by mammography. False-negatives occur more often in younger women than in older women because the breast tissue of younger women is more dense. The size of the tumor, the rate of tumor growth, the level of hormones, such as estrogen and progesterone, in the woman's body, and the skill of the radiologist can also affect the chance of a false-negative result.

False-positive test results can occur.

Screening test results may appear to be abnormal even though no cancer is present. A false-positive test result (one that shows there is cancer when there really isn't) can cause anxiety and is usually followed by more tests (such as biopsy), which also have risks.

Most abnormal test results turn out not to be cancer. False-positives are more common in younger women, women who have had previous breast biopsies, women with a family history of breast cancer, and women who take hormones, such as estrogen and progesterone. The skill of the doctor also can affect the chance of a false-positive result.

Mammograms expose the breast to radiation.

Being exposed to radiation is a risk factor for breast cancer. The risk of developing breast cancer from radiation exposure, such as screening mammograms or x-rays, is greater with higher doses of radiation and in younger women. For women older than 40 years, the benefits of an annual screening mammogram may be greater than the risks from radiation exposure.

The risks and benefits of screening for breast cancer may be different for different groups of people.

The benefits of breast cancer screening may vary among age groups:
In women who have a life expectancy of 5 years or less, finding and treating early stage breast cancer may reduce their quality of life without helping them live longer.

In women older than 65 years, the results of a screening test may lead to more diagnostic tests and anxiety while waiting for the test results. Also, the breast cancers found are usually not life-threatening.

It has not been shown that women benefit from starting mammography at younger than 40 years.

Routine breast cancer screening is advised for women who have had radiation treatment to the chest, especially at a young age. The benefits and risks of mammograms and MRIs for these women are not known. There is no information on the benefits or risks of breast cancer screening in men.

No matter how old you are, if you have risk factors for breast cancer you should ask for medical advice about when to begin having mammograms and how often to be screened.

Risks From Not Being Screened

"Maybe in 20 years we will have a better test to tell us which cancers are the dangerous ones," said Ingrid Kossler, president of the Swedish Breast Cancer Association, who chaired the session Friday on screening guidelines. "But until then, we have to use what we have and treat the cancers we find." (Maria Cheng, AP)

Personal Experience

A woman in this community went in for a sentinel lymph node biopsy. While she was still on the operating table, a radiologist looked at the node the surgeon removed and determined it was cancerous. The surgeon then removed her right breast and 30 more nodes. The next day, another radiologist looked at the sentinel node and determined it was not cancerous. Today, she is disfigured and because of the large number of lymph nodes removed, she suffers from lymphoma. (According to Wikipedia, the hypothetical sentinel lymph node is the first node or group of nodes reached by metastasizing cancer cells from a primary tumor.)

Find a Doctor and Hospital You Trust & Decide With Him About Screenings

Despite knowing that women may receive needless masectomies, the possibility of dying from cancer is much worse. My opinion regarding the debate over breast cancer screenings is that this should be left up to the individual. Each woman and her doctor knows her medical history and her body better than any policy maker. The doctor should inform his patient of pros and cons of not screening and let her decide. According to The American Cancer Society, false positive and false negative results can be reduced by regular screenings as the breast tissue can be compared with previous screenings to see changes.

Women should also get digital mammography screenings-the sharp detail is unbelievable compared to the old film mammographies.

If diagnosed with cancer, before undergoing surgery, get second, even third opinions from radiologists and surgeons practicing at different hospitals. This advice again comes from personal experience. One woman, after being diagnosed with cancer, was told by one oncologist that she needed to be placed in the hospital for four weeks, have her breast removed and stem cells taken from her bone marrow, then receive massive doses of chemo and radiation. She sought a second opinion. The next oncologist told her that the procedure the first oncologist wanted to do had already been proven to be no more successful than standard doses of chemo--additionally, it was life threatening. She asked the oncologist "How do you know that the dose you are giving me isn't too much?" He replied, "We don't. In some cases, I'm sure we overdose, but that is our protocol--take it or leave it." She left it and went to a third oncologist. After looking at her xrays, and biopsy results he informed her "The involvement of your lymph nodes was so miniscule that I don't believe you need chemo or radiation. If you want, you could take an anti-estrogen drug" She decided to do nothing. That was in May of 2006--she is alive and healthy today.

Policy makers should not dictate who can and can't get screenings.

Sources:

American Cancer Society, Cancer.org, "False Positive Result Mammograms Vary Among Radiologists"

Associated Press article, "Experts Debate Merits of Breast Cancer Screening" by Maria Cheng

BreastCancer.Org answer by Cecilia Brennecke, M.D.

Cancer.gov, Risks of Breast Cancer Screening

Daily Mail article "Breast Screening Fails to Cut Cancer Deaths" by Jenny Hope"

Wall Street Journal article, "Breast-Screening Advice Is Upended" by Shirley Wang

Wikipedia.org, Sentinel Node Biopsy