We’ve written to you many times in the past about mammograms. Despite the fact that this breast cancer screening procedure is painful and risky the mainstream still chooses to cling to it like it’s a long lost child.

In recent years, mounting evidence has challenged the validity and safety of mammograms in breast cancer prevention… Now, a recent study by Southampton University researchers has found that too many screening programmes, including mammograms, lead to misdiagnosed results and the overtreatment of harmless breast lumps.

Weighing up the pros and cons

When it comes to cancer, an early diagnosis is absolutely imperative and screening programmes are supposedly designed to save lives through early diagnosis of cancer. The question now is, has the mainstream got it wrong?

Back in 2001, a controversial report, published in the medical journal The Lancet, concluded that breast cancer screening, offered to all women in the UK over the age of 50, does not reduce deaths. Even back then some experts felt that screening may do more harm than good.

Now, 10 years later, the latest study, published in the British Medical Journal, echoes exactly the same sentiment. The Southampton researchers say that the negative outcomes of screening programmes cancel out up to half of the benefits that others get from living longer lives.

In short, this means that while a positive result after screening may give an extra year of life to one breast cancer victim, it could result in six months’ worth of suffering due to unnecessary treatment for another patient.

Previous research has shown that for every 2,000 screenings, 200 women will have a “false positive” result and 10 of those women will have unnecessary surgery, but only one life will be saved.

The lead researcher of the Southampton study, Prof James Raftery, said: “To save one life, that woman will have surgery, but 10 more will have surgery that do not need it. The reason is they have lumps that are diagnosed as cancer but… most of those lumps would not have gone on to become cancer or to have killed a person.”

Needless surgery cuts the benefits

In 1986, the Forrest Report led to the introduction of breast cancer screening in the UK. According to the Forrest Report, the effectiveness of these screening programmes would be measured in “quality of life years” (QALYs) — the extra years of life patients gain as a result of screening.

Back then, it was estimated that screening programmes would gain patients 3,301 QALYs over a 20-year-period. However, this estimate did not take into account the potential harm of false positive results. As a result, the damaging impact of false positive diagnoses and needless surgery cut the expected QALYs of 3,301, by more than half to 1,536 QALYs, according to the results of the latest study.

The researchers added that for the first eight years, women were more likely to be harmed than to enjoy any benefit. Only 20 years after screening do the net benefits for patients really begin to accumulate.

Prof Raftery said: “”There are lots of women who have had surgery who believe their lives were saved when in fact only around one in 10 has had their life saved.”

Lay out the options

Of course, this does not mean that women should stop being screened for breast cancer altogether. However, patients should be warned about the possible negative effects of screening and have a better understanding of the risks of unnecessary treatment before they are screened. Yet this is clearly not happening…

A damning report from the Cochrane Collaboration, published in 2010, said that women are being seriously misled by health officials who dramatically downplay the risks of mammography X-rays while overstating the benefits. The report also questioned the prevailing view that mammograms save lives and says that this is based on shoddy and biased science.

Women should also be given the option to choose the method of screening they prefer. As I mentioned earlier, mammograms are extremely painful and invasive procedures. The real kicker is that a breast cancer tumour is only detected by a mammogram after it’s grown for several years, and achieved more than 25 doublings of the malignant cell colony. So, by the time you get a warning from your mammogram the tumour may already be at a growth-stage where it is too difficult and too late to treat. Worse still, the compression required for mammograms can actually break down cancer tissue and rupture small blood vessels that support the cancer, causing it to spread.

Luckily, there are safer and less painful screening options, like thermography or thermal imaging. Mammograms look at anatomical changes in the breast, as they detect masses or lumps in the breast tissue. Thermograms, on the other hand, look at vascular changes in the breast, as they detect blood flow patterns, inflammation and asymmetries, which allows them to detect irregular patterns in the breast before a noticeable lump is formed.

In the case of inflammatory cancer, there are no detectable lumps, which makes self-examination and mammograms pointless. However, thermography will certainly help in these cases with an early detection.

Thermal imaging does not cause pain, is non-invasive and quick – your multi-image examinations usually take less than 15 minutes. Plus, it makes no contact with your body – no compression (unlike mammograms) and it emits absolutely NO radiation.

It all adds up: No radiation, no squashing and bruising, early detection, quicker diagnoses and prevention and a healthier cancer-free you!

Sources:

‘Breast cancer screening could cause more harm than good’ published online 09.12.11, telegraph.co.uk

The California State Legislature passed a bill last Friday requiring doctors to inform women if they have dense breasts after a mammogram, making California the second state this summer and the third state so far to have passed a so-called breast density law.

The bill, SB 791, passed the state Senate 35-1, and is now going before Gov. Jerry Brown to get signed.

When he signs it, starting next year, Calif. radiologists will have to send women with dense breasts, as determined by an American College of Radiology-developed system, this text:

Because your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, depending on your individual risk factors. A report of your mammography results, which contains information about your breast density, has been sent to your physician’s office and you should contact your physician if you have any questions or concerns about this notice.

Texas Gov. and Republican presidential hopeful Rick Perry signed into law a similar bill, Texas Act HB 2102, or Henda’s Law, in June. And breast density legislation was also passed in Connecticut in 2009.

New Hampshire, Massachusetts, New York and Florida all have similar legislation pending.

The American College of Radiology Imaging Network says that around 40 percent of women getting screening mammograms have dense breasts, with younger women typically having denser breasts.

Dense breasts are less fatty, with more connective tissue. The connective tissue appears white on a mammogram, just like the cancer, making it harder to diagnose, according to Are You Dense, an advocacy group.

A January 2011 study by the Mayo Clinic found three-quarters of cancers in women with dense breasts are missed by mammograms.

“When it comes to your health, ignorance is not bliss. What you don’t know can hurt you,” State Sen. Joe Simitian, a Democrat from Palo Alto who authored the bill, said in a statement.

The idea for the bill came from by Amy Colton, a registered nurse who had breast cancer not discovered by a mammogram, and who learned she had dense breasts only after her cancer was diagnosed, according to Are You Dense. She suggested the bill in Simitian’s “There Oughta Be a Law” contest.

However, the bill met some opposition from the California Medical Association. Writing about an earlier incarnation of the bill, SB 173, the CMA warned that it could bring legal and practical problems for Calif. doctors.

“Because the scope of who must receive the notice is so broad, women will be ‘scared’ into thinking they need these expensive additional screenings when it isn’t at all warranted, leading to increased costs and pressures on a physician’s practice,” the group wrote in a notice on its website. “Moreover, because the grading of the condition that may/may not lead to their receipt of the prescribed notice is subjective in nature, the absence of the notice could lead to lawsuits against doctors if a patient is later diagnosed with breast cancer.”

But the bill was backed by several other groups, including the California Nurses Association, the Breast Cancer Fund, the California Association of Health Underwriters and California NOW.

J OANN  G. E LMORE , M.D., M.P.H., M ARY  B. B ARTON , M.D., M.P.P., V ICTORIA  M. M OCERI , P H .C., S ARAH  P OLK , B.A., P HILIP  J. A RENA , M.D.,  AND  S UZANNE  W. F LETCHER , M.D.

A BSTRACT Background The cumulative risk of a false positiveresult of a breast-cancer screening test is unknown. Methods We performed a 10-year retrospective co-hort study of breast-cancer screening and diagnosticevaluations among 2400 women who were 40 to 69years old at study entry. Mammograms or clinicalbreast examinations that were interpreted as indeter-minate, aroused a suspicion of cancer, or promptedrecommendations for additional workup in women inwhom breast cancer was not diagnosed within thenext year were considered to be false positive tests. Results A total of 9762 screening mammogramsand 10,905 screening clinical breast examinationswere performed, for a median of 4 mammograms and5 clinical breast examinations per woman over the 10-year period. Of the women who were screened, 23.8percent had at least one false positive mammogram,13.4 percent had at least one false positive breast ex-amination, and 31.7 percent had at least one falsepositive result for either test. The estimated cumula-tive risk of a false positive result was 49.1 percent (95percent confidence interval, 40.3 to 64.1 percent) after10 mammograms and 22.3 percent (95 percent confi-dence interval, 19.2 to 27.5 percent) after 10 clinicalbreast examinations. The false positive tests led to870 outpatient appointments, 539 diagnostic mam-mograms, 186 ultrasound examinations, 188 biopsies,and 1 hospitalization. We estimate that among wom-en who do not have breast cancer, 18.6 percent (95percent confidence interval, 9.8 to 41.2 percent) willundergo a biopsy after 10 mammograms, and 6.2 per-cent (95 percent confidence interval, 3.7 to 11.2 per-cent) after 10 clinical breast examinations. For every$100 spent for screening, an additional $33 was spentto evaluate the false positive results.

To read the rest of the study, click here to download the PDF.

Elmore JG, Armstrong K, Lehman CD, Fletcher SW.

Source

Department of Medicine, University of Washington School of Medicine, Seattle, USA. jelmore@u.washington.edu

Abstract

CONTEXT:

Breast cancer screening in community practices may be different from that in randomized controlled trials. New screening modalities are becoming available.

OBJECTIVES:

To review breast cancer screening, especially in the community and to examine evidence about new screening modalities.

DATA SOURCES AND STUDY SELECTION:

English-language articles of randomized controlled trials assessing effectiveness of breast cancer screening were reviewed, as well as meta-analyses, systematic reviews, studies of breast cancer screening in the community, and guidelines. Also, studies of newer screening modalities were assessed.

DATA SYNTHESIS:

All major US medical organizations recommend screening mammography for women aged 40 years and older. Screening mammography reduces breast cancer mortality by about 20% to 35% in women aged 50 to 69 years and slightly less in women aged 40 to 49 years at 14 years of follow-up. Approximately 95% of women with abnormalities on screening mammograms do not have breast cancer with variability based on such factors as age of the woman and assessment category assigned by the radiologist. Studies comparing full-field digital mammography to screen film have not shown statistically significant differences in cancer detection while the impact on recall rates (percentage of screening mammograms considered to have positive results) was unclear. One study suggested that computer-aided detection increases cancer detection rates and recall rates while a second larger study did not find any significant differences. Screening clinical breast examination detects some cancers missed by mammography, but the sensitivity reported in the community is lower (28% to 36%) than in randomized trials (about 54%). Breast self-examination has not been shown to be effective in reducing breast cancer mortality, but it does increase the number of breast biopsies performed because of false-positives. Magnetic resonance imaging and ultrasound are being studied for screening women at high risk for breast cancer but are not recommended for screening the general population. Sensitivity of magnetic resonance imaging in high-risk women has been found to be much higher than that of mammography but specificity is generally lower. Effect of the magnetic resonance imaging on breast cancer mortality is not known. A balanced discussion of possible benefits and harms of screening should be undertaken with each woman.

CONCLUSIONS:

In the community, mammography remains the main screening tool while the effectiveness of clinical breast examination and self-examination are less. New screening modalities are unlikely to replace mammography in the near future for screening the general population.

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CNN) — The use of mammograms has dipped since a medical task force made controversial recommendations that women in their 40s may not need to get breast cancer screenings every year, according to one of three small studies to be presented Monday.

The studies related to this topic will be presented at the American Roentgen Ray Society annual meeting. They do not appear in peer-reviewed journals.

The studies suggest that fewer physicians are recommending annual mammograms for women in their 40s, fewer patients in that age group are getting screened and that tumors found through routine mammography are more likely to be detected in early stages of cancer.

The studies examined the impact of the controversial guidelines issued by the U.S. Preventive Services Task Force, a federal advisory board.

Who decides about mammograms? Inside the task force

In November 2009, the group stated that yearly mammograms should not be automatic at age 40 and that physicians should discuss their risks and benefits with their patients. It recommended routine mammography screenings every two years for women ages 50 to 74.

2010: New mammogram research

2010: Mammograms in 30s: No benefit? “The benefit in 40- to 49-year-old women is pretty small,” said Dr. Virginia Moyer, chair of the task force, about annual mammograms. “There is a real, but rather modest benefit. There are also risks, and they are greater in younger women than older women.”

Mammograms are less effective in detecting growths in younger women, whose breasts may be denser. The screening gets better with older women because breast tissues change over time.

As a result, some women experience false positives, anxiety and unnecessary biopsies because of mammograms, according to data. Roughly 15% of women in their 40s detect breast cancer through mammography.

Should I get a mammogram?

“The benefit is modest enough it needs to be an individual decision,” Moyer said about mammograms for women in their 40s.

This contradicted advice from cancer groups such as the American Cancer Society and Susan G. Komen for the Cure, which told women 40 and older to get screened every year. It sparked immediate outcry from such groups and cancer survivors, who say routine mammograms for women younger than 50 can save lives.

Once-dropping U.S. breast cancer rates now stable

Suspicious growths caught in regular-screening mammograms are more likely to be in early stages and therefore more treatable, said Dr. Donna Plecha, division chief of mammography at University Hospitals at Case Medical Center in Ohio.

She reviewed records of 524 biopsies (samples of suspicious growths in breasts) from women in their 40s during 2008 to 2009 at her hospital.

Of the 359 biopsies from screening mammography patients, 15% had cancer. These cancers were more treatable because they were caught in earlier stages, Plecha said.

Although 85% of those biopsies turned out to be noncancerous, some “may show us the patient is at higher risk of breast cancer,” she said.

“I haven’t met many patients who don’t appreciate us being thorough, to trying to find the cancers at an early stage,” Plecha said. “I would still recommend screening mammograms starting at age of 40,” because cancers caught earlier would be more curable.

Breast cancer ID’d more accurately by docs who see more scans

Plecha’s findings were not surprising to Moyer. It’s obvious that annual screenings would catch cancers before they progress, she said.

The study presumes that catching earlier stages for women between the ages of 40-49 would translate into fewer breast cancer deaths.

“The data that we have suggests that 1 in a thousand will benefit from mammograms in the 40-49 age,” she said. “There are whole lots of assumptions that are not supported by the data they presented.”

The task force did not say don’t get mammograms, Moyer said.

“It might make women not want to get the test,” she said. “This is a decision that should belong to the woman with appropriate info on hand.”

In another study, Dr. Lara Hardesty, section chief of breast imaging at the University of Colorado Hospital, examined survey results from fewer than 50 internists, gynecologists, family practitioners and nurse midwives.

She found that fewer clinicians were recommending annual mammograms after the task force’s guidelines were issued.

Before the guidelines, 56% recommended yearly mammograms for women in the 40- to 49-year-old range. After the guidelines, that rate decreased to 20%, and 56% of the clinicians reported they were discussing the risks and benefits of screening with patients. That decrease, Hardesty said, “is a statistically significant difference,” but it also showed more doctors were discussing mammograms with patients.

Hardesty also found that there were 205 fewer mammograms among women in their 40s after the guidelines were issued. Among patients 50 and older, mammograms increased slightly from 4,479 patients to 4,498.

It was unclear why mammograms in the 40s decreased while older women’s mammograms increased slightly.

Hardesty offered this hypothesis: Older women are used to having annual mammograms because they’ve done it for years. Meanwhile, younger women may feel as though they don’t have to get this screening.

Although the task force concluded that the net benefit of mammography in the 40s is small, Hardesty said: “If you’re the one person we find your cancer, it’s the world to you.”

When Dr. Deborah Rhodes orders a diagnostic test that involves radiation, she consults a chart in her office that lists the amount of radiation exposure from each test. She considers the patient’s total past exposure, and then carefully weighs the risks and benefits of each test and any alternative approaches she can take.

Two new studies appearing in Tuesday’s issue of the journal Radiology suggest more physicians should take this approach. One study found that certain nuclear-based breast imaging exams that involve injecting radioactive material into patients expose women to far higher doses of radiation than regular mammography, increasing their risk of cancer in vulnerable organs beyond the breast, like the kidneys, bladder or ovaries.

Over all, the United States population’s annual radiation dose from medical procedures increased sevenfold between 1980 and 2006, a second paper reports.

“I’m a radiation phobe — I’ll come right out and say this,” said Dr. Rhodes, an internist at the Mayo Clinic who is doing research to develop screening technologies that require less radiation exposure to the patient. “I’m constantly monitoring radiation doses in my patients.”

Unfortunately, she said, “this is something that isn’t well understood, not just by the public — but by physicians who order the tests.”

R. Edward Hendrick, a physicist who has studied breast imaging for almost 30 years, said he was motivated to quantify the radiation exposure from nuclear breast imaging technologies in a published paper because of similar concerns.

“I would go to the international breast meeting and the big radiology meetings, and nobody had a clue what the doses and risks were,” Dr. Hendrick said. “They’re treating all the tests as if they have the same radiation dose and risk as mammography, and the truth is they have a much, much higher risk. The point of the paper was to say that not all the breast imaging procedures have comparable risks and doses.”

Dr. Hendrick, a clinical professor of radiology at the University Colorado-Denver School of Medicine in Aurora, Colo., is a consultant to G.E. Healthcare regarding digital breast tomosynthesis, another breast imaging technique, and is on the medical advisory boards of Koning and Bracco, which make other imaging technologies.

The nuclear technologies breast-specific gamma imaging (B.S.G.I.) and positron emission mammography (P.E.M.) are meant to be used as complements or adjuncts to mammography and ultrasound, once there is concern about a cancerous lesion, and not for routine screening. These technologies are also more useful in women who have very dense breast tissue, when mammography often does not provide clear images.

But a single breast-specific gamma imaging or positron emission mammography exam exposes patients to a risk of radiation-induced cancer that is comparable to the risk from an entire lifetime of yearly mammograms starting at 40, according to Dr. Hendrick’s study.

While digital mammography has an average lifetime risk of inducing 1.3 fatal breast cancers per 100,000 women aged 40 at exposure, a single B.S.G.I. exam was estimated to involve a lifetime risk 20 to 30 times greater in women aged 40, and the lifetime risk of a single P.E.M. was 23 times greater.

Moreover, mammography only increases a woman’s risk for breast cancer while B.S.G.I. and P.E.M. increase the risk of cancer in other organs, such as the intestines, kidneys, bladder, gallbladder, uterus, ovaries and colon, the study said.

There is also a concern that use of the imaging technologies will become more widespread and casual. “B.S.G.I. and P.E.M. are great tools for problem solving, if you have a patient with an abnormal mammogram and you’re not really sure,” said Dr. Rhodes. “The problem is these tests are now being considered and even being used in some cases as screening tests, and this is not appropriate.”

“I’m not saying ‘Don’t do the test,’ I’m just saying ‘Don’t prescribe these tests willy-nilly like you would an ultrasound exam,’ ” Dr. Hendrick said.

In another paper in the same issue of Radiology, William R. Hendee, a distinguished professor of radiology, radiation oncology, biophysics and bioethics at the Medical College of Wisconsin in Milwaukee, called on radiologists to spearhead a campaign to reduce overuse of imaging technologies that expose patients to radiation unnecessarily and drive up health costs in the process

Suggested proposals for curbing excessive use of imaging include developing national evidence-based appropriateness criteria for imaging, educating referring physicians and the public, curbing the physician practice of self-referral and finding ways to reduce duplicate exams.

Companies that make the two nuclear-based breast imaging exams did not argue with the assessment of radiation exposure, but said the comparison with mammography — which exposes patients to very low levels of radiation, equivalent to about two months of natural background radiation — was inappropriate because the tests are used differently.

“The comparison to mammography is a bit like comparing apples to oranges,” said Doug Kieper, vice president of science and technology for Dilon Technologies Inc., which developed the B.S.G.I. technology. “This is not being used as a screening procedure for the general asymptomatic population who have no indication of disease.” He added that studies were already under way to see if the same results could be obtained using lower doses of radiation.

Guillaume Bailliard, vice president for marketing for Naviscan, which makes the P.E.M. scanner, said it should never be used as a tool for routine screening. “It is true that P.E.M. provides a higher dose than mammography,” he said, “but physicians balance the risk-to-benefit when making decisions.”

 Under pressure from doctors, some women’s groups and imaging equipment makers, lawmakers are likely to require coverage for more mammograms in health reform legislation than is currently recommended by the U.S. Preventive Services Task Force, the Wall Street Journal reports.

According to the Journal, many doctors’ and patients’ groups in recent years have formed alliances — such as sponsorships, joint events and endorsements — with companies that make mammography equipment. The groups and their corporate partners “swung into action” in November 2009 after USPSTF issued new guidelines suggesting that routine mammograms were not necessary for women in their 40s who have normal cancer risk, the Journal reports. USPSTF said the risks associated with annual mammograms — such as false positives, unnecessary treatment and low-level radiation exposure — could outweigh the benefits for many women in their 40s. The panel recommended that women ages 50 through 74 receive mammograms biennially.

The new recommendations “sowed unease and confusion,” including among major medical societies that disagree with USPSTF, the Journal reports. Advocacy groups stepped up lobbying, and their supporters “swamped lawmakers with angry calls and e-mails” urging them to guarantee access to mammograms under health reform legislation, the Journal reports.

The House in December 2009 voted 426-0 for a nonbinding resolution — named for Rep. Debbie Wasserman Schultz (D-Fla.), a breast cancer survivor — saying that insurers should not use the USPSTF recommendations to deny coverage for routine mammograms. The Senate adopted a similar amendment by Sen. Barbara Mikulski (D-Md.) to its health reform bill (HR 3590). Congressional aides say that a version of the amendment is likely to be in the final bill.

Meanwhile, a few women’s health groups that receive little or no corporate financing are standing behind the USPSTF guidelines. Fran Visco, founder of the National Breast Cancer Coalition, said, “The guidelines were always going to create a firestorm because they threaten some groups’ existence.” Adriane Fugh-Berman, a professor at the Georgetown University School of Medicine, said, “You have to ask if there’s a conflict of interest, because breast cancer advocacy has become big business.”

Sen. Chuck Grassley (R-Iowa) last month sent letters to 33 major not-for-profit groups requesting that they disclose their industry funding. The American Cancer Society said that it had received less than $1 million from screening device makers over the past five years, a sum that its spokesperson said is small compared with its more than $1 billion in annual revenue. The money does not influence ACS’ recommendations, the spokesperson added. Nancy Brinker — co-founder of Susan G. Komen for the Cure, which has received money through partnerships with GE — said the organization has always pushed for early detection (Mundy, Wall Street Journal, 1/12).

Reprinted with kind permission from http://www.nationalpartnership.org. You can view the entire Daily Women’s Health Policy Report, search the archives, or sign up for email delivery here. The Daily Women’s Health Policy Report is a free service of the National Partnership for Women & Families, published by The Advisory Board Company.

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The two techniques look at different things. Thermography looks at abnormal blood vessel formation, which is an early event in the life of a cancer. Mammography looks at masses (1 centimeter or larger) and calcification patterns, which are later developments.

Each has reliability in the recent literature of around 88 percent to 96 percent. Each misses tumors picked up by the other (perhaps as many as 10 percent). Mammography cannot visualize tiny tumors with new vessels, which show up on thermography. Conversely, tumors large enough to show up on mammography don’t always have thermographically abnormal vessels.

So, each technique is weak where the other is strong. The techniques are complementary. It is not a case of either one or the other.

One of the reasons for moving the starting age to 50 for mammograms was the vast number of negative breast biopsies for calcifications. I suspect, in my personal experience, I did 20 benign biopsies for calcification for every cancer we picked up. That is way too many, but abnormal calcifications are pretty common — and frequently benign.

Personally, I think the most prudent course for a woman to take is to get a baseline mammogram somewhere between the age of 40 and 50 (unless she has a high-risk family history, in which case earlier is better) to be reasonably sure larger lumps are not seen, and get a baseline thermography to look for early blood-vessel formation.

If both are negative, then follow with annual thermography looking for new vessel formation, with mammography every few years to look for solid lumps. Less frequent mammography means less radiation and mechanical pressure.

That regimen allows a woman to take advantage of the strengths of each technique without undue risks from radiation or unnecessary biopsy and, it seems to me, to maximize cost-benefit considerations.

— Robin A. Bernhoft, M.D., practices medical toxicology in Ojai.

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