Making Sense of Mammography

I am often asked, do you really think I should get a mammography, or a colonoscopy, or whatever screening method my doctor is recommending. I understand the hesitation. Routine screening for cancer has certainly received a bad rap in the media in the past years. This is based, ostensibly, on recent studies that have raised suspicions about the effectiveness of cancer screening procedures, i.e. Do they generate more false positives than actually diagnose early cases of cancer?

Probably the first of these large studies to pave the way for “doubt” was the study published in 2001 on 266,064 women in Shanghai, China. In this study, half of the women were taught to conduct breast self-exams, meaning that they were taught to look for lumps every month on their own. If they found something, they were instructed to go to the doctor. The other half of the women who just received routine care. After ten years, the researchers determined that there was no difference in the mortality between the two groups, meaning no woman’s life was saved because she checked her breasts every month [1].

This led to an immediate wave of revised protocols and urgent press releases by health promotion organizations and government regulatory bodies all over the world. They all declared that we must stop teaching women how to check their breasts once a month, and instead promote “breast awareness.” Now, since this is a public forum, I will restrain from making all the snide comments that I think of when confronted with the term “breast awareness.” Suffice it to say that there is no one specific definition of what it means to be “breast aware.”

Then came another randomized control trial, the gold standard of research studies, in Canada in 2000. This study looked at 39,405 women, comparing those who were selected to receive routine mammographies vs. those who were not. Again, after a ten year follow up, the researchers saw no difference in mortality between those women who had received a mammography during the five year study period vs. those who had not [2].

This was followed by a 25 year follow up study showing that there was no difference in mortality between women who received mammography and those who had not [3].

Then in the prestigious journal, the Journal of the American Medical Association, JAMA, a review of all of the current statistics was published to assist women in making an informed decision when deciding whether or not to get a mammography. Their statistics? “Among 1,000 US women aged 50 years who are screened annually for a decade, 0.3 to 3.2 women will avoid a breast cancer death, 490 to 670 will have at least 1 false alarm, and 3 to 14 will be over-diagnosed and treated needlessly.”[4]

I was sent this article by a professor from a well-known university in response to my request that he participate in a training session to teach physicians how to help women from high risk communities access mammography screening. I figure you can guess at his answer.

So why, you may ask, am I still roaming the country talking to women and encouraging them to engage in routine cancer screening?

Not all cancer screening is the same

It is important to remember that today mainstream health officials recommend that women receive three types of cancer screening: Pap smears for cervical cancer, colonoscopies or FIT/FOBT for colon cancer and mammography and CBE’s (clinical breast exams conducted by a trained physician) for breast cancer. Feel free to read about these topics in my article, Ins and Outs of Cancer Screening in Israel. Men after aged 50 are also recommended colonoscopies or FIT/FOBT and everyone should be aware of changes in the shape of moles on their skin (to prevent skin cancer).

Colonoscopies and Pap smears don’t have the same bad rap as mammography. Maybe that’s because they don’t involve any x-rays in their execution and the false negative rate is much lower. Be that as it may, I do recommend all three and I will tell you why.

The cancer risk still exists

Despite all of our improvements in cancer treatment and the amazing statistics of increasing survival from many types of breast cancer, in Israel, among Jews, women have a one in nine lifetime risk of developing breast cancer. The most common age span is from age 50-65 (Israel Cancer Registry). WOMEN WHO HAVE A FAMILY HISTORY (MOTHER,SISTER,AUNT) WHO WERE DIAGNOSED, HAVE A MUCH GREATER CHANCE OF GETTING BREAST CANCER.

We are fortunate to have a test, an imperfect and inexact one, but a test nonetheless, that may reveal cancerous growths when they are in their initial stages, a fact that everyone agrees is beneficial for future survival. So in spite of the anxiety inherent in false positives, I am still in favor of routine mammography.

Yes this comes with a tradeoff and one that women must understand how to manage:

Women must accept that no screening test is perfect and cancers could be missed. There are no guarantees.
The false positive rate is high and women must be aware that even if the doctor sees something on the film, there is a strong chance that is nothing. She may need an ultrasound, another mammography or even a biopsy to rule out the possibilities. Remember, screening techniques DO create further interventions.
If, unfortunately, she does get a positive diagnosis, it is very important to have a detailed conversation with the physician about treatment options, because some findings may be pre-cancerous or, or not dangerous in the long term. Thus intervention may not actually be the best path to choose.

I do realize that what I am saying is lovely, in theory, but when a woman receives that phone call from the doctor’s secretary, or in the best case scenario, the doctor herself, the woman usually doesn’t hear anything following “Possible positive finding DEATH IS IMMINENT!”

She immediately pictures her funeral, all the family events she’ll never be at, her husband remarrying, all before she’s even rescheduled. So what I am suggesting is that a woman go into a mammography knowing that a false positive result is possible. This may help prevent her from going down that mental path if indeed it does occur.

This mindset needs to be part and parcel of any cancer screening project. Perhaps before getting a mammogram, women should receive a 45 minute therapy session about how not to “grieve” before anything has actually happened.

If you feel that is just impossible for you, and that every mammogram you go to is fraught with mental anguish, then perhaps you need to consider not going. Here, the combination of mental anguish and very real threat of a false positive may outweigh the benefits of breast cancer screening.

If, however, you feel that you can exist within the cognitive dissonance of participating in an activity, understanding the limitations and fuzziness and possible future benefits, then I HIGHLY RECOMMEND ROUTINE MAMMOGRAPHIES

Further reliable resources in English:

http://www.dslrf.org/breastcancer/

http://www.cancer.org.il/template_e/default.aspx?PageId=7645

References

Thomas DB, Gao DL, Ray RM, et al. Randomized Trial of Breast Self-Examination in Shanghai: Final Results. J Natl Cancer Inst . 2002;94 (19 ):1445-1457. doi:10.1093/jnci/94.19.1445 .

Miller AB, To T, Baines CJ,Wall C. Canadian National Breast Screening Study-2: 13-year results

of a randomized trial in women aged 50-59 years. J Natl Cancer Inst. 2000;92(18):1490-1499.

Miller, AB ,Wall, Claus ,Baines, Cornelia J ,Sun P, To, T & Narod, S A. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ. 2014; 348: 1756-1833.