First, I should point out that the opinions represented here are my own, and my own understanding of these issues. Now that the disclaimer is out of the way, let me proceed to tell you why I’ve felt like punching myself in the face the past few days regarding the USPSTF recommendations for mammograms and Breast Self Exams (BSE).
First, I’d like to touch on the points that are continually being misrepresented in the media, discuss uncomfortable yet counter intuitive evidence (all cancers not created equal, BSE) , and finally what I feel is missing out of the whole debate.
Misrepresentations? Well, the first “I’m going to scream feeling” comes anytime I hear people generalize cancer, women at risk, or mammograms. Let’s start with mammograms, the mammograms that USPSTF is discussing are related to screening mammograms. Screening mammograms are for the general population, women who haven’t discovered a lump, who have no symptoms, and are at various risk rates. Who are the USPSTF guidelines for? Women who turn 40 and turn up for a mammogram because that’s what their doctor says to do. Diagnostic mammograms are for women who have symptoms, have found lumps, etc. Not a single soul is telling anyone that if they find a lump they should do nothing.
At risk women, as defined by USPSTF guidelines are women “with a family history of breast cancer in a mother or sister, a previous breast biopsy revealing atypical hyperplasia, or first childbirth after age 30”. Additionally, “the recommendation for women to begin routine screening in their 40s is strengthened by a family history of breast cancer having been diagnosed before menopause”. So, if you’re in any of those categories, pay no attention to the news.
Mammograms are not prevention. BSEs are not prevention. A mammogram and a BSE will not prevent you from having breast cancer. In fact “a 1997 review, using risk estimates provided by the Biological Effects of Ionizing Radiation report of the National Academy of Sciences, estimated that annual mammography of 100,000 women for 10 consecutive years beginning at age 40 would result in up to 8 radiation-induced breast cancer deaths”. So, once again, mammograms and BSEs are not preventative measures.
Here is the part that is counter intuitive. The question that should be asked around mammography is “does mammography save lives” yet the question that is often asked is “does mammography find cancer”. Not all cancers are created equal, not by a long shot! So when DCIS (Ductal Carcinoma In Situ) is found it’s not quite cancer yet. Cancer, by definition is invasive, and since this cancer isn’t invading yet, it isn’t technically cancer. However, there is currently no way to tell what DCIS will turn in to. There is the chance it could regress, there is the chance it could become very, very aggressive. But we don’t have the diagnostic tools to tell us which is will be. So at the moment, many women (and men) are treated incredibly aggressively, because there isn’t a way to tell the minority from the majority when it comes to slow growing or aggressive cancers.
A 40 year old woman can’t know if a mammogram saved her life, because there isn’t a way to tell what type of cancer her lesion would become at the time she was diagnosed. She could have found it a year later in the shower, or in while getting dressed. She could have had a slow growing cancer that wouldn’t have harmed her, or she might have a cancer that is responsive to treatment (because few are) and her prognosis would have remained the same. Or she could have had a very aggressive tumor that responds to no treatment. Again, there is now way to tell. The debate shouldn’t rest on anecdotes, it should rest on evidence. Though, that didn’t help the breast cancer community in the 90’s when similar recommendations were made. There was an outcry and Congress overruled the NIH’s suggestions. Where has the pink ribbon taken us?
Instead of focusing on scientific evidence people are clinging to the pink ribbon safety blanket. Instead of directing your outrage at the guidelines, how about getting angry that women have been told a simple and false message for so many years?! Why aren’t we putting all the time, money, resources and focus that goes to shower cards and BSE’s towards research that will make a difference. There simply isn’t enough evidence to support a broad screening program and we should be putting our resources to find what works.
If you’re curious, you should check out this link, ’cause I agree with these folks.
