Several words about the mammogram and BSE guidelines
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.
November 28th, 2009 at 4:27 pm
BSEs … (At first I thought you meant bovine spongiform encephalophy, or whatever the medical term for mad cow disease was).
Yeah, so I’ve never heard of BSEs causing cancer. I have heard of women feeling a lump and going to their doctor with a lump, getting it diagnosed as cancer. Would it have been diagnosed as cancer without her BSE? Probably, eventually. Since BSEs find larger lumps, it’s more advanced. But they can’t hurt (although it is weird examining my own breasts, I’ll admit). They might catch something you wouldn’t otherwise know about. Oh, and they’re free, by definition. So why not do them? That’s how I look at it. Plus, you also can notice things like blocked ducts or cysts (not cancers) that are still good to know about.
And intuitively, mammograms expose you to radiation. That’s why the age and frequency is debated: will the mammogram cause cancer or will it detect earlier breast cancer than you’d otherwise known? No one can know, like you say. Do most women need annual mammograms? No, most women do not need them ANNUALLY. But risk factors do come into play. That’s between patient and doctor to decide.
People wear a pink ribbon (which often doesn’t even support breast cancer) and think they’ve done their part. If you want to prevent breast cancer, you can do the same things that are THOUGHT to prevent all cancers: eat healthy (fruits & veggies), ensure you don’t over consume alcohol, maintain a healthy weight, be active. These are the things that prevent overall cancer rates, but they’re not as “flashy” or “cool” as pink ribbons, are they?
Good post! Definitely food for thought, and scientifically based!
November 28th, 2009 at 5:12 pm
Hey Krista,
Thanks for commenting!
USPSTF is recommending that women practice breast awareness, but as for the regimented, scheduled, pie chart/grid style self breast exam they haven’t been shown to make a difference in respect to mortality. I just feel like Breast Self Exams (BSE’s) are part of the “flash” of pink ribbons. They’re a simple (though false) message to women.
November 29th, 2009 at 12:45 am
I agree with you: BSE can be flash if women are not educated into their actual meaning. It’s not the be-all, end-all.
As for borrowing your cats: maybe we’ll have to look into that!
We don’t want our dog to hunt the mice – first, she probably couldn’t catch them, but second we don’t want her to learn to hunt. Currently, she tries to CHASE vehicles when we go on (leashed) walks, so we don’t want to encourage chasing!
November 30th, 2009 at 12:50 am
If lack of evidenced based care/practice/reccomendations drive your crazy in relation to breast cancer JUST WAIT until you get pregnant and start looking into birth. There are many, many, many hospital practices kept in place with no evidence that they are the best (and often evidence to the contrary) and as you can imagine, it makes me crazy.
December 14th, 2009 at 1:32 pm
I respectfully disagree about mammograms and know many active members of the oncology medical community would woud as well. All women should be advised that they should make these decisions for themselves after discussing things with their loved ones and their medical staff. Be informed and remember to make desicions that are best for you. These types of general announcements pertain to the masses but you as an individual are whats important to your loved ones.
December 14th, 2009 at 2:11 pm
@Sarah. I think you should re-read the guidelines, here is a link to them http://www.ahrq.gov/clinic/USpstf/uspsbrca.htm at the top you’ll find a quote from Diana Petitti, MD, MPH urging women to do exactly what you recommended – to have a conversation with their doctor.
December 21st, 2009 at 2:11 pm
This is a really intelligent post on a touchy issue. I’ve tried to put out the new recommendations and some reasons why I agree with them, but I get a lot of emotional knee-jerk back, like, “the administration just doesn’t want to pay for mammograms.” No, they’re just not nearly as helpful as people thought they were.
December 21st, 2009 at 2:56 pm
@blake thanks for your comment! What I were were a simple issue of science is a highly charged emotional one. I think that for so long, women have been given incorrect information and because the resources haven’t been put toward finding a better diagnostic tool women are feeling as though they don’t have another option. If not BSEs or Mammograms, then what? But we don’t have the answer, so people are understandably frustrated. It’s just a shame they’re misdirecting their anger.