To Mammo or Not Mammo (Sujatha)

A few days ago, the headlines blared that a federally appointed Task Force of doctors and scientists recommended that the age for using mammography as a screening tool to detect breast cancer be increased from the current 40-49 years to 50-59 years, be dispensed with for those older than 75 and be biannual for those in the suggested age range for screening, rather than annual, also that breast self-exam teaching to women was essentially useless and generated more anxiety than results.

A furore erupted. The American Cancer Society and almost all major medical bodies  vehemently attacked these recommendations as being unwarranted, given that the screening for women aged 40-49 has saved many lives. The emotional/familial cost benefit of a life saved vs. a thousand more women subjected to 'anxiety from needless tests' was vastly more than the corresponding economic cost benefit.

These recommendations are what happen when the cold realities of models and benefits of screenings vs. lives saved are weighed as the major factor in deciding public policy.

Among the studies quoted by the task force:

JAMA- "Rethinking screening for Breast and Prostate Cancer"

"After 20 years of screening for breast and prostate cancer, several observations can be made. First, the incidence of these cancers increased after the introduction of screening but has never returned to prescreening levels. Second, the increase in the relative fraction of early stage cancers has increased. Third, the incidence of regional cancers has not decreased at a commensurate rate. One possible explanation is that screening may be increasing the burden of low-risk cancers without significantly reducing the burden of more aggressively growing cancers and therefore not resulting in the anticipated reduction in cancer mortality. To reduce morbidity and mortality from prostate cancer and breast cancer, new approaches for screening, early detection, and prevention for both diseases should be considered."

SEER Stat Fact Sheets:

"SEER Incidence

From 2002-2006, the median age at diagnosis for cancer of the breast was 61 years of age³X Close
Table I-11 (http://seer.cancer.gov/csr/ 1975_2006/results_single/ sect_01_table.11_2pgs.pdf). Approximately 0.0% were diagnosed under age 20; 1.9% between 20 and 34; 10.5% between 35 and 44; 22.5% between 45 and 54; 23.7% between 55 and 64; 19.6% between 65 and 74; 16.2% between 75 and 84; and 5.5% 85+ years of age."

Compared with say, lung cancer, the number of women per 100,000 who die of lung cancer is approximately 40, as opposed to 24 in 100,000 due to breast cancer, from the SEER website. So breast cancer is not the number-one killer cancer of women, though with all the pink ribbons, we might think that it is the most deadly cancer for women in the US.

So, the good doctors assembled and came to the conclusion that pushing for early screenings for a cancer that is deadlier in an older age group is nonsensical, and that it causes unnecessary scaremongering for younger women who aren't quite as likely to die of breast cancer. Hence the recommendations.

But here's when the intersection occurs of  'One life saved is worth it' and emotional appeals from 100,000 women freshly diagnosed with ductal carcinoma in situ at the age of 40 or thereabouts, followed by chemotherapy regimens designed to kill those and label all of them as breast cancer survivors who proudly wear pink ribbons to announce their status, even as they muster courage to fight on, while death is held at bay through expensive medication to prevent recurrence. The argument moves from the numbers and public health policy decisions to that of emotional appeals.

As for me, maybe I'll take the middle way out, given that  I live in a much more xenoestrogenic environment in the US, as opposed to where I was born and brought up. I'll mammo after another 4-5 years, rather than immediately.

As for Pap smears, there appears to be no hue and cry over the new recommendations by the physicians' body for OB-Gynes, so I'll take their word for it and postpone those uncomfortable tests to match their new suggested schedule.

"Dr. Iglesia said the argument for changing Pap screening was more compelling than that for cutting back on mammography — which the obstetricians’ group has staunchly opposed — because there is more potential for harm from the overuse of Pap tests. The reason is that young women are especially prone to develop abnormalities in the cervix that appear to be precancerous, but that will go away if left alone. But when Pap tests find the growths, doctors often remove them, with procedures that can injure the cervix and lead to problems later when a woman becomes pregnant, including premature birth and an increased risk of needing a Caesarean."

Comments

[Ruchira]

Thanks for the common sensical wrap up on cancer screening. I was put on the yearly mammo routine by my physicians when I turned 40. I have more or less been faithful to that schedule even though my risk level for breast cancer was deemed to be very low. I always doubted the necessity of the annual "big squeeze" for a person with my risk profile, but I went along with the recommendation because 1) my doctors insisted 2)most of my friends in my peer group were following the regimen 3)the media were full of stories promoting the benefit of a yearly screening.

While I am a bit less certain about the numerous environmental triggers for breast cancer (heredity and diet are among the two more clear correlations), I was more certain of my risk for cervical cancer. After determining that my age and lifestyle put me at a minuscule risk for the latter I now no longer plan to undergo annual pelvic exams and Pap smears. In fact I haven't had one in two years and don't plan to for at least one more. I am also seriously rethinking my next scheduled mammo coming January.

Yesterday an opinion page article in the NYT by a physician from Pennsylvania echoed the recommendations of the federal Preventive Services Task Force. Here is an opposing view.

[Sujatha]

Lots of factors contribute to breast cancer: as diverse as environmental endocrine disruptors like BisphenolA, to oral contraceptives which are in common use which raise the risk slightly, to the overall estrogen/progesterone proportions in the lifetime of a woman(dependent on a variety of factors, number of pregnancies, onset of menarche/menopause, etc.). It isn't only a function of heredity and diet.
I would rate my risk as being on the lower side, based on heredity/diet/gyne history. But factoring in the environment, water and air quality where I live, it makes sense to me to wait for a few years before going in for a mammogram.
The opposing view in the NYT article cites congresswomen who have been on the opposite sides of the abortion debate. It's amazing that they share common ground over mammaries, unlike uteri;)

[kochuthresiamma p j]

the alarming increase of incidence of breast cancer in kerala has become a subject ofdiscussion here. one in eight is the latest stats. absolutely scary.
i thought US was thinking of replacing mammo with MRI cos the former is not dependable. nothing being done in that direction?

[Sujatha]

As of now, the recommendations still focus on mammography.
MRIs are still considered experimental to diagnose certain types of breast cancer.
"In women with a high inherited risk of breast cancer, screening trials of MRI breast scans have shown that MRI is more sensitive than mammography for finding breast tumors. It is common for MRI breast scan results to appear abnormal even though no cancer is present. Screening studies of breast MRI in women at high inherited risk are ongoing."

Has anyone looked into environmental factors in Kerala, or possibly toxins ingested via seafood, since that is an important protein component in the Keralite diet?