Chapter 22. Mammogram Guideline Reversal – What Does It Mean?
In a dramatic break from past guidelines, the US Preventive Task Force now advises beginning screening mammograms at age of 50 instead of age 40, and advises against screening for the 40-50 age group as more harmful than beneficial. Annual frequency of screening mammograms was revised to every other year instead of annually.
Setting Back Evidence-Based-Medicine with Fear Mongering
The mainstream media, government and corporate medicine have come out opposed to these revised guidelines. Using slick marketing, fear mongering, and appealing to emotion, Kathleen Sebelius, appeared on national television and advised women to ignore her own Department's task force panel, and continue with screening mammograms in the 40-50 age group. She avoided discussing the real problem with screening mammography.
Is There a Mortality Benefit, Yes or No?
Surprisingly, this question is still under debate because the 7 or 8 randomized trials of screening mammography found differing mortality benefits. The U.S. Preventive Services Task Force USPSTF reviewed eight randomized controlled trials (RCTs) of mammography screening. The mortality benefit depends on which of the seven or eight randomized trials you regard as valid. Two of the studies had no mortality benefit at all. That is ZERO reduction in mortality. One mammography screening study for 40-50 aged women found increased mortality in the screened group (the opposite of what is expected). The most optimistic trials reported mortality reductions of 32 %. The task force did their best to sort out the studies and finally compromised on a 16% mortality reduction as a "best guess".
The 2006 Cochrane report screening for breast cancer with mammography reviewed the same 7 or 8 clinical trials and finally compromised on an estimated 15% reduction in mortality, same as the USPSTF task force. Considering the harms of screening mammography, over diagnosis, overtreatment and radiation exposure, the Cochrane report concludes."It is thus not clear whether screening does more good than harm."
Screening Mammography was once thought beneficial in young women with the BRCA gene, which carries a high risk of breast cancer. However, this was abandoned because the excess radiation itself induced breast cancer and offset any benefit. (28-29)
Instead of Mortality- Look at Local, Regional and Distant Disease Numbers
Since mortality benefits of screening mammography vary from zero to 30% depending on the study, let's take a different approach to the numbers by looking at 20 years of data on local vs. advanced breast cancer numbers. This is exactly what Laura Esserman did in JAMA (October 2009). She says:
"There are several reasons that may help to explain why screening has not led to a more significant reduction in deaths from breast cancer in the United States. First, screening increases the detection of indolent cancers. Second, screening likely misses the most aggressive cancers. In other words, tumor biology dictates and trumps stage, so the basic assumption of these screening programs that finding and treating early stage disease will prevent late stage or metastatic disease may not always be correct."
She also says "Ductal carcinoma in situ, rare prior to widespread screening, now represents 25% to 30% of all breast cancer diagnoses (>60 000 new case-diagnoses annually) ... Ductal carcinoma in situ is considered to be a precancerous lesion and standard of care is excision and adjuvant treatment. However, after 2 decades of detecting and treating DCIS, there is no convincing evidence of substantial reduction in invasive breast cancer incidence. The 2002 decrease in incidence leveled off in 2005 and is attributed to a reduction in postmenopausal hormone therapy use, not DCIS removal."
This point made by Dr Esserman in JAMA is important. Mammography screening is detecting large numbers of DCIS cases which are then treated with surgery and radiation with no real benefit in terms of reducing the numbers of invasive breast cancers.
The Basic Problem With Screening Mammography Not Mentioned by Sebelius
The Reservoir of Silent Disease
The basic underlying problem with screening for breast cancer with mammography is the "reservoir of silent disease". A series of autopsy studies show that indolent breast cancers are common in the population. These early cancers, called DCIS, are silent and rarely cause clinical disease. The most impressive study was from Denmark in 1987.(30-31) The Danish group used specimen radiography on autopsy samples, which most closely approximates screening mammography, searching small clusters of calcifications. The Danish team found breast cancer in one out of five women, most of which was DCIS (Ductal Carcinoma in Situ). One out of 5 women show breast cancer at autopsy, yet only 2 to 3 women per 10,000 die from breast cancer annually. (20% versus 0.03%) This indicates a paradox, a contradiction between a huge reservoir of silent and clinically insignificant disease, and the much smaller numbers of invasive breast cancers which actually come to medical attention. Something here does not add up.
DCIS in 18% of the Population
Current screening mammography technology detects more than 60,000 cases of DCIS annually, and this is only a small fraction of total DCIS which is present in one out of five women in the population. DCIS is ductal carcinoma in situ, an early form of cancer with good prognosis, a 98% five year survival with no treatment. I expect future refinements in x-ray technology to allow detection of even greater numbers of DCIS cases which have small calcifications. Ultimately the technology will catch up and replicate the Danish autopsy findings. Do we really want this? Do we really want to detect DCIS in one out of every five women, and then submit all these women to surgery for biopsy and lumpectomy? This is exactly what is advocated by the corporate-government-media sponsored mammography screening programs. I question this.
Just Stop Calling It Cancer
Recently, an NIH panel has asked pathologists to stop calling DCIS (ductal carcinoma in situ). Here is the NIH Consensus statement: "Because of the noninvasive nature of DCIS, coupled with its favorable prognosis, strong consideration should be given to elimination of the use of the anxiety-producing term “carcinoma” from the description of DCIS. "
Less is Better
I beg to offer a differing opinion more in line with the US Preventive Task Force revisions. The detection of massive numbers of cases of DCIS results in harmful over-treatment of the population with little benefit in terms of reduced mortality from breast cancer. This opinion is echoed by Dr Laura Esserman in a recent JAMA article on the limitations, and disappointing benefits of screening mammography. The discovery of a large reservoir of silent disease is a wake-up call that something is dreadfully wrong. Rather than screen the population for small calcifications, called DCIS, generating massive numbers of lucrative procedures with biopsies and lumpectomies that have little impact on overall mortality, I suggest a better approach.
Breast Cancer Prevention with Iodine Supplementation
The evidence is overwhelming that Iodine deficiency is a major risk factor for breast cancer, and Iodine supplementation prevents and treats breast cancer. Iodine supplementation is less expensive and more effective than corporate-government-media sponsored runaway train called mammogram screening. Iodine tablets are available OTC on the internet without a prescription.
For references and links, see my web site: www.bioidenticalhormones101.com
References for Chapter 22. Mammogram Guideline Reversal
http://www.newsday.com/opinion/oped/opinion-statistics-deny-that-early-screening-for-breast-cancer-saves-lives-1.1625438 Newsday, Opinion: Statistics
deny that early screening for breast cancer saves lives November 27, 2009 By
Barron H. Lerner, M.D
(2) http://www.latimes.com/news/nationworld/nation/la-na-mammogram17-2009nov17,0,3942708.story By Judith Graham and Thomas H. Maugh II November 17, 2009 Mammogram guidelines spark heated debate . A government panel's recommendation that women under 50 do not need regular mammograms is attacked by oncologists, gynecologists and cancer groups.
(3) http://www.annals.org/content/151/10/716.full Clinical Guidelines. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement U.S. Preventive Services Task Force. Annals Int Med. November 17, 2009 , vol. 151 no. 10 716-726.
(4) http://www.annals.org/content/151/10/I-44.full Summaries for Patients. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendations. Annals of Internal Medicine November 17, 2009, vol. 151 no. 10 I-44.
(5) http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2009/11/18/MNLT1ALVJA.DTL Anger, shock at new U.S. mammogram guidelines Victoria Colliver, Chronicle Staff Writer San Francisco Chronicle November 18, 2009.
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Life, Huffington Post, Lauren Cahn.
(8) http://www.desmoinesregister.com/article/20091119/OPINION03/911190343/-1/debatedem/New-mammogram-guidelines-are-right-approach DesMoines Register , New Mammogram Guidelines.
(9) http://www.msnbc.msn.com/id/33973665/ns/health-womens_health/ MSNBC. New mammogram guidelines
(10) http://www.euref.org/ Mammography screening offered every two years to all women aged
50-69 This is in keeping with both International Agency for Research on Cancer (IARC) recommendations and the European Council Recommendation on Cancer.Screening..
New Breast Cancer Screening Guidelines Opposed by Societies Laurie Barclay, MD
Breast cancer over-diagnosis results in unnecessary treatment for one in three. Sarah Boseley, health editor guardian.co.uk, Friday 10 July 2009
Dr. Peter Klatsky.Physician November 22, 2009 When Less Is More... Mammography and Paps
(14) http://www.nytimes.com/2009/11/23/health/23cancer.html?hpw Behind Cancer Guidelines, Quest for Data By GINA KOLATA Published: November 22, 2009
(15) http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=4194 Mammography and the Corporate Breast Medicine and Business Adriane Fugh-Berman and Alicia Bell, 11/24/2009
The Mammogram Mess Last week, new guidelines for breast cancer screening inspired a panic. Will we ever be able to discuss effective health care reasonably? by Paul Waldman, November 24, 2009.
(17) http://blog.lib.umn.edu/schwitz/healthnews/2009/11/10-things-that.html 10 things that stand out from the mammography week to remember (forget?) By Gary Schwitzer on November 23, 2009
confusion-outrage-over-new-mammogram-recommendations/ Confusion, Outrage Over New Mammogram Recommendations by Dr. Manny Alvarez .
Sebelius's cave-in on mammograms is a setback for health-care reform By Steven Pearlstein Friday, November 20, 2009 , Washington Post.
LA Times, Sebelius distances herself from new mammogram guidelines.
Health chief says mammograms at 40 right call. by Randolph E. Schmid The Associated Press
Doctors Divided Over New Mammogram Guidelines Tuesday, November 17, 2009 . Fox News.
New Guidelines on Breast Cancer Draw Opposition By RONI CARYN RABIN Published: November 16, 2009 , NY Times.
(24) http://www.dotmed.com/news/story/10839 New Mammography Guidelines Could Have Deadly Effects for American Women November 24, 2009 Hologic
47,000 Women Could Die As a Result of the New Mammogram Guidelines By George Lakoff, AlterNet. Posted November 25, 2009.
Mammograms and politics: Task force stirs up a tempest. search, recommendations for breast cancer screening have long been debated. Dan Eggen and Rob Stein Washington Post Staff Writer Wednesday, November 18, 2009
(27) http://www.medscape.com/viewarticle/712473 USPSTF Issues New Breast Cancer
Screening Guidelines Laurie Barclay, MD Medscape.
(28) http://www.ncbi.nlm.nih.gov/pubmed/11104455 MedGenMed. 2000 Mar 9;2(1):E9. Is mammography indicated for women with defective BRCA genes? Implications of recent scientific advances for the diagnosis, treatment, and prevention of hereditary breast cancer.Friedenson B.
(29) http://www.ncbi.nlm.nih.gov/pubmed/19176458 J Natl Cancer Inst. 2009 Feb 4;101(3):205-9. Estimated risk of radiation-induced breast cancer from mammographic screening for young BRCA mutation carriers. By Berrington de Gonzalez A, Berg CD, Visvanathan K, Robson M.
(30) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2002422/ Breast cancer and atypia among young and middle-aged women: a study of 110 medicolegal autopsies. M. Nielsen, J. L. Thomsen, S. Primdahl, U. Dyreborg, and J. A. Andersen,tal, Copenhagen, Denmark.
(31) http://www.annals.org/content/127/11/1023.full Using Autopsy Series To Estimate the Disease “Reservoir” for Ductal Carcinoma in Situ of the Breast: How Much More Breast Cancer Can We Find? Ann Intern Med December 1, 1997 127:1023-1028. H. Gilbert Welch, MD, MPH, and William C. Black, MD