21. Rethink Pink October Breast Cancer
Pink October Breast Cancer Month - A Closer Look at Screening Mammography
Left Image: Screening Mammogram
showing small cancer (upper left arrow), courtesy of the National Institute of
Health and wikimedia commons.
A bombshell article appeared in October 2009 JAMA (the
Journal of the American Medical Association) questioning mammography breast
cancer screening. (1) Dr. Laura Esserman
reviewed 20 years of data and concludes that screening the population for
breast cancer has significant drawbacks.
The expected survival benefits have not materialized. She says that it is true that early stage
breast cancer has decreased due to mammography, however, the data shows no decrease in the advanced, “killer”
cancers. Overall mortality rates from
breast cancer have declined slightly; however, Dr Esserman attributes this to
better treatment rather than to screening mammography.
Cases Go Up With Screening Mammography
The combined 20 years of breast cancer data shows essentially
no change in the annual cases of breast cancer cases detected, until 1983 when
screening mammography was introduced, with an immediate spike and dramatic increase
in the number of breast cancer cases detected annually, thanks to this new
diagnostic tool, the mammogram.
Cased Detected, But Only a Modest Decline in Cancer Mortality
Although screening mammography detects dramatically
more cases of breast cancer, this increased detection has not translated into
decreased mortality in the population. Yes,
mortality numbers have decreased slightly. The annual mortality rate for breast
cancer from 1930 to 2006 was stable at about 30 cases per 100,000 women, and
declined over the last few years to about 25 cases per 100,000. However, this is not due to screening
mammography. Dr. Esserman suggests this
rather modest decline in mortality is due to improvement in treatment, not
increased detection. (1)
Breast Cancer Mortality - Where's the Benefit?
While the incidence of early stage breast cancer has
decreased by 2.8 per cent per year since 2001, incidence rates of advanced
(distant-stage) disease have remained remarkably stable over this same time
period. In 2009, 192,370 women were
diagnosed with breast cancer and 40,170 women died of breast cancer. Mammography has increased the detection of
very early stage cancer, called DCIS (ductal carcinoma in situ), with 60,000
cases of DCIS detected annually, however, the number of advanced breast cancer
cases, the serious fatal type, has not changed by the introduction of
mammography screening. This lack of
benefit is disappointing.
Esserman's 2009 Observations Were Made
in 2002 by Barnett Kramer
Dr. Barnett Kramer, director of the Office of
Disease Prevention at the National Institutes of Health, was interviewed in a
2002 article in the New York Times, in which he said:
"The number of women with breast cancers with
the worst prognosis, those that spread to other organs, had been fairly
constant in the years before mammography was introduced, and that trend did not
change after the introduction of mammography...If screening worked perfectly,
every cancer found early would correspond to one fewer cancer found later. That
did not happen. Mammography, instead has resulted in a huge new population of
women with early stage cancer but without a corresponding decline in the
numbers of women with advanced cancer." (31)
Point: Mammography Has Failed to Live Up To Expectations
Mammography has not lived up to expectations. Although more cases of early
breast cancers are found, this has not reduced the number of late stage or
Weighing the Pluses and Minuses of Screening Mammography
Dr Gilbert Welch in his BMJ editorial says the
following about mammography screening for breast cancer: (7)(8)(9)
in 1,000 women annually screened for 10 years will avoid dying from breast
2 to 10 women will be over-diagnosed and treated needlessly.
10 to 15 women will be told they have breast cancer earlier than they would
otherwise have been told, but this will not affect their prognosis.
100 to 500 women will have at least one "false alarm" (about half of
these women will undergo a biopsy)
- Finding the Reservoir of DCIS
Mammography screening finds the small indolent
cancers called DCIS, ductal carcinoma in situ, that represent a reservoir of
silent disease in up to 18% of the population, demonstrated by autopsy studies.(18) This leads to over diagnosis and
overtreatment. For the invasive cancers which
we know are present in one to two per cent of the population, (demonstrated by autopsy series), screening
detection is of little help, with little change in the number of advanced
cancer cases, and about 40,000 deaths every year. Dr. Gilbert Welch sums it up with the
following sage advice: "doctors who
recommend less-aggressive mammography (less frequently, waiting until you are
age 50, or stopping it when you are older) or are less quick to biopsy may not
be bad doctors but good ones."
reason why mammography has had little impact on breast cancer mortality is
that mammography is an X-Ray imaging technique that finds small
calcifications indicating DCIS, an indolent, non-aggressive lesion with a
good prognosis. (42-50). The data suggests that finding and aggressively
treating DCIS does not reduce mortality rates from advanced breast
Just Stop Calling It Cancer
One glaring problem with screening mammography is
the detection of DCIS at a rate of 60,000 cases per year.(17) DCIS is ductal carcinoma in situ, a pathology
diagnosis which carries a very good prognosis, a 98 per cent - five year
survival. In spite of the rather benign
natural history of DCIS, mainstream medicine treats these lesions aggressively
with surgery and radiation. Recently,
the NIH has called for a change in terminology, asking pathologists to stop
calling it "cancer". 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.”(2)
Fletcher in the New England Journal Sums IT UP
Dr Suzanne Fletcher summed up the issues with
screening mammography detection of DCIS nicely in her 2003 article published in
the New England Journal with this quote: (38)
risk of death from breast cancer within 10 years after the diagnosis of DCIS (ductal carcinoma in situ) was 1.9
percent. Such an excellent prognosis
could be attributable to the detection of lesions before they become invasive
cancers, which could save lives. However, if ductal carcinoma in situ were the
usual precursor to early invasive cancer, the incidence of early-stage invasive
breast cancer should decrease as the incidence of in situ cancer increases, but the opposite is happening. Also,
autopsy studies in women who died from causes unrelated to breast cancer have
shown a substantial “reservoir” of ductal carcinoma in situ in such women.
(Welch)(18) Therefore, detection of
ductal carcinoma in situ may be an example of overdiagnosis — finding early
neoplasms, many of which will never become invasive breast cancer.
Unfortunately, ductal carcinoma in situ can progress to invasive cancer. The
eight-year rate of recurrence in one study of treatment with only surgical
excision was 27 percent, and half the recurrences were invasive cancers. It is not clear who is at risk for recurrence
and whether survival results would be the same if surgery were undertaken only
after early invasive cancer had been diagnosed. In sum, women who undergo
screening mammography are more likely than other women to be given a diagnosis
of ductal carcinoma in situ. Whether
finding it (DCIS) saves lives or merely increases the number of women who
receive a diagnosis of breast cancer is not yet clear. “endquote Dr
Just Don’t Know the Natural Course of Untreated DCIS
A large part of the problem is that we simply do not
have a good understanding of the natural course of DCIS. Although we know that some cases of DCIS will
progress to invasive cancer, many will not.
We have no reliable tools to distinguish the “stable/benign” DCIS
cases from the “aggressive” DCIS cases destined to become invasive. Dr. Erbas says, “The available evidence suggests not all DCIS will progress to invasive
cancer in the medium term but precise estimates of progression are not possible
given the limitations of the data. “(39)
Hopefully, in the near future, new diagnostic tools will be developed to
tell us which DCIS cancers need more aggressive treatment and which ones need
less aggressive treatment.
Breast Cancer 15 to 30 years after diagnosis of DCIS !!
finding is that when following DCIS cases over 30 years, invasive cancers
are found fifteen to twenty five years after the initial biopsy. (40-41) . This is remarkable. In
my opinion, this reflects an underlying nutritional deficiency, biochemical or
genetic abnormality which places the patient at increased risk for breast
cancer during their lifetime.
An Iodine Deficiency Disease?
Breast tissue takes up Iodine by virtue of an active
transport called the NIS, Sodium Iodide Symporter. (54-55) In addition, iodine deficiency is a known
risk factor for breast cancer, and iodine has been suggested as an adjuvant
treatment for breast cancer.(51-53) Are
DCIS patients Iodine deficient, and that is why these individuals have a
propensity for breast cancer ? Unfortunately,
most breast cancer studies ignore Iodine, and do not measure urinary Iodine
levels, so we don’t know the answer. In a few anecdotal cases with a history of
treated breast cancer, we have found profoundly low iodine levels. Perhaps new studies sponsored by NIH funding
can answer this question. However, in
the mean time, it is reasonable to test Iodine levels and provide Iodine
supplements to patients at risk for breast cancer or recurrence. Urinary spot iodine testing is widely available
at all national labs.
Iodine supplementation is our best
tool for breast cancer prevention.
to Prevent Breast Cancer – Our Program
1) Iodine Supplementation ( Iodoral tablets)
2) Natural Progesterone, topical cream
3) Avoid carcinogenic chemicals, xenoestrogens, pesticides, etc.
4) Vitamin D Supplementation. (Vitamin D3 capsules)
For references and links, see my web site: www.bioidenticalhormones101.com
References for Chapter 21.
Rethink Pink October Breast Cancer Mammogram
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Prostate Cancer Screening By Peggy Peck, Executive Editor, MedPage
Today October 21, 2009
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