The daily news reports over the resignations of the Founder and the President of Komen for the Cure are filled with drama. That Nancy Brinker’s life’s work seems to have been tarnished makes for compelling media. But the best outcome of this coverage could be that America engages in a serious discussion about the dangers of breast cancer screening.
Mammography: Time for a New Screening Protocol
Despite the loud protests of many breast cancer organizations and advocacy groups, the U.S. Preventative Services Task Force got it right. Women do not need as many mammograms as they are receiving.
In November of 2009, the Task Force updated its recommendations on breast cancer screening. Previous standards stated that women be screened annually from the age of 40 onwards. A furor arose over the Task Force recommendation that women between 40-49 years old should not have annual mammograms.
Overtreatment of breast cancer is epidemic, a toxic tragedy that leaves the health of hundreds-of-thousands of women compromised for the remainder of their lives. The over-treatment starts with over-diagnosis in early screening for breast cancer—the belief that early detection is the best protection. It is not.
Cancer screening enjoys virtually unquestioned cultural acceptance. On the surface, the logic of screening for breast cancer seems unassailable. A mammogram can pick up lesions as small as 0.5 cm, a size that you are seldom able to feel. The test can detect up to 85-percent of all breast cancers. In short, screening for breast cancer seems to make sense.
But the screening is not without significant shortcomings and health risks. With mammography, the weak points of screening include:
- If a woman has dense breasts, a lump is typically not visible.
- In women under 50-years of age, at least 25-percent of the tumors will be missed.
- In women with smaller breasts, the screening is even less accurate.
According to Dr. Susan Love, mammograms will miss cancers between 9- and 20-percent of the time. And if nothing is found, women are given a false sense of security that all is well.
There’s more. Approximately 5-percent of all mammograms read as positive for cancer. Of these five, 97.5-percent will be false positives. This means no cancer is present. In other words, out of every 1,000 mammograms, fifty are read as positive and between one and two will actually turn out to be breast cancer. The fact is mammograms are, for the most part, inconclusive. Yet we treat them as the gold standard of breast cancer screening.
Early screening brings a host of related risks of which American women remain uninformed. Radiation from routine mammography poses significant cumulative risks of initiating and promoting breast cancer. Contrary to conventional assurances that radiation exposure from mammography is minimal and tolerable, we have known for at least forty years that the pre-menopausal breast is highly sensitive to radiation. Each exposure increases breast cancer risk resulting in at least a cumulative 10-percent increased risk over ten years of pre-menopausal screening.
Mammography also poses a risk from breast compression. As early as 1928, physicians were warned to handle “cancerous breasts with care for fear of accidentally disseminating cells” and spreading cancer. Mammography requires tight and often painful compression of the breast, particularly in pre-menopausal women. Experts have warned that compression may lead to distant and lethal spread of malignant cells by rupturing small blood vessels in or around small, as yet undetected breast cancers.
Mammography’s reliability is seldom discussed by the medical providers with their patients. These discussions must become the norm. The message:
- Missed cancers resulting in false negative readings are especially common in pre-menopausal women. This is due to the dense and highly glandular structure of their breasts and increased proliferation late in their menstrual cycle.
- Missed cancers are also common in post-menopausal women on estrogen replacement therapy, as about 20 percent develop breast densities that make their mammograms as difficult to read as those of pre-menopausal women.
- False positive readings, which are mistakenly diagnosed cancers, are common with mammography. Again, they are common in women on estrogen replacement therapy. False positives result in needless anxiety, more mammograms and unnecessary biopsies. For a woman with multiple high-risk factors, including a strong family history of breast cancer, prolonged use of contraceptives and early menarche, the cumulative risk of false positives increases to “as high as 100 percent” over a decade’s screening.
The widespread and virtually unchallenged acceptance of this early screening protocol has resulted in a dramatic increase in the diagnosis of ductal carcinoma-in-situ (DCIS), a pre-invasive cancer. DCIS was historically recognized as micro-calcifications. For decades, they were considered benign but suspicious. The screening guidance was another test in six months to determine if there were noticeable changes.
Today DCIS is widely treated as actual breast cancer. The treatment is defended by the medical community because with current testing and diagnostic procedures, it is not possible to know if a given DCIS may become malignant or if it will disappear. Some 80-percent of all DCIS never become invasive even if left untreated. Furthermore, the breast cancer mortality from DCIS is the same, approximately 1-percent, both for women diagnosed and treated early and for those diagnosed later following the development of invasive cancer. Early detection of DCIS does not reduce mortality. This fact is startling and seems counterintuitive. But the data speaks the truth.
A Clarion Call: New Screening Guidelines
Studies do show that screening mammography does reduce the death rate in women over 50 years of age by approximately 30-percent. Early detection in this age group works. However, equal results are available from much less-invasive and non-toxic clinical breast examinations coupled with breast self-exams.
What is more worrisome are new studies which show that in women under 50, screening mammography can increase the death rate from breast cancer by up to 50-percent. The suspected reason is because these women accumulate radiation toxicity. Even more, other studies show screening mammography leads to more frequent diagnosis and aggressive treatment of breast cancer. These same studies also show aggressive screening and treatment does not decrease overall breast cancer mortality.
America clearly needs new breast cancer screening guidelines. Below is a wise approach widely accepted in countries other than the United States for women under 50-years old:
- Employ annual clinical breast examinations and monthly breast self-examinations as your primary early detection protocol.
- Once a year, every year, without fail, schedule an appointment with your healthcare provider to perform a clinical breast examination.
- Once a month, every month, without fail, set aside 15 minutes to conduct thorough breast self-examination. Perform it on the first day of menstruation.
- Schedule a mammogram only if needed for diagnosis of a suspected lump. Even then, be sure to schedule that mammogram within the first 14 days of your menstrual cycle.
For women over 50-years old:
- Employ annual clinical breast examinations and monthly breast self-examinations as your primary early detection protocol.
- Once a year, every year, without fail, schedule an appointment with your healthcare provider to perform a clinical breast examination.
- Once a month, every month, without fail, set aside 15 minutes to conduct thorough breast self-examination. Schedule it on the first day of your period if you are still menstruating.
- Schedule a mammogram if you discover a suspicious change in the feel of your breast. Even then, be sure to schedule that mammogram within the first 14 days of your menstrual cycle if you are still menstruating.
- Employ mammography screening every other year.
Annual clinical breast examination combined with monthly breast self-examination is a safe and effective alternative to mammography. That most breast cancers are first recognized by women themselves was admitted in 1985 by the American Cancer Society, the leading advocate of routine mammography for all women over the age of 40. “We must keep in mind the fact that at least 90-percent of the women who develop breast carcinoma discover the tumors themselves” Furthermore, as previously shown, “training increases reported breast self-examination frequency, confidence, and the number of small tumors found.”
A pooled analysis of several studies showed that women who regularly performed breast self-examinations detected their cancers much earlier and with fewer positives nodes and smaller tumors than women failing to examine themselves. Plus breast self examinations also enhance earlier detection of missed cancers, especially in pre-menopausal women.
Let’s be clear. The effectiveness of breast self-exam critically depends on careful training by skilled professionals. Further, confidence in self-exams is enhanced with annual clinical breast examinations by an experienced professional using structured individual training. And finally, this strategy requires discipline. Every year, a clinical breast exam; every month, a breast self-exam. If a woman cannot or will not meet that standard of discipline, the entire process stands in jeopardy.
The question of more screening extends to what have come to be known as the “breast cancer genes,” BRCA1 (BReast CAncer gene one) and BRCA2 (BReast CAncer gene two). Women who inherit a mutation in either of these genes have a higher-than-average risk of developing breast cancer and ovarian cancer.
The function of the BRCA genes is to keep breast cells growing normally and prevent any cancer cell growth. When these genes contain the mutations that are passed from generation to generation, they do not function normally and breast cancer risk increases. Abnormal BRCA1 and BRCA2 genes may account for between 5 and 10-percent of all breast cancers.
Should you choose to undergo genetic testing to find out your status? A genetic test involves giving a blood sample that can be analyzed to pick up any abnormalities in these genes. Testing for these abnormalities is not done routinely, but it may be considered on the basis of your family history and personal situation. But remember that most people who develop breast cancer have no family history of the disease.
Do mammograms save lives? The answer is very, very few. But the massive over-diagnosis and overtreatment they initiate makes routine mammography a very real health hazard. Were mammograms an automobile, The National Highway Traffic Safety Administration would have recalled them years ago. A less-is-more breast cancer screening protocol must replace our current policy. This is the first necessary shift in the evolving integrated breast cancer care model. Current annual mammography guidelines are exposing nearly all American women to exceedingly high levels of radiation. It’s part of the toxic tragedy that is making us sicker—and poorer.
The Woodlands, Texas (September 28, 2012): In honor of October as Breast Cancer Awareness month, Lilly Pulitzer will be hosting a national “Shop and Share” event on October 6, 2012. Similar to other local “Shop and Share” events held to support local organizations throughout the year, participating stores will donate ten percent of sales from the one-day event to The Breast Cancer Charities of America (BCCA). Customers can help contribute to this cause by shopping at any of the 18 Lilly Pulitzer retail stores and at over 45 participating Lilly Pulitzer Signature stores throughout the nation on that day. The donation will benefit BCCA’s primary program service, The Help Now Fund (an emergency financial assistance program that helps with the rent and utilities of breast cancer patients who are going through treatment), and The University Education Program.
