BMJ: Mammograms for ages 40-59 useless

Nrdsb4 · February 14, 2014, 1:34pm

Has the question been answered that early detection via mammogram, while not extending life, can indeed improve quality of life (vis a vis less radical surgeries, delaying metastasis, etc.)? Or do we care only about cure vs. death?

gouf78 · February 14, 2014, 1:57pm

Just remember the study showed women are OVER diagnosed with cancer and receive treatment even though they did not have cancer.

actingmt · February 14, 2014, 2:11pm

“Everyone in Washington”? The USPSTF in 2009 reduced the recommendations for mammogram screening for breast cancer. It was every 1-2 years for women age 40 and over, changed to every 2 years for women age 50-74 and based on individual factors for women age 40-49. That ignited a political firestorm about health care rationing and death panels, ironically with the supposed “conservatives” arguing against the (incidentally cost-saving) reduction in mammogram screening."

True. Everyone in Washington is obviously incorrect. That was a clumsy attempt to avoid politics. My apologies. There are those who think we should all decide these personal health matters individually and there are those who think a government appointed panel should make the decision and the taxpayer should provide the funding. Useless or not. And, as others have said, perhaps even harmful, which is just scary.

GTalum · February 14, 2014, 2:28pm

But it does tell us that. It tell us there was no difference in mortality, which also typically means survivorship (how many years of living with cancer). I am not sure we have the evidence of how tumor load effects mortality/survivorship.

No Nrdsb4, it doesn’t tell us about quality of life, but we don’t know a lot such as whether early detection by mammogram does delay metastasis. Of course we have studies that show that stage 1 breast cancer has a better cure rate, but how many of those cancers would not be detected without a mammogram and never would have been a problem? In that case, someone can argue they decrease quality of life.

MJMAMA · February 14, 2014, 3:13pm

Part of what’s misleading is the title of the thread, “mammograms for ages 40-59 useless.” I think we’d all agree that they are not “useless.” I don’t think that it’s all or nothing and it’s a very difficult issue. Some women have increased risk factors and obviously should have more aggressive screening. The bigger issue is routine screening for the rest of us. I do believe that there are many unnecessary procedures and a lot of over-treatment that result from all of this screening, but that’s not enough reason for me to stop having mammograms, as much as I hate them. I think that US physicians have relied on mammograms(and technology in general) for so long, that I wouldn’t trust many of them to do as thorough a physical exam as may happen in places without such easy access to testing. And I wouldn’t expect them to be so quick to dismiss mammograms as necessary, because we live in a very litigious society. Would you want to be the physician who says that screening mammograms are unnecessary when one of your patients ends up having a delayed diagnosis? You would still be blamed. It doesn’t matter what the study shows. There are always patients who are outliers and no one would want to take that risk. That being said, this study is very important for individuals deciding when and if they want to have screening mammograms.

moonchild · February 14, 2014, 3:36pm

This is one study. There have been many over the years that have shown that early detection saves lives. It’s very easy to find them - Science Daily has published several from research groups over the years.

<a href=“Breast cancer screening saves lives, new study shows | ScienceDaily”>http://www.sciencedaily.com/releases/2012/09/120906112253.htm</a>

<a href=“Mammography significantly lowers death rate in women 40-49 | ScienceDaily”>http://www.sciencedaily.com/releases/2010/09/100930101551.htm</a>

I’m not in favor of mammo screening for everyone every year, but my fear is that people will read this info and think that it really doesn’t matter when you find breast cancer, and that’s just not true. The problem with waiting until the tumor is felt is that it is larger and more likely to have spread. There really is no argument about this- larger tumors are more likely to have already found their way into the blood stream, whether they are found in the nodes or not.

People who argue that early detection isn’t important, I’ll give you two options. Imagine that you have been told you have breast cancer, and you get to choose; a tumor that is one centimeter, or one that is two and a half centimeters. So how many of you would say, “meh, makes no difference. You pick.” The fact is that many women present with tumors much larger than that from the get-go because they have not been screened by a professional, and the tumor may be close to the chest wall or not felt due to breast density, other cysts, etc.

Treating cancer while it’s small won’t guarantee you are cancer free, it certainly improves your chances. Once the cancer load is larger and creating more blood vessels, metastasis is more likely. This is not speculation.
While some are railing against the medical community for over treatment, where is the outrage that 40,000 women are dying every year from breast cancer? Frankly, there is not enough research in curing this disease once it has progressed beyond the breast. There are billions of dollars going into awareness, but relatively little press showing what living with metastatic disease means. Women don’t die from Stage I disease, and yes, you can manage it for a long time, but once these women have progressed beyond the pink ribbon stage, it’s not such a pretty picture. That’s 40,000 women every year, dead.

Where do mammograms fit into this? They are not an answer, but one tool in finding something that will kill you if you without treatment. Does it find other stuff that doesn’t kill you without treatment? Sometimes, but that’s why you follow up with other means of diagnosis and testing.

Lergnom · February 14, 2014, 3:38pm

Flipping through the pages of comments … I think it’s extremely important to emphasize the non-mammogram group was screened by trained professionals. I almost put that in capital letters.

We tend to refer to mammography as “screening”. I heard Nancy Snyderman say that twice on NBC News. It’s radiation based screening, not “screening”; every woman in the Canadian study received regular screening, just half were not radiation screened on top of manual screening by a trained professional.

I think the study clearly makes this point: trained screening without radiation is as good as trained screening plus radiation screening. Period. Can’t go without trained screening.

The next level, which they could not investigate because this was a controlled study, is whether careful identification of risk factors could improve results by selecting more of those people who could benefit from adding radiation screening to trained screening without harming a bunch of people unnecessarily.

JHS · February 14, 2014, 3:38pm

cptofthehouse: You are right when you say the study doesn’t address what kinds of treatments people received. You are dead wrong when you suggest that the study doesn’t measure when they died, as opposed to whether they died. What is devastating about the study is how little difference there was between the two groups as to how many women died of breast cancer and when, relative to enrollment in the study, not relative to when they were diagnosed.

This chart shows the rate of death from breast cancers diagnosed during the five-year screening period: <a href=“http://www.bmj.com/highwire/filestream/686205/field_highwire_fragment_image_l/0.jpg[/url]”>http://www.bmj.com/highwire/filestream/686205/field_highwire_fragment_image_l/0.jpg</a> If you drill down, you see that women in the mammography group tended to die of cancers diagnosed early in the screening period, whereas in the control group deaths were weighted to cancers discovered at the end of the screening period, but when the women died was very close to the same. Note that most of the women in both groups were being treated successfully. There were 1,190 cancers diagnosed during the screening period, resulting in 351 deaths from those cancers over the 25-year course of the study.

As one would expect, women in the mammography group were diagnosed with cancer at a higher rate compared to the control group, and were treated for cancer at a higher rate. So their “survival” rate was much higher and their death rate much lower – there were lots more diagnoses in the denominator for essentially the same number of cancer deaths, at the same times, in the numerator. In the mammography group 180 women died over 25 years of 666 cancers diagnosed in the screening period; in the control group 171 women died from 524 cancers diagnosed. If you look out 10 years, as one would expect, the control group caught up somewhat with the mammography group in terms of cancer diagnoses, but there remained a gap of about 100 diagnoses in the mammography group that were never reflected in the control group.

This chart shows the rate of breast cancer death for all women in the study over a 25-year period, including those diagnosed in the screening period and those diagnosed later: <a href=“http://www.bmj.com/highwire/filestream/686204/field_highwire_fragment_image_l/0.jpg[/url]”>http://www.bmj.com/highwire/filestream/686204/field_highwire_fragment_image_l/0.jpg</a> If you look at the numbers, there seems to be a tiny advantage for the mammography group – a difference of about 2 in 10,000 women, but the chart shows that that difference doesn’t even show up until 25 years after enrollment, which means 20+ years after the screening period ended. Before that, there’s no difference in when the women died of cancer.

Nrdsb4 · February 14, 2014, 3:42pm

gouf78 said:

No, according to the OP, that’s NOT what the study shows:

moonchild · February 14, 2014, 3:48pm

Yes, Bay. That’s it. There are other studies, many actually, that say otherwise, however.

Lergnom- yes, thank you.

Decorative22 · February 14, 2014, 3:48pm

The Swedish study promoting the usefulness of mammography screening has been shown to be highly flawed. Repeatedly:
<a href=“http://mobile.dudamobile.com/site/preventdisease?url=http%3A%2F%2Fpreventdisease.com%2Fnews%2F10%2F093010_study_ignores_mammogram_dangers.shtml#2436”>http://mobile.dudamobile.com/site/preventdisease?url=http%3A%2F%2Fpreventdisease.com%2Fnews%2F10%2F093010_study_ignores_mammogram_dangers.shtml#2436</a>

From the article:
“This is a very unscientific study based on findings and conclusions which completely ignore the potential risks and dangers associated with mammograms,” said Dr. Kimberely Schor, a panelist who examines medical research.

<hr>

There are many many rebuttals available online to show why.

Change is hard. It is really when we feel comforted by feeling as if we are doing something to help, and it is really hard when we realize that the things we think are helping, in the end, are not helping, and are harming.

moonchild · February 14, 2014, 3:58pm

And there are rebuttals to the Canadian study as well. It’s not hard to find a study that shows mammogram benefit. What makes this one news is that it doesn’t.
And it may be right. But it’s just one study.

Almost all medical procedures have the capacity to harm, unfortunately. That means we need to try to improve them. I’d love to see women have the option of MRI or ultrasound every other year. We would still find things that might not need treatment, but we can only act on what we know, and right now, we don’t know which cancers are going to kill us.

Decorative22 · February 14, 2014, 4:05pm

The Canadian study is not the only one that shows this information. It just expands the previously known information and age range. Confirming and expanding.

I understand the pull towards keeping things as they have been. What I am unable to do is accept and continue a practice that the best evidence shows does not work.

Even if that counters what the part of me that is fearful would wish.

I would really like to believe and accept that more good than bad comes from current practice.

But it doesn’t. And that is why I firmly believe ( with apologies to Maya Angelou) that when you know better, you do better.

Decorative22 · February 14, 2014, 4:13pm

Another Swedish Study:

<a href=“New Swedish Mammography Research Finds No Survival Benefit”>New Swedish Mammography Research Finds No Survival Benefit;

In an interview with Medscape Medical News, Dr. Autier said that these “results reinforce the growing body of data showing that randomized trials on mammography screening were biased and ended up with results that suggest that reductions in breast cancer mortality are associated with screening.”

He added that mammography screening increases the diagnosis of indolent cancers that are not life-threatening (overdiagnosis). “One should think about alternatives to mammography screening and provide women with information more in line with questions about the effectiveness of that screening test.”

moonchild · February 14, 2014, 4:35pm

If anyone wonders why I’m rather passionate about early detection, it’s because I didn’t find my cancer early enough, and I now have Stage IV disease. There is no doubt that had my cancer been found before it had spread to my blood stream, I would not be facing death from this disease.

Because my tumor was small- less than 2cm- and close to the chest wall, I never felt it. One day after a sharp pain on that breast, I went to the doctor for an exam, and he sent me for a mammogram where it appeared. Had I gone for either a mammo OR a doctor exam the year prior, (hadn’t been for over two years) it would have been found and most likely would not have progressed with treatment. As it was, I was Stage I at the original diagnosis- no node involvement- but because it had already found it’s way into my blood stream,unknown at diagnosis, it set up shop in my bones.

It’s not an aggressive cancer- it’s has been stable in my spine, skull, hips and ribs for 2 1/2 years with a short course of radiation and my monthly medications. I’m fortunate to have the newest, promising treatments and doctors, and I have an excellent quality of life. When my mets were discovered, I was numb from the chest down because the cancer had eaten through my vertebra and was pressing on my spinal cord. I thought I had injured myself from weight training. Well, I had actually, but not in the way I thought. If it weren’t for the treatments from some very knowledgeable doctors, I’d be in a wheelchair for the rest of my life.

I’m doing very well now, walk my dog a few miles a day, garden, enjoy my family, danced at my son’s wedding, and while know my days are numbered, I have hope that a new treatment will be in the pipeline by the time this one stops working. But, omg, how much better it would have been to have been diagnosed when the tumor was half the size! The stats for tumors less than a centimeter are really quite good. They can often stay in remission indefinitely with treatment.

I feel there is a small window of time a woman has a breast cancer that has the potential to metastasize to have it removed before it grows enough blood vessels to sustain it and travel in the bloodstream, and it’s different for every cancer, depending on the body’s environment and a lot of things we don’t know. Would I have been safe at .8, or 1cm? Or even 1.2? No one knows. But at some earlier point, had I known about it and had it removed, that would have been enough and I’d be worried about getting a recurrence instead of living with one.

JHS · February 14, 2014, 4:57pm

moonchild, my understanding is that it IS hard to find studies showing benefits from mammograms. I am not a scholar in the field at all, I just happen to have some friends who are. They have been intensely skeptical of mammogram benefits for decades.

This article is just the latest in a series of articles reaching the same conclusion. This one makes a big splash because of the size of the study (90,000 women, in six different Canadian provinces), the actual randomization, which is very rare in public health studies, and the long period of time over which the women were tracked (25 years). It also shows that there is no difference between women in their 40s and women in their 50s. There had been earlier articles from the same study, but mammogram proponents kept arguing that the time periods looked at were not long enough to capture the benefits of earlier detection.

Public health bodies have been recommending de-emphasizing mammography for years, and facing heated opposition from radiologists and oncologists (whose rice bowls are being broken), from cancer-related charities, and from survivors who (like many here) fervently and understandably believe that mammography saved their lives.

Honestly, it’s easy for me to write this stuff, but I know from experience that when a friend is told she has DCIS or a small tumor, and she decides to treat it aggressively, I never even come close to questioning that decision to her face. I say, “I’m so glad you caught it early” and “I am praying that the treatment works and you are cancer-free.” Because I am praying that.

Cardinal_Fang · February 14, 2014, 5:00pm

I’m really sorry about your cancer, moonchild. I can understand why you get emotional talking about breast cancer. I hope that a new treatment comes along for you.

That being said, I have to point out this statement, while true, is misleading:

The Canadian study calculated that of the cancers that were detected by mammogram but weren’t palpable, fully half of them never would have progressed during the lifetime of the woman. It’s not surprising, then, that small tumors often stay in remission with treatment, since half of them stay in remission without treatment.

Screening mammogram advocates say that we have to catch small tumors before they can be felt, because otherwise they’ll get big and CANCER CANCER AAAAAH! We now know, however, that in half the cases, rather than CANCER CANCER AAAAAH! the result would be … nothing.

moonchild · February 14, 2014, 5:07pm

JHS-Of course you wouldn’t question her decision- you might make the same one faced with a similar situation. You don’t know until you’ve been there.
But yes, I’m on board with finding a better way to detect early BC- not wedded to mammography at all. If women would actually go to a well-trained doctor or NP for annual manual exams, that would help- but they
don’t. And telling women that early detection makes no difference is certainly not going to get them to the GYN!
So I hope that the message of this study is that, while early detection is important, mammograms are not better than yearly, professional manual screening. But some kind of screening will save lives.

moonchild · February 14, 2014, 5:19pm

Hey, I’ll take that “nothing” half, any day. You won’t find me feeling too sorry for women who have a cancer that doesn’t metastasize, even if they have to take Tamoxifen for a few years. The real problem, and why they are treated “for nothing” of course, is that there’s no way to know it’s for nothing, at this point in time. 
Hey, researchers- drug companies. Let’s find out why some cancers grow and kill us and some don’t.

Decorative22 · February 14, 2014, 5:37pm

I am very sorry about your cancer, Moonchild. I understand your passion.

BMJ: Mammograms for ages 40-59 useless

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