Is the American Cancer Society Abandoning Screening Mammography? The short answer is no!

This Tuesday’s New York Times front-page story suggested that the American Cancer Society was having second thoughts about screening campaigns. The catalyst for the New York Times story was the article “Rethinking Screening for Breast and Prostate Cancer” which appeared in this week’s Journal of the American Medical Association.

In response to the New York Times story, the ACS issued a press release that stated: The American Cancer Society stands by its recommendation that women age 40 and over should receive annual mammography, and women at high risk should talk with their doctors about when screening should begin based on their family history.

Clearly, the ACS wasn’t expecting its concerns about screening to be the highlight of the story. That said, it’s good to see a story that focuses the public’s attention on a conversation that has been going on in the medical community for some time.

Screening is predicated on the notion that all cancers are the same: they grow slowly and then “get out.” This, in turn, suggests that if we can find cancers early we can prevent them from metastasizing.  But all cancers are not the same, there are at least five different kinds of breast cancers and they have different risk factors and different levels of aggressiveness.

Mammography is best at finding what I think of as the slow growing “good” cancers. It doesn’t do as well at finding aggressive cancers when they are still at a curable stage. If “early detection” worked, we would see significantly less breast cancer deaths. But we don’t. Instead, we see a lot more breast cancer diagnoses. This tells us that mammography is finding many cancers that would not cause death in the first place. In the medical field we refer to this problem as “overdiagnosis.” When you diagnose more “good” cancers, the percentage of women dying of breast cancer will decrease. Yet, as we know, the actual number of women dying from breast cancer hasn’t really changed.

What does this mean for you? The message to women over 50 is this: There is data that regular (every one to two years) mammography will reduce a woman’s chance of dying from breast cancer by about 30%. That is a lot and is worth it. That’s the benefit.  The risk is that mammography will find a dormant or “good” cancer. What are these lesions? Autopsies of women who have died of something else show that many of these women have dormant breast cancer cells in their breasts that are not clinically significant. If these cancers had been found on a mammogram, these women would have been treated -- in fact, overtreated -- with surgery, radiation, possibly chemotherapy, hormone therapy, and targeted therapy that they did not need! All of these treatments have significant side effects, some of which can be life threatening. These include heart disease from some kinds of chemotherapy or blood clots from hormone therapy.

We shouldn’t be focusing on ways to do more screening. What we need to be doing is figuring out which cancers are significant and need to be treated and which do not.  And we need to focus on finding the cause of this disease so that we can prevent the aggressive cancers that are slipping past the screening techniques. This is the goal of the Love/Avon Army of Women, and it’s why every woman should join today!

Should we change public health messages about breast cancer screening? I think that we might want to consider relaxing the schedule of screening. We are the only country that recommends mammography screening in women every year. We are also the only country that recommends women begin mammography screening before the age of 50. I think we should reevaluate both of those recommendations.

Women over 50 can probably have mammograms every two years. We also should study whether women whose breasts are not dense (we now know that breast density is also a risk factor for breast cancer) might be able to have mammograms even less frequently, since their risk is lower.  In women under 50, there is no data to suggest that mammography saves lives at that age, and it often misses things while exposing you to radiation and giving you a false sense of security.

The bottom line: We should probably reevaluate mammography in terms of frequency and age but certainly not abandon it.  And we should focus our efforts not on finding cancers that are already there but into finding the cause of the disease and preventing it. Join the Love/Avon Army of Women and become part of stopping the disease once and for all.