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June 10, 2004 |
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Breast Health Mammography Is the Gold Standard Fool’s Gold? Fear of breast cancer is a very real issue for many women. A 1995 Gallup poll found that 40 percent of women believe they will die of breast cancer, even though the actual risk of death from the disease is less than 4 percent. I can remember feeling fearful about developing breast cancer myself when my beloved grandmother died of the disease in 1969, one year before I entered medical school. When mammography became more widely available during my years as a doctor-in-training in the early 70s, I was hopeful that this screening would fulfill its promise of saving the lives of many women. Since that time, physicians have mandated that women need annual mammograms in order to detect breast cancer at a much earlier stage, thereby allowing for more effective treatment and life-saving intervention. If you are like millions of other women, you have come to depend on this gold standard for the early detection of breast cancer. My early hopes and those of millions of others have been called into question with the recent publication of two studies in the Lancet. Danish researchers Ole Olsen and Peter Gotzsche reviewed seven randomized, controlled mammogram trials which supported the benefits of mammography in reducing the mortality from breast cancer. They found that 5 of the 7 studies were so flawed they couldn’t even be reviewed, and instead focused on the remaining two. They found that even these studies had major evaluation biases and design flaws. As a result, they determined that mammograms had no effect on deaths attributed to breast cancer. The studies also showed that, in many cases, mammograms led to needless treatments, and were linked to a 20 percent increase in mastectomies, many of which were unnecessary. Researchers speculate one reason may be that the screening identified slow-growing lesions that would never have become life-threatening had they been left alone. A National Cancer Institute advisory panel has supported these findings. In January 2002, they concluded that the benefits of mammography are uncertain and the chance of receiving a false positive result is substantial. Ironically, traditional medicine continues to support the regular and continued use of mammography, despite the overwhelming evidence to the contrary. In fact, 19 medical organizations, including the American College of Obstetricians and Gynecologists, urge women to continue receiving annual mammograms. The National Cancer Institute even extended its recommendations to include annual screenings for women age 40 and up, despite contrary advice from its own panel. I feel strongly that you should be aware of this accumulated body of negative studies regarding mammography, as well as the growing controversy within the medical community regarding its use, when you are making your own decisions about having annual mammograms. Inherent Flaws with Mammography These new studies are just the tip of the iceberg. A number of negative studies regarding mammography have appeared in the medical literature over the past decade, casting doubt as to its benefits and emphasizing its many risks. As reported in the Journal of the National Cancer Institute in 2000, the cumulative risk of having false positive mammograms is quite significant in many women. While this can occur with women of all ages, women in their 40s are at higher risk, since they tend to have denser and more fibrous breasts, which can be mistakenly read on a mammogram as suspicious for breast cancer. Andrew Wolf, M.D., an associate professor at the University of Virginia School of Medicine, supports these findings. In a May 2002 review article on breast cancer screening in Consultant, Dr. Wolf states, If we start screening at age 40, there’s virtually a 100 percent chance that some kind of abnormality will show up that will warrant at least a follow-up mammogram, an ultrasound scan, or a call from the doctor recommending a 6-month follow-up examination. There is also a high likelihood that over the course of a lifetime many women will undergo an unnecessary breast biopsy. Then there are those women who are given a false sense of security when they are told that they have a negative mammogram. Based on recent research, a June 27, 2002 article in The New York Times reported that mammograms don’t detect breast cancer in 30 to 40 percent of the women who actually have the disease. Worse yet, mammograms don’t appear to reduce the mortality from breast cancer any better than a simple breast examination, as illustrated in a 2000 study from the Journal of the National Cancer Institute. After following nearly 40,000 women between the ages of 50 and 59, researchers found that annual mammograms were no more effective than standard breast exams in reducing breast cancer mortality. In other words, mammography did not increase the survival rate of women with breast cancer, even though they were diagnosed earlier. Another study published in the Journal of the American Medical Association also found that most women age 70 and older found little benefit from mammography. Finally, some researchers even doubt the safety of mammography, questioning whether regular exposure to ionizing radiation from the screening itself may cause cancer. A 1994 study published in Lancet addressed another concern that the breast compression which occurs during a mammogram may cause small, in-situ tumors to rupture, thereby spreading cancer cells into surrounding tissues and potentially leading to more invasive cancers and metastases. My Recommendations Given all of these negative studies and the evidence that detecting breast cancer by mammography will have very little impact on reducing a woman’s mortality from this disease, I do not believe that women of any age should be told that they need to have routine, annual mammograms. Rather, I believe they should be offered the option after having a frank discussion with their physician regarding the pros and cons of the procedure. Additionally, I believe that mammography should be offered to women who have strong risk factors, such as a significant family history of breast cancer, where the benefits of early detection may balance out the risks. Thankfully, there are alternative screening techniques, such as thermography, currently under development that may be more widely available in the near future. To see if this type of testing is available near you, check with a complementary physician or naturopathic doctor in your area. I feel strongly that the best protection a woman has against breast cancer is modifying her own lifestyle towards prevention of this disease. This means engaging in regular, moderate aerobic exercise for seven or more hours per week. As reported in the October 1999 Archives of Internal Medicine, this alone can reduce the risk of breast cancer by nearly 20 percent. I also suggest that you minimize your intake of alcohol, caffeine, and saturated fat. Finally, I recommend that you perform monthly breast self-exams, and be sure to have a thorough breast examination done by your physician during your regular visits.
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