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Breast Cancer Detection (Mammography)

by Hans R. Larsen, MSc ChE

Breast cancer - The importance of a second opinion
Hans Larsen ANN ARBOR, MI. Breast cancer can present a diagnostic challenge, especially regarding such issues as the extent and histological nature of the disease. This in turn impacts management recommendations. In many cases, the initial diagnosis will not originate at a multidisciplinary breast cancer clinic. This study reviewed the medical records of 149 consecutive (to avoid bias) patients referred to such a clinic over a 1-year period. The records were reviewed retrospectively for changes in radiologic, pathologic, surgical and medical interpretations and the effect of these alterations on recommended surgical management was examined. The review of imaging studies resulted in changes in interpretations in 45% of patients studied, and this resulted in changes in surgical management in 11% of patients. Pathological reinterpretation resulted in 9% of patients having changes made in recommended surgical management, and for 34% of the patients, changes in surgical management resulted only from the multidisciplinary discussion with the surgeons, medical oncologists and radiation oncologists. Six patients were actually downgraded to benign disease. In all, approximately half the patients had a change in management as the result of this second opinion from a multidisciplinary center and for 32% of the women, the changes were based not on a disagreement about the radiology or pathology findings but rather on a different view of what constitutes the standard of care.
Newman, E.A. et al. Changes in Surgical Management Resulting from Case Review at Breast Cancer Multidisciplinary Tumor Board. Cancer, 2006, Vol. 107, pp. 2364-51.

Mammography information questioned
COPENHAGEN, DENMARK. A large study of the benefits of mammography screening for breast cancer was carried out in 2001 by the prestigious Cochrane Institute. The study questioned the benefits of screening and pointed out that screening could be harmful in that it frequently leads to over-diagnosis and over-treatment. The Cochrane Institute has now released the results of a new study aimed at determining how fairly the benefits and dangers of mammography are presented on web sites. They evaluated 13 sites maintained by advocacy groups, 11 maintained by governmental institutions, and 3 maintained by consumer organizations. They found that all the advocacy group sites accepted sponsorship from industry without restriction. The close relationship can perhaps best be summed up in this quote from the Canadian Cancer Society, "Partnership with the Canadian Cancer Society can assist your company in reaching your commercial objectives."

The researchers found that all the governmental agencies and advocacy groups heavily favoured screening and significantly downplayed the drawbacks; the consumer health organizations took a much more balanced view. The advocates particularly highlighted a 30% reduction in the risk of dying from breast cancer if regular screening takes place. They often failed to mention that this 30% reduction is a relative reduction and not an absolute reduction. Of course, emphasizing a 30% reduction is much more impressive that stating that having mammograms may reduce the risk of dying from breast cancer by 0.1% over a 10-year period. The advocates also downplayed the fact that women having regular mammograms would have a 49% chance of being recalled for a biopsy during a course of 10 mammograms and that mammograms can be painful - so painful in fact that many women refuse a second one.

The researchers conclude that, "The information material provided by professional advocacy groups and governmental organizations is information poor and severely biased in favour of screening. Few websites live up to accepted standards for informed consent such as those stated in the General Medical Council's guidelines."
Jorgensen, KJ and Gotzsche, PC. Presentation on websites of possible benefits and harms from screening for breast cancer: cross sectional study. British Medical Journal, Vol. 328, January 17, 2004, pp. 148-53

Editor's comment: It is indeed unfortunate that mammography has such a stranglehold on breast cancer detection at least in North America and Western Europe. This virtual monopoly and the enormous industry supported by it is no doubt responsible for the fact that newer, more accurate, less dangerous, and painless techniques such as thermography, scintimammography, nipple secretion analysis, and duct imaging are not given a fair trial.

New rapid, painless test for breast cancer
PHILADELPHIA, PENNSYLVANIA. The standard screening for breast cancer involves physical examination and mammography. Mammography is notoriously unreliable and often results in unnecessary biopsies and much anxiety. Researchers at the Thomas Jefferson University now report the preliminary results of a new rapid, accurate, non-invasive, painless breast cancer screening test. The test involves collecting a very small amount of breast nipple fluid (1 microliter) with an ordinary breast pump and then analyzing its protein content using the SELDI (surface-enhanced laser desorption/ionization time of flight-mass spectrometry) technique.
The researchers tested the procedure on 20 women with breast cancer and 13 healthy controls. They found that the women with breast cancer excreted five proteins that were not excreted, or excreted in miniscule amounts, by the healthy women. Thus a protein with a molecular mass of 6500 Da was found in 75 per cent of the women with breast cancer, but not in a single one without. Similarly a protein with a molecular mass of 15940 Da was found in 80 per cent of the women with breast cancer, but not in any of the healthy women. The researchers conclude that the new technique may materially aid in detecting breast cancer in its earliest stages.
Sauter, E.R., et al. Proteomic analysis of nipple aspirate fluid to detect biologic markers of breast cancer. British Journal of Cancer, Vol. 86, May 6, 2002, pp. 1440-43

Mammography debate rages on
STOCKHOLM, SWEDEN. Swedish researchers have reviewed the results of four mammography- screening trials carried out in Sweden up to and including 1996. The studies included 129,750 women who were invited to undergo screening (actual attendance rate was about 80 per cent) and 117,260 controls. The women were followed up for an average 15.8 years from time of entry to the study. During the follow-up there were a total of 22,398 deaths in the screening group of which 795 (3.5 per cent) were ascribed to breast cancer. The corresponding numbers for the control group was 20,945 total deaths of which 847 (4.0 per cent) were ascribed to breast cancer.
A closer examination of the data revealed that the benefits of mammography were limited to women between the ages of 55 and 69 years at the start of the study. The reduction in breast cancer mortality ascribed to mammography screening was 24 per cent (29 deaths per 100,000 women years versus 38 deaths per 100,000 women years in the control group) for the ages 55 to 59 years. It rose to 32 per cent for the age groups 60 to 64 years and 65 to 69 years. No statistically significant benefits were seen outside the age range of 55 to 69 years.
Dr. Karen Gelmon of the British Columbia Cancer Agency says that, "the data confirm that screening mammography has a real but modest effect to decrease mortality from breast cancer and that effect varies with age." She points out that it is still debatable whether mammography screening is of value for women under 50 years of age.
Nystrom, Lennarth, et al. Long-term effects of mammography screening: updated overview of the Swedish randomized trials. The Lancet, Vol. 359, March 16, 2002, pp. 909-19
Gelmon, Karen A. and Olivotto, Ivo. The mammography screening debate: time to move on. The Lancet, Vol. 359, March 16, 2002, pp. 904-05 (commentary)

Newspapers biased on mammography
In 1993 the National Cancer Institute concluded that there is insufficient evidence to recommend routine mammography screening for women aged 40 to 49 years. Other organizations have also questioned the benefits of screening in this age group. Yet despite this evidence most newspaper articles on the topic still push screening. Researchers at the University of Maryland reviewed 187 articles on mammography published in six American high-circulation newspapers between 1990 and 1997. They found that mammography screening was recommended twice as often as no screening for women aged 40 to 49 years. They conclude that newspapers tend to over-represent support for screening in this age group and often do not provide the sources of their information and recommendations.
Annals of Internal Medicine, Vol. 135, December 18, 2001

Mammography debate continues
COPENHAGEN, DENMARK. The prestigious Cochrane Institute has issued a review of the benefits of breast cancer screening. This latest review is based on the conclusions reached by two Danish researchers, Ole Olsen and Peter Gotzsche, in a previous study published in 2000. The review concludes that there is no evidence that mass screening mammography reduces overall mortality among women ( Says Richard Horton, editor of The Lancet in commenting on the study, "At present, there is no reliable evidence from large randomized trials to support screening mammography programs."
The Danish researchers also concluded that mass screening programs are associated with a 20 per cent increase in mastectomies and a 30 per cent increase in overall surgery ( The Cochrane Breast Cancer Group did not include this observation in the final review as they found it too controversial.
It would appear that the support for mass screening (mammography) for breast cancer is waning. The Cochrane review concludes, "The currently available reliable evidence does not show a survival benefit of mass screening for breast cancer (and the evidence is inconclusive for breast cancer mortality). Women, clinicians and policy makers should consider these findings carefully when they decide whether or not to attend or support screening programs." Editor's Note: The fact that mass screening for breast cancer is ineffectual does not mean that mammography cannot be a useful diagnostic tool if breast cancer is suspected.
Olsen, Ole and Gotzsche, Peter C. Cochrane review on screening for breast cancer with mammography. The Lancet, Vol. 358, October 20, 2001, pp. 1340-42 (research letter)
Horton, Richard. Screening mammography - an overview revisited. The Lancet, Vol. 358, October 20, 2001, pp. 1284-85 (commentary)
Mayor, Susan. Row over breast cancer screening shows that scientists bring "some subjectivity into their work". British Medical Journal, Vol. 323, October 27, 2001, p. 956

New breast cancer screening tool
Researchers at Guy's Hospital in London have developed a camera so small that it can be inserted into one of the 15 or so holes in a woman's nipple. Once inside the milk duct it can scan for lumps or dull surfaces that may be indicative of a developing cancer.
New Scientist, October 27, 2001, p. 29

Breast cancer mortality and mammography
TORONTO, CANADA. Several clinical trials have observed a reduction in mortality from breast cancer in women over 50 years of age who received regular mammograms. It is not known, however, whether this benefit is greater than that obtained by an annual physical examination alone. Researchers at the University of Toronto now report the results of a study designed to answer this question. The clinical trial involved 39,405 women aged between 50 and 59 years at time of entry into the study between 1980 and 1985. The women were randomized to receive either an annual mammogram (two- view) and physical examination of the breasts or just physical examination alone. All participants were taught and encouraged to practice self-examination as well.
By December 31, 1993 622 invasive and 71 in situ breast carcinomas had been discovered in the mammography plus physical examination group and 610 invasive and 16 in situ cases had been observed in the physical examination group only. Although the cancers tended to be discovered earlier in the mammography group there was, after 13 years of follow-up, no difference in breast cancer mortality between the two groups (107 deaths in the mammography group and 105 in the physical examination group only).
The biopsy rates were considerably higher in the mammography group. In this group 24.3 per cent of the participants underwent biopsy after the first screen as compared to 8.7 per cent in the physical examination group. The researchers also noted a significant increase in deaths from pancreatic cancer in the mammography group (42 deaths) as compared to the physical examination group (18 deaths). Although this difference is statistically significant it could, according to the researchers, be due to chance.
The researchers conclude that mammography screening does not result in a decrease in the absolute rate of advanced breast cancer and does not reduce mortality when compared to physical examination only. They suggest that physicians and their patients (women aged 50-59 years) consider the option of an annual physical examination carried out by a health professional trained to recognize the signs of early breast cancer plus regular self-examination as an alternative to annual mammograms. [43 references]
Miller, Anthony B., et al. Canadian National Breast Cancer Screening Study-2: 13-year results of a randomized trial in women aged 50-59 years. Journal of the National Cancer Institute, Vol. 92, September 20, 2000, pp. 1490-99

Older women may benefit from mammography
BOSTON, MASSACHUSETTS. Older women, that is women over 65 years of age, account for 48 per cent of all newly diagnosed invasive breast cancers and 58 per cent of breast cancer deaths. Although there have been many studies concerning the efficacy of mammography few, if any, have addressed the question "Does it benefit women over 65 years?" Researchers at the Harvard Medical School have just released the results of a study aimed at answering this question.
Their study involved almost 10,000 women aged 67 years or older who had been diagnosed with a first primary breast cancer between 1987 and 1993. The researchers found that women who had never had a mammogram were three times more likely to be diagnosed with advanced (stage II) breast cancer than were women who had regular mammograms (at least two at least 10 months apart). Women who had never had a mammogram were also three times (OR=3.38) more likely to die from breast cancer than were women who had regular mammograms. The likelihood of being diagnosed with late stage (stage II or higher) breast cancer, not surprisingly, increased with age with women over 85 who did not use mammograms having a seven times greater risk than regular mammography users. The relative risk between non-users and regular users in the 67 to 74 year age group was 2.46. The researchers noted that 38 per cent of all deaths in this group of breast cancer patients was due to breast cancer. They conclude that regular use of mammography will reduce the mortality and incidence of late stage breast cancer among women aged 67 years and older.
McCarthy, Ellen P., et al. Mammography use, breast cancer stage at diagnosis, and survival among older women. Journal of the American Geriatrics Society, Vol. 48, October 2000, pp. 1226-33

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Mammography and hormone replacement therapy
MELBOURNE, AUSTRALIA. Many women over 50 years of age are prescribed hormone replacement therapy (HRT) in order to ameliorate menopause symptoms and prevent excessive loss of bone mass. Unfortunately, HRT has been associated with an increased risk of breast cancer. It is therefore important that women on HRT be checked for breast tumors at periodic intervals. Public health authorities in most developed countries recommend screening with mammography every one or two years for women over the age of 50 years. Australian researchers now report that mammography is less accurate in women on HRT than in women not on HRT. Their study involved 103,770 women in the state of Victoria who had a mammogram for the first time in 1994. The use of HRT among these women varied from 20.2 per cent in those aged 40-49 years to almost 40 per cent in women aged 50-59 years. The detected incidence of breast cancer among women in the 50-59 year age group was 0.33 per cent (141 cases out of 43,090) for women not on HRT as compared to 0.58 per cent (100 cases out of 17,209) for women on HRT. Unfortunately, the sensitivity of the screening was found to be significantly poorer in the case of women on HRT. In the age group 50-69 years (the most vulnerable group) the sensitivity (percentage of actual cancers detected) of mammography was only 64.3 per cent among HRT users as compared to 79.8 per cent among non-users. So not only does HRT use increase the risk of breast cancer, but it also makes it significantly harder to detect. The researchers suggest that women on HRT may wish to discontinue therapy for a brief period before mammography and also recommend that women be told about the lack of accuracy of mammography in HRT users when they are faced with the decision about whether to start HRT.
Kavanagh, Anne M., et al. Hormone replacement therapy and accuracy of mammographic screening. The Lancet, Vol. 355, January 22, 2000, pp. 270- 74

Does mammography screening really save lives?
COPENHAGEN, DENMARK. Medical researchers at the Nordic Cochrane Centre have reached the surprising conclusion that "screening for breast cancer with mammography is unjustified". The researchers reviewed eight randomized trials aimed at determining the effect of mammography screening on mortality from breast cancer. The trials carried out in the United States, Canada, Scotland, and Sweden involved over 500,000 women. A careful study of the design of the trials showed that six of them were biased in a direction which would tend to exaggerate the benefits of mammography. In some of the trials the women in the screening group were significantly younger than those in the control group. In others the screened women were in a significantly higher socio- economic stratum than the women in the control group. The researchers conclude that only two studies, the Canadian Mammography Screening Study and a study carried out in Malmo, Sweden were sufficiently unbiased to be of value. The pooled results of these studies showed no reduction in breast cancer mortality due to the use of mammography screening. The researchers back up their contention that mammography screening is unjustified by pointing out that there has been no decrease in breast cancer mortality in Sweden since the introduction of mammography in 1985.

The researchers conducted a more detailed analysis of the findings from the Malmo and Stockholm trials and found that women in the mammography groups were far more likely to have undergone surgery and radiotherapy than had women in the control groups. Dr. Harry J. de Koning of the National Evaluation Team for breast cancer screening in the Netherlands comments on the Danish report in an accompanying editorial. He believes there has been a reduction in breast cancer mortality in the UK due, in part, to the national breast screening program. About 800,000 women are screened every year in the Netherlands, but no statistically significant reduction in breast cancer mortality has been found in the first nine years of the screening program. Dr. de Koning concludes that we still need answers to the question "Are screening programmes justified and at what cost to women and to society?"
Gotzsche, Peter C. and Olsen, Ole. Is screening for breast cancer with mammography justifiable? The Lancet, Vol. 355, January 8, 2000, pp. 129- 34
de Koning, Harry J. Assessment of nationwide cancer-screening programmes. The Lancet, Vol. 355, January 8, 2000, pp. 80-81 (commentary)

Mammography: A risky procedure?
ABERDEEN, SCOTLAND. Researchers at the University of Aberdeen warn that the compressive force used in order to obtain useable mammograms may be a contributing factor to breast cancer. The British standard for the force used to squeeze the breast as flat as possible corresponds to placing twenty 1 kilogram bags of sugar on each breast. The researchers fear that this force may be excessive and enough to dislocate and spread any existing cancer cells. Animal experiments have shown that the number of cancer sites can increase by as much as 80% when tumors are manipulated mechanically. A recent study in Malmo, Sweden found that the death rate from breast cancer among women under 55 was 29% higher in a group which had been screened with mammography than in the unscreened control group. The screening procedure used "as much compression force as the women could tolerate".
The Lancet, July 11, 1992, p. 122

Canadian study questions the benefits of mammography
TORONTO, ONTARIO. The results of the Canadian National Breast Screening Study are now in. This massive study involving almost 90,000 Canadian women aged 40 to 59 was carried out between 1980 and 1985 and provided for a seven-year follow-up period. The researchers conclude that although annual mammograms were found to be effective in detecting small, node-negative tumors at an early stage there was no indication that regular mammography had any impact on the rate of death from breast cancer within the 7 year follow-up period. NOTE: This study has created a great deal of controversy and has been vehemently condemned by many U.S. radiologists.
Canadian Medical Association Journal, November 15, 1992, pp. 1459-88

Vested interests attack Canadian mammography study
BOSTON, MASSACHUSETTS. The major, surprising finding of the Canadian National Breast Screening Study was that there is no evidence that screening for breast cancer with mammography is effective for women under 50 years of age. Not surprisingly, this conclusion has been vehemently attacked by American radiologists. Women in their 40s are the best customers for regular mammograms. As many as 40% of them have an annual mammogram at a cost of $50- 100 each. Now another study in Sweden supports the Canadian findings. Dr. Lazlo Tabar followed 35,000 women aged 40-49 for 11 years. He found no evidence that regular mammographic screening of these women had any benefits.
Gray, Charlotte. US resistance to Canadian mammogram study not only about data. Canadian Medical Association Journal, Vol. 148, No. 4, February 15, 1993, pp. 622-23

Is mammography necessary at all?
BOMBAY, INDIA. Dr. Mittra of Tata Memorial Hospital in Bombay adds his voice to the growing chorus of doctors and scientists questioning the value of routine mammography screening. He believes that physical examination by skilled practitioners is just as effective as mammography in detecting life- threatening tumors. He also points out that the National Breast Screening Study in Canada found no difference in mortality between women screened by physical examination alone and women screened with physical examination plus mammography. He estimates that the cost of mammography is 5-10 times higher than the cost of physical examination. Dr. Mittra points out that mammography may cause anxiety in women awaiting their test results and often leads to unnecessary biopsies and treatments. He concludes that the question is not "how to refine mammographic screening, but whether we need it at all".
Mittra, I. Breast screening: the case for physical examination without mammography. The Lancet, Vol. 343, February 5, 1994, pp. 342-44

Breast cancer screening may cause more harm than good
VANCOUVER, CANADA. Women over 40 years of age have long been advised to have an annual mammogram. Now questions are being raised within the medical community about the wisdom of this advice. Two Canadian medical professors conclude that the benefits of a general program of breast cancer screening are marginal, that the potential for harm is substantial, and that the cost is enormous. They estimate that only one in every 20,000 women screened actually receive a benefit from the procedure; this converts into a cost of about $1.2 million for each life saved. The professors do not question the value of mammography in the case of women who have signs of the disease, but consider mass screening to be a waste of resources.

An Australian team from the University of Queensland echoes the conclusions of the Canadians. They see little, if any, benefit in screening women under 50 years of age, but they do point out some of the serious negative effects - later ill effects from the radiation they are exposed to during the mammogram, the possibility that an existing tumor may spread due to the pressure exerted on the breast during screening, and the anxiety caused by frequent false- positive results. The Canadian researchers point out that a false-positive result may not only produce great stress, but may also lead to unnecessary biopsies and surgery. They also point out that mammography misses 10-15 per cent of early breast cancers thus providing a false sense of security. Both teams agree that mass screening of women under 50 years is of little benefit and has the potential to cause a great deal of harm.
Glasziou, Paul P., et al. Mammographic screening trials for women aged under 50. The Medical Journal of Australia, Vol. 162, June 19, 1995, pp. 625-29
Wright, Charles J. and Mueller, C. Barber. Screening mammography and public health policy: the need for perspective. The Lancet, Vol. 346, July 1, 1995, pp. 29-32

False positives in mammography a serious problem
STOCKHOLM, SWEDEN. Swedish medical doctors report that erroneous diagnoses of breast cancer in women screened with mammography is a serious and costly problem. Their study involved a total of about 60,000 women aged 40 to 64 years who were screened for breast cancer. Of the 60,000 women screened, 726 were referred to the oncology department for follow-up because of the detection of abnormal lesions. Additional tests confirmed that 224 of the women did indeed have cancerous lesions while the remaining 502 (70 per cent) were found to be cancer-free. The proportion of false positive results was particularly high in women under 50 years; here more than 86 per cent of the women referred for further testing turned out to be cancer-free. Of the women who did have cancerous lesions 26 per cent were found to have ductal carcinomas in situ, a form of breast cancer which is usually not considered life-threatening. The researchers point out that false positive mammograms can produce a high degree of anxiety in the women concerned. The follow-up testing is also very expensive and often lengthy; in the present study follow- up of false positive results accounted for almost a third of the cost of the entire screening programs. The authors conclude that the benefits of mammography in women under 50 years must be carefully weighed against the potentially negative aspects.
Lidbrink, E., et al. Neglected aspects of false positive findings of mammography in breast cancer screening: analysis of false positive cases from the Stockholm trial. British Medical Journal, Vol. 312, February 3, 1996, pp. 273-76

Breast cancer overdiagnosed and overtreated
SAN FRANCISCO, CALIFORNIA. Ductal carcinoma in situ (DCIS) of the breast is a fairly common non-invasive form of breast cancer. Most cases of DCIS are detected through the use of mammography. It is estimated that DCIS accounts for about 30 to 40 per cent of all mammographically detected breast cancers and constitutes about 12 per cent of all diagnosed breast cancers in the United States. Almost all cases of DCIS are treated with some form of disfiguring surgery - this despite the fact that it is unknown whether the detection and treatment of DCIS actually extend the lives of the patients. The number of detected and surgically treated DCISs has risen astronomically since the introduction of screening mammography. Between 1973 and 1983 the age-adjusted rate for DCIS rose by 53 per cent in the United States. Following the introduction of mammographic screening in 1983, the incidence of DCIS increased by 328 per cent in the period between 1983 and 1992. It is estimated that at least 200 per cent of this 328 per cent increase is due to the use of mammography. The increase in diagnosed DCIS has been particularly high in women under 50 years of age where the growth in annual incidence rate was about 4,000 per cent greater for the period 1983-1992 than for the period 1973-1983.

In 1992, about 44 per cent of all cases of DCIS were treated with mastectomy (removal of entire breast), 23 per cent were treated with lumpectomy (removal of affected area only) plus radiation, 30 per cent were treated with lumpectomy alone, and about 3 per cent were not surgically treated at all. Survival rates during the first one to nine years were generally 100 per cent irrespective of type of treatment. The use of mastectomy was found to vary widely by geographical area from 28.8 per cent in Connecticut to almost 60 per cent in New Mexico. The authors of the recent report from the University of California express serious concerns about the increasing number of DCIS cases being detected through screening mammography especially since almost all of these cases are treated with disfiguring surgery. The concern is particularly acute in the case of younger women (30 to 39 years of age) where 92 per cent of all cancers detected by mammography are classified as DCIS. The authors conclude that there is an urgent need to study the appropriateness of the various treatment options from mastectomy to watchful waiting.
Ernster, Virginia L., et al. Incidence of and treatment for ductal carcinoma in situ of the breast. Journal of the American Medical Association, Vol. 275, No. 12, March 27, 1996, pp. 913-18
Page, David L. and Jensen, Roy A. Ductal carcinoma in situ of the breast. Journal of the American Medical Association, Vol. 275, No. 12, March 27, 1996, pp. 948-49

More tests lead to more surgery
PORTLAND, MAINE. Physicians have long been puzzled why some areas of the New England states have very high rates of heart surgery while others have relatively low rates. Now researchers at the Maine Medical Center report that the amount of heart surgery (bypass surgery and angioplasty) done in an area is almost entirely dependent upon how much diagnostic testing is done in that area. In other words, it bears little or no relation to the actual prevalence of heart disease. The researchers found a strong linear relationship between the number of stress tests done in a certain geographical area and the number of subsequent angiography examinations and surgical interventions. This relationship could only be explained by concluding that more testing leads to more surgery. Other New England researchers have arrived at a similar conclusion and have also discovered that more mammography leads to more biopsies and more breast surgery, that more spine x-rays lead to more back surgery, and that more prostate biopsies and most likely more PSA tests lead to more radical prostatectomies. The researchers conclude that "how much disease is diagnosed depends on how hard one looks." They also suggest that physicians should recognize that just as more therapy may be harmful so may more diagnostic tests. The total Medicare billings by American physicians in 1993 for diagnosis and treatment of coronary heart disease exceeded one billion dollars. Medical researchers estimate that 80 per cent of all angiographic procedures are inappropriate and that half of all bypass operations performed in the United States are unneccessary or of no benefit.
Wennberg, David E., et al. The association between local diagnostic testing intensity and invasive cardiac procedures. Journal of the American Medical Association, Vol. 275, No. 15, April 17, 1996, pp. 1161-64
Verrilli, Diana and Welch, H. Gilbert. The impact of diagnostic testing on therapeutic interventions. Journal of the American Medical Association, Vol. 275, No. 15, April 17, 1996, pp. 1189-91

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Mammography screening not recommended for women under 50
SAN DIEGO, CALIFORNIA. The American College of Preventive Medicine has joined the American College of Physicians and the American Academy of Family Physicians in recommending routine annual or biannual mammography screening for women aged 50 to 69 years. The College does not recommend screening for women under 50 years as there is no evidence that this practice is useful. The proportion of false positives is high when screening younger women and there have even been suggestions that early screening may increase mortality. The Canadian Task Force on Periodic Health Examination specifically recommends against mammography screening of women aged 40-49, but does support routine annual screening for women aged 50-69. The American College of Preventive Medicine recommends further research to clarify the risk/benefit ratio of mammography screening in women under 50 years of age and also suggests that menopausal status rather than age may be a better indicator of when screening should begin.
Ferrini, Rebecca, et al. Screening mammography for breast cancer: American College of Preventive Medicine practice policy statement. American Journal of Preventive Medicine, Vol. 12, No. 5, September/October 1996, pp. 340-41

New, simple test for breast cancer developed in Japan
FUKUOKA, JAPAN. Medical researchers at the Kyushu University report the development of a new, simple test for breast cancer which is non-invasive, avoids exposure to radiation, and is exceptionally accurate. The new test involves placing an absorbent pad on the nipple and leaving it there for 24 hours to absorb the normal secretions from the area. The contents of the pad are then analyzed for the presence of carcinoembryonic antigen (CEA) using an enzyme immunoassay technique. The researchers' initial study of the new test involved 22 healthy women without any signs of breast cancer and 32 women with confirmed breast cancer. The CEA content in the pads from the healthy women averaged 0.6 units from each nipple. The amount of secretion was found to be unrelated to the menstrual cycle. The CEA content in the pads from women with breast cancer was much higher; an average of 16.1 units in the cancerous breast and 2.0 units in the non-cancerous breast. The test successfully confirmed the presence of cancer in 30 of the 32 women giving a rate of false- negative results of 6 per cent. The incidence of false-positive results was 0 per cent. The location of the densest stains (heaviest secretion) on the absorbent pad was found to be closely related to the location of the actual breast tumor. Heavy staining on the upper or lower, and outer and inner part of the pad was found to correspond with tumor locations in the upper, lower or outer or inner part of the breast as confirmed upon removal of the tumor. The researchers speculate that each CEA stain on the absorbent pad corresponds to the excretory ducts of the mammary glands that open into the nipple.
Imayama, Shuhei, et al. Presence of elevated carcinoembryonic antigen on absorbent disks applied to nipple area of breast carcinoma patients. Cancer, Vol. 78, No. 6, September 15, 1996, pp. 1229-34

Temperature sensitive pads detect breast cancer
CRANFORD, NEW JERSEY. An American engineer, Zsigmond Sagi, has developed a temperature sensitive pad which can be used to detect breast cancer in its early stages. The soft, lightweight pads are worn inside the bra for 15 minutes and are then visually analyzed for telltale signs of temperature variations. The pads record the skin temperatures across three large areas of each breast. If an area of one breast shows a temperature 2oF or more higher than the corresponding area of the other breast there is a high probability that a cancerous tumor is present. Clinical trials of the pads carried out prior to FDA approval found that they were accurate in predicting breast cancer in 80 per cent of all women and in 90 per cent of women under 50 years of age. The pad technology is particularly valuable for younger women where mammography is not very accurate and is far safer and more comfortable than mammography. The technique is, however, not suitable for women who have had a mastectomy or lumpectomy or whose breasts are mismatched for other reasons. The presence of mastitis or sclerosing adenosis can provide false postive readings due to the heat generated by inflammation. A large clinical trial of the pads involving almost 6,000 women is currently underway. This trial will compare the pad results with the results of biopsies and the participants will be followed-up for four years. NOTE: The pads, BreastAlert Differential Temperature Sensor, are available to physicians from Humascan Inc., Cranford, NJ and cost $25/pair.
Heat-seeking pads may help find early breast cancers. Journal of the National Cancer Institute, Vol. 89, October 1, 1997, pp. 1402-04

Energy medicine device detects breast cancer
LONDON, UNITED KINGDOM. The initial diagnosis of breast cancer is usually made during a physical examination or from a mammogram. The majority of the lesions or masses discovered will turn out to be benign. However, to establish this fact the women involved have to go through additional diagnostic tests such as further mammography, ultrasound, fine needle aspiration or open surgical biopsy. These additional tests are expensive and anxiety-provoking. Now a team of researchers from eight European hospitals and universities reports that an energy medicine device, the Biofield Diagnostic System, can provide accurate information as to whether an abnormal breast mass is cancerous or not. The study involved 661 women with suspicious lesions who had been scheduled for surgical biopsy. Prior to the biopsy the women were tested on the Biofield device. The test involves placing electrodes (similar to those used in obtaining electrocardiograms) on the skin over the suspicious breast mass as well as around the mass and in an identical pattern on the unaffected breast. Reference electrodes are placed on the palms of the hands. Electropotential (voltage) measurements are made over a one-minute period and recorded. The researchers found a very strong correlation between the magnitude of the differences in electropotential between the involved and uninvolved breasts and the likelihood that the suspicious lesion would be cancerous (as determined by the subsequent biopsy). The researchers conclude that the Biofield test can be used to reliably rule out malignant disease with a negative predictive value as high as 99.1 per cent. The accuracy of the test is somewhat less with non-palpable lesions because of the difficulty in placing the sensors accurately. NOTE: This study was partly funded by Biofield Corp., the manufacturer of the device.
Cuzick, Jack, et al. Electropotential measurements as a new diagnostic modality for breast cancer. The Lancet, Vol. 352, August 1, 1998, pp. 359- 63

Breast cancer screening made easy
SYDNEY, AUSTRALIA. A team of Australian, American, and Japanese researchers report the development of a new, highly-accurate test for breast cancer. The test uses a single scalp or pubic hair and was found to be 100 per cent accurate in predicting the presence of breast cancer. The hair sample is examined by X-ray diffraction using synchrotron radiation. Hair samples from breast cancer patients exhibit a characteristic change in their X-ray scattering patterns. In one trial, 23 out of 23 hair samples from breast cancer patients showed the characteristic pattern while only four out of 28 samples from healthy women had an abnormal scattering pattern. The test was also found to be useful in identifying women who were at greater risk of developing breast cancer either because of the presence of a genetic mutation or because of a family history of breast cancer. The researchers recommend further research into the sensitivity and specificity of the new test and conclude that this may lead to a simple and reliable screening method for breast cancer using a single hair.
James, Veronica, et al. Using hair to screen for breast cancer. Nature, Vol. 398, March 4, 1999, pp. 33-4 (scientific correspondence)

New, painless test for breast cancer
NEWCASTLE, AUSTRALIA. X-ray mammography is widely used to screen women for breast cancer. Unfortunately, mammography is not very accurate and can produce a significant number of false positives (no cancer present) and false negatives (cancer present, but not detected). The test can be very painful due to the compression of the breast necessary for clear pictures and there is some evidence that this compression can actually promote or spread existing cancer. There are several alternative screening tests available, but none have been able to dislodge x-ray mammography from its preeminent position. Medical researchers at the John Hunter Hospital in Australia now suggest that scintimammography may be superior to x-ray mammography in many ways. Scintimammography makes use of a radioactive tracer (Technetium-99m) which is injected into a vein followed by examination of the breasts by a gamma camera. The new test can be done using standard equipment available in any nuclear medicine department. The researchers examined 115 women scheduled for breast cancer surgery using x-ray mammography, scintimammography, and ultrasound examination and fine needle biopsy where appropriate. Of the 96 confirmed cancer cases scintimammography correctly identified 81 whereas standard mammography identified only 61. Similarly, while scintimammography failed to detect 15 existing cancers x-ray mammography failed to detect 31 cases. X-ray mammography also indicated that six out of 19 non-cancerous women had cancer while the number of false positives with scintimammography was only three out of 19. Scintimammography was found to be vastly superior to x-ray mammography in detecting cancer in patients who had had previous breast surgery or radiation treatments. The researchers conclude that scintimammography has the potential to prevent unnecessary breast biopsies and offers additional advantages in patients who have already undergone treatment for breast cancer.
Howarth, Douglas, et al. Scintimammography: an adjunctive test for the detection of breast cancer. Medical Journal of Australia, Vol. 170, June 21, 1999, pp. 588-91

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