Breast Cancer Detection (Mammography)
by Hans R. Larsen, MSc ChE
Breast cancer - The importance of a second opinion
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
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
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.
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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
Mammography and hormone replacement therapy
Does mammography screening really save lives?
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?"
Mammography: A risky procedure?
Canadian study questions the benefits of mammography
Vested interests attack Canadian mammography study
Is mammography necessary at all?
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.
False positives in mammography a serious problem
Breast cancer overdiagnosed and overtreated
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.
More tests lead to more surgery
Mammography screening not recommended for women under 50
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