All screening tests cause harm – but we tend to ignore that

American Cancer Society chief medical officer Dr. Otis Brawley has gone on the web with two recent videos on screening issues. His latest is on the continuing discussion about mammography recommendations for women in their 40s. The video appeared on the CNN website.

Dr. Brawley is an effective communicator. His mammography message in this clip is moderate and acknowledges that the number of lives saved by mammography in the 40s “is quite small.” But there was one glaring omission in his message: he never mentioned harms. This is a recurring theme in the discussion of screenings’ benefits and harms: the benefits tend to be emphasized and the harms tend to be minimized – or, in this case, ignored altogether.

Talk to women who’ve had false positive mammogram results and you’ll hear stories of harm. Talk to women who’ve received a diagnosis of a sometimes so-called “non-invasive” cancer like DCIS or ductal carcinoma in situ and you’ll often hear stories of harm. And such findings may occur more often the younger you do mammograms.

For truly shared decision-making to take place, women need to be given accurate, balanced and complete information on not only benefits but on harms. Then they can make their own decision. That is precisely what the US Preventive Services Task Force wrote – a recommendation that was misconstrued and miscommunicated by many who knew better. USPSTF authors wrote:

“The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.”

One of our medical editors once urged me to educate journalists about this true statement:


That’s a message that was missing in this video, as it usually is in screening discussions. We can do better.

One example of “the other side” to this discussion was published in the Washington Post this week – “Nurse practitioner explains why she refuses to endorse routine mammography.” ( Excerpted from the October issue of Health Affairs.)

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Jody Schoger

October 14, 2010 at 1:35 pm

I watched this video a number of times earlier this week, actually, and have a number of thoughts, concerns, questions and comments.
First, thanks for your continued attention on mammography, screening and breast cancer coverage. It is rife with emotional overload and as part of the breast cancer survivor population, it’s essential to me that I understand the issues.
Without going back and watching the video again, my take away was that Dr. Brawley did mention mammography drawbacks. This is also a video sponsored by the ACS, so I don’t give it the complete rating system that I would the NY Times or LA Times. He definitely stated that he didn’t care for the term “overdiagnosis” and referred to false positives. That was my impression but I will watch it again. Yes, it IS this important, because I write a blog that plenty of women read.
What I’d like to see you, Dr. Brawley, Susan Love, DJ Sampson, and breast surgeons from NCI discuss in depth — in one meeting —
1) Screening has risks. For mammography they are: false positives (how many), “overdiagnosis” treatment for the segment of DCIS cancers that never would have turned invasive, and the lifetime radiation risk (of a woman living to 80) if she starts yearly screening at 40, or 50. That is a difference of ten mammograms? The question becomes then: what is your risk of cancer from the radiation of ten mammograms.
2) I’ve seen risk reduction numbers from screening in various places. Most recent was that mammography reduced a woman’s lifetime risk of cancer by only 30% where the cervical cancer vaccine reduced the risk of cervical cancer by 90%, w/CRC screening reducing risk by 60%. Is it true that the overall effectiveness of mammography is really that low?
3) In light of the fact that literally nothing else is available for screening now (my own oncologist told me that MRI was not cost effective, and the general health of the American populations is trending overweight (a known risk), and inactive (another risk) then it seems to me Dr. Brawley’s remarks were appropriate for the state of the breast cancer screening as it is now.
This is a tough situation. Last year’s chaos over the USPSTF guidelines was awful. Let’s continue shedding light on the topic.
Thank you,
Jody Schoger

Gary Schwitzer

October 14, 2010 at 1:54 pm

Thanks for your note. I always appreciate your thoughtful perspectives.
I wonder if we’re talking about the same video.
In my blog post above, I referred to the one on the CNN site.
I just watched the one that the ACS just posted on YouTube.
I think you may be referring to this one, not the CNN video.
He never mentioned harms on the CNN video; he did on the longer ACS YouTube video.
One observation: the CNN video ran only 2:06.
The ACS YouTube video ran 6:30.
The CNN video was “hip” as one ACS staffer referred to it – carefully lit and arranged studio setting.
The ACS YouTube video looked like it was shot in cable access studio.
I prefer the meat and potatoes, cheap studio, longer YouTube video. Breast cancer – and mammography – discussions don’t need hip sets and flash. They need more time and substance.
Gary Schwitzer


October 15, 2010 at 8:26 am

It is actually interesting to hear the opposing point of view, too often we only tend to hear the ‘everything is good’ before anything else.

Gregory D. Pawelski

October 15, 2010 at 9:33 am

Dr. Brawley was quoted in the New York Times admitting “that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated.” This was the same view he had at the Stockholm news conference in 2002, on The Lancet publication of the Swedish meta-analysis. What Brawley failed to mention was the numbers the news media are flinging around are the “relative” benefit. What is obscured is the number that really matters, the “absolute” benefit.


October 15, 2010 at 6:11 pm

Dr. Brawley has expressed concerns about the lack of informed consent for prostate cancer testing in the most strident terms – he compared it to the Tuskegee syphilis “study” – a quote:
“Many of my views about ethics and misleading people about what is scientifically known and what is not known and distinguishing it from what is believed come from my experiences in working in the aftermath of the Tuskegee Syphilis Study.”
He believes that black guys have been unfairly targeted by prostate snatchers, yet he sells women down the river on breast cancer screening.
Why on earth does everyone think it’s OK to mislead women about the risks of screening mammography? Even the National Cancer Institute now posts the fact that about 33% of the “cancers” discovered by screening mammography represent overdiagnosis on its website. Something is wrong here – why is everyone OK with the fact that breast cancer incidence skyrocketed something like 40% after the advent of breast screening?
Why can’t women be told the truth about this issue?

Bob Gilmour

November 10, 2010 at 2:10 pm

Having lost my mother to breast cancer I read this with great interest. I hate to jump in the camp that says “if early screening saves just one life…” but I can’t help but wonder if things would have turned out differently if screeing in my mother’s case had started at 40. )she was 43 when diganosed and it was too late for her)