Pioneer Press publishes my call for balance in cancer screening messages

Pioneer Press.jpg The Saint Paul Pioneer Press published an editorial I wrote in response to one of their recent news stories. I appreciate being given that forum. Unfortunately, their online version did not include the hyperlinks I provided. So I have republished the editorial here, complete with links:

It sounded so inviting, so harmless, so caring.

But it was so incomplete, imbalanced, and even potentially harmful for some readers.

When the Pioneer Press reported “Hastings hospital’s mammogram parties offer women a dose of pampering to calm the nerves (January 19, 2011),” it quoted two different hospital marketing people promoting their “Mingle & Mammograms” parties. The story described pampering, appetizers, chocolate, sparking cider or wine, flowers, swag bags, massages, foot reflexology, and cuticle paraffin treatments.

But in a 1,000-word story, fewer than 100 words even hinted that there is important scientific disagreement about mammography. More than twice as many words were devoted to what marketing people said. There was not one word about the very real tradeoff between benefits and harms of mammography for women in their 40s.

Here are some perspectives missing from such news and such promotions.

Dartmouth’s Dr. Gil Welch (author of “Should I Be Tested For Cancer? Maybe Not, And Here’s Why”) wrote about mammography in a medical journal: “The question is no longer whether overdiagnosis occurs, but how often it occurs.” He included the following table to explain the tradeoffs of harms and benefits (debits and credits) – and this was for 50-year old women, for whom the evidence of benefit is stronger than it is for those in their 40s.

Screen shot 2011-02-10 at 9.16.11 AM.jpg

Welch explains, “The benefit of breast cancer screening is that some breast cancer deaths can be avoided. Unfortunately, it doesn’t happen very often: most women destined to die from breast cancer, will still do so – even if they are regularly screened.” So while in 1 in 1,000 benefits, the other 999 would be screened for 10 years and gain nothing. Some, as shown, are harmed.

Dr. Laura Esserman, director of the breast care center at the University of California San Francisco, co-authored a journal article, “Rethinking Screening for Breast Cancer and Prostate Cancer.” Excerpt:

“After 2½ decades of screening for breast and prostate cancer, conclusions are troubling: Overall cancer rates are higher, many more patients are being treated, and the absolute incidence of aggressive or later-stage disease has not been significantly decreased. Screening has had some effect, but it comes at significant cost, including overdiagnosis, overtreatment, and complications of therapy.”

Dr. Danielle Ofri, an NYU professor of medicine, wrote a column, “The Engine of Cancer Screening Rolls On.” Excerpt:

“There are all sorts of commercial entities that stand to gain with an aggressive indiscriminate screening message. Mammography is a big business. Imagine a high-tech product (iPhone or Android for example) that 25 percent of the population needs to purchase every single year. Somebody, somewhere, is raking in boatloads of money.

Unfortunately, conveying nuance and uncertainty is not a strong suit of the media, the public discourse, or doctors, for that matter. Everyone wants clear, definitive answers from a situation that will never be able to offer one.

But complex, imperfect scientific facts rarely translate into sexy poster slogans.”

Indeed, the marketing of other screening tests has upset officials of the American Cancer Society. Dr. Otis Brawley said on a YouTube video:

“I’m very concerned. There’s a lot of publicity out there – some of it by people who want to make money by recruiting patients – that oversimplifies this – that says that ‘prostate cancer screening clearly saves lives.’ That is a lie. We don’t know that for sure… We’re not against prostate cancer screening. We’re against a man being duped and deceived into getting prostate cancer screening.”

The Cancer Society also criticized the marketing of CT scans for smokers after results of the National Lung Screening Trial were released. Excerpt:

“…although enormously promising, the data was not enough to call for routine use of this screening test …But our greatest fear was that forces with an economic interest in the test would sidestep the scientific process and use the release of the data to start promoting CT scans. Frankly, even we are surprised how quickly that has happened.”

Too often, conflicted parties exaggerate the benefits of screening tests and minimize or ignore completely the harms, the uncertainties, or the lack of evidence. They make screening decisions sound simple. They are not and should not be.

There are intelligent, informed people who say “no” to screening. You’d never know it from hospital marketing messages promoting “Mingle & Mammogram” events. We don’t usually hear from them in news stories. I know a nurse practitioner – an intelligent health care provider – who has written about why she will no longer have mammograms – even though her sister died of breast cancer.

This is not meant to discourage anyone from screening. It’s a call for accurate, balanced and complete information on screening to help people make informed choices.

That would be something to celebrate.

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Elaine Schattner, M.D.

February 10, 2011 at 11:12 am

With respect –
From Dr. Welch’s paper (BMJ, your link):
“The cumulative risk of a false positive mammogram result varies widely on the basis of geography, but women largely accept this risk. We do not know how women feel about being diagnosed at a younger age without this influencing their prognosis (those destined to die still do, those destined to survive would have done just as well if diagnosed later).”
My take:
1. Yes, the risks of false positives vary geographically. But we can reduce that risk by better training of radiologists, by certification of mammography facilities (as happens in most of the U.S.) and by the use of digital mammograms in pre and peri-menopausal women who have dense (FP-prone) breasts.
2. Excessive concern about “how women feel” is patronizing, especially if it delays their getting appropriate care.
3. It’s incorrect that being diagnosed early doesn’t help in younger women with BC: young women tend to have the most aggressive tumors, as opposed to older women among whom there’s a greater proportion of indolent tumors.
Accurate, early detection likely has the greatest impact among young and middle-aged women. This is especially true if you value their extended years of life.


February 10, 2011 at 7:00 pm

Gary, from your mouth to God’s ear. It would be so wonderful if this were the year that healthy people (who feel good and don’t have symptoms) actually got an inkling of the complexity involved in decisions about cancer screening.
It would be brilliant if 2011 was the year that marked an end to women coercing each other into getting their breasts irradiated annually – it’s clear that almost no women in the US understand the ramifications of breast cancer testing, and this has got to change.
It would be so darn fantastic if 2011 were the year that people like Dr. Schattner would stop pretending that the worst thing that can happen when women are screened for breast cancer is that their feelings could be hurt (false positive). No, Dr. Schattner, the worst thing that can happen is that they will be treated for breast cancer unnecessarily. Hopefully, some women are finally beginning to wake up to the fact that this happens. A recent NYTimes article about a NCI-funded study concerning lymph node removal in some breast cancer patients brought out a number of posts that discussed the possibility of unnecessary treatment and post breast cancer-treatment agony:
“After a lumpectomy (pin point cancer was said to have been found), 12 lymph nodes were removed (a month later). A month later 31 radiation treatments I underwent. Not only did they butcher my armpit; several years later I developed lymphedema. I’ve been hospitalized five times with cellulitis. AND find a doctor who specializes in lymphedema!!!!! Very few exist. AND what’s more I don’t think I even had cancer.”
Getting treated for breast cancer is clearly no picnic. And let’s get this straight: for every woman who gets to live longer 2 to 10 women are treated for cancer unnecessarily. And cancer treatment can ruin your life, period.
Women need to know the facts about being screened. What would be so bad about informing women of the facts and letting them make up their own minds? Talk about patronizing – it’s potentially the most important health decision a woman will make in her entire life and the powers-that-be have apparently decided that we shouldn’t worry our pretty little dumb heads about it. The current situation is dominated by people like Dr. Schattner, who lie by omission, and know they are lying. Women currently have no inkling of the stakes involved. Hopefully, people like Gary can help change this, and the sooner the better.

John LaForge

February 11, 2011 at 9:26 am

Thanks for making the hazards of breast X-rays or “mammograms” more easily understandable.
Have you ever looked into the number of breast cancers being caused by mammograms?
The late Dr. John Gofman found that mammograms cause more breast cancers than they detect.
Gofman wrote “Preventing Breast Cancer” (1996),”X-Rays: Health Effects of Common Exams” (1985), and other books on the subject. See also: “Mammography: An Individual’s Estimated Risk that the Examination Itself Will Cause Radiation-Induced Breast Cancer,” by Dr. Gofman, June 9, 1998.

Gregory D. Pawelski

February 22, 2011 at 4:59 pm

The realm of cancer early detection is just in the image scanning realm. Dr. Robert Nagourney of Rational Therapeutics, described a novel application of the cell search technology developed by Veridex, LLC (a subsidiary of Johnson & Johnson) that may provide an extemely sensitive tool for the early detection of cancer. Four major cancer centers in the United States are conducting an analysis to determine the accuracy of this method for early diagnosis.
Over recent years, it has been recognized that cancer patients circulate small numbers of tumor cells in their blood. Using microbead technology, these tumor cells can be isolated from the blood stream and characterized. The original application of the technology was a prognostic marker by which patients with breast, colorectal or prostate cancers and high levels of circulating tumor cells, fell in the “high-risk” groups. This provides a new opportunity for early diagnosis.
As we speculate on the ramifications of this discovery, certain questions are raised. The most immediate being: What to do with the data? It has previously been suggested that many cancers arise 20 or 30 years before they are clinically detected. Malignant populations measuring in the hundreds of thousands, millions or even hundreds of millions, may still lie below the radar screen of modern diagnostic tools.
If we have the capacity to identify patients 10 or 20 years before their cancers can be clinically detected, would we then begin therapy decades before clinical disease arises? If so, what treatments will we administer? Will the early detection of cancer cells be associated with the further characterization of tumors, such that targeted agents can be utilized to eliminate these clones at their earliest inception?
It will be interesting to see how we answer the questions that arise.