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Why did last week’s mammography study get so much news, but the DCIS study didn’t?

Last week, journalists were handed a wonderful opportunity to educate readers about one important part of the dilemma in breast cancer screening recommendations.  Most of them blew the chance.

Two unrelated papers were published in two different journals.   But while the work behind the papers was unrelated – different research teams with a different focus – the topics of the two were inseparable. Yet, only one received widespread mainstream news media attention.

young woman mammogramThere was a great deal of news coverage about a special report in the New England Journal of Medicine, “Breast-Cancer Screening — Viewpoint of the IARC Working Group,” a report from experts from 16 countries in the International Agency for Research on Cancer. Somewhat predictably – and somewhat like the old tale of the blind men and the elephant – different journalists reported markedly different angles on the report. Some headlined it:

  • Breast screening helps save lives, say experts
  • Breast cancer screening reduces risk of death
  • Screening reduces risk of breast cancer death by 40 per cent

Others headlined it:

  • International Group Says Mammograms Of ‘Limited’ Value For Women In 40s
  • Panel Doesn’t Back Mammograms in 40s

Here’s what the international group actually wrote: “After a careful evaluation of the balance between the benefits and adverse effects of mammographic screening, the working group concluded that there is a net benefit from inviting women 50 to 69 years of age to receive screening…..the evidence of efficacy for women in other age groups was considered inadequate.”  The group said it reaffirmed its earlier evaluation that the evidence of benefit was “limited for women 40 to 49 years of age, and inadequate for women younger than 40 or older than 69 years of age.” 

The Associated Press reported:

“The new advice gives a global perspective, coming from 29 cancer experts from 16 countries, convened by the International Agency for Research on Cancer. They include Dr. Robert A. Smith, breast cancer screening chief for the American Cancer Society, which has long recommended annual mammograms starting at age 40. The cancer society soon will update its own guidance, said its chief medical officer, Dr. Otis Brawley. The international panel’s stance ‘does demonstrate that there is legitimate scientific question about screening women in their 40s,’ he said.”

But there was almost no mainstream news media coverage  – NPR and HealthDay were all I could find – on a paper in JAMA Surgery, “Survival Benefit of Breast Surgery for Low-Grade Ductal Carcinoma In Situ.” 

Breast surgeon Deanna Attai*, president of the American Society of Breast Surgeons, and one of our editorial contributors, offers this background on ductal carcinoma in situ or DCIS:

“Ductal carcinoma in-situ is also referred to as noninvasive, or Stage 0 breast cancer. It is primarily diagnosed by screening mammogram, as it often does not form a palpable lump. DCIS accounts for approximately 20% of mammographically detected breast cancers. As screening mammography has become more prevalent, the rate of DCIS detection has increased. As DCIS does not always progress to invasive cancer, it is a very reasonable for a newly diagnosed woman to ask “Do I need surgery?”

Dr. Attai said the NPR headline, “Surgery Doesn’t Help Women With Early-Stage Breast Carcinoma,” was misleading.  Early stage breast cancer can refer to Stages 0, I, and 2, and the study cited only refers to low grade ductal carcinoma in situ – sort of the earliest of the earliest of Stage 0. But most of the NPR story was right on target. Excerpt:

“DCIS doesn’t always progress to invasive breast cancer, which is the life-threatening kind. In fact, some physicians and researchers, including a working group convened by the National Cancer Institute, say it’s not accurate to call DCIS a form of cancer at all, and that the terminology is contributing to overly aggressive treatment.

“We are certainly overtreating this disease, but we haven’t figured out who can get less treatment, no treatment or active surveillance,” says Mehra Golshan, a breast surgeon at Brigham and Women’s Hospital in Boston.”

Why were NPR and HealthDay the only two mainstream news organizations that I saw that reported on both studies?  Maybe because more of these organizations live and die each week by whatever comes from the New England Journal of Medicine rather than the lesser known JAMA Surgery journal? Or is it because the mammography study allowed journalists to light another match under the health care controversy they find so easy to fire up, while the DCIS study presented an issue they don’t know about or don’t understand? Many times, when speaking to groups of journalists, I’ll ask how many know what DCIS is.  A few hands pop up.  Then I ask how many have reported about it.  Even fewer hands.

In my mind, the two studies are inextricably connected. And the fact that more news organizations didn’t connect the two may show why so many news consumers are so confused about these complex issues.

The younger you start mammograms and the more you do them, the more likely it is that DCIS will be the leading troublesome finding from the mammogram.  And DCIS may be one of the biggest treatment dilemmas in all of medicine.

In a comment left online in response to a recent Health Affairs Blog post, “Breast Cancer Screening: Let Evidence Trump Fear,” a woman wrote:

“Thank you for this excellent article. I am one of thousands of women who have been HARMED with OVER diagnosis and OVER treatment of DCIS thanks to a mammogram. Thankfully I took the time to investigate this problem and got an expert 2nd pathology opinion and said NO to mastectomy, radiation therapy and tamoxifen….all were being pushed heavily… after a core needle biopsy and 3 lumpectomies (which did not get clean margins)……all of these procedures are very invasive and the emotional toll is even worse. Then come all the bills…very stressful…and the docs just want to prescribe Xanax! Nobody really understands what the harms truly mean…unless you live through it. We must find a better solution than mammograms as they find too many NON cancers and miss too many aggressive cancers. My story and resources to help other women be more informed about DCIS and support for less aggressive treatment options can be found on my blog: http://www.dcis411.com more resources with studies here: http://www.dcisredefined.org “

Dr. Attai says:

“The concern is that we are overdiagnosing and overtreating many women. It is estimated that approximately 25-50% of cases will likely progress to invasive disease – 60% over 10 years for high grade vs 16% for low grade. Given the low rate of progression to invasive disease, it is not surprising that no survival advantage was seen after surgery for patients with low-grade DCIS (in the JAMA Surgery article).”

Journalists struggle with how to capture the complexity of mammography screening studies.  They apparently struggle with (or don’t know about) the problem of DCIS. And not many have done a deep dive on how a shared decision-making encounter could take place between a truly informed patient and her physician.

For journalists who live by the latest out of the journals, last week provided a golden opportunity.  It’s not too late to do a followup.

* Please see Dr. Attai’s complete blog post on the latest DCIS study on her own blog, in a piece entitled, “Do I Need Surgery For DCIS?

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Comments (3)

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Michael Benjamin

June 9, 2015 at 12:43 pm

These new findings are not really surprising given the well-known limitations of breast imaging technology. In addition, it’s hard to leave emotion out of the discussion, and both screening and anti-screening voices have staked out a moral high ground.
Clearly we are failing too often on both fronts–failing to prevent all cases of advanced disease even with screening, and overdiagnosing clinically insignificant disease. I’m hopeful the public will increasingly recognize what an inexact science breast cancer screening continues to be–hopefully broader demand for a better answer will spur innovation.

S. E. Miller

June 9, 2015 at 1:44 pm

Unfortunately, the media would rather stir up controversy instead of presenting women with balanced information that would allow them to make an informed choice. The recent report from the IARC stated that a 23% reduction in death from breast cancer was seen in the women invited for screening and a 40% reduction in the women that attended screening. Every news article that I read selected the 40% figure. If there’s a 23% reduction in death for the women who are just invited to be screened whether or not they actually have a mammogram, the 40% reduction cannot be totally from mammograms. I read one article from a British Newspaper that interviewed a physician at the IARC convention. The physician said that the 40% reduction was likely exaggerated. It was based on observation and not a randomized study. Of course, the harms of overdiagnosis were downplayed once again.

Patricia Battaglia

June 16, 2015 at 2:49 pm

There are nuances to the issue of screening for breast cancer, as your comparison and connection between the two above papers highlight so well. But nuance is lost when attempting to make a one-size-fits-all recommendation. The fear of underdiagnosis is real, as are the harms of overdiagnosis. I fall firmly in the camp of those who hope someone, somewhere is working on a better answer. But breast cancer is too confoundingly difficult a disease for me to believe we will ever have a completely accurate screening tool. I would, however, be very happy to see improvements to the current state of affairs.