Kevin Lomangino is the managing editor of HealthNewsReview.org. He tweets as @Klomangino.
It may not be her favorite mistake, but it was a mistake nonetheless for the singer and breast cancer survivor Sheryl Crow to advocate in an aggressive, unbalanced way on behalf of a 3D mammography device.
That’s the takeaway of a number of breast cancer experts who’ve reviewed the content of the manufacturer-sponsored “education campaign” and Crow’s statements regarding breast cancer screening. They found blatant abuse of statistics and misleading guidance about the appropriate role of mammography screening in breast cancer prevention and treatment.
An obligation to market responsibly
“Celebrities need to recognize that they are not experts, and their experience does not reflect that of the general population,” said Deanna Attai, MD, an assistant clinical professor of surgery at the David Geffen School of Medicine at the University of California Los Angeles and immediate past president of the American Society of Breast Surgeons . “A celebrity endorsement or statement, especially related to a disease so prevalent as breast cancer, carries weight. I certainly understand from the corporate standpoint the desire to use a popular celebrity to endorse their product. However, companies as well as the media have a responsibility to market their products and technology in ways that are not misleading to the general public.”
According to a news release from Hologic, the Marlborough, Massachusetts-based company that markets the Genius™ 3D MAMMOGRAPHY™ exam, Crow will act as “celebrity spokesperson” for the company’s campaign that will include “a satellite media tour and social media outreach.” Among the statements that Crow and Hologic share with readers are the following:
Early detection — it’s NOT that simple
Experts emphasized that guidance around mammography is actually much more complicated than Crow’s message of “early detection saves lives.” As Dr. Attai explained, while 3D mammography may well improve the rate of early breast cancer detection, especially in women with dense breast tissue, the absolute increase in cancers detected is small and the increased detection rate comes at a price.
“Unfortunately, as mammography technology improves to provide us with clearer pictures, we also wind up detecting things that may be of little or no clinical significance, but result in the recommendation for biopsy and/or treatment. This includes benign lesions, high risk lesions, and some cancers,” she says.
In other words, a woman’s “best chance at survival” — as Crow describes early detection with 3D mammography– may not be much better than the alternative of conventional 2D screening or even no screening. And that incremental benefit needs to be weighed against the potential for increased harms from unnecessary treatment — something never addressed in the Hologic promotional materials.
“An early diagnosis does provide more options for care,” said Christine Norton, a patient advocate with the Minnesota Breast Cancer Coalition. “But an early diagnosis may be overdiagnosis. Recent research has shown that some breast cancers will never progress and some even disappear without any treatment at all. The KEY problem is definitively determining which breast cancers will progress and therefore must be treated and which breast cancers will not progress and can be watched but not treated. I wish more focus were on solving that problem.”
It is well recognized that some cases of ductal carcinoma in situ (DCIS), a type of precancerous lesion, may never pose a threat to the patient but are often treated aggressively. Treating these lesions may not be beneficial but exposes women to potential harms from unnecessary chemotherapy, radiation, and surgery.
Advocate AnneMarie Ciccarella, who blogs at ChemoBrainFog and was profiled recently in a HealthNewsReview.org podcast, also called the focus on early detection inappropriate. “To those whose disease was caught early and still metastasized outside the breast, this [early detection] messaging is insulting. To the rest of us, it’s misleading. Using a celebrity spokesperson for new technology … I have to question if we are feeding the misguided notion that we should be getting our medical information from a celebrity rather than the science community and our clinicians.”
Abuse of statistics: Fear-mongering and false hope
The Hologic campaign also trots out tired statistics that have been thoroughly debunked and are misleading. For example, the claim that “One in every eight women will develop breast cancer in her lifetime” vastly overstates the risk that most women face. Suzanne Hicks, also an active member of the National Breast Cancer Coalition, pointed to an analysis of that statistic from the Dr. Susan Love Research Foundation which notes: “[the 1 in 8 statistic] is one of the most misunderstood breast cancer statistics. [It] doesn’t accurately reflect the average woman’s breast cancer risk. Age is the most important risk factor for breast cancer, so as a woman gets older, her breast cancer risk increases, approaching a one in eight risk after age 70.” At age 40, the risk is “1.45 percent (or 1 in 68).”
And what about the idea that early detection leads to a five-year survival of “nearly 100 percent”? That’s another whopper. In fact, “If there were an Oscar for misleading statistics, using survival statistics to judge the benefit of screening would win a lifetime achievement award hands down,” noted Drs. Steve Woloshin and Lisa Schwartz in a 2012 BMJ commentary.
The “nearly 100% survival” statistic is flawed and “generates false hope about the benefit of mammography screening,” Woloshin and Schwartz wrote. The first problem they point to is lead-time bias in survival outcomes. Aggressive screening finds cancers earlier than they otherwise would have been detected, which leads to higher survival at 5 years compared with no screening even though patients may not actually live any longer than patients whose cancer was identified at a later stage. Overdiagnosis — detection of non-invasive or slow-growing cancers that would never actually cause symptoms or death — also plays into it. The more patients who are overdiagnosed with cancers that don’t need to be treated, the higher the survival rate will be.
Dr. Attai told me that in her opinion, “it is never appropriate to include cases of ductal carcinoma in situ (DCIS) when discussing breast cancer mortality, and thus I find this [nearly 100% survival] statement very misleading. The breast cancer specific and overall survival rates for DCIS approach 100%, often regardless of treatment (or lack of treatment). When physicians discuss ‘early stage’ breast cancer, we are generally referring to Stage I and II invasive disease. Survival rates for these early stage invasive breast cancers vary depending on stage as well as tumor biology. As we learn more about tumor subtypes and tumor biology, it is becoming clear that stage at diagnosis is only one factor impacting breast cancer survival rates, and in some cases, it may not be the most important factor.”
Spare us the encore
This isn’t the first time that Crow has been called out for giving simplistic advice to women about breast cancer screening. In a 2014 AARP profile where she called her cancer diagnosis “a gift,” she also gave a blanket recommendation for regular mammograms that some breast cancer patient advocates found wanting.
In the new Hologic campaign she calls for all women to get regular mammograms at age 40 — a statement that conflicts with evidence-based screening guidelines from the US Preventive Services Task Force and American Cancer Society (ACS). These organizations recommend, respectively, that screening be done regularly starting at age 50 or 45, and that women at average risk be encouraged to have “a discussion of screening around the age of 40 years” that includes “information about risk factors, risk reduction, and the benefits, limitations, and harms associated with mammography screening” (ACS recommendation).
Women might reasonably choose to start mammograms at age 40 and some organizations endorse that starting point. But no matter the recommendation, any discussion of mammography should be more nuanced than the “get screened” message that Crow is putting out there. And it can’t be ignored that this simplistic message happens to dovetail nicely with the interests of the company she’s being paid to promote.
Crow is a prolific endorser of products ranging from hair coloring to the Wall Street Journal. But breast cancer screening isn’t something anyone should be hawking with simple slogans and trumped up statistics.
As advocate Suzanne Hicks told me, “Just as not all women are successful entertainers, not all cancers are equally risky. Risk factors…..gender, age, race, etc……should be the focus of the doctor/patient partnership, not a technology promotion campaign.”