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New study questions mammograms

There's a new salvo in one of the most politically and emotionally charged debates in medicine: How often should women get routine mammograms?

That question erupted in the middle of the battle over overhauling the health care system when a federal task force recommended that women reconsider the exams before routinely getting them. Opponents of the legislation seized on the recommendation as supposed evidence that health care would be rationed. But it came as part of a long-term reassessment of the X-ray exams.

Now a new study, published in this week's issue of the New England Journal of Medicine, appears to support the federal task force's findings. It analyzed data gathered in Norway between 1996 and 2005 on more than 40,000 women in their 50s and 60s. Regular mammograms reduced the risk of dying from breast cancer by just 10 percent, which is far lower than had been thought, even by the panel that raised questions about mammograms during the health debate.

The overall breast cancer death rate in the United States has been decreasing two percent a year since 1990. Previous estimates had attributed 15 to 23 percent of the reduction in breast cancer mortality to mammograms. Instead, the findings indicate that the drop in deaths from breast cancer have come mostly as a result of other factors, such as better treatment and awareness of the disease.

Put another way, the study indicates that routine mammography reduces the number of women who will die from breast cancer from 996 per 1,000 women to 995.6. Mammograms can come at price. False positives -- as well as precancerous growths detected by mammograms that would not become life-threatening -- can prompt many women to undergo unnecessary, painful, debilitating and disfiguring surgery, radiation and chemotherapy. The Norway findings add more evidence that they should be considered more carefully. Mammograms should no longer be "an indicator of the quality of our health care system," according to H. Gilbert Welch of Dartmouth Medical School, who wrote a commentary that was published with the study.

Mammography supporters immediately attacked the study. The American College of Radiology, which has led the battle supporting mammograms, issued a detailed critique from Daniel Kopans of Harvard Medical School, a leading mammogram proponent. Among other things, Kopans argued that the study may have failed to follow women long enough to fully appreciate the benefit of mammograms.

So, this is clearly not an issue that is going to be settled by one study, or any time soon.

What do you think? Are mammograms saving lives? Or are they being overused?

By Rob Stein  | September 23, 2010; 10:37 AM ET
Categories:  breast cancer, Cancer, Medical Technology, Reproductive Health, Women's Health  
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I went to a Susan Komen supported Breast Cancer screening. I received a letter after my mammogram stating that I needed to come in again because there was something suspicious. As I was talking to my neighbor, who also had a mammogram at the same center, she also received a letter recommending an extra mammogram. Who would have thunk it?? I guess those extra mammograms really help to pay for that fancy waiting room, those peppermint candies, the flowing music. Well, three years later I went to another center (that does not have the bells and whistles) to get screened. Nothing suspicious. DUH!

Posted by: nthieret | September 23, 2010 11:15 AM | Report abuse

Until the government reduces the use of chemicals and carcingens in our everyday environment and food, and everyone has full access to latest cancer treatments w/o going bancrupt, it's better to be safe than sorry. I don't hear anybody recommend lessening prostate cancer screening for men.

Posted by: lidiworks1 | September 23, 2010 11:38 AM | Report abuse

Rob, you forgot a crucial part of the debate: Mammograms themselves can induce breast cancer. In the X-ray kind of mammograms, the breasts are exposed to radiation. This raises the risk of future breast cancer.

I also should also point out that there are many confounding factors in estimating death rates using screening processes. Often, early screening catches things that may not have killed you for 10 years or even ever. As a result, when you look at the 5-year survival rate for people, early screening can significantly increase the survival rate, even though such screening may not actually reduce any deaths over the 5-year period. The screening simply picks out more cancers, thereby increasing the denominator in the equation.

Posted by: rlalumiere | September 23, 2010 11:40 AM | Report abuse

At my baseline mammogram in my late 30s they found numerous pre-cancerous growths. I opted to have a mastectomy and later found that there was invasive cancer as well. If I had not had the mammogram I probably would not have discovered the cancer until much later. So yeah, I'm pro-mammogram.

Posted by: teadc | September 23, 2010 11:44 AM | Report abuse

After mammograms on two occasions found small growths, I went through biopsies that, happily, proved negative for cancer. The surgery may have been unnecessary, but I'm still pro-mammogram—with reservations. One is that every effort should be made to find a non-invasive procedure or group of tests that can determine whether a growth is cancerous. The other is that if mammograms for a number of years prove negative, the mammogram schedule should be every two or three years, rather than yearly, to decrease the harmful effects of exposure to radiation. In my case, this means annual exposure, possibly harmful, for more than two decades.

Posted by: DianaK1 | September 23, 2010 12:32 PM | Report abuse

This site is great to explain in plain language why women need mammograms starting at age 40.

Posted by: DrSinalin | September 23, 2010 1:00 PM | Report abuse

Both my mother and my best friend's mother were recently diagnosed with breast cancer. Both of them found out they had cancer, very early on, before it had spread, at their yearly mammograms.
Sure, fine, women who found out they had cancer later rather than sooner still may not necessarily die, but the treatment they had to go through is certainly worse than the treatment they would have had to receive if the cancer was discovered later. Surgery would be more invasive, the chance that the cancer would spread must certainly be higher etc.

The study argues that false positives force women to go through treatment, but the article doesn't give the rate of false positives. I'd imagine they must be comparatively low compared to either neutral results or actual positives.

How is it not a good idea to practice preventive medicine?

Posted by: lawschoolsophist | September 23, 2010 1:09 PM | Report abuse

To nthieret and all the other skptics - Please see the big picture and stop complaining about inconvenience and money! You should all get annual mammograms once a year after age 40 (earlier if family history)and guys should be screened for prostate cancer every year after age 40 (earlier if family history indicates). I had my mammogram yesterday -five minutes of discomfort for a year of peace of mind. Just be glad you live in this country and not in the middle of Africa - with no health care. So, you had to go back for a second screening. Did you miss Oprah - is that why you're mad! Get real and know that these screenings save lives! Stop being a whiny American!

Posted by: magenta2 | September 23, 2010 1:19 PM | Report abuse

Anecdotes aside, lawschoolsophist and others, the statistics are what are important. They bear out the important conclusions that can be drawn.

The problem, lawschoolsophist, is that you're assuming that mammograms are "preventive medicine". Well, so is getting a double mastectomy at age 30, but should we recommend all women get one? It would certainly cut down on the number of people getting and dying from breast cancer. Clearly, we need a more sophisticated idea of "preventive medicine" for it to make sense. That's where statistical analyses come into play -- they can begin to tease out the actual effect of the procedure.

In the case of mammograms, there has been slowly accumulating evidence that they are not nearly as effective at reducing deaths due to breast cancer as people had originally assumed. Presumably, people assumed this for the reasons you give -- "How is it not a good idea to practice preventive medicine?" One reason for why they are less effective than suspected has to do with what I've already said in an earlier post: You increase the 5-year survival rate because you've now detected more cancers that would have never killed the person. In fact, evidence suggests that very small tumors often resolve on their own, but no one wants to take that chance. If a doctor finds a small tumor on a mammogram, you're going to undergo treatment for it. But what if the tumor were going to go away on its own anyway? How would you know whether the treatment actually did anything, let alone whether the mammogram was even useful? You can't know that. The reality is that mammograms, due to their detection resolution, can pick out tumors that are undetectable otherwise BUT NOT ALL TUMORS EVENTUALLY GROW, SPREAD, AND KILL YOU. Obviously, those that do grow will be detected by conventional means. All in all, when you do a basic analysis on tumors detected by mammograms vs. conventional means, you may find a higher success rate for treating tumors detected by mammograms, but that may be due to feature of the tumor itself NOT because of "preventive medicine".

(By the way, what does "preventive medicine" mean in the context of cancer anyway? Wouldn't that mean preventing the cells from becoming cancerous in the first place? Detecting them, whether by mammogram or conventional means, is an after-the-fact way of doing medicine.)

Posted by: rlalumiere | September 23, 2010 1:22 PM | Report abuse

Good, diplomatic reporting, Rob. The truth sometimes hurts, yet often it releases victims from the shackles of deception. Mammograms are not safe, can lead to metastasis of otherwise benign tumors, and are inaccurate [false positives] in way too many cases. When will the general public wake up, and realize cancer is a huge business with practitioners in it for profit and livelihood?

Posted by: HealingNews | September 23, 2010 2:06 PM | Report abuse

Was the Komen center mammogram your first?

It is very common to get called back for followup from your first mammogram. If they've never seen you before, every little weirdness of your anatomy needs to be checked out and documented. Also, the younger you are, the harder it is to get a clear picture. So you may go back and have six or eight different squishes and zaps to try to get a good image of a particular area that has nothing wrong with it except it didn't come out in the picture. One radiology tech told me the callback on baselines is over 20 percent, but if they told women that, nobody would do it, so they don't tell you. I must seem weird to that gal, because I would have felt better knowing that ahead of time, instead of being told that baselines are "just so they have something to compare with if you have a problem ten years from now."

The risk of overtreatment is not huge but it is real. Many of us think it's worth it. Some think it is not. But it would be nice if the medical community would be more honest about what we're getting into when we go for a screening (of any type).

Posted by: di89 | September 23, 2010 2:28 PM | Report abuse

Everyone must concede that it is possible that the kind of early screening mammograms provide may not help prevent deaths from breast cancer. We do not want to concede that some battles cannot be won, but that may be the truth. If not detected through mammograms, how is breast cancer detected? Feeling for lumps? How were the people who survived breast cancer diagnosed? Maybe we should spend time and energy promoting those methods. Rather than spending money on mammograms that really don't seem to save lives, let's spend that money on research for a real cure.

Posted by: kimk1 | September 23, 2010 3:03 PM | Report abuse

A mammogram saved my life, not once, but twice. I don't think I can answer the question more succinctly than that.

Posted by: Fan035 | September 23, 2010 3:04 PM | Report abuse

rlalumiere, you forgot to tell us how to tell which tumors are going to go away on their own and which are going to grow and kill you. Bearing in mind that those of the latter category may well be seeding as they grow, how much growth would you tolerate before saying, "yes, let's treat this"?

Posted by: patrickd314 | September 23, 2010 3:32 PM | Report abuse

I AM PRO-MAMMOGRAM! I am alive because of a car accident, a chest CT and a mammogram. I am a 2-year, 10 month Stage IIA invasive ductile carcinoma breast cancer survivor. I am 38 years old; I was diagnosed at 35. My mother is a 10-year breast cancer survivor. We both were blesssed to find our cancers early and get early, fast treatment. I urge, encourage and will even attend if asked, my friends' mammogram appointments to ease their fears. In my heart and in my opinion, it's too important to not get one. The difference can mean life or death for the woman and financial/emotional tragedy for her family and loved ones.

Of course the gov't and big medicine want to put a price tag on people's lives and health. They feel that if they wait long enough the person will either give up fighting the red tape or die (literally and figuratively) trying to get the necessary treatment or tests; esp. if you're a minority and/or are poor. I've had to fight for my surgeries and I am a Federal employee whose premiums are taken pre-tax from my paycheck every 2 weeks without fail. I am currently fighting to get my PET/CT scans to make sure my cancer has not returned nor spread to other parts of my body, but I am going to persist and insist until I get the preventive treatment my doctor wrote a script for. It is better to pay the fees for mammograms and other preventive tests than to wait until the person is so sick that the insurance company and the patient incur huge bills and then die; the bills won't get paid for sure then (at least I hope that a death certificate will cease collection activities) and the expenses left behind will get shifted to the taxpayer in the form of increased insurance premiums and out-of-pocket expenses. "An ounce of prevention is worth a pound of cure."

Posted by: Survivor2007 | September 23, 2010 3:53 PM | Report abuse

"The American College of Radiology ... issued a detailed critique ..."

Do you hear the cash registers ringing ?

Posted by: observer31 | September 23, 2010 6:03 PM | Report abuse

I sometimes have problems with numbers and statistics. I am hoping the authors or a reader can explain this statement better:

"Put another way, the study indicates that routine mammography reduces the number of women who will die from breast cancer from 996 per 1,000 women to 995.6. "

996 out of 1000 women will die from breast cancer? Or 996 out of 1000 women diagnosed with breast cancer will die? Or out of 1000 women who were going to die from breast cancer, mammography would save 4? Or another reading that I haven't come up with yet?

Thanks for the help & clarification.

Posted by: warmfuzzymom | September 24, 2010 7:30 AM | Report abuse

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