More abut stop mammography

Source: Vancouver Sun

Radiologist Dr. Paula Gordon, a leading B.C. breast-cancer expert and medical director of BC Women's Breast Health Program, predicts an increase in cases and deaths if women and doctors pay too much heed to “alarming” recommendations from a Canadian task force. Gordon is pictured at a press conference in January 2011.

Radiologist Dr. Paula Gordon, a leading B.C. breast-cancer expert and medical director of BC Women’s Breast Health Program, predicts an increase in cases and deaths if women and doctors pay too much heed to “alarming” recommendations from a Canadian task force. Gordon is pictured at a press conference in January 2011.

Photograph by: Nick Procaylo, PNG files

VANCOUVER — A leading B.C. breast-cancer expert predicts an increase in cases and deaths if women and doctors pay too much heed to “alarming” recommendations from a Canadian task force.
Radiologist Dr. Paula Gordon doesn’t deny that screening can occasionally lead to false positives, overdiagnosis and overtreatment. But she said certain studies were ignored — including a B.C. one — that show a 25-per-cent reduction in mortality among women screened by mammograms.
The task force also put too much stock on research that was poorly designed or was done decades ago, she contends.
“False positives can indeed cause harm because they can be traumatizing, and I agree that women should consider the potential harm of screening. But it is absurd that the task force is recommending no self-examination by women [without risk or symptoms] and no clinical examination by family doctors,” said Gordon, who was reacting to the task force report as chairwoman of an early detection working group of the Canadian Breast Cancer Foundation (BC/Yukon). She is also medical director of the breast health program at B.C. Women’s Hospital.
“This puts us back to the 1960s because the task force relied on old trials using equipment that is now obsolete. So it’s advising women in their 40s to make decisions based on scientific evidence that is older than they are,” said Gordon, referring to the advice against regular screening for low-risk women aged 40 to 49.
Gordon said mammograms do turn up abnormalities that are not cancerous, but false positives are inevitable and occur in all screening tests, including pap smears for cervical cancer. However, she cited surveys that show even with the risks of false positives, women would still rather have tests or even biopsies done, rather than delay diagnosis and treatment.
As to the task force’s recommendation that women at average risk of breast cancer have no need to routinely examine themselves or seek the same from doctors, “women are effectively being told to wait till they see a lump in their breast in the mirror before they seek treatment.
“ By that time, even with excellent care, mortality rates will return to what they were in the 1970s.”
Task force members, including Simon Fraser University researcher Michel Joffres, said not all breast tumours require treatment because some small ones may spontaneously regress. But Gordon disputed that.
“Nobody has evidence of self-healing and regression,” she said. “When we see cancer, it is not possible to predict how long it will take to grow. Just because we need to get better at knowing these things doesn’t mean it’s okay to stop looking for cancer.”
Joffres said about 12 per cent of women who go for screening are told they have an abnormality, and of those, seven per cent will be told, after further testing, they have cancer. One study showed that five of every 1,000 women aged 39 and older screened through mammography may be overdiagnosed and have unnecessary surgery to remove breasts or portions of them “and that is not an insignificant proportion,” he said.
Joffres and Gordon did agree on one thing: more confusion for women and primary care doctors. Joffres said the task force guidelines are meant to provoke more informed discussion between women and their doctors.
“These are weak recommendations; we’re not saying don’t do it,” he said.
B.C. was the first province in Canada to establish a breast cancer screening program in 1988. Women aged 40 to 79 are offered an X-ray at least every two years. Twenty per cent of cancers occur in women in their 40s, 25 per cent in females in their 50s, 27 per cent in their 60s and 28 per cent of breast cancers occurs in women over 70, Gordon said.
Carol Thorbes, an SFU communications officer who had routine mammograms and was considered an average risk when she was diagnosed with breast cancer at 49, said she’s concerned doctors will be less vigilant as a result of the proposed guidelines.
Her sister in Ontario died of breast cancer at 46 and Thorbes says there are pronounced differences between the provinces, with B.C. doctors far more supportive of routine screening, even in low-risk patients.
Sun Health Issues Reporter

Read more:

Time to stop mammography screening

Mammakarzinom, ID T1b. Mammography, breast can...Image via Wikipedia

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British breast cancer screening now under independent review

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Source: Health News Review

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Questions about how best to communicate to the public about the tradeoffs of potential benefits versus potential harms of mammography do not end at America‘s shores.

An independent investigation into breast cancer screening has been set up by the government’s cancer chief to try to settle the growing controversy around its usefulness and potential harms.

Prof Sir Mike Richards‘s move is an attempt to put to rest the criticisms of a number of scientists, who say the NHS (British National Health Service) screening programme wrongly identifies cancers that might never harm women, leading to unnecessary and potentially damaging treatment with surgery, drugs and radiation therapy.
They also contest the official NHS position, which is that although there is some over-treatment as a result of screening, mammograms save lives.
The BMJ today published a letter from Susan Bewley, professor of complex obstetrics, Division of Women’s Health, King’s College London, to the man BMJ calls “England’s cancer tsar,” Mike Richards. Excerpt of her letter: 

“I declined screening when it was offered, as the NHS breast screening programme was not telling the whole truth. As a non-expert in the subject, I found myself examining the evidence for breast screening with increasing doubts. I compared the NHS and Nordic Cochrane Centre leaflets and found that the NHS leaflets exaggerated benefits and did not spell out the risks. Journals showed a reputable and growing body of international opinion acknowledging that breast cancer screening was not as good as used to be thought. The distress of overdiagnosis and decision making when finding lesions that might (or might not) be cancer that might (or might not) require mutilating surgery is increasingly being exposed. The oft repeated statement that “1400 lives a year are saved” has not been subjected to proper scrutiny. Even cancer charities use lower estimates. I expressed my misgivings to you “behind the scenes” as a work colleague. You replied in a personal email “that the large majority of experts in this country disagrees with the methodology used in the Cochrane Centre reviews of breast screening.”

It is extraordinary to be told that methodology is contentious so many years into the national programme.”

“I take the current controversy very seriously. I will do my best to achieve consensus on the evidence, though I realise this may not ultimately be possible. Should the independent review conclude that the balance of harms outweighs the benefits of breast screening, I will have no hesitation in referring the findings to the UK National Screening Committee and then ministers. You also have my assurance that I am fully committed to the public being given information in a format that they find acceptable and understandable and that enables them to make truly informed choices.”

Most women with screen-detected breast cancer have not had their life saved by screening

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That’s the conclusion of an article published today in the Archives of Internal Medicine. I’m on the run today, but here’s the abstract

Background Perhaps the most persuasive messages promoting screening mammography come from women who argue that the test “saved my life.” Because other possibilities exist, we sought to determine how often lives were actually saved by mammography screening.

Methods We created a simple method to estimate the probability that a woman with screen-detected breast cancer has had her life saved because of screening. We used DevCan, the National Cancer Institute‘s software for analyzing Surveillance Epidemiology and End Results (SEER) data, to estimate the 10-year risk of diagnosis and the 20-year risk of death–a time horizon long enough to capture the downstream benefits of screening. Using a range of estimates on the ability of screening mammography to reduce breast cancer mortality (relative risk reduction [RRR], 5%-25%), we estimated the risk of dying from breast cancer in the presence and absence of mammography in women of various ages (ages 40, 50, 60, and 70 years).
Results We found that for a 50-year-old woman, the estimated risk of having a screen-detected breast cancer in the next 10 years is 1910 per 100 000. Her observed 20-year risk of breast cancer death is 990 per 100 000. Assuming that mammography has already reduced this risk by 20%, the risk of death in the absence of screening would be 1240 per 100 000, which suggests that the mortality benefit accrued to 250 per 100 000. Thus, the probability that a woman with screen-detected breast cancer avoids a breast cancer death because of mammography is 13% (250/1910). This number falls to 3% if screening mammography reduces breast cancer mortality by 5%. Similar analyses of women of different ages all yield probability estimates below 25%.
Conclusions Most women with screen-detected breast cancer have not had their life saved by screening. They are instead either diagnosed early (with no effect on their mortality) or overdiagnosed.

Breast Cancer Screening

By Graham McMahon

The latest article in our Clinical Practice series reviews current recommendations for breast-cancer screening and thesupporting evidence, including the controversy regarding mammographic screening of women in their 40s.
Worldwide, breast cancer is now the most common cancer diagnosed in women and is the leading cause of deaths from cancer among women, with approximately 1.3 million new cases and 458,000 deaths reported in 2008.OK

Clinical Pearls

 How have the screening recommendations from the U.S. Preventive Services Task Force (USPSTF) changed in recent years?
In contrast to its 2002 guidelines, the more recent recommendations of the USPSTF, published in November 2009, support a reduction in the use of screening mammography. The two most controversial changes were the reclassification of screening for women between the ages of 40 and 49 years from a B recommendation (based on moderately strong evidence) to a C recommendation (“the decision . . . should be an individual one and take into account patient context, including the patient’s values regarding specific benefits and harms”), and the recommendation that the frequency of screening be reduced from every 1 to 2 years to every 2 years.
 What is the consensus recommendation regarding mammographic screening for women between the ages of 50 and 69?
Screening mammography for women 50 to 69 years of age is universally recommended. All but one of the trials that included women in their 60s showed a significant reduction in mortality in the screened group, although this was not true for the subgroup of women in their 50s. Still, a meta-analysis revealed significant reductions in the number of deaths in both these age groups — 14% for women in their 50s and 32% for those in their 60s.

Morning Report Questions

Q: For a 42-year-old woman with no risk factors, what are the benefits and risks of screening mammography?
A: Her chance of having invasive breast cancer over the next 8 years is about 1 in 80, and her chance of dying from it is about 1 in 400. Biennial mammographic screening will detect two out of three cancers in women her age and will reduce her risk of death from breast cancer by 15%. However, there is about a 40% chance that she will be called back for further imaging tests and a 3% chance that she will undergo biopsy, with a benign finding.
Q: What are the benefits of digital mammography?
A: The contrast between breast tumors and surrounding normal parenchyma is greater with digital mammography than with film mammography, particularly when the breast tissue is dense. In one study in which almost 50,000 asymptomatic women 40 years of age or older underwent both digital and film mammography, the two techniques were equivalent overall in sensitivity (70% and 66%, respectively) and specificity (92% for both). However, in women under the age of 50 years, digital mammography was significantly more sensitive than film (78% vs. 51%).
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