“Slap on a pink ribbon, call it a day” is an unfair way to characterize the debate about breast cancer screening.

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Barbara Ehrenreich at Salon:

… What we really need is a new women’s health movement, one that’s sharp and skeptical enough to ask all the hard questions: What are the environmental (or possibly life-style) causes of the breast cancer epidemic? Why are existing treatments like chemotherapy so toxic and heavy-handed? And, if the old narrative of cancer’s progression from “early” to “late” stages no longer holds, what is the course of this disease (or diseases)? What we don’t need, no matter how pretty and pink, is a ladies’ auxiliary to the cancer-industrial complex.

That is the concluding paragraph to an essay in which Ehrenreich endorses the new breast cancer screening guidelines, which are, in part, as follows:

The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient’s values regarding specific benefits and harms.

Here is another, earlier excerpt from Ehrenreich’s essay:

… In 2000, at the age of 59, I was diagnosed with Stage II breast cancer on the basis of one dubious mammogram followed by a really bad one, followed by a biopsy. Maybe I should be grateful that the cancer was detected in time, but the truth is, I’m not sure whether these mammograms detected the tumor or, along with many earlier ones, contributed to it: One known environmental cause of breast cancer is radiation, in amounts easily accumulated through regular mammography.

And why was I bothering with this mammogram in the first place? I had long ago made the decision not to spend my golden years undergoing cancer surveillance, but I wanted to get my Hormone Replacement Therapy (HRT) prescription renewed, and the nurse practitioner wouldn’t do that without a fresh mammogram.

As for the HRT, I was taking it because I had been convinced, by the prevailing medical propaganda, that HRT helps prevent heart disease and Alzheimer’s. In 2002, we found out that HRT is itself a risk factor for breast cancer (as well as being ineffective at warding off heart disease and Alzheimer’s), but we didn’t know that in 2000. So did I get breast cancer because of the HRT — and possibly because of the mammograms themselves — or did HRT lead to the detection of a cancer I would have gotten anyway? …

Ehrenreich is undoubtedly correct that current approaches to breast cancer research and “awareness” don’t seem to be doing much good. And quite possibly she is right that the profit motive is leading to too many mammograms and too much aggressive treatment of breast cancer. But there are profit related goals that are served if the amount of screening that gets done is reduced also. And Ehrenreich admits she doesn’t really know whether the mammograms helped or hurt her. I heartily endorse her concluding paragraph (featured at the top of the post) – we do need to be asking hard questions about why all the money being spent on breast cancer research hasn’t been more successful at isolating the causes of the disease. But we also need to ask how strong the evidence is that reducing screening will improve women’s health. The only study I have seen (and which is specifically referenced by Ehrenreich and almost every other media source that addressed the new guidelines) was conducted by the US Prevention Services Task Force. Here is what it [hereinafter "the Report"] says:

There is convincing evidence that screening with film mammography reduces breast cancer mortality, with a greater absolute reduction for women aged 50 to 74 years than for women aged 40 to 49 years. The strongest evidence for the greatest benefit is among women aged 60 to 69 years.

So the Report endorses mammographies. How will reduced screening change these numbers? We don’t know. Here is another excerpt from the Report:

A series of randomized clinical trials that would compare the results of stopping breast cancer screening at different ages (by first comparing stopping screening at age 75 years with continued screening, and then further comparing stopping screening at earlier ages, depending on the results of the first study) would be ethical and informative.

Extended follow-up of this type of study might also provide useful information about overdiagnosis in this age group. In general, more studies of overdiagnosis, including comparisons of lifetime breast cancer incidence among similar screened and unscreened women, would be helpful. Studies on overdiagnosis might also include long-term follow-up of women with probable missed cases of DCIS on the basis of microcalcifications that were missed in an earlier mammogram. Such studies could provide the percentage of these women who develop invasive breast cancer over the next 10 or more years.

Randomized clinical trials of film versus digital mammography among women with dense breast tissue, with sufficient follow-up to detect stage shifts (reductions of late-stage cancer) or decreases in clinical interval cases, would also be ethical and helpful.

Better understanding of certain facets of tumor biology is needed, particularly how age, race, breast density, and other factors may predispose certain women toward tumors with faster growth rates and greater lethality. This would improve the ability to determine at diagnosis which patients can be treated minimally.

In short, the Report is pretty equivocal about whether reducing breast cancer screening will have net benefits beyond cost savings, reducing “psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results,” and overdiagnosis. How much overdiagnosis? We don’t know. The Report admits: “Methods for estimating overdiagnosis at a population level are not well established, and thus the proportion of all detected DCIS lesions that constitute overdiagnosis is uncertain.”

I just don’t think there is enough certainty expressed in the Report to flagellate or mock women who don’t immediately and reflexively embrace the new guidelines. I agree that we should be open minded and try to stay informed, and I especially agree that more and different kinds of research are necessary. I wish more women had questioned the efficacy of HRT louder and sooner, maybe there would be less breast cancer now. Rhetorically beating up on women for questioning the new guidelines is just wrong.

–Ann Bartow

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3 Responses to “Slap on a pink ribbon, call it a day” is an unfair way to characterize the debate about breast cancer screening.

  1. Jay says:

    Ann, while I agree that women who question the new guidelines should not be mocked or flaggelated, I do think that women need more information before discussing the guidelines. For that matter, women should be given more information before they even get mammograms.

    In your post, you mention DCIS several times. DCIS is a non-invasive condition which cannot threaten a woman’s life unless if becomes invasive cancer. Here’s the key part of the Task Force Report: “the likelihood that DCIS will progress to invasive cancer is unknown.” Why is that significant? Women with DCIS are told that they have found “early cancer” (yay!) and are then told that they can get rid of it by having surgery, radiation, and tamoxifen (which can cause uterine cancer). But it’s not early cancer; most DCIS never becomes stage 1 cancer. DCIS is invisible – it doesn’t cause a lump, and it is not seen on mammogram (calcifications are just evidence of DCIS). In many cases, it’s not seen on MRI either. Therefore, surgery is often a fishing expedition — surgeons don’t know how much there is and whether it will ever become cancer. Some women are even told to have mastectomies for DCIS.

    Women are urged to get mammograms regardless of their risk factors for breast cancer. Yet there is probably no other Stage Zero cancer that is treated as aggressively as DCIS. Consider a cancer that both men and women get, like skin cancer. Is Stage Zero skin cancer treated with “slash, burn, poison?” No. Just slash, and then close monitoring. Women with DCIS are not offered close monitoring.

    As a feminist, I am troubled by the health system treating me like a pair of breasts and nothing else. While I have low risk for breast cancer, I am urged to get mammograms every year. On the other hand, I am at high risk for skin cancer but no one urges me to get my skin checked every year. If my mammogram finds stage zero breast cancer, I will be subjected to disfiguring surgery and toxic treatments. If I find early skin cancer, I will be treated reasonably. That’s a tragedy for all women.

  2. Ann Bartow says:

    Jay, the whole point of the post is to highlight the need for more information.

    And you seem to be providing medical advice. Are you a physician? Even the new guidelines embrace mammograms, just less frequently, as I noted in the post. Nobody knows what all the risk factors are for breast cancer, so you may or may not be “low risk” but you are free to decline mammograms and you can decline” disfiguring surgery and toxic treatments for “stage zero”" or any stage breast cancer you want. In fact, if you have health insurance, I’m sure your insurer will be thrilled to have you forgo mammograms and/or cancer treatment.

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