The Mammogram Debate
By Joel Fuhrman, M.D., www.drfuhrman.com
Learn the startling facts about this common but controversial procedure!
The story of Jane Silverstein is all too common. At age thirty-seven, Jane went for her first mammogram. Because of suspicious findings, she was asked to return the next day for a repeat mammogram and ultrasound. By the time these were completed, she was trembling.
The following day, Jane was advised to make an appointment to see a breast surgeon for an excisional biopsy. She had to wait two weeks for the appointment with the surgeon and then another week for the surgery. During this entire period, she worried so much about breast cancer and the possibility that her children might be left without a mother that she slept poorly and suffered anxiety. Her family physician put her on anti-anxiety medications, which helped somewhat, but left her feeling “drugged” and uncomfortable.
Fortunately, the breast surgery had no complications, the biopsy was negative, and Jane was told she was “fine.” Fine, except now she is on Paxil and Xanax for the anxiety she suffered. Hopefully, she eventually will recover and be able to be weaned off the medications.
Did Jane make a good decision?
Breast cancer is the second leading cause of death in North American women. (Heart disease is number one.) In spite of modern cancer detection and treatment methods, the percentage of women dying from this common cancer has not changed much in the last thirty years.1 As the use of mammograms increased markedly in this time frame, the percentage of women dying of breast cancer has remained remarkably stable.
A Campaign of Fear
More than a decade ago, the American Cancer Society recommended that women get a baseline mammogram at age thirty-five, followed by annual screenings beginning at age forty. The campaign to position mammograms as the key weapon in the fight against breast cancer was initiated by the American Cancer Society, with a number of medical groups joining the fray. Instilling fear about breast cancer was a campaign strategy. To achieve this, the American Cancer Society used greatly exaggerated numbers and faulty math to overstate breast cancer risk. They admitted they did this—and continue to do it—to promote mammograms. 2 They still trumpet the claim that women face a one-in-eight chance of developing breast cancer during their lifetimes.
Where does this one-in-eight figure come from? It is a cumulative probability derived from adding up all the chances a woman has of developing breast cancer between birth and age 110. Since women do not generally live that long, this figure is not based on reality. More sophisticated risk assessment gives the actual risk of being diagnosed with breast cancer before age sixty as about one in 500. Even women in their eighties do not face a one in- eight chance of developing breast cancer. For example, at the age of seventy, the risk of developing breast cancer during the next ten years is one in twenty-three. In their zeal to help women, the American Cancer Society and other groups have created an epidemic of fear. Unfortunately, that fear has not been used to direct women to prevent breast cancer—by avoiding the causes of breast cancer. Rather, it has been used to convince women to think that using mammograms to find cancer after it already has developed is their best hope for survival.
Multibillion Dollar Industry
Mammograms have been positioned as the centerpiece of women’s health care, and they are the most prevalent “medicine” delivered to our female population. Women shuffle from their doctors to radiologists and back, and if their mammograms show abnormalities, they are transferred to surgeons for needle biopsies and excisional biopsies. Today’s woman goes to doctors to get yearly mammograms and breast exams with little thought given to the medical literature on these subjects and the shocking facts it reveals. Suffice to say, gynecologists whose practices revolve around giving postmenopausal women estrogen replacement therapy (a disproved and dangerous practice) and ordering mammograms will have little left to do if women become better informed about the risks associated with mammograms.
Mammograms help detect breast cancer, and they help detect it earlier than other diagnostic tools. But in the process, they cause a lot of fear and result in countless unnecessary breast biopsies. In order to uncover cancer and not give false reassurance, radiologists are forced to advise biopsies even when the findings suggest the chance of cancer is small. More than 80 percent of all breast biopsies are negative for cancer.3 In addition, these mammograms with false positive results (sent for biopsy and then found to be negative) occur most frequently in the forty to fifty age range. By the time a woman has nine mammograms between the ages of forty and forty-nine, her chance of having a false positive result that requires her to have a biopsy is 43 percent.4 Nearly half of all women getting mammograms are eventually sent for biopsies to evaluate “suspicious” findings. When a woman with risk factors (such as a family history of breast cancer) gets nine or ten mammograms between ages thirty five and fifty, her chance of the radiologist finding something suspicious and sending her to get a biopsy that returns negative for cancer rises to 98 percent.
The problems caused by false positives and unnecessary biopsies might be acceptable if the increased use of mammograms saved women’s lives. But it does not appear from the statistics that many lives are being saved by this so called “early detection.”
Between 1970 and 1990, as more and more women got mammograms at the urging of the medical profession and health authorities, breast cancer rates rose 24 percent. As expected, more cancers were being detected, and they were being detected “earlier.” Five- and ten-year survival rates improved, and it appeared that women were living longer with their cancers. But those figures were misleading. Sadly, the exact same percentage of women still died of breast cancer at the same age as they did prior to the widespread use of mammograms. (See chart below) Increased use of mammography has accomplished little more than giving an increasing number of women the painful knowledge that they have breast cancer.
Myth of “Early Detection”
Mammograms never detect “early” breast cancer. By the time a cancer is visible to the human eye on a mammogram, it is already teeming with over a hundred billion cancer cells—which have been there for at least eight years—and it already has had ample time to spread to other parts of the body. In the majority of cases, the cancer has spread outside the breast, but the small groups of cells that have traveled to other parts of the body may be undetectable for years.
Most breast cancers found on mammograms, even the ones with negative lymph nodes that appear to be localized, will later be found to have metastasized. Lumpectomy for breast cancers that are thought to be localized only stop the cancer in a minority of cases, because in most cases microscopic cancerous cells already have left the breast. Women with larger tumors or with positive lymph nodes are treated with radiation and then chemotherapy in an attempt to destroy both the localized cancer cells and those that have migrated.
Mammograms enable us to treat more patients who are found to have breast cancer, but if the treatments are not very effective, what good is it to detect it earlier? Chemotherapy for breast cancer still should be considered experimental, because the chemotherapeutic agents used have a dismal track record in producing long-term survival of more than 15 years. Chemotherapy has been shown to offer some survival benefit in young (premenopausal) women with breast cancer, because the cancer is more aggressive in that age range, but not a significant increase in life expectancy in older women.5,6 More aggressive cancers are more sensitive to chemotherapy.
US Breast Cancer Incidence and Mortality Chart Goes Here.
Mammograms done in the thirty-five to fifty age range—before menopause—are even more controversial. Many respected medical authorities are clearly against mammograms in this age group. First of all, the risk of having breast cancer before age fifty is about one in a thousand. The dense breast tissue, and the high incidence of benign disease of the breast in young women, leads to decreased accuracy of mammograms. The chance of having breast cancer in this age group may be exceptionally low, but the chance of having an abnormal finding, necessitating further views, ultrasounds, and repeated tests and biopsies, is quite high.
In 1995, a meta-analysis of thirteen studies found no evidence that mammograms before age fifty saved lives. That same study did show a benefit for women over the age of fifty. Researchers at the RAND Corporation, a think tank in California, performed a cost/benefit analysis and did not recommend women below age fifty receive mammograms because—at a cost of over 1.1 billion dollars annually— there was no evidence of benefit.7
In January 1997, a National Institute of Health consensus conference was conducted to consider whether or not screening mammography reduces breast cancer mortality among women aged forty to forty-nine. The twelve-member panel represented the fields of oncology, radiology, gynecology, geriatrics, and public health. Thirty-two experts presented scientific data to the panel. The panel, working with this data and with data in the scientific literature, concluded that mammography recommendation for women in their forties was not warranted.8
Since this time, most researchers reluctantly have been forced to accept the consensus that mammograms are not beneficial in this age group. Many greeted this conclusion with dismay and outrage. Other groups, most notably the American Cancer Society and the American Medical Association, reaffirmed their recommendations that even these younger women should get annual mammograms. By contrast, the Canadian Task Force on Preventive Health Care, the American Academy of Family Physicians, and the American College of Physicians do not recommend routine mammograms in the age range of thirty-five to fifty.
On The Ship of False Hope
Mammograms in all age groups are a very poor screening tool. About 5 percent of mammograms are abnormal or suspicious, and of these 80 to 93 percent are false positives that cause unnecessary anxiety and further procedures, including surgery. If that were not enough to question the reliability of mammograms as a diagnostic tool, consider the unfounded reassurance that results from the false negatives that occur in 10 to 15 percent of women who already have breast cancer that will manifest clinically within one year.
In the October 2001 issue of The Lancet, the Nordic Cochrane Centre of Denmark published a follow-up report on its groundbreaking 2000 analysis of the efficacy of screening mammograms in reducing breast cancer death.9 The new report confirmed the earlier findings. After reviewing the seven largest mammography- screening trials, no benefit attributable to mammograms was found for any age group. The new research focused on the ability of mammograms to reduce total mortality because, as stated by the report’s authors, this is the only “reliable” measure of benefit.10
The Danish researchers found numerous flaws in the mammography- screening trials. They found that the studies under review did not tally fatal cases that were misclassified or that were triggered by cancer treatment such as radiotherapy. For example, none of the leukemia deaths and cardiac deaths occurring as a result of chemotherapy for breast cancer and none of the increased cases of fatal lung cancer caused by radiation to the breast during diagnosis and treatment were ever considered in prior studies. Lung cancer is a known late-stage side effect to breast cancer radiation,11 and congestive heart failure is a known late side effect of the cardiac toxicity of chemotherapy.12 The Cochrane researchers found that the studies’ claims that mammograms reduce breast cancer deaths by 25 to 30 percent were invalid, since those investigators did not consider all other deaths related to breast cancer treatments.
The researchers also found that the studies that claimed to show some benefit from mammograms for women in their fifties and sixties were 1) biased in favor of screening and 2) incorrect because they only looked at breast cancer mortality, not all-cause mortality. Based on this highly respected review, The Lancet editors concluded, “There is no reliable evidence from large randomized trials to support screening mammography at any age.”
The recent reassessment of the 2000 Cochrane analysis also confirmed that breast cancer screening with mammograms creates an overuse of aggressive treatments. The authors reasoned that the mammograms detect lots of slow-growing tumors that will never progress to cancer within the patient’s lifetime and classify these as cancer. These account for the mammograms’ so called “successes.” There are cellular changes that may be histologically cancerous but biologically benign. Carcinoma-in-situ may be treated by bilateral mastectomy even though they do not progress to invasive disease— ever. The flawed studies count these as mammogram successes, when they are not. At the same time, the cancers that are truly invasive are not really caught early enough to make a difference. The patient only appears to live longer because the disease is diagnosed earlier. As stated previously, the same percentage of women are dying at the same ages they were before the widespread use of mammograms. The inescapable conclusion drawn from these carefully performed investigations is that mammograms do not provide a survival benefit in any age group. Those who benefit are balanced out almost equally by those who are hurt.
Facts vs. Vested Interests
The business of medicine is rarely deterred by facts. The findings of the Danish researchers did nothing to change the position of the American Cancer Society, The American College of Radiology, and the National Cancer Institute. These institutions still support the discredited notion that mammograms “prevent” breast cancer. Mammograms are entrenched in the practice of conventional medicine. The politics and economics within the world of medical policy-making govern the messages that are disseminated to the public. The fact is—at best—mammograms detect, they do not prevent. To use the word prevent in the same sentence as mammograms is a tremendous distortion of reality. The only proven approach to prevention of breast cancer is the adoption of lifestyle modifications that help stop cells from becoming cancerous in the first place.
Controversies in the medical literature rarely reach the public. In the case of mammography, doctors almost never admit to patients that the benefits from mammograms, if any, are marginal at best. This does not mean that some women will not be diagnosed with breast cancer early enough to have a curative lumpectomy. For that woman, the mammogram will have extended her life. However, for every woman whose life is extended, there are almost an equal number who would have lived longer had their breast cancer not been discovered and treated. For those women, the medical treatments will shorten, not lengthen their lives.
Cause or Cure?
Unfortunately, mammography can be the cause of a woman’s breast cancer. When calculating its supposed benefits, we need to include in the equation the percentage of women whose breast cancer was promoted by the radiation exposure from the mammograms themselves. The younger you are when the mammograms are performed, the greater the risk of radiation-induced cancer.13,14 According to Michael Swift,M.D., chief of medical genetics at the University of North Carolina at Chapel Hill, between 5,000 and 10,000 of the 180,000 cases of breast cancer diagnosed each year could be prevented if women’s breasts were not exposed to radiation from mammograms. Over a million American women carry the gene for ataxia-telangiectasia (A-T), which makes them unusually sensitive to the ionizing radiation in X rays and five times more likely to develop breast cancer.15
The decision to screen for breast cancer using mammograms should not be made lightly or based solely on emotions. Intuition, hope, and compassion can lead to the conclusion that screening mammograms should save the lives of young women, and it is frustrating that science has demonstrated otherwise. Our desire to help a loved one by “doing something about it” is instinctive. When it comes to breast cancer, the question is not whether to do something or not, but rather what to do about it. It is wrong to instruct patients to depend on mammograms, knowing that they will inevitably undergo the anxiety and frustration of repeated exams, callbacks, biopsies, and unneeded surgeries for nothing but a false sense of security. As caregivers, we need to tell our loved ones and all women that there are proven steps they can take to help prevent cancer from ever developing in the first place.
All the misleading publicity devoted to mammograms undercuts the urgently needed efforts to teach women that dietary and lifestyle changes are their best weapon in the fight against breast cancer. Women are continually urged by doctors, private and government agencies, and the media to undergo mammograms. How much better it would be if the same amount of effort would be put into telling women that those who eat four to five servings of vegetables per day have a 46 percent lower risk of breast cancer than those eating only one to two servings per day, and that women who eat six fruits per day have a 35 percent lower risk of breast cancer than those eating fewer than two fruits per day.16
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12.Rock E, De Michele A. Nutritional approaches to late toxicities of adjuvant chemotherapy in breast cancer survivors. J Nutr 2003 Nov;133(11 Suppl 1):3785S-3793S.
13.Brenner DJ, Sawant SG, Hande MP, et al. Routine screening mammography: how important is the radiation-risk side of the benefit-risk equation? Int J Radiat Biol 2002 Dec;78(12): 1065-7.
14.Jung H. Is there a real risk of radiation-induced breast cancer for postmenopausal women? Radiat Environ Biophys 2001 Jun;40(2):169-74.
15.Den Otter W, Merchant TE, Beijerinck D, Koten JW. Breast cancer induction due to mammographic screening in hereditarily affected women. Anticancer Res 1996 Sep- Oct;16(5B):3173-5.
16.Trichopoulou A, Katsouyanni K, Stuver S, et al. Consumption of olive oil and specific food groups in relation to breast cancer risk in Greece. J Natl Cancer Inst 1995;87(2):110-116.