Can’t See the Metastatic Forest for the Breast Cancer Screening Trees

Others can speak far more knowledgeably and eloquently about the recent pink ribbon funding controversy. My concern is that we are missing the forest for the trees. Setting aside the funding issue, let’s consider the truth worth of these exams. Screening and self exams can be helpful. But let’s not kid ourselves. These tests are frankly not that great.

“Women are regularly told that screening mammograms save lives,” says the National Breast Cancer Coalition. “Evidence of actual mortality reduction is, in fact, conflicting and continues to be questioned by scientists, policy makers and members of the public. Since evidence does not currently significantly support, nor disprove the effectiveness of this test, receiving a screening mammogram should be a personal choice, not a medical mandate.”*

Essentially, we have better imaging technologies. The  average size lump found by first mammogram is about the size of a dime (~1.5 cm) but even tumors as small as pencil erasers can be seen.

The real problem is we don’t know WHAT we are looking at.

We don’t know  WHY some tumors spread beyond the breast.

We don’t know HOW to stop metastatic growth.

We are seeing more and more breast cancers earlier and earlier. In some cases, people are overtreated: It’s the oncological equivalent of using a shotgun to kill an ant. Many women may be diagnosed and treated for a cancer growing so slowly it might never have caused any symptoms or threatened their lives.

As surgeon/scientist/blogger David Gorski, explains, “… for mammographically-detected small tumors, almost always those detected by screening mammography, it’s not so clear whether all of these need to be treated. Overdiagnosis is being increasingly appreciated as a significant problem, and, indeed, may account for as many as 1 in 3 breast cancers detected by screening mammography (although more common estimates are on the order of 20%). There is even evidence–not bulletproof by any means, but intriguing evidence–that as many as 20% of mammographically detected tumors may actually spontaneously regress.”

Screening is just one tool. We need to look at the bigger picture. Unfortunately, the under treated are always with us:

“If we did what we already know, at least 37% of cancer deaths in people between the ages of 27 and 64 could be avoided right now,” writes ACS’s Dr. Len Lichtenfeld. “Where is the national conversation about the fact that poverty is a carcinogen? Are you talking about it? Is the media talking about it? If the silence is deafening, then perhaps you have your answer. “

Finally, as much as I have a vested interest in breast cancer research, it shouldn’t come at the expense of addressing other diseases. I concur with ACS’s Dr. Otis Brawley:  “The wisest advocacy for cancer science is support for more money for cancer research in general and support for funding the best science and encouraging scientific investigators to maintain an open mind,” says Brawley.  “Scientists must look for additional applications of findings beyond just their cancer of interest.”

You’ve probably heard of the chemotherapy drug Herceptin, which is used to treat about 25% of breast cancer patients. It was developed to treat neuroblastomas and gliomas, both cancers of the nervous system, but it didn’t work for those cancers.
Another example, cisplatin, was first developed as a treatment for testicular cancer.  It is now the most commonly used chemotherapy in the treatment of lung cancer and ovarian cancer. It is also used in some breast cancer treatments. The drug oxalaplatin used in colon cancer therapy was developed from cisplatin.  So testicular cancer research benefited a number of other cancers.
Similarly, the drug leuprolide was developed in the mid-1980s as a hormonal treatment for metastatic prostate cancer. This drug has since been FDA-approved for not only treatment of metastatic prostate cancer, but also premenopausal breast cancer, endometriosis, and precocious puberty.

The number of drugs that were developed for one disease but ended up being useful in others  is legendary and goes beyond cancer.

*Women age 40 and older should have mammograms every 1 to 2 years. Women who are at higher than average risk of breast cancer should talk with their health care providers about whether to have mammograms before age 40 and how often to have them.

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10 thoughts on “Can’t See the Metastatic Forest for the Breast Cancer Screening Trees

  1. I too am skeptical of mammograms as the end-all, be-all diagnostic tool. Personally, I had a 5-cm area in my “unaffected” breast that went undetected by a baseline mammo, a diagnostic mammo, and an MRI. Post-mastectomy pathology found it, though. What’s the answer? I have no idea. But I agree with you 100 percent that it would be most helpful to know more about how this disease acts once it’s gained a foothold.

  2. Barb says:

    I’m for finding a vaccine to prevent breast cancer. If we can have a vaccine to prevent some cervical cancers, why not breast cancer? Are there scientists out there working on it?

  3. katherinembc says:

    ESSAY
    Real Race in Cancer Is Finding Its Cause
    By SUSAN LOVE, M.D.
    Published: February 6, 2012

    http://www.nytimes.com/2012/02/07/health/breast-cancer-screening-matters-but-prevention-is-the-real-goal.html?_r=1

    ….In reality, we still do not know what causes breast cancer, which means we really do not know how to prevent it, either. That has pushed us to focus on looking for cancers that are already there, a practice long based on the assumption that all cancers were the same, grew at a similar rate and were visible in the breast for a period of time before spreading. It made sense: If you could find cancers earlier, you could save lives.

    Indeed, the original screening study done in the 1950s on postmenopausal women in New York demonstrated a 30-percent decrease in deaths from breast cancer. It also led to the conjecture that if we just carried out more screening at a younger age, and more often, we could improve these statistics and “win the war” on breast cancer.

    But decades later, the success rate of screening remains nearly the same, even with much better imaging: routine mammography screening results in a 15- to 20-percent decrease in mortality in women over age 50.

    Why hasn’t the situation improved? It turns out that there are at least five, and probably more, different types of breast tumors, growing and spreading at different rates. Some are so aggressive that they have almost always spread before they are visible on mammogram. But other tumors, if left alone, may never spread at all and do not need to be found.

    This more complicated picture explains why mammography has not further decreased mortality. The X-rays find some cancers at a point that makes a lifesaving difference — but not all of them. British researchers estimated last year that one death from breast cancer is prevented for every 400 women ages 50 to 70 who are screened regularly over a 10-year period.

    Does this mean we should stop screening? No, it is still the best tool we have. But we have to start looking for other approaches to decreasing deaths from breast cancer…

  4. MJ says:

    Thanks for this Katherine. One of my favorite recent articles is, “Mammograms Save Lives — But Just Barely”. Puts things into perspective, in a non-blame-the-victim kind of way.

    Another creepy thing I saw recently was from my local mammo facility. Their slogan is, “We create survivors.” I though, wow how true that is — someone could have been an (untreated) BC survivor, with spontaneous regression or death from another cause, and not even know it! Screening mammos create survivors!

  5. We Create Survivors. Interesting….. I just began to question if my ANNUAL screening beginning at age 30 and for 18 subsequent years somehow contributed to my diagnosis. I was high risk due to my mom and now my No BRCA family is a breast cancer mess ….. mom and two sisters…. I worry about my daughter who will be screened through the roof. It was when my breast surgeon and I were discussing a course of action for my daughter and she said, NO Mammo’s…. would use MRI. We find them useless in younger women because of the density of the tissue and we may actually be doing damage with the radiation. A-HEM….

    So, I ask…. Did my heavy duty screening make me a survivor because it actually contributed to the cancer?? The slogan, We create survivors……for me…. definitely cuts both ways!!

  6. Carol Conti says:

    I blame mammograms for my breast cancer – and I used to be a mammographer!
    Breast Thermography can be performed on young women without radiation and compression at a fraction of the cost of MRI.

  7. Lorene F. says:

    When I was 64 years old back in February 2003, I went to my family doctor for my annual exam (‘annual” being a misnomer in this case) 14 months after my last mammogram. My doc did a routine breast exam and found nothing wrong, and scheduled me for a mammo a few days later, When the image was read, there was a suspicious lump in my left breast, and a then an ultrasound was scheduled, and it also found the suspicious lump. I was referred to a surgeon, who took a core biopsy. He looked at the tissue that was extracted and said it looked like cancer tissue. I was in denial and thought this surgeon was nuts! When the report came back from the pathology lab, it confirmed that the lump indicated lobular carcinoma, and it was between Stage II and Stage III.

    My surgeon explained all the choices I had with regards to the surgery: from a lumpectomy to a radical mastectomy. I chose the latter, and I was placed on Tamoxefin. I stayed on this medication until one day four years later when I went to my local hospital to have an x-ray of my kidneys (for a reason unconnected to my cancer). Imagine my shock when my physician came to my room and told me that my BC had metastasized to my bones, as the kidney x-rays indicated bone mets in my pelvis. I was then referred to a nearby larger city for a total bone scan and an MRI. These images indicated that the bone mets were in my spine, at least two ribs, my right clavicle, and both femurs. I was then referred to an oncologist in this larger city for cancer treatment.

    Now, nearly nine years later, I have received all the oral cancer medications and chemotherapy that will help me. I was able to walk and drive my car until this past September when I suddenly couldn’t lift my right foot more than an inch or two off the floor, and I began falling down and needed to call 911 three times. I ended up in the hospital in my small town for 17 days and then transferred to a nursing home in the larger city. Today I had my first meeting with the director of the Hospice I have chosen to aid me through my last few months or however long (or short) a time I have left.

    The point of this long story is to stress how important I think annual mammos are. If I hadn’t had the mammo when I did, both the length and quality of my life would have been much different. I was able to enjoy many high-quality years, even though my husband of nearly 49 years passed away in 2007, a few months after I learned I had extensive bone mets. I was his caregiver for the previous five years. Later I was able to take three wonderful trips to southern Calif. to vist one of my daughters because of the excellent care I received from both my oncologist, and from my radiation oncologist In spite of everything, life has been quite good to me.

    • katherinembc says:

      Hi Lorene
      Thanks for writing. I think your point is a good one–in a perfect world we might have better tests but we should make use of today’s tools. It sounds like you have achieved a peaceful outlook–I am glad for that. While I am sorry treatment has failed, I am glad you are using the hospice resources–it’s good to have that help and guidance.
      Take care

  8. Thanks for always telling it like it is, Katherine.

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