Woman should not be given mammograms for the same reason that men should not have PSA tests! This is the conclusion that would be very easy to come away with after reading an article in today’s New York Times (November 25, 2008), “Study Suggests Some cancers May Go Away”, by Gina Kolata.
Researchers, for many years have known that in rare cases some cancers just go away on their own, without any type of treatment. This phenomena has been seen in instances of melanomas, neuroblastoma and kidney cancers. Most cancers are treated early when detected, so we are forced to consider the possibility that if less cancers are detected, less would be treated and we would have many more spontaneously cured. Currently, these spontaneous cures are considered oddities, but maybe if more cancers were not treated, or even detected, more would just disappear.
Researchers in Norway have begun to ask this question about current detection and treatment of breast cancer. They have published a study in “The Archives of Internal Medicine” that suggests that even invasive cancers may sometimes disappear spontaneously without treatment and in more significant numbers than ever guessed.
Robert A. Smith, director of breast cancer screening at the American Cancer Society has said, “Their simplification of a complicated issue is both overreaching and alarming,” He feels that large-scale breast cancer screening must continue to be made available to all women. He feels that these finding have no practical applications because no one knows whether a detected cancer will disappear or continue to spread or kill.
However, Robert M. Kaplan, the chairperson of the department of health services at the School of Public Health at the University of California, Los Angeles, does not agree. He is persuaded by the analysis. Dr. Kaplan feels the potential significance of these finds is potentially enormous. He said, “If the results are replicated, he said, it could eventually be possible for some women to opt for so-called watchful waiting, monitoring a tumor in their breast to see whether it grows. (Does this sound familiar?) People have never thought that way about breast cancer.”
The Norwegian study was conducted by Dr. H. Gilbert Welch, a researcher at the VA Outcomes Group at Dartmouth Medical School; Dr. Per-Henrik Zahl of the Norwegian Institute of Public Health; and Dr. Jan Maehlen of Ulleval University Hospital in Oslo. The study, which was a well-powered one that compared two groups of women, ages 50 to 64 for two consecutive six-year periods.
One group of 109,784 (pre-screening cohort) women was followed from 1992 to 1997. Mammography screening in Norway was first introduced in 1996. In 1996 and 1997, all women were offered mammograms, and nearly every woman accepted. The second group of 119,472 women (post screening cohort) was followed from 1996 to 2001. All were offered regular mammograms, and nearly all accepted.
The researchers anticipated that the two groups would have roughly the same number of breast cancers, either detected at the end or found along the course of the monitoring. To their surprise, they found that the women who had regular routine screenings (post co-hort) had 22 percent more cancers.
Dr. Welch concluded, “There are some women who had cancer at one point and who later just don’t have that cancer.” Their cancer’s just disappeared from their bodies by natural processes.
Dr. Smith (American cancer Society) still insists that mammograms save lives. He said, “Even though they can have a downside — most notably the risk that a woman might have a biopsy to check on an abnormality that turns out not to be cancer — the balance of benefits and harms is still considerably in favor of screening for breast cancer.” He feels that women should continue to have mammograms, since so little is known about the progress of most cancers.
An emerita professor of ambulatory care and prevention at Harvard Medical School, Dr. Suzanne W. Fletcher said that it was also important for women and doctors to understand the entire picture of cancer screening. The new finding, she said, was “part of the picture.” However, she did not say that mammogram screening should be stopped. (Editor’s comment- The issue is the unintended consequences seem to be no different than it is with PSA testing where PSA testing can cause unneeded biopsies and treatment.)
Dr. Barnett Kramer, director of the Office of Disease Prevention at the National Institutes of Health, was surprised with the results and said “People who are familiar with the broad range of behaviors of a variety of cancers know spontaneous regression is possible, but what is shocking is that it can occur so frequently.” Dr. Kramer also said, “Although the researchers cannot completely rule out other explanations, they do a good job of showing they are not highly likely.”
Donald A. Berry, chairman of the department of biostatistics at M. D. Anderson Cancer Center in Houston, threw his hat into the controversy when he expressed his concerns that the study increased his worries about screenings that find cancers earlier and earlier. “Unless there is some understanding of the natural history of the cancers that are found — which are dangerous and which is not — the result can easily be more treatment of cancers that would not cause harm if left untreated, he said. He added, “There may be some benefit to very early detection, but the costs will be huge — and I don’t mean monetary costs,” Dr. Berry said. “It’s possible that we all have cells that are cancerous and that grow a bit before being dumped by the body. ‘Hell bent for leather’ early detection research will lead to finding some of them. What will be the consequence? Prophylactic removal of organs in the masses? It’s really scary.”
Why have I spent so much time on this topic on an advanced prostate cancer blog? Just go back and reread the post, but substitute the word mammogram for PSA testing and you will see the exact same argument with the exact same results. However, the difference is that PSA testing will continue to be under attack while the support for mammograms will continue unharmed by the controversy.
The prostate cancer community will continue to not be supported by the nation’s largest non-governmental organization, the American Cancer Association. They will continue to question the value of PSA testing while following Dr. Smith’s lead, championing the virtues of the mammogram, despite the remarkable similarities surrounding the concerns for incidental consequences.
My own personal opinion, both mammograms and PSA testing do save lives and should be freely available to all. The problem is not with the screening, but with the lack of and poor quality of the post-biopsy counseling.
Joel T Nowak MA, MSW