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Abigail Trafford
Abigail Trafford
(The Post)
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Health Talk:
Controversy Over Mammography

Hosted by Abigail Trafford
Washington Post columnist

Thursday, Jan. 8, 2002; 2 p.m. EST

Welcome to Second Opinion, a weekly column and Health Talk discussion with Post Health columnist Abigail Trafford.

A new study has challenged the dogma that mammography screening saves lives -- and touched off another breast cancer war. For decades women have been told to get a mammogram to detect cancers at an early stage for a cure. Many breast cancer survivors believe that they are alive today because a mammogram picked up their disease. But a report in the British medical journal, "The Lancet," concludes that "screening for breast cancer with mammography is unjustified." Where does that leave you?

To discuss the latest chapter in the mammography debate is Barron H. Lerner, MD, PHD. He is the associate professor of medicine and public health at Columbia University, and author of "The Breast Cancer Wars: Hope, Fear, and the Pursuit of a Cure in Twentieth-Century America."

The transcript follows.

Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.



Abigail Trafford: Hello everybody. Welcome to the latest battle in the breast cancer wars. What is the value of mammography? What is the value of early detection? Send us your comments and questions.


Abigail Trafford: Hello and welcome, Dr. Lerner. Let's talk about the recent report that challenged the value of mammography as a screening tool. What is the take home message to the medical community? And to women?

Barron H. Lerner:
Hi Abby. Thanks for inviting me.

I think the take home message to the medical community is that some smart researchers in a prestigious journal are questioning the value of mammography. This was not really news for women under 50, but they are also skeptical for women over 50. Doctors need to acknowledge this report and share the information with patients. But doctors also need to remember that other smart researchers still strongly advocate mammograms based on their own reading of the data.

I think women need to know about this debate--just like their doctors do.


Abigail Trafford: The findings of the analysis of mammography also question whether early detection is the most important factor is overcoming the disease. Please explain this.

Barron H. Lerner:
Early detection has been the gospel for breast cancer for decades because it made sense both medically and from an intuitive basis. Getting something earlier had to be better, right? But now we know that breast cancer is more complicated. Some cancers spread when they are really tiny, so they're not so early. So it makes sense that mammography is not as wonderful as we might otherwise expect.


New York, NY: All these mammography studies that have been trashed are, I believe, many years or even decades old. Does it matter that they can be picked apart? If not for mammography, how can one account for the reduction in the size of tumor detected these days and the increase in longevity of breast-cancer survivors? or are those data also mirages?

Abigail Trafford: Wow, New York. You have described the essence of the controversy. Dr. Lerner, what do you say?

Barron H. Lerner:
Good questions. The data from the pro and anti-mammography studies are older than we would like. Part of the problem is that researchers are choosing to throw out some of the studies and keep others. And for those not trained in biostatistics (like me!) it's very hard to know who to believe.

We surely are finding cancers when they are smaller and women are living longer. But some of this is due to better treatment, like chemotherapy. Mammograms surely find cancers when they are smaller. But the issue is whether the outcome would be any different if you found them 6 or 12 months later. According to the Lancet, the answer is "no."



Washington, D.C.: My fiance's mother had/has breast cancer and had a mastectomy two years ago. Although my fiancιe is only 31, when should she get a mammogram?

Barron H. Lerner:
She should consult a breast cancer specialist. One rule of thumb is to get your first mammogram when you are 10 years younger than your mother was when she got breast cancer. But each case differs.


Fairfax, Va.: Where can I read more about the report in the British medical journal? I haven't heard anything about this new development.

Abigail Trafford: Dr. Lerner, let's go back and review the study. What kind of study was it? How solid is this kind of research? The journal, The Lancet, is available on line at www.lancet.com.

Barron H. Lerner:
This study was what is called a meta-analysis--combining the data from the 8 randomized controlled trials of mammography. This is clearly the best type of data to have. But even meta-analyses are not "objective." All data are subject to interpretation. This theme was the one that seemed to come up most often as I was writing my book. And it's also very difficult to apply this type of population-based data to individual women.



Madison, Wis.: Smith of ACS and Kopans of Harvard are saying in essence that the new analysis has more holes than a Swiss cheese and should be ignored. I take it you disagree. Can you say more?

Barron H. Lerner:
Smith and Kopans are smart researchers who are reading the data differently. For example, they are very skeptical of the data from the Canadian trial of mammography, which is one of the two studies that the Lancet researchers favored. I surely think that ignoring the Lancet study is a mistake. Women deserve to know that critics of mammography exist. But pro-mammogram folks have the right to argue back. What I regret is all the fighting. I think we need to begin to discuss how women and their doctors should process information that is (regretfully) ambiguous. This type of issue is becoming more and more common as medical technologies advance.


New York, NY: Is screening mammography more useful for women than PSA screening for men?

Barron H. Lerner:
PSA is its own can of worms. I would surely say that no data exist for PSA that are nearly as comprehensive as for mammography. After all, we have been doing randomized trials for mammograms for decades. PSA testing is much newer and the data to date are largely uncontrolled.

PSA is another example of a case in which doctors should tell patients there is a sincere difference of opinion. At my own institution, there are docs who always order it and others who never do. They are both wrong. They need to inform patients of the choice. The same is true for mammography--now more than ever.


Springfield, Va.: Isn't it true that the seven randomized controlled trials regarding screening mammography have probably undergone more scrutiny than any other medical intervention and have demonstrated a survival advantage for women who were screened with mammography?

Barron H. Lerner:
So many questions, so little time!

To the previous questioner, yes, it is true we are using old data. Radiologists often argue that better techniques now make the earlier data obsolete. This _may_ be true but we should not also assume that the better technology works any better at saving lives. Here is an important limitation of data gathering in medicine: what we study has often become obsolete by the time we have data.

The answer to this question is yes--ABSOLUTELY more scrutiny than any other screening test. If you put the seven trials together, you do get a survival advantage for screened women, probably on the order or 25-30 percent. This is what we have hung our hats on. And, this is why many of us, myself included, have not changed our tune about getting mammograms for women 50 and older. But I'm also glad to know that some researchers question this belief, even though it makes my life--and my patients' lives--more complicated.


Fairfax,VA: I have read a few books claiming that mammography can raise the chances of getting breast cancer because of increased radiation exposure, especially in women who are already higher risk. Does this study address this? Where can I read more about this claim?

Barron H. Lerner:
This study does not specifically address this issue but there is much in the medical literature about this. There are also a group of non-MD skeptics (in the good sense of the word) who have been arguing this for years. What is clear is that there is much less radiation being used now for mammograms than in the past.

I am glad you raised this topic because it reminds me to mention another reason that there is opposition to routine mammography, especially for women under 50. And that is the finding of false-positive lesions that appear to be cancer but are not. These lead to worry and unnecessary biopsies. And many argue that we over-treat some of the lesions--like ductal carcinoma in situ--that mammography picks up.


Madison, Wis.: One area where mammograms seem to be more effective is for monitoring "high risk" women. What is the current thinking on the most important risk factors for breast cancer - both from the perspective of modification for prevention and for increased attention to the use of mammography?

Barron H. Lerner:
High risk women are getting tremendous attention. In addition to mammograms, there is now also genetic testing. Again, high risk women should consult specialists. In most cases, doctors will favor early, aggressive screening for such women (and possibly tamoxifen).

But what I argue in my book is that we are a very risk-averse country when it comes to breast cancer. We are willing to screen and treat the many to save the few. This is especially true for high risk women, some of whom will have their breasts removed preventively. I think it's crucial to realize how our culture, and issues of gender and sexuality, influence how we interpret scientific data about risk and other issues.


Washington, D.C.: I am 32 and had a total hysterectomy at 28 due to severe endometriosis. My doctor informed me that I should start having mammograms every other year. Do you think I have an increased risk of breast cancer due to hormone replacement therapy, which I've been on for the last 4 years?

Thanks, MN

Barron H. Lerner:
You are at increased risk if you have been on HRT for four years. But realize mammograms don't work very well for women your age and on estrogen. So you may very well discover lesions that are not cancer. The issue is: are you willing to possibly discover these lesions (and maybe have unnecessary testing) on the chance that you might pick up a cancer? This is what you and your doctor need to discuss.


Houston, Texas 77036: I do not have insurance and my doctor has joined some group that he has to account to.
He insists that I have a mammogram, even though I have no reason to do so except he wants me to.
I think he should leave that up to me.

Barron H. Lerner:
You are the boss. But do listen to his arguments. Most women (especially 50-69) are still getting routine mammograms.


New York, N.Y.: Does the American Cancer Society have a vested interest in promoting screening, in the sense that it can increase donations if it can tell women to "do" something the prevent disease?

Barron H. Lerner:
This is such a fascinating topic and something I address in depth in my book. The ACS is in a difficult situation. Money aside, it is nearly impossible to lead a cancer crusade without presenting a positive message. So someone has to do it. But what happens is that the ACS (and other groups, such as radiologists, or, for that matter, skeptical biostatisticians!) are not unbiased observers of the data. So we should listen to the ACS but know where it is coming from.


Madison, Wis.: Dr. Lerner,

When a doctor informs the average risk woman of age 50-60 about mammography, what should she or he be telling her?

Abigail Trafford: And what about mammography in women over 70? I've heard that the risk starts to decline after a certain age.

Barron H. Lerner:
Re: age 70, there is very little data. In this age group, cancers grow slower on average, so one would expect that screening would have a somewhat less beneficial effect.

I would hope that MDs are telling patients that there are pros and cons to mammography, although it is appropriate for the doctor to give a recommendation also. MDs should not simply be suppliers of data.


Wash DC: So you think DCIS should not be treated? ever?

Barron H. Lerner:
I tried to word my answer carefully but have never typed so much in my life!

No, I do think DCIS should be treated. But women should know here, again, about ongoing debates. Some women lose their breast for DCIS when they would just get a lumpectomy for actual cancer. Others get lumpectomy, radiation and tamoxifen for DCIS, which is a "precancer" but not a "cancer." This gets at what I was saying before about over-treatment.

We like to smash breast cancer or its precursors with as much might as we can. Doctors like this, and so do patients. It makes us feel we are doing everything. But some of this is cultural and not based solely on the data.


New York, N.Y.: Have the Race for the Cure and other Komen-like initiatives been, on the whole, beneficial?

Barron H. Lerner:
I think so, absolutely. In the early part of this century, breast cancer was in the shadows. Women rarely discussed it in public. It was seen as shameful and they were made to feel guilty for getting it.

So getting pink ribbons and other types of publicity out there is marvelous. The spirit of a Race for the Cure is truly uplifting.

But we should not confuse the hope and optimism that surround these events with reality. Breast cancer is still killing tens of thousands of women and we still don't know the best ways to fight it. And we must be careful not to blame women who die from the disease for not "fighting" hard enough. It is not their fault. They had bad luck.



20036: I don't understand.... why would it be bad to have a tumor detected early?

Barron H. Lerner:
For two reasons:

Either the tumor would never have become a dangerous cancer or the same outcome would have happened if you had found the tumor later. These are the suppositions of the Lancet authors.

Having said this, many women find these arguments non-compelling. Indeed, my wife always asks me, "Well, why wouldn't I want to find it if there was a chance there was cancer?" I politely decline to answer and tell her to see her doctor!


Abigail Trafford: How would you counsel a healthy 65-year old woman who said: Doctor, I don't ever want to have a [screening] mammogram again.

Barron H. Lerner:
The Lancet data make me more likely to not argue with her. But I would encourage her to see both sides of the issue before deciding.


Wash DC: When it comes to someone's life, don't you think it is ok to do things that are not solely based on data--emotional health cannot be easily measured by the data.

Abigail Trafford: But what if you do a medical treatment that causes harm? In the end, that wouldn't benefit a person's emotional health. Dr. Lerner?

Barron H. Lerner:
Such a question with 5 minutes to go! Yes, this is what I was trying to get at before. Individual women must interpret data in their own way and make the right decision for themselves. But, of course, the more likely the decision was to cause harm, the more I would "play doctor." This issue arose when Suzanne Somers declined chemotherapy. I can't say she did the right thing but she did not deserve all of the flak she got. She did what she thought was best for herself.


Abigail Trafford: It seems a key is what kind of tumor is it? Is it fast growing or slow growing? There are different forms of breast cancer. What proportion are fast-growing? Would it make a difference to detect these tumors early? Or are the tumor cells so virulent, it wouldn't make much difference when the cancer was treated?

Barron H. Lerner:
Yes, this is key. When the first skeptics criticized early detection in the 1950s, this is what they said. There are some nasty cancers that early detection can't help. There are others so slow-growing that early detection won't help. It is the ones in the middle that we can influence. Not much has changed today. This is why mammography may help some women but not others. A crucial point.


Madison, Wis.: Is it worthwhile to search for a mammography center that double reads its mammograms or uses CAD (computer aided diagnosis) to read mammograms?

Abigail Trafford: I think it's really important for women to go to high-quality mammography centers. How can a woman make sure the center uses the latest equipment and has the expertise to read mammograms?

Barron H. Lerner:
Computer-aided diagnosis is being studied. No clear advantage yet. Stay tuned.


Annapolis, MD: I hope you will commend to the listeners Ellen Leopold's excellent social history of breast cancer, A Darker Ribbon: Women, Breast Cancer and their Doctors, published by Beacon Press in 1999, which provides essential historical and contemporary insight into the ongoing "cancer wars." Have you read her work?

Barron H. Lerner:
I have read her book and liked it. I tried to build on her work in writing my own book covering topics like mammography and genetic testing, for example.


Rockville, Md.: Hello. I have saline breast implants. Will I still be able to have a mammogram and if so, will it pick up signs as well? Thank you.

Barron H. Lerner:
Again, some controversy. There is no good data suggesting that women with implants die from cancers that are missed on mammography.


Delhi, ON: On the question of "survival advantage" - Would the case of a woman of (say) 60 who has a slow growing cancer picked up by mammography and after treatment survives 20 years to die at 80, be claimed as increased over the same woman, same tumor but not discovered clinically until age 65 who survives only fifteen years after diagnosis but still dies at age 80?

Barron H. Lerner:
Survival should not be confused with cure. If you survive longer with an early detected cancer but die when you would have anyway, the screening accomplished nothing. A basic, but often missed, lesson of biostatistics.


vienna, VA: Why are male mammograms not emphasized more?
Men can and do get breast cancer too, although admittedly it is much rarer in men than in women. My uncle developed it in his 60's.

Abigail Trafford: Men wouldn't get a screening mammogram because male breast cancer is so rare. But Dr. Lerner, what about a mammogram for men to diagnose a cancer? Is that technically feasible with the size and shape of men's breasts? Or are there better ways to diagnose breast cancer in men?

Barron H. Lerner:
A real problem, not the least of which is that men who find breast lumps tend to ignore them due to ignorance or embarrassment. Once lumps are found, mammograms can help to diagnose cancer in men. But the incidence is so low, men do not get screening mammograms--only diagnostic mammograms.


Madison, WI: Do you think the greater problem with mammography lies with early tumors that are missed, or in unnecessary follow-up care for erroneous positive findings?

Abigail Trafford: What is the false positive and false negative rate? Presumably if a woman had a cancer and got a false negative finding one year, she'd get picked up the next year--or she might feel a lump. Or does it make any difference according to this new study? Also, my sense is that the unnecessary follow-up and anxiety from erroneous positive findings are given short shrift by doctors. Yet women suffer tremendously. It seems that mammography as a screening tool leaves a lot to be desired. What are the chances for developing a really good screening tool?

Barron H. Lerner:
Both false-positives and negatives are drawbacks. The technology is far from perfect, although as advocates remind us, it's all we have. Surely the data in breast self-examination does not show a mortality advantage.


Washington, D.C.: What happened to the e-mail I sent you earlier today? I wondered about "benign cysts" and why there has been so little written about them.

Abigail Trafford: Let me pass on the message you sent me on benign cysts and the role of mammography. "My niece and I, in different years, both paid little attention to the (fatal?) lump, since we both had a history of benign cysts. One of mine put me into the operating room . . . . Fortunately I had insurance coverage at the time, which I didn't have when the real thing came along. However I've never been sure that "the real thing" was really the real thing.. . ." You raise several important questions here. Although Dr. Lerner can't address your specific case, he can explore the issues: 1. what are benign cysts? Are women with benign cysts at increased risk of developing breast cancer? 2. Does mammography detect benign cysts as sometimes malignant? 3. And how can women get treatment for breast cancer if they do not have insurance?

Barron H. Lerner:
Benign cysts are just that. No higher risk of breast cancer. But there are a series of other intermediate findings from mammograms, like atypical ductal hyperplasia, and lobular neoplasia, that seem to convey a future higher risk.

Insurance is a huge topic. Happily, screening programs for poor women now exist, thanks to the great work of the breast cancer organizations of this country. And now such women may also have treatment paid for. But more money for these programs, and more outreach, is needed.


Abigail Trafford: The guidelines are for women over 40 to get regular mammograms. Those guidelines have not changed in the wake of this one report. Should women still have regular mammograms?

Barron H. Lerner:
I am still recommending that my patients from 50-70 get screening mammograms. For under 50, I remain skeptical but discuss options with them.

What I learned from writing a history of breast cancer screening and treatment was that things are more often gray than black and white. This is not to say there is not good news. A woman diagnosed with breast cancer has an 80 percent chance of long-term survival--much better than in the past. But we should not oversell what we have to offer women. They deserve to learn as much as is known about mammography and all other breast cancer technologies.


Abigail Trafford: Alas we've gone over our time. This has been a great discussion. Thank you Dr. Lerner. Thank you all for your questions and comments. Join me again next week, same time, same place.



© Copyright 2002 The Washington Post Company

 


 
 
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