Some questions about the mammogram controversy and a big What if?

[hedgehog]

Let's stipulate that mammograms find tumors that are too small to be felt on breast exam.

The thinking has always been, early detection increases the odds for cure.

But - suppose that some cancers are slow growing and/or self limiting. Maybe these cancers never need treatment. This is important to me because my very elderly mother recently had a mastectomy and is emotionally devastated by the surgery. Her doctors proceeded on the best information we have today. The cancer was contained and slow growing. Did they save her life or did they remove a cancer that would never have grown or spread?

Suppose also that other cancers are fast growing. Does it make a difference to find these cancers early? Does a once a year mammogram really find that many of them before they grow large enough to be felt as a lump?

These are questions that were not answered in the media. Maybe no one has the answers today. Maybe we keep doing mammograms in case they are helping us, but until these questions are answered definitively, we don't know for sure that mammograms are useful.

Now, for the big What if? There is some very serious research out there today exploring the possibility that low Vitamin D levels are a major factor in breast cancer:

http://www.grassrootshealth.net/media/download/20091103garland.pdf

What if: instead of doing mammograms, we should be checking serum levels of Vitamin D? What if, instead of finding cancer, we could be preventing cancer? What if we have set the RDA for other vitamins too low, and other diseases are actually long term deficiency diseases?

[MannyGoldstein]

1. +1

That's exactly the issue.

[hedgehog]

2. I think a lot of people engage in magical thinking: If I get a mammogram,

I'll never get cancer, or if I do, it won't be serious.

[azmouse]

3. I think what you said explains the near hysteria

when the new recommendations were announced.

Mammograms are diagnostic, not preventative, medicine. A fact many have forgotten.

[unblock]

4. it's complicated, of course.

the FIRST question is, indeed, how to prevent.

the SECOND question is, how to go about detecting.

the THIRD question is, what to do if something is detected. a tumor showing up on a mammogram does not necessarily mean a mastectomy is indicated. perhaps the best answer is that mammographies should be encouraged, but if they do find something "small and slow growing", that merely indicates more frequent monitoring and less radical forms of treatment.


i'm no doctor, but it seems to me that telling women to not bother checking an additional 10 years is going to mean some women will die from undetected cancers. but surely it's not an all or nothing question. isn't there a middle ground for women aged 40-50?

[Iggo]

5. Why "instead of"? Why not "in addition to"?

[MH1]

7. if doing mammograms annually is a waste of resources then why do it?

[hayu_lol]

8. I've read in a few places recently...

that Pap smears are also under consideration for doing fewer or not doing them until a certain age(to be determined).

"They" are targeting women. Overall, women probably use more health assets than any other single group. They are better at going to Drs. than men are when something appears to be going wrong.

[hedgehog]

12. The reason not to do the Pap smears on younger women is that

the Pap smears revealed anomalous cell structures. In older women, these are precursors to cancer. It turns out that in younger women, these are normal and go away by themselves. The treatment, cutting away the involved tissue, leaves scars on the cervix which can cause premature labor should the woman ever decide to have children later.

[hedgehog]

10. There are numbers around about how many lives were saved

per so many mammograms, and there are a lot of anecdotes. It's not clear to me whether it made any real difference for the small number of women in this cohort who had their cancer discovered by mammogram. Would the cancer have been found later on anyways? Would the cancer have been resolved without treatment? Did early treatment make a difference? What we don't know, and probably never will, is how many cancers were caused by mammograms. What if the number saved matches the number who develop cancer? I do know that many doctors are becoming leery of ordering CT scans unless absolutely necessary.

[MH1]

6. nice to see an intelligent discussion of the issue. nt

[amborin]

9. prevent AND find

early detection provides the best chances

[hedgehog]

11. That seems obvious, but is increasingly becoming a point of contention.

Does it make any difference how soon you find an aggressive cancer? Does mammogram look good because it catches cancers that would never have gone anywhere in any case? (i.e. are we finding and treating cancers that the body would take care of itself?)

[noamnety]

14. Should we be basing medicine on what works for white women?

The more aggressive cancers in young women are disproportionately found in black women. What's the implication of discounting that, and instead basing national health policies and insurance restrictions on what works for most white women?

[hedgehog]

15. Good point - we need more info and more research. I'll take this opportunity

to once again push The Army of Women:

http://www.armyofwomen.org/

organized by Dr. Susan Love, this is an internet data base of women willing to take part in research to prevent breast cancer.
Here's a sample of their work:

The program issued its first call-to-action research initiative, The Sister Study, within the first month of its launch
(http://www.armyofwomen.org/current/view?grant_id=82 ). The Sister Study, is a national study investigating how the
environment and genes affect the chances of getting breast cancer. The study, which on average recruits a few hundred
women per month towards the goal of 50,000 women, registered over 2,000 qualified Army of Women volunteers to be a
part of the study within the first week of the call to action announcement. This is the largest number of women to join the
study since its organizers, the National Institutes of Health, began recruiting women six years ago.

Most recently, the campaign announced its second study -The Milk Study, a research project to determine whether or not breast cancer and breast cancer risk can be accurately assessed from a breast milk sample and, hopefully, reduce biopsies amongst women who are nursing (http://www.armyofwomen.org/current/view?grant_id=99 ). Despite the complex criteria, over 25 qualified women were signed on to participate in the project within a matter of days.


I believe some of the research studies have focused on women of color. BTW, the higher incidence of breast cancer in young black women may be another indicator that low levels of Vitamin D are part of the picture.

[amborin]

26. months are precious to someone dying of infiltrating ductile breast cancer

it's hard for us to appreciate that

so, yes, it does matter how soon an aggressive cancer is discovered

and, an aggressive cancer can be discovered before it's metastasized

[hedgehog]

13. If the general population received regular chest X-rays, a certain number of

people would be diagnosed with TB sooner than otherwise. But all the other people would be receiving unnecessary X-rays.

[Contrary1]

16. First, I would like to offer my sympathy to you mother...

A mastectomy is devastating. I hope that with some time, she heals emotionally. I don't think anyone ever completely recovers, but after a while; it does become easier to accept.

Your question as to whether or not slow growing and/or self limiting cancers need treatment in my opinion, can't be answered.

My breast cancer was determined to be slow growing, but it had spread. My oncologist estimated by the rate of growth that it had started 7-8 years earlier. I asked him at what point it had metastasized, and he told me there was no way of knowing exactly when.

I really wanted an answer to that because on my previous mammogram (8 months earlier), the tumor clearly showed up. For whatever reason, it was not included in the written report. I will always wonder if the 8 months lost between the mammogram, and my finding the lump myself cost me a breast.

[hedgehog]

18. I think you've provided a perfect example of how much in the dark

we all remain. Right now I think there are a lot of treatment options, but I'm not sure doctors know when to treat.

There's a similar situation facing those with prostate cancer. The younger you are, the more likely it is that you have an aggressive cancer that should be treated ASAP. The older you are, the more likely you have a slow growing type that wouldn't bother you for another 20? 40? years. No one really knows because very few 80 year old men live another 40 years. So, treat aggressively if you find a tumor in a 50 year old man, do nothing if you find a tumor in an 80 year man, but what do you do with a 65 year old man? Does it matter if he is in good shape or not? Some 65 year old men are very active and will recover quickly from treatment surgery to live another 15 or 20 good years. But if you have a 65 year old man in poor health, maybe with COPD and diabetes? Will you cure his cancer only to make his last few years miserable? Is it ageism if you give the sick 65 year old palliative treatment only? Clearly, patients need to educate themselves on all options.

[hedgehog]

19. It might settle your mind regarding your diagnosis to consider what the

tumor looked like on the original mammogram. It's possible that it looked like dense tissue or whatever in the original mammogram. Then when someone looked at compared the first mammogram to the one with the tumor, they could look at the little shadow or bright spot and say, yeah, there's the tumor.

The ability to spot changes year to year is one reason you should get all mammograms done at the same office.

[Contrary1]

22. No, in this case someone clearly screwed up...

When that earlier mammo was sent to the breast surgeon, the tumor had been circled, a big question mark next to it, along with the date. It just didn't get written up. Mistakes happen.

But, every now and then I just have to wonder "What if...?"

[Berry Cool]

17. One problem here is you talk about "increasing the odds for a cure." There IS no cure.

Repeat: Breast cancer cannot be cured. That simple. You can get rid of it and a woman might eventually die of something else when she's 100 years old, but that doesn't mean her breast cancer was "cured." "Curing" breast cancer is not possible.

As for the other issues, they've been brought up well by you and other people here. I'm sorry about your mother's mastectomy, and it would be even more devastating if it turned out she had a form of cancer that never would have grown or spread. I sincerely hope that her medical advisers did not encourage her to get a mastectomy despite having a form of cancer whose pathology was not that dangerous. I would sue them for malpractice if that were the case.

Some cancers are indeed slow growing and/or self limiting and may never need treatment. Others are so fast growing that, no, it really doesn't make a difference to find these cancers early? And a once-a-year mammogram may not find that many of them before they grow large enough to be felt as a lump. It may not even matter if it does. And to some extent the mammogram may be causing cancers. The thing is, we just don't know.

What we do know, I think, is that we need a better form of diagnosing existing cancer than the mammogram. And, yes, we need a focus not just on detection, but on prevention. We have, indeed, been fed a misleading message for many years by the media: that early detection equals cure or early detection equals prevention. It's just not true, but people still don't want to believe it because they don't want to believe there are aspects of all this that are out of their hands or that they've been lied to for years. They just want to squeal about possibly being denied their right to a mammogram because they think a mammogram alone always makes the difference between life and death. Ah, if only it were that simple. But it's not.

[hedgehog]

20. I think my mothers' doctors gave the best advice they could with the information

they had. It's possible that in five or ten years, with a similar case, their advice will be different. We just know too little about this disease, and I can understand doctors being very aggressive with treatment. How can we find out if some older women can live with this disease when so many women are dying from it?

[Sparkly]

21. My mother too had a "radical mastectomy" -- both breasts

I thought that sufficiently early detection allowed the cancer to be removed before it spread to lymph nodes, etc. No?

In other words, isn't early detection of any cancer a matter of life and death, in terms of how far it has spread?

As for diagnosis, I am prescribed an annual mammogram and sonogram, both.

[cornermouse]

23. Why don't you ask Molly Ivins whether mammograms

should be done? I can't help but think about all the columns we have missed due to breast cancer and she's only one of many.

[Contrary1]

24. Molly Ivins had Inflammatory Breast Cancer...

That's a whole different ball game. IBC doesn't usually involve a lump, and more often than not won't show up on either a mammogram or ultrasound.

[cornermouse]

25. Why you're not right.

http://www.cancer.gov/cancertopics/factsheet/Sites-Types/IBC

# What are the symptoms of IBC?

Symptoms of IBC may include redness, swelling, and warmth in the breast, often without a distinct lump in the breast. The redness and warmth are caused by cancer cells blocking the lymph vessels in the skin. The skin of the breast may also appear pink, reddish purple, or bruised. The skin may also have ridges or appear pitted, like the skin of an orange (called peau d'orange), which is caused by a buildup of fluid and edema (swelling) in the breast. Other symptoms include heaviness, burning, aching, increase in breast size, tenderness, or a nipple that is inverted (facing inward) (3). These symptoms usually develop quickly—over a period of weeks or months. Swollen lymph nodes may also be present under the arm, above the collarbone, or in both places. However, it is important to note that these symptoms may also be signs of other conditions such as infection, injury, or other types of cancer (1).

# How is IBC diagnosed?

Diagnosis of IBC is based primarily on the results of a doctor's clinical examination (1). Biopsy, mammogram, and breast ultrasound are used to confirm the diagnosis. IBC is classified as either stage IIIB or stage IV breast cancer (2). Stage IIIB breast cancers are locally advanced; stage IV breast cancer is cancer that has spread to other organs. IBC tends to grow rapidly, and the physical appearance of the breast of patients with IBC is different from that of patients with other stage III breast cancers. IBC is an especially aggressive, locally advanced breast cancer.

Cancer staging describes the extent or severity of an individual's cancer. (More information on staging is available in the National Cancer Institute (NCI) fact sheet Staging: Questions and Answers at http://www.cancer.gov/cancertopics/factsheet/Detection/staging on the Internet.) Knowing a cancer's stage helps the doctor develop a treatment plan and estimate prognosis (the likely outcome or course of the disease; the chance of recovery or recurrence).

I'm going to take a moment here to point out that if your breast is red, swollen and warm, indicating a possible infection of some sort you'll probably head in to see the doctor who will either do a biopsy or a mammogram or ultrasound (see above). Nevertheless, if you feel that mammograms are unnecessary, by all means don't get one. That doesn't mean you have to right to push for something that will stop other women from getting the mammogram and possibly saving their lives.

[Contrary1]

27. Inflammatory breast cancer does not usually show up on a routine mammogram...

and if it does, it is often overlooked by a radiologist.

"Mammogram, and breast ultrasound are used to confirm the diagnosis..."

That would indicate the doctor already suspects IBC. The mammogram ordered would not be a normal screening type, it would be diagnostic.


"Use caution when relying on the interpretations and reports of the mammogram or ultrasound! Inflammatory breast cancer usually grows in nests or sheets, rather than as a confined solid tumor. IBC may not be detected using either mammography or ultrasonography. Increased breast density compared to prior mammograms should be considered suspicious..."

http://www.ibcresearch.org/symptoms/

I don't know if the last two sentences of your post were directed at me, or everyone who reads this thread. No way would I ever discourage a woman from getting a yearly mammogram.

I belong to a breast cancer support group. Many of the women I've met have had cancer that was discovered in the early, more treatable stages through mammography.

I do wish they would come up with a more reliable diagnostic tool. A few years ago, before my second mastectomy, I was asked if I would participate in a clinical trial involving a new imaging tool. I was an ideal candidate, since they could compare the removed breast with the data collected beforehand. It tomographic ultrasound imaging in warm water. Definitely less stressful than a mammogram.

[hedgehog]

28. Your question makes several assumptions.

1. That Molly Ivins didn't get mammograms.

2. that if she had gotten a mammogram, she'd be alive today.

I have no idea if either statement is true. For all we know, she had regular mammograms and the cancer developed sometime after her last clean mammogram and before her next one. Mammograms do not prevent cancer.. They identify small tumors. It is a serious question whether all the tumors identified via mammogram need treatment. It's possible that the apparent usefulness of mammograms is an illusion. If a certain percentage of the cancers identified with mammograms would have gone away on their own,and those are the women who credit early detection for their survival, then mammograms serve to put some women through unnecessary treatment while offering false hope to women with aggressive cancers.

Now, I don't know what the next few years will reveal about any of these questions. What I do know is that a group of researchers looked at a lot of data and concluded that, barring extenuating circumstances (e.g having a gene that is connected with breast cancer), mammograms do not benefit women of all ages equally. Compare it to getting a bone scan for osteoporosis. Some people will develop this early, but in most cases it doesn't make sense to start the scans before menopause.