Mammograms and breast cancer

breast cancer incidenceAs a young surgeon, I was really interested in academics. I wanted to publish papers. I wanted to present at major meetings. I felt that I had little or no guidance in the arena of trauma (where I practice now), so I turned to a breast surgeon and helped him with cases. We discussed the literature. I also went to the tumor conferences (a monthly conference that most hospitals have in which they talk about the cancers that have been discovered over the last month or so).

I learned a lot about breast cancer. I learned a lot about mammograms and CT scans of the breast. I learned a lot about how to operate on the breast and how to get the best cosmetic result. I saw a lot of women with breast cancer. With this as my backdrop, I would like to reiterate that I am not an expert but I know more than your average Joe.

First of all, I think it’s important to say that breast cancer is still a very serious disease in the United States. Close to 200,000 women will be diagnosed with invasive breast cancer this year. Over 40,000 women will die in the United States as a result of breast cancer. Lung cancer is the only cancer that kills more women in the United States. So this is not a benign disease.

The incidence of breast cancer increases with age for women. The incidence peaks between ages 75-79. Women ages 20-24 have a rate of breast cancer of approximate 1.4 in every 100,000 women, whereas the incidence for women in their late 70s is approximately 400 cases for every 100,000 women.

The next thing is that it’s important to know before you can evaluate the recommendations which were handed down by the US Preventive Services Task Force is how a woman’s breast changes as they age. For the most part, women in their 20s have extremely dense breasts filled with breast tissue. (I know this sounds stupid but stay with me.) By the time a woman reaches her 50s, this breast tissue is replaced by fat.

The reason that this is important, is that it relates to the imaging modalities that physicians use to diagnose breast cancer. Mammograms are very sensitive in patients with fatty breasts. Mammograms become far less sensitive when women are young and their breasts are very dense.

So, it is clear that mammograms in women who are in their 20s and 30s are extremely difficult to read. This is the reason why most physicians do not recommend routine mammograms in this age group. Mammograms in women over 50 make sense because they are relatively easy to read and the incidence of breast cancer in this age group is increasing. For over 30 years, the question has been what to do with women between the ages of 40-49.

In my opinion, in this age group, the risk benefit ratio should be individualized. What is the risk of not getting routine mammograms? What is the risk of radiation? What is the risk of a false positive causing women to worry unnecessarily when it turns out that the little dot on the mammogram was nothing? (What effect does the negative biopsy have on the woman’s ability to have follow-up mammograms?) On the other side of the equation, there are huge benefits from early detection of breast cancer. Small breast cancers usually have not metastasized and the five and 10 year survival rates are greater than 95%. Once a breast cancer grows greater than 2 cm (a little less than an inch), survival rates began to drop dramatically. So, I think it’s extremely important for women to have open and honest discussions with their physicians. They need to talk to physicians who have an excellent knowledge of the breast literature. They need to have physicians who will take the time to sit down and talk to them about their individual risks. It may turn out with the reduction of prolonged hormone replacement therapy that the incidence of breast cancer will drop dramatically, I have my doubts. Personally, I think it is extremely important for women to diagnose their breast cancers early. Breast self-examinations are good, but most women do not do them on a routine basis.

This is an extremely important topic. I’ve only scratched the surface of its complexity. I’m extremely disappointed that the talking heads of the media have gotten a hold of this issue and are using it as a way to drive ratings. I urge women to talk to their physicians. If you don’t like your physician, find another one. This topic is crucial. You need to understand the various recommendations that are out there. Finally, it is important to realize that the American Cancer Society, the National Cancer Institute and several other organizations have stated that they will not change their own guidelines.

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0 Responses

  1. Thanks I appreciate your thoughts. 

    I would add that if men got any cancer at the rate of that women get breast cancer, we would already have a cure. 

  2. “Breast cancer mortality is 52 percent higher in Germany than in the United States and 88 percent higher in the United Kingdom.” http://www.hoover.org/publications/digest/49525427.html

    Since you are advocating for a European style health care system to be instituted here, how do you reconcile the poorer performance of countries like the UK when compared to the American system?

  3. I for one would be very happy to see doctors having a rational and evidence-based discussion with patients over what diagnostic tests are needed.  My doctor (who I’m stuck with due to my HMO) refuses to have this discussion about yearly gyn exams and pap smears.  Instead, she holds my yearly birth control prescription hostage until I come in for a pap.  I’m in a low risk age group, monogamous, have never had an abnormal pap.  I’m a survivor of sexual assault, and gyn exams are very traumatic for me, so this is more than just a costly inconvenience.  I’d really prefer to do exams at a less frequent interval, and I feel this should be my decision to make.

    When it comes to mammograms, what this study means is that when I reach my 40s yearly mammograms are much more likely to result in me being misdiagnosed, even unnecessarily operated on, than to save my life.  I’m glad to have that information in making my decision.  The question is, will my doctor or my insurance company respect my choices?

  4. Joe – 

    Are you comparing apples to apples.  In the US, more women are diagnosed at an early stage. The age at which a woman has her first child will influence the rate of breast cancer. What is the difference in the rates? When you compare breast cancer stage for state is there a difference in mortality?

    The Hoover article does not list any references. Where did they get their data from. 

    thanks for your comments.

  5. Whether we are simply diagnosing earlier, or treating more aggressively, or a combination —

    wouldn’t you agree that we’re doing a much better job of keeping women alive?

    You can argue about the WHY, but my point is the WHAT.

  6. This point is very important. If we are diagnosing more women with Stage I breast cancer is that because more women are doing breast exams and going to their MD more often? Is it because Germany is refusing to have women at age 40 get regular exams? Do we have more breast surgeons and therefore more physicians with more expertise? Do women in Germany with Stage 3 breast cancer do exactly the same as they do here? Do Germans have a higher rate of familial breast cancer which is more aggressive?

    I know that you want to get to the what but if we don’t or can’t analyze the data properly then our conclusions can be and probably will be wrong. 

  7. “It is often claimed that people have better access to preventive screenings in universal health care systems.  But despite the large number of uninsured, cancer patients in the United States are most likely to be screened regularly…….. in the United States, 84 percent of women aged 50 to 64 years get (mammograms) regularly — a higher percentage than in Australia, Canada or New Zealand, and far higher than the 63 percent of British women.”  http://www.ncpa.org/pub/ba596

  8. Exactly.  I don’t have the money to buy private health insurance, and my employer offers only this HMO.  I need the birth control, and none of the doctors in the practice will prescribe it without the annual pap and exam.

    Also, I just saw the American College of Ob/Gyns has just issued reccommendations that women in their 30s only need a pap every 3 years.  (Cue outraged internet response.)  Maybe I can take it to my next appointment.

    Here’s the url of the AP story on pap smear reccommendations.  http://www.salon.com/wires/ap/scitech/2009/11/19/D9C32F180_us_med_fewer_pap_smears/index.html

  9. Joe – 

    The article that you link to was written by Betsy McCaughey. She is the person who said that the Health Care Reform legislation supported Death Panels. She brought the legislation onto the Daily Show and then was embarrassed on national television because she couldn’t read the English language. I have no faith that she will be able to read several studies and synthesize the data.

    Here are the findings of the study that McCaughey uses as the back bone of her paper (I didn’t buy the whole article for $31!) – “Global variation in cancer survival was very wide. 5-year relative survival for breast, colorectal, and prostate cancer was generally higher in North America, Australia, Japan, and northern, western, and southern Europe, and lower in Algeria, Brazil, and eastern Europe. CONCORD has provided the first opportunity to estimate cancer survival in 11 states in USA covered by the National Program of Cancer Registries (NPCR), and the study covers 42% of the US population, four-fold more than previously available. Cancer survival in black men and women was systematically and substantially lower than in white men and women in all 16 states and six metropolitan areas included. Relative survival for all ethnicities combined was 2—4% lower in states covered by NPCR than in areas covered by the Surveillance Epidemiology and End Results (SEER) Program. Age-standardised relative survival by use of the appropriate race-specific and state-specific life tables was up to 2% lower for breast cancer and up to 5% lower for prostate cancer than with the census-derived national life tables used by the SEER Program. These differences in population coverage and analytical method have both contributed to the survival deficit noted between Europe and the USA, from which only SEER data have been available until now.”

    If you are going to compare access, you can look at this Public Health study. Or you can look at folks that the government classifies as poor in a couple of countries (I haven’t seen this study but I’m sure that it is out there). Are their outcomes the same? 

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Errington C. Thompson, MD

Dr. Thompson is a surgeon, scholar, full-time sports fan and part-time political activist. He is active in a number of community projects and initiatives. Through medicine, he strives to improve the physical health of all he treats.

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