Mammography Review Shatters the Status Quo: Doubts About Its Value Alarm Many
By Ceci Connolly
Washington Post Staff Writer
Sunday, February 17, 2002; Page A01
Her patients cannot believe it. For years they had taken it for granted that mammograms saved their lives, or would. For years they had subjected themselves to the cold metal of the machine, the painful pinch of the plates. After all, everyone knew that early detection prolongs life. But new assessments of the pivotal research supporting the effectiveness of mammography have cast serious doubt on that assumption, and Carolyn Hendricks, a Bethesda oncologist, finds herself "inundated" with questions. "Many patients are asking me, 'Why bother? What really is the point?'" she said. "Many women feel betrayed."
Thousands of miles away in Seattle, Joann Elmore says she no longer pressures women to undergo the X-ray screening. "We are learning from this experience that perhaps we oversold ourselves and the public on the benefits of mammography," said Elmore, head of general medicine at Harborview Medical Center. "We're hoping that it works. But we don't know."
In Minneapolis, Richard Carlson, a breast imaging specialist for 15 years, feels as if he has lost his medical moorings. "If true, this is going to be a very serious setback for breast cancer treatment and cures," said Carlson, whose wife was diagnosed with the disease three years ago. "This would put us back to the beginning: How are we going to reduce mortality from this disease?"
Three weeks after a National Cancer Institute advisory panel concluded there is insufficient evidence to prove that mammography reduces breast cancer deaths, doctors and patients are coming to grips with the chilling prospect that what they thought was medical gospel is anything but. "It's conceivable mammography has a benefit, although if it does it is small," said Donald Berry, chairman of the NCI panel that threw Carlson and other physicians into such turmoil. "It's also conceivable it does not have a benefit. The bottom line is uncertainty."
Modern medicine is full of uncertainty, but mammography had been widely accepted for decades as the best way to spot abnormalities before they grow into deadly tumors. At times, scientists have debated the risks of radiation exposure and whether younger women should be screened. But confident that early detection saves lives, leading medical authorities have long advocated annual mammograms for women 50 and older. The wave of doubt began with two scientists in Denmark, Peter Gotzsche and Ole Olsen. The researchers reviewed the seven leading studies of mammography screening and concluded there were significant enough questions about the quality of the research to undermine the results. The data simply did not prove that mammography reduces breast cancer deaths, the two said. That prompted the NCI panel to reexamine the issue.
For women who begin annual mammograms in their forties, annual screening appears to add 36 hours to their life spans, said Berry, who is also chairman of the bio-statistics department at M.D. Anderson Cancer Center in Houston. "You would get a better benefit from walking to the doctor's office than getting those mammograms," he said. Every woman who gets a yearly mammogram through her fifties has a 50 percent chance of receiving at least one false positive reading, said Mary Ann Napoli, head of the New York-based Center for Medical Consumers. In addition to anxiety and expense, many will undergo unnecessary procedures — from a simple needle biopsy to a mastectomy. Some experts say the risks of mammography may outweigh the benefits for some women. "These are healthy, symptomless women" getting annual screening mammograms, she said. "You may end up with a lot of collateral damage to women who do not have invasive cancer."
Subsequent analyses have challenged the Danish study and the work of Berry's panel. The American Cancer Society, the National Cancer Institute and other leading medical organizations are still recommending routine mammography. In the coming weeks, the NCI, several medical groups and Congress will further scrutinize the issue. But it's unlikely the debate will be resolved soon. "We're about the business of trying to prolong the survival of women with this deadly disease," Carlson said. "If we learn that we can't rely upon these studies to show a reduction in mortality from breast cancer in women who undergo routine screening, then we have very bad news for the women of the world."
Like Carlson, one of his patients, Jane Gregerson, wants to see much more research, not just on mammography but on the cause of breast cancer and possible treatment. "This whole thing reminds me of the red wine debates," she said. "Red wine is good, red wine is not good."
In several breast centers, doctors say a small number of women have canceled appointments, setting off fears in the medical community that tumors will go undetected. "Every day in my practice I see breast cancer that would not have been picked up without mammography," said Washington breast cancer surgeon Peter Petrucci. He said he cringes over the latest headlines. "I know I'll have a bunch of patients who won't follow through and get a mammogram." But Petrucci also acknowledges that legal and economic pressures — and the difficulties in reading some X-rays — can influence a course of treatment. "I see mammography overread because of concerns about liability," he said, adding that when in doubt, some radiologists err in favor of recommending surgery for a mysterious mark on the film. Although mammograms can provide the first glimpse of breast cancer, a growing number of researchers say that does not necessarily mean the test saves lives. Abnormalities on the X-ray could be benign. In instances where the tumor is malignant, modern therapies — not early detection — may make the difference in mortality.
In recent years, physicians have made progress with less invasive surgery, such as lumpectomy, chemotherapy and hormonal therapy. So maybe all mammography does is detect some cancers earlier, but not necessarily when they are any more treatable. But doctors such as Hendricks worry that in their search for better types of detection and cures, researchers will abandon a valuable tool. "I am holding on to the promise [that] mammography helps me in the detection and treatment of breast cancer," she said. "I can't do my job without it."
Breast cancer survivors in particular, fiercely cling to mammography as the gold standard in health screening — and perhaps the only thing a woman can actively do to improve her chances of survival. They say that even the risks of mammography are minimal compared with the chance of detecting and curing cancer early. Susan Hunt, 50, said the pain of surgery and days spent waiting to have a mysterious lump checked are awful. In her case, two scares over 10 years turned out to be benign. "But I'd sooner be in that category of trauma than the trauma of breast cancer," the Seattle lawyer said.
For Carl D'Orsi, chairman of the breast cancer committee of the American College of Radiology, there is no debate. "Women must have their mammograms; it is the only way to drop the mortality rate," he said, noting that breast cancer death rates have declined as mammography screening has increased. Even if mammography does not lower mortality rates, it can mean less invasive treatment and greater "breast conservation" than if a large lump were discovered in a physical exam years later, several specialists said. "As one patient said to me, 'If it doesn't save lives, at least it saves breasts,' " said Katherine Alley, director of the breast center at Suburban Hospital. To her, it is counterintuitive that early screening might not be beneficial.
But it is not unusual for anecdotes to clash with data, said Fran Visco, president of the National! Breast Cancer Coalition. "My breast cancer was found at age 39 with mammography," she said, acknowledging it is natural for patients to credit the X-ray machine with saving their lives. "Until I understood the evidence, I probably would have said the same thing."
© 2002 The Washington Post Company