If it's not foods that are good for you and then aren't, it's drugs like hormone replacement therapy, handed out like vitamin pills to midlife women until we learned they could cause breast cancer. Now, controversy and confusion swirls around screening for breast and cervical cancer. Women are understandably "bothered and bewildered." Is there a way to sort out how to take care of ourselves?
The debate over when and how often to get mammograms has actually been ongoing for years. In the 1960s, randomized controlled studies were conducted but the complex data they provided led to different interpretations and recommendations. In 1971 a large-scale study found that mammograms were of limited benefit to women under fifty. In 1997, a consensus conference at the National Institutes of Health concluded that there was insufficient evidence to recommend screening for women under age fifty. Still, the Senate voted unanimously in support of women under fifty getting mammograms so the National Cancer Institute endorsed screenings for women in their forties.
Meanwhile, women's health education and advocacy organizations were making their position clear. Breast Cancer Action (BCA), the National Women's Health Network, and others, stated that pre-menopausal women should not have regular screening mammograms. Everyone, they said, should know the benefits and risks of all screening methods (mammograms, breast self-exam, clinical breast exam) so they could make the best decisions for themselves based on individual risk assessment.
BCA argues that we need to put aside individual situations in favor of public policy decisions that affect large numbers of people. "Emerging science tells us that we need to try to do that if we're going to get to the best place in terms of reducing deaths from breast cancer and minimizing the harms that occur when we do mammography screening." Among those harms, says BCA, are false negative results, or false positive results that lead to unnecessary invasive procedures. There is also the risk of cumulative exposure to radiation. Often, cancers that will not progress and are not life-threatening will be diagnosed and treated even though they pose no real problem.That's why risks must be balanced against benefits of finding breast cancer early enough to effectively treat the disease. ""Early detection' doesn't really mean what we've been led to believe -- that finding breast cancer early is the key to survival. It's not that simple," says Barbara Brenner, executive director of BCA.
Women diagnosed with "early" breast cancer fall into one of three categories: those with breast cancer that responds to currently available treatments; those with breast cancer that will never become life-threatening; and those with very aggressive disease that can't be effectively treated with available therapies. The only people who benefit from early detection are those in the first group because their lives can be saved if they get timely and appropriate treatment. It is these women who need screening.
Last November the U.S. Preventive Services Task Force recommended that women begin regular breast cancer screening at age fifty rather than forty. Dr. Robert Aronowitz, an internist at the University of Pennsylvania, supports that recommendation. "You need to screen 1,900 women in their forties for ten years in order to prevent one death from breast cancer," he wrote on NYTimes.com. "In the process you will have generated more than 1,000 false positive screens and all the overtreatment they entail." Noted breast cancer surgeon Dr. Susan Love concurs. "There are no studies that indicate mammograms will reduce deaths from aggressive tumors in young women," she says. "It's not whether women under fifty get breast cancer. They do. The question is whether mammography is the best way to find them and really change the outcome."
While cancer groups like The American Cancer Society and the National Cancer Institute are split on guidelines issued by the Task Force, its recommendations are consistent with international findings and standards. The World Health Organization recommends starting screening at age fifty. In Europe, mammograms are given to post-menopausal women bi-annually. Detection rates are similar to those in the U.S.
Just after the Task Force recommendations for breast cancer screening were presented, the American College of Obstetricians and Gynecologists (ACOG) announced a similar revision to its screening guidelines for cervical cancer. ACOG now advises women to get their first Pap test at age twenty-one. (Previously they advocated a pap test three years after sexual activity began or at age twenty-one.) The new recommendation also promotes testing biannually instead of annually for women under thirty. According to Dr. Alan Waxman of the University of New Mexico, "the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs and avoids unnecessary interventions that could be harmful."
Changing health behavior, especially when it reverses prevailing norms, is not easy. Patients and providers alike will struggle with these new recommendations as they begin to think differently about risk and disease reduction. Some will question the timing of these recommendations given the current political climate regarding health care financing and reform. Certainly we should not throw out the baby with the bathwater, especially since women often receive routine health screening only when they visit their gynecologists for pap smears and breast exams.
Still, marrying evidence-based protocols to intuitive risk assessment is not a bad idea. As Barbara Brenner says, "We have suffered from oversimplification of the early detection message for far too long. The new recommendations on screening may help us move to a more nuanced understanding of cancer, and ultimately a better place for all of us."