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There has been a fair amount of controversy over the past couple of weeks with regard to various articles in the media reporting on a study performed in Canada decrying the “over diagnosis” of breast cancer and that perhaps screening shouldn’t be performed, Especially in women below the age of 50. As the senior breast imaging specialist in these parts, I feel it is incumbent upon me to explain a few things to your readers.
This Canadian study has been going on for more than 20 years and it has been refuted many times for its poor methodology, including a lack of randomization for many patients, pre-selection biases, poor imaging quality and poor interpretation skills amongst several of the radiologists participating in the study.
Screening mammography has been consistently and reproducibly shown to save lives and to decrease mortality. Numerous studies, properly designed, applied to large populations, have proven beyond any reasonable doubt that this is so. This has proven true around the world, including the landmark studies published by Laslo Tabar in Sweden as well as the very large HIP trial in New York state.
More recent studies including a large study just published this month by the group at the UH/Case Western Reserve system. Have demonstrated why this is so. Screening, which delivers a negligible radiation dose to the breast with modern mammography equipment, allows us to detect cancers when they are much smaller. When breast cancers are small, they are much less likely to have spread to adjacent lymph nodes or to other organs.
It allows us to detect premalignant lesions such as the various atypical hyperplasias. Such lesions can often be successfully treated with various medication regimens instead of surgery. Sometimes these lesions prompt further diagnostic workups for contralateral disease and some even prompt genetic testing and counseling. Mammographically detected lesions also allow the performance of breast-sparing procedures such as lumpectomy instead of the more drastic technique of mastectomy.
Is mammography perfect? Of course not. And either am I. Lesions can be missed for a host of reasons. Very dense breasts can obscure small lesions. Some lesions are just plain invisible at conventional mammography due to their patterns of growth and biology. If I lived in a perfect world with infinite resources, every woman I take care of would get yearly screening mammography, breast ultrasound, AND MRI( with the requisite self –exams, of course).
So what exactly is the impetus for various academics and, more tellingly, government bureaucrats, to criticize screening mammography? I believe the answer is revealed every time one of these people utters the word “over diagnosis.” I am convinced that this is but the beginning of an effort by various governmental and university actors to try to limit the amount of care that people receive, all under the guise of science (they recently tried the same thing with PSA tests for men).
I realize better than most that , the U.S. government is broke, but I become very concerned when their efforts to rein in costs involve transparent attempts to limit the utilization of a test that has not only saved countless lives but whish has also dramatically reduced suffering. Whenever you hear the phrases “over diagnosis,” “over treatment” and “excessive intervention,” I would urge you to take a very hard look at the data presented, look at the motivations of the authors and, unfortunately, probably assume that they don’t necessarily have your best interest foremost in their minds. Medicine is undergoing wrenching changes for a host of reasons and there are enormous cost pressures in play. Buyer ( and reader) beware.
Making it a great day! S