Early Diagnosis Doesn’t Solve Every Problem
Last month, in an attempt to resolve the roiling debate over whether healthy women should have routine mammography screening, the U.S. Preventive Services Task Force announced flatly that “mammography reduces deaths from breast cancer.” It would be nice if the issue were that simple. It’s not. Some studies have suggested that screening mammography saves lives; others have found it does not. One thing is clear, however: The debate is drowning out other important discussion.
Thanks to the billions of dollars invested in mammography screening and the vested interest that the U.S. government and many organizations have in it, the mammography controversy will never die. But many women will--unless we make some real progress in breast cancer beyond mammography, and unless everyone diagnosed with breast cancer has access to advances in treatment.
The recent debate about mammography screening masks the real issue in breast cancer diagnosis: the value of early detection. Women are routinely told that early detection is their best protection, as breast cancer found early is almost 100% curable. The basis for the “almost 100%" figure is that 95% of women diagnosed by screening mammograms are alive five years after diagnosis. Being cancer-free for five years is considered a cure for some cancers, but breast cancer can and does recur at any time.
Meanwhile, breast-cancer awareness campaigns urging women to have yearly mammograms are based on a flawed premise. Women diagnosed early with breast cancer fall into one of three groups. The first group has a very aggressive disease that, no matter how small a tumor is when it is found, cannot be effectively treated with current therapies. These women will die of breast cancer no matter what treatment they are given, unless something else kills them first.
The second group has a type of either non-aggressive (indolent) invasive disease or a kind of cancer called “ductal carcinoma in situ” that, left untreated, will never be life-threatening.
The third group responds to currently available treatments, and finding breast cancer earlier does increase the likelihood that treatment will work for them.
Given these divisions and the treatments currently available, early detection only matters for women in the latter group. We have no way of tracking how many women historically have fallen into each of these three groups, and we have no way of figuring out at the time of diagnosis which group a woman belongs to. The result is that we mistreat or over-treat a lot of women diagnosed with breast cancer in our effort to help the others. In the end, women are left simply to pray that they are in that lucky treatment-responsive group.
Until we have a way of distinguishing those who will be helped by treatment from those who won’t, there are better ways to spend limited resources than on developing methods of ever-earlier breast cancer detection.
Resources could be well used today, for example, on making sure that women--and men--diagnosed with breast cancer have access to the most current information about treatment, as well as to the medical care necessary to take advantage of that information. While the public’s attention is focused on the mammography controversy, a woman is being diagnosed with potentially life-threatening breast cancer every 3 minutes in this country, whether by mammogram, breast self-exam or clinical breast exam. With each diagnosis, another person enters a world filled with more questions than answers.
The answers available to a new member of the dreaded breast-cancer sorority are likely to be determined by her available resources. Well-educated women are far more likely to do the kind of research necessary to take advantage of new treatment developments. Women living in major urban areas, where the big cancer centers are typically located, have better access to up-to-the-minute information and treatment than folks who live in suburban or rural areas. While we can’t be sure that any currently available treatment will “cure” a given case of breast cancer, we do know that there are some things that will reduce the harm caused by those treatments--if a woman knows about them.
Take the example of axillary lymph node dissection. This is the process of removing lymph nodes under the arm on the side of a woman’s body adjacent to the affected breast. The purpose of removing these lymph nodes is to assess whether cancer cells have spread into them, thus indicating a greater likelihood that the cancer will spread to life-sustaining organs. (Breast cancer in your breast can’t kill; it’s breast cancer that spreads to other organs or to bones that does.) The problem is that removing a large number of lymph nodes increases the risk of lymphedema, a serious and debilitating condition characterized by swelling and pain.
The good news is that there is now a procedure called “sentinel lymph node biopsy” that can reduce the number of lymph nodes that need to be removed. By removing and examining the one or two lymph nodes leading from the breast to the arm pit, doctors can learn whether cancer cells are likely to spread to other parts of the body without removing large numbers of nodes from under the arm. Reducing the number of lymph nodes that are removed lessens the chance of lymphedema.
But to take advantage of this procedure, women often have to ask for it--which means they have to know about it. Access to information is critical. A woman also needs to be sure that her doctor has performed enough sentinel lymph node biopsies to be proficient at them, which again comes back to access to good medical care. Whether women have access to information and care is too often a function of where they live and how much money and other resources they have available.
Even with access to sentinel node biopsies, many women are likely to face a dilemma posed by the procedure itself. Some researchers are beginning to question whether chemotherapy is necessary when only a few cancer cells are found in a sentinel node. But researchers don’t make treatment decisions, women with breast cancer do.
The issues posed by axillary node dissection are among the first faced by women with breast cancer who have access to information and treatment choices. But whether the issues are related to surgery, radiation, chemotherapy, hormonal therapy or alternative or complementary treatments, each treatment decision is filled with similar dilemmas. Every woman should have the information and access necessary to address these challenges. It’s time we moved past the mammography dilemma to make sure that they do.