National Breast Cancer Awareness Month is so important. Over the years it has helped to raise awareness of the severity of the disease in medical and economic impact. Ultimately, we look for ways to save human lives. Much has changed over the years. One has to remember that just not long ago, we “Baby Boomers” watched as our mothers succumbed to the most common death inducing cancer in women, uterine cancer. That’s right. Up until the early 1970’s, this was the cancer most common in killing women. The fight with breast cancer has been ongoing, with diagnostic screening meeting new challenges around every turn.
In 1959, the introduction of a standard screen called The Papanicolaou (Pap) smear changed everything, and a national campaign to get women into the doctor for Pap screenings created a paradigm shift in the routine care of women when visiting their doctor. With this tool, we eventually discovered that there was a culprit now known as, “The Papillomavirus”; we were able to develop a vaccine against. With this victory, however, Breast cancer became the real malignant villain in taking down women. It has become rampant, involving all kinds of theories as to cause, including everything from medicines, hormones, and lifestyle practices to oncogenetics and environmental exposure.
Controversial guidelines in physical screenings and imaging continue to change. Economically, it seems sometimes that insurance companies drive our screening studies. Basing guidelines on thready actuarial information, they change mammography guidelines constantly, jumping on any information that suggests spending less on screening. Now, a recent study suggests that mammography may not be as important as previously thought in reducing a woman's risk of dying from breast cancer. Coming on the heels of guideline changes from the U.S. Preventive Services Task Force in 2009, indicating women do not need mammograms in their 40s, this latest research, published in the New England Journal of Medicine, adds another “scratch your head” position to the idea that mammograms make a substantial impact in saving lives.
The study, conducted in Norway, showed that women who receive breast cancer screenings have a 10 percent lower risk of dying from cancer, but researchers could trace only a third of this so-called reduced risk to mammograms themselves. Screenings reduced death from breast cancer by only 2.4 per 100,000 women. The Norwegian study followed more than 40,000 women with breast cancer.
American women shouldn't be too quick to back away from recommended biannual screenings for breast cancer for those over age 50, however. Dr. Otis Brawley, chief medical officer of the American Cancer Society, feels the Norwegian study was too short in duration. According to Dr. Brawley, "The report's estimate of the relative value of mammography is lower than in a number of previous screening studies". This may be due to the relatively short two year follow-up of the population. Brawley points out, that most randomized trials have at least 10 years of follow-up after the last round of screenings, and many have covered periods of 20 to 40 years.
Dr. Daniel B. Kopans, professor of radiology at Harvard Medical School, agrees and feels the study was incomplete and not long enough in duration. "This study contradicts other studies from the Netherlands and Sweden which show just the opposite, namely that screening accounts for over 60% of the decrease in deaths seen over the past 50 years," he says. "I suspect that most everyone who cares for women with breast cancer would acknowledge that therapy only saves lives when breast cancers are found and treated early."
As a physician, I must add that the ability of doctors to perform a thorough palpatory exam is crucial. Many doctors just have their patient lie down on the exam table and circumferentially feel both breasts and consider them examined. The real physician will ask pertinent questions while examining the “patient”, not just their breasts. In addition, the exam should start with a visual exam of the patient and her breasts, looking carefully for skin and nipple changes, and then utilizing maneuvers that force breast tissue to respond to different angles of muscular contraction along the chest wall. This captures lesions deep along the ligamentous attachments of the breasts. This should then be followed with a very thorough palpatory exam of both breasts and the axillae.
I should also comment that regular breast cancer screenings heighten women's awareness of the disease. This leads to early detection and a better prognosis. While the American Cancer Society no longer recommends monthly breast self-examination, I feel current guidelines regarding mammography should not be changed. The total body of science supports the fact that regular mammography is an important part of a woman's preventative health care.
Wear some pink this month,