Phew! It's nothing.
Suddenly, the debate over mammograms was personal
No one wants to be the woman in the mammography waiting room who gets called back for another set of breast images. Or the one who gets a call a week later saying the radiologist wants more imaging done.
But there I was, back for more. After faithfully getting screened through my 40s and early 50s, I had graduated to the next level of breast cancer diagnosis. Some women get ultrasound imaging to distinguish between benign cysts and tumors, but radiologists had spotted a cluster of calcifications in one of my breasts, and ultrasound alone wouldn’t be able diagnose it. Magnified, circled, and pinpointed, these calcium deposits looked like specks of salt on a blackboard. Calcifications can be fellow travelers with cancer cells, I was told, so I needed to have a biopsy to sample the surrounding cells to see if they were ductal carcinoma in situ, or DCIS, precursors of cancer that grow in the breast’s milk ducts.
I nodded my head, but I didn’t like seeing the box for “abnormality’’ checked on my chart. I felt like my luck was running out, no matter how healthy my habits or long-lived my relatives. Knowing so many women with breast cancer, some quite advanced, I also figured, why not me?
My abnormality was in a spot where it couldn’t be sampled by the relatively common procedure of using a needle that a radiologist guides by ultrasound to withdraw cells for a pathologist to test for cancer. I required a needle to be inserted for a different purpose: to locate the abnormality so I could be wheeled from the radiology suite into the operating room with it still in place. My surgeon would make an incision, snare some tissue around the needle, and send it to the lab for biopsy.
I missed two days of work and three days of training for the marathon I’m running on Sunday. I had slight bruising and a hair-thin scar, and resounding relief when I found out my abnormality was not cancer.
I am fortunate. I don’t have to contemplate surgery, radiation, or hormone therapy. I don’t have to worry about cancer shortening my days, at least not for now. I don’t have to agonize over whether I really needed to go through all that for an early form that might not get worse. But I do wonder how many other women have to travel this path.
Nearly a year ago a government advisory group cast doubt on the wisdom of women routinely getting screening mammograms before age 50 and annual screenings thereafter, igniting a firestorm of controversy that still smolders today. Mammograms save lives, both sides agree, but how many and at what cost are hotly contested.
Diagnoses of DCIS, sometimes referred to as stage 0 cancer, have climbed along with widespread screening mammograms, from fewer than 2,000 cases in 1970 to more than 50,000 in the US this year, according to the American Cancer Society.
Women with DCIS have to wrap their minds around the fact that not all of these early cancers progress beyond the precursor stage to become cancer that spreads. But no one knows which DCIS will never grow and which will become lethal. So when radiologists see something that looks like DCIS and pathologists confirm it, cancer doctors advise treatment that usually includes surgery to remove it, radiation to kill any cells in the neighborhood, and hormone therapy to thwart recurrence if the cells carry certain characteristics linked to regrowth.
That uncertainty about treating an early stage cancer raises the question of overdiagnosis, which some say starts before a woman sits in the mammography waiting room, tugging her johnnie tight as she waits for word on whether she can go home feeling safe for the next year. What I had was a false positive, which means my mammograms showed something suspicious that didn’t turn out to be cancer when examined under the microscope. Overdiagnosis means finding something — a type or stage of cancer — that most likely would not have caused health problems, but treating it anyway.
Using numbers analyzed by the US Preventive Services Task Force in its controversial November report, Dartmouth researchers Dr. Steven Woloshin and Dr. Lisa Schwartz broke down the benefits and harms of screening. Screening did reduce deaths, but false positives and overdiagnosis also added up to harm because they expose women to unnecessary procedures.
“The question is, where do you draw the line? Is it five cases of overdiagnosis or a hundred?’’ Woloshin said. “For the individual person, the first decision is, ‘Do I get screened?’ ’’
The American Cancer Society says yes.
“We have definitive evidence that we certainly save lives by testing everyone,’’ said the society’s chief medical officer, Dr. Otis Brawley. “There are some precancerous lesions like DCIS that may end up being treated but not needing to be treated. I can in good conscience encourage all women who have a diagnosis of breast cancer to get treated.’’
Cancer specialists know that a fraction of breast cancers — even palpable tumors — do not get worse. Studies from 60 years ago followed women who were diagnosed with breast cancer before effective treatments were available. Most of them died of their cancers, but 10 percent didn’t. The same principle holds true today, Brawley said.
“When I have 10 women with invasive breast cancer that’s one centimeter in size, we don’t have a test that says these are the nine women with cancer that, if left alone, is going to spread and cause problems . . . and this is the one lady who has cancer that is never going to bother her,’’ Brawley said. But “I definitely know if I treat 10 of these women, 10 women as a group are going to be better off than if I don’t treat all 10.’’
Dr. Daniel Kopans, director of breast imaging at Massachusetts General Hospital, vigorously opposes the revised recommendations, which said the benefits of mammography might not be worth the risks for women in their 40s, and that screening for women in their 50s could be done every other year instead of annually. He questions the credentials of the panel, disputes the studies on which it based its findings, and rejects the computer model it used to project deaths avoided by screening.
On DCIS diagnoses, he said 1 to 2 women out of 100 screened will end up having a biopsy and about 1 in 4 to 1 in 5 of those women will have breast cancer. Given the possibility that DCIS will progress to cancer, he sees both screening and treatment as lifesavers with parallels elsewhere in medicine.
“There are many things we overtreat [when] we can’t distinguish who needs treatment and who doesn’t,’’ Kopans said. “Take pneumonia. A lot of people get better on their own but other people will die. So we treat everyone with antibiotics. . . . Mammography has been shown to actually save lives. The tradeoff is yes, there will be some women who are overtreated and overdiagnosed.’’
The American Cancer Society has not changed its guidelines, urging women in their 40s to start getting mammograms on an annual basis.
“The reason why women have a one-third less risk of death from breast cancer is mammography, breast cancer awareness, and improvement in treatment,’’ Brawley said of the 30 percent drop in mortality among women in the United States between 1990 and 2010. “We are concerned that the confusion could deter women’’ from getting mammograms.
Dr. Judy Garber of the Dana-Farber Cancer Institute said the task force recommendations are reasonable. But she sympathizes with women in their 40s and 50s — and their primary care physicians trying to advise them what to do.
“Everyone remembers their friend from college who had cancer at the ‘wrong time,’ ’’ she said. “The challenge is where to make the [age] cutoff.’’
I know one thing: The top number on my blood pressure dropped about 20 points when I saw my surgeon for a post-operative checkup, back down to an anxiety-free runner’s low. That’s a number I can live with.
Ask me next year if I’m still feeling lucky.
Elizabeth Cooney can be reached at email@example.com.