June 28, 2014

In DFW, debate continues over breast cancer study

A disputed Canadian study casts doubt on the effectiveness of regular mammograms.

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With no family history of breast cancer and no concerning lumps, Pam Eckroat wasn’t too worried about receiving bad news at her annual screening mammogram earlier this year.

Eckroat, 62, said no tumors had ever been detected during any of the mammograms she has regularly received over the past decade. So the Azle woman was stunned when her doctor’s office called the next day, asking her to come in for more tests. Doctors immediately performed a second, more detailed mammogram and biopsied the small tumor found in her right breast.

“They called me the next day to tell me that it was cancer. Boom, boom, boom,” said Eckroat, who underwent surgery and radiation treatment earlier this year for her Stage 1 breast cancer. “Even after they found my cancer, I never felt the lump. Without that routine mammogram, I don’t know when I would have found it.”

Eckroat credits her annual mammogram with catching her tumor early and saving her from even more extensive surgery and treatment.

But one of the largest studies of its kind recently casts doubt on the need for annual screening mammograms and whether they do more harm than good.

The study, published in February in the British Medical Journal, found a nearly identical death rate between women ages 40 to 59 who received regular screening mammograms and those who only received physical breast exams and standard care.

The 25-year study, which involved nearly 90,000 women in Canada, also found that nearly 22 percent of invasive breast cancers detected by screening mammograms turned out to be non-life-threatening, leading to unnecessary surgery, radiation and chemotherapy for patients.

Doctors in the Dallas-Fort Worth area say they are concerned that the study’s findings may discourage women under the age of 60 from receiving annual screening mammograms, which can detect much smaller tumors than can be found by self or clinical examinations. Some also question the effectiveness of the technology used in the study, which began more than 25 years ago.

“Right now there is so much conflicting information, people are confused,” said Dr. Scott Woomer, Baylor Grapevine Comprehensive Breast Center’s medical director. “When you have reports like this it kind of opens the door for people who don’t want something done to say, ‘Well, I don’t have to.’ ”

Nearly 1 in 8 women in the United States will develop invasive breast cancer during their lifetime, according to the American Cancer Society. The organization recommends that women age 40 and older receive annual screening mammograms, which can detect tumors that cannot be felt.

About 37 million mammograms are performed annually in the United States at a cost of about $100 each, according to a New York Times article on the Canadian breast cancer study.

“You don’t find early breast cancer unless you are doing screening,” Woomer said.

Breast cancer death rates in the country have fallen by about 30 percent since 1989, which is believed to be a result not only of better treatment but also of earlier detection through screening.

“Suppose screening mammography doesn’t work? The only way to know that is to stop doing that and watch the increase in the death rate. I would hate having to go back to 30 percent more breast cancer deaths,” said Dr. Tilden Childs III, a diagnostic radiologist at Texas Health Arlington Memorial.

Screening guidelines

may be reviewed

The Canadian study found that 4,789, or 10.7 percent, of the 44,925 women who received regular screening mammograms died from breast cancer during the 25-year period. In comparision, 4,688, or 10.4 percent, of the 4,910 women who only received clinical or self-breast exams died of breast cancer during the same time period.

But the study did find that the survival period for women whose smaller, non-palpable cancer detected by mammogram was longer than women whose cancer was found once it could be felt. A palpable cancer is a lump that can be detected by touch.

Earlier studies that linked screening mammograms to a reduction in breast cancer deaths were done in the 1960s to 1980s, according to an editorial titled “Too Much Mammography” that accompanied the Canadian study. Recent studies conclude that improved treatment options, such as the use of drugs like tamoxifen, are behind the sharp decline in breast cancer deaths, the editorial cited.

Dr. Stephen Richey, a physician at Texas Oncology Fort Worth 12th Avenue, said he doesn’t believe the Canadian study will change current screening guidelines, but it could spur further research into mammography.

“Most of the data we have to look at has pointed toward an improvement in survival. We still feel screening mammography has a role in women’s health,” Richey said. “I see a lot of women who develop breast cancer at a very early age, younger than the screening guidelines. My recommendation is that you should really talk with your doctor about how you want to approach screening and what are the risks and benefits of screening or not.”

The study also found that invasive breast cancer that had been detected by mammogram was overdiagnosed for one out of every 424 women who received the screening.

Though some tumors or abnormalities, such as a precancerous condition known as ductal carcinoma in situ, detected in a mammogram may ultimately be determined to be non-life-threatening, local physicians and radiologists say finding truly invasive breast cancer early through screenings can result in less-expensive treatment and a better outcome for the patient.

“Those of us who treat breast cancer patients know that finding the cancer early — when it’s small — that the treatment required to cure the disease or prevent it from coming back is much less complicated,” Richey said. “The larger the tumor gets, the more involved surgery becomes. When the cancer spreads to the lymph nodes, then surgery is more involved. Chemotherapy is involved. The treatment becomes more complicated, and there are a lot of side effects from treatment.”

A new study published this month in the Journal of the American Medical Association found that three-dimensional breast imaging, called tomosynthesis, combined with digital mammograms can reduce the number of false positives for cancer detection.

Besides experiencing the psychological toll of a false positive, a woman could wind up spending hundreds or thousands of dollars for additional testing.

A 2011 study published on the National Institute for Health website estimated that false positives could account for nearly $1 billion in healthcare spending if just 10 percent of the 37 million mammograms performed each year in the U.S. were falsely positive.

‘It’s not just life and death’

Dr. Kory Jones, a breast surgeon and medical director for Texas Health Arlington Memorial’s Breast Cancer Program, said she agrees with the study’s findings that screening mammograms don’t reduce mortality. But they are still beneficial, she said.

One of the most important roles screening mammograms play is finding cancer when it is small, which may allow a woman to lose less of her breast through surgery and avoid chemotherapy, Jones said. Many breast cancers are not palpable until they are larger than 1.5 centimeters, she said.

“I do find that people who are getting regular screening mammograms will usually find their cancers that are a centimeter or less in size. Anything that is under 2 centimeters and hasn’t spread to the lymph nodes is stage 1 and that makes a difference in treatment,” Jones said.

Sometimes it can take up to three years for a tumor to become large enough to be felt, acccording to the Centers for Disease Control and Prevention.

Though mildly uncomfortable, Eckroat said she believes an annual screening mammogram can save women and their families from the emotional and financial devastation that may come with finding a more advanced case of breast cancer.

Eckroat, who underwent a partial mastectomy and 33 radiation treatments, was grateful her cancer was detected early enough so she was able to continue working full time and avoid the rigors and side effects of chemotherapy.

“It’s not just life or death. It can be the difference between a complete mastectomy or a partial. It could mean going back to work in two weeks instead of six weeks,” Eckroat said. “Waiting three years can be devastating. Quite frankly, I believe that report is irresponsible. I think you need to go every year.”

Studies such as the one out of Canada will help the medical field re-evaluate whether all women should begin annual screening mammograms at age 40, Jones said.

“It does bring up some interesting points. Maybe it’s not that straightforward. Maybe would we should look at their risk factors. Maybe you can go every couple of years. Or maybe you have high risk factors and should start going at the age 35,” Jones said.

Because of known flaws with mammograms, Susan G. Komen has invested more than $33 million in early cancer detection research, including blood and tissue tests, said Judy Salerno, president and chief executive officer of the breast cancer organization.

“This study adds to a growing body of evidence that mammography is an imperfect screening tool for breast cancer. We agree. It is based on 1950s technology, and can lead in some cases to overdiagnosis and overtreatment of breast cancers. The problems with mammography have been established for many years,” Salerno wrote on the Komen website earlier this year.

“The more important question, and the one we ask every time one of these studies is released, is what we can do to provide women with more reliable and cost-effective tests to detect breast cancer. Once detected, we need tests that can tell us, with more certainty, which tumors are likely to become invasive and which might not require extensive treatment. The search for better early detection methodologies is an important focus for research.”

Minimal intrusion

Women who undergo a biopsy only to find their lump or suspicious spot is noninvasive don’t suffer much beyond some bruising and anxiety, local doctors said.

“Biopsies today are very much less invasive than they used to be,” said Childs, who is also Texas Radiological Society president.

The procedure was previously done in an operating room with the patient under general anesthesia, but it can now be done as an outpatient procedure with local anesthesia, he said.

“Most of my patients say it didn’t hurt as much as going to a dentist,” said Childs, adding that today’s biopsy incision is so small it doesn’t require a suture.

After her cancer was found, Eckroat returned to her primary care physician and thanked her in person for scheduling the screening mammogram.

“If she had just said ‘Go and make an appointment,’ I may have not done it right then. I’m a busy person,” Eckroat said. “I am forever grateful.”

After her own unexpected brush with cancer, Eckroat said she’s concerned that publicity surrounding the controversial findings of the Canadian study might cause women to take the need for screening mammograms less seriously.

“Most of us are going to look for any justification to put off a mammogram. Who wants to do it?” Eckroat said. “They just need to be screened. It’s not a big deal. Do it.”

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