Discord on Mammography Roils the ACS – Parts 1 & 2
Ralph Moss, Ph.D
There appears to be discord at the top of the American Cancer Society (ACS) over the promotion of breast cancer screening. According to a front-page article in the New York Times, the ACS intends to abandon its rigid advocacy of mammography screening of the age 40+ female population. The Times states that in early 2010 the ACS will modify its long-held position. The stated reason is that screening mammography does not actually save many lives, since it mainly detects innocuous tumors that will never become life threatening. Meanwhile, it fails to detect most of the dangerous tumors. But a press release from the ACS soon afterward directly contradicted its own medical director's stated positions.
The failure of mammographic screening has been widely discussed for years and so the "news" was that the ACS was going to finally acknowledge this reality. "The American Cancer Society, which has long been a staunch defender of most cancer screening," wrote Times science reporter, Gina Kolata, "is now saying that the benefits of detecting many cancers, especially breast and prostate, have been overstated" (Kolata 2009).
Breast cancer thus turns out to be much like prostate cancer. In prostate cancer, the use of the prostate specific antigen (PSA) blood test has created an "epidemic" of new cancers, most of which would never have progressed to become life-threatening conditions. Doctors have been busy "curing" artifacts of the testing process itself. Widescale PSA screening turned many otherwise healthy men into traumatized cancer patients. Anxiety over one's PSA level became a disease in its own right called "PSA-itis," to quote the distinguished Toronto oncologist, Ian F. Tannock, MD (Lofters 2002). Meanwhile, deadly forms of prostate cancers-which are rapid growing and prone to metastasize-are less likely to be detected through PSA screening in time to make a survival difference.
Criticism of Mammography
There have been similar criticisms of mammography over the years. One thinks of the efforts of John Bailar, MD, PhD, a former editor of the Journal of the National Cancer Institute, who, starting in 1976, vigorously disputed the efficacy of mammography. One also thinks of Samuel Epstein, MD, of the University of Illinois, who pointed out the danger of the radiation involved in repeated mammograms. I myself wrote critically about mammography in my book The Cancer Industry (1980)PRIVATE "TYPE=PICT;ALT=" and in a more recent Moss Report on the topic (see below).
A lucid discussion of the uncertainty of cancer screening has been made by H. Gilbert Welch, MD, and colleagues at the VA Outcomes Group and the Dartmouth Institute for Health Policy and Clinical Research, White River Junction, VT. Welch is the author of a provocative book, HYPERLINK "http://www.amazon.com/gp/product/052024836?ie=UTF8&tag=cancerdecisio-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=052024836"Should I Be Tested for Cancer? Maybe Not and Here's Why (2005)FPRIVATE "TYPE=PICT;ALT=" as well as numerous articles. For example, Dr. Welch wrote in 2009 in the British Medical Journal:
"Overdiagnosis of cancer occurs when the cancer grows so slowly that the patient dies of other causes before it produces symptoms or when the cancer remains dormant (or regresses). Because doctors don't know which patients are overdiagnosed, we tend to treat them all. Overdiagnosis therefore results in unnecessary treatment" (Welch 2009).
This week, the ACS dam appeared to be breaking, as a result of a recent article in the Journal of the American Medical Association, reiterating many of Welch's points. The lead author was Laura J. Esserman, MD, a breast surgeon at the University of California, San Francisco. According to the Times, the ACS was "spurred in part by an analysis published Wednesday in The Journal of the American Medical Association." This JAMA article shows that there has been a "40 percent increase in breast cancer diagnoses and a near doubling of early stage cancers, but just a 10 percent decline in cancers that have spread beyond the breast to the lymph nodes or elsewhere in the body" (Kolata 2009).
This contradicts the very purpose of mammography screening, which is to find breast tumors in an early and curable stage, before they become deadly. If that were indeed happening, then the statistical increase in early-stage breast cancer should be accompanied by an equivalent decrease in the number of late-stage tumors. Instead, there was only a 10 percent decrease in late-stage cancers. So the net effect has been to greatly increase the number of breast cancer cases, finding innocuous pseudo-malignancies, without significantly impacting the death rate.
As the JAMA paper put it, mass screening increased "the burden of low-risk cancers without significantly reducing the burden of more aggressively growing cancers and therefore not resulting in the anticipated reduction in cancer mortality" (Esserman 2009). Or, to quote the Times, there was a "real risk of over-treating many small cancers while missing cancers that are deadly."
Last week I began a discussion of the discord at the American Cancer Society (ACS) over its recommendations for screening mammography. I conclude, with references, this week.
The American organization that has been most firmly associated with screening mammography is the ACS. Apparently, the JAMA article momentarily tipped the scale in the debate against mammography. Although the ACS gives lip service to evidence-based medicine, in this case the evidence tilts away from mammography and towards skepticism. The new ACS chief medical officer, Otis W. Brawley, MD, told the Times, he was ready to embrace the factual approach. "I'm admitting that American medicine has over-promised when it comes to screening. The advantages to screening have been exaggerated" (Kolata 2009).
Dr. Brawley is a well-regarded medical oncologist who took over the top administrative position at the ACS two years ago. It took a lot of courage for him to try to adjust ACS's positions to the facts on the ground. Before coming to ACS, Dr. Brawley had expressed personal reservations about cancer screening, especially the use of the PSA test for prostate cancer. In 2000, he told a patients' Web site:
"I have never had a PSA and do not desire one. I have had relatives with the disease. I just do not believe it saves that many lives…. I am aware of 23 different organizations of experts in screening around the world who have considered the question and all have chosen not to make the blanket statement that screening saves lives and men should be screened. Most actually recommend men not get the test because it is not proven effective" (www.psa-rising.com).
So, if anything, Dr. Brawley could be considered a skeptic regarding cancer screening. But he also told the Times, "We don't want people to panic" over the new mammography position. But apparently the idea of scaling back mammography did lead to panic within ACS. Less than a day after publication of the Times article, the ACS put out a press release: "American Cancer Society Stands By Its Screening Guidelines."
Stands by its guidelines? How was that possible, when just hours before its medical director had directly contradicted those guidelines? Were they attempting to deny the accuracy of the Times report? One day it is revising its guidelines, and the next day standing by them? Here is an excerpt from the press release. Read it carefully:
"Today's New York Times…indicates that the American Cancer Society is changing its guidance on cancer screening to emphasize the risk of over-treatment from screening for breast, prostate, and other cancers. While the advantages of screening for some cancers have been overstated, there are advantages, especially in the case of breast, colon and cervical cancers. Mammography is effective – mammograms work and women should continue get them."
Notice that the press release does not say that the Times article was wrong or that Dr. Brawley had been misquoted. It simply falls back on the time worn argument that "mammograms work." It claims that breast is like colon and cervical cancer, not like discredited prostate cancer screening. It thus totally ignores the powerful arguments of Welch, Esserman and many others. It cites some studies of its own "proving" that mammography is effective, but just ignores the more recent and (in my opinion) more powerful arguments in JAMA and elsewhere.
Notice too how the ACS release associates mammography with colon and cervical cancer screening, rather than with prostate cancer screening. That is convenient, because there is little debate over the efficacy of colonoscopies for colon cancer or Pap smear (and HPV virus) screening for cervical cancer. The whole point of the recent JAMA article, however, was that mammography more closely resembles the faulty PSA screening program in its failure to significantly increase actual survival.
Although the ACS has now backtracked, I suspect that this reversal is only temporary. Dr. Brawley's previous skepticism about screening is well known. As long as he remains medical officer, he will probably push for clarity on this question. The mammography recommendations are now looking like the fringe position, while the position of the erstwhile skeptics has become mainstream. ACS cannot hold back this trend and sooner or later, it will have to modify its outdated position. That will be a victory for evidence-based medicine.
I hope, however, that ACS will make this revision in the context of a sweeping public review of its method of debating scientific issues, including its high-handed tendency to crush opponents, rather than engage in reasonable dialogue. For instance, we have seen in the past how ACS abandoned its notorious 'quackbuster' position regarding complementary and alternative medicine without making a clean sweep of its disgraceful history in that regard. ACS should admit that it (and not "American medicine" in general) was mainly responsible for the mammography recommendation and for various reasons got that wrong, long after many others had pointed out its errors. This may hurt in the short run, but it would be incredibly salutary for the long-term health of the organization. Or would such honesty be asking too much from a multi-billion organization?
OUR REPORT ON MAMMOGRAPHY
We have a special 36-page report on "Mammography, Biopsy and the Detection of Breast Cancer." Here is what one reviewer, Samuel Epstein, MD, professor emeritus of Environmental and Occupational Medicine at the University of Illinois School of Public Health, said about this report:
"A characteristically thoughtful and incisive work that not only exposes the very real dangers of breast cancer screening…but also lays bare the astonishing lack of scientific evidence underpinning current screening recommendations. This is an outstanding and important work by an outstanding and important author."
—Ralph W. Moss, Ph.D.
Esserman L, Shieh Y, Thompson I. Rethinking Screening for Breast Cancer and Prostate Cancer. JAMA. 2009;302:1685-1692).
Bailar JC, III. Mammography: a contrary view. Annals of Internal Medicine. 1976;84:77-84.
Bailar JC, III. Screening for early breast cancer: pros and cons. Cancer. 1976;39:2783-2795.
Bailar JC, III. Mammographic screening: a reappraisal of benefits and risks. Clinical Obstetrics and Gynecology. 1976;21:1-14.
Epstein SS, Bertell R, Seaman B. Dangers and unreliability of mammography: breast examination is a safe, effective, and practical alternative. Int J Health Serv. 2001;31:605-615.
Kolata, Gina. Cancer society, in shift, has concerns on screening. New York Times, Oct. 20, 2009, page A1.
Lofters A, Juffs HG, Pond GR, Tannock IF. "PSA-itis": knowledge of serum prostate specific antigen and other causes of anxiety in men with metaststic prostate cancer. J. Urol. 2002;168(6):2516-2520.
Welch HG. Overdiagnosis and mammography screening. BMJ. 2009;339:b1425