How a charity oversells mammography
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5132 (Published 02 August 2012) Cite this as: BMJ 2012;345:e5132
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The Effort to Deny Women Access to Screening by Misleading Physicians and the Public about Mammography
The British Medical Journal has rejected the following for publication, but has permitted it as a rapid response to the attack on the Komen Foundation by Woolfshin and Schwartz (1). One might wonder why a medical journal would publish a critique of an advocacy organization except that the editor of the BMJ is on the Board of the “Nordic Cochrane Center” (NCC) (2) which is a group that has been trying for years to eliminate access to mammography screening (3). The attack on the Komen Foundation for supposedly exaggerated claims is ironic since much misinformation about mammography screening has come from the Dartmouth Institute for Health Policy and Clinical Practice. This is far more egregious than the Komen advertisement (which is actually factually correct). In 1993 using a misleading paper published in the Journal of the American Medical Association (4) (whose deputy editor is also on the NCC Board) a Dartmouth "expert" promulgated the fallacious information in the Annals of Internal Medicine (whose editor is also on the NCC Board).
"The yield [of cancers] of the first mammogram was five times higher in women 50 years of age and older (10 cancers per 1000 studies compared with 2 cancers per 1000 studies)...Clearly mammography is much more efficient in detecting breast cancers in older women." (5)
The actual data showed that the cancer detection rate increased steadily with increasing age. Only by grouping and averaging was it made to appear to jump suddenly at the age of 50. There have never been any data that show that any of the parameters of screening change abruptly at the age of 50 or any other age (6). Misleading information has guided screening recommendations around the World despite the fact that there is no scientific support for using the age of 50 as a threshold for starting screening (7,8).
A book from Dartmouth (9) completely, misrepresented the 1997 Consensus Development Conference on Mammography Screening (I was a participant at that meeting) in an effort to discredit supporters of screening and to support the author's belief that there is little benefit from screening beginning at the age of 40 when, in fact, the data presented at the CDC clearly showed a statistically significant decrease in deaths for these women (10).
The authors decry the use of observational data, yet they support papers that used scientifically unsupportable “observational” methodology (11,12) that have, fallaciously, suggested that 30-50% of cancers found by mammography are “overdiagnosed” and would “melt away” if left undetected. If tens of thousands of cancers are disappearing each year on their own, why is there not one reliable report in the modern literature of breast cancers disappearing without therapy? Who is “overselling” what? The randomized, controlled trials, the only way to measure "overdiagnosis", show that it is less than 10% and likely less than 1% (13).
Mammography is not the cause of “overtreatment”. In 1940 (prior to any mammography) 30% of women with breast cancer survived over 30 years without systemic therapy (14). Since it is still not possible to determine who these women are, most are now "overtreated" using systemic therapy. Unfortunately, 40,000 women still die each year despite systemic therapy. Were they also “overtreated”? Pathologists make the diagnosis and oncologists determine therapy. To blame mammography and deny women access to screening is like suggesting that the way to stop automobile accidents is to stop selling cars.
Opponents of screening, like the NCC, claim no conflict of interest by ignoring the funding they receive for their nihilistic analyses. Over 40 experts in breast care were highly critical of the poor science promulgated by the NCC (15). It is of great concern that the NCC has recruited editors from high visibility medical journals in which they boast that they have published numerous articles (16). Some of the same journals, repeatedly, reject papers in support of screening. Pressured by the NCC, the UK is, once again, reviewing mammography screening. The head of the UK Panel is on the NCC Advisory Board, and one of the advisors to the UK Panel is from Dartmouth. Written concerns have been ignored. The “foxes are [truly] guarding the chicken coop”.
The pejorative “harms of screening" have been exaggerated. Equating the anxiety caused by recalls from screening with dying from breast cancer is at best insensitive and at the worst, outrageous.
In our practice if 1000 women are screened
80 women are recalled for additional evaluation and are made anxious, but 920 (92%) are reassured.
45 of the 80 women will be reassured after having a few extra images or a negative ultrasound examination.
40 of the 80 women with a less than 2% risk of cancer, will be asked to return in 6 months (BIRADS 3). This is no different from a clinician asking a woman with a clinical finding to return in several months to be certain it has not changed.
15 of the 80 women will be advised to undergo a needle biopsy using local anesthesia.
5 of these women (30%) will be found to have breast cancer.
When biopsies are done for a palpable lump the percent “false positives” is much higher (17), and the “harms” are greater since palpable cancers are at a larger size and later stage than those detected by mammography (18).
Opponents of screening suggest that the major decline in breast cancer deaths that began, suddenly in 1990, five to seven years after screening began in the U.S.(19), is due to improved therapy. Yet not one of the major oncology organizations has urged that screening be stopped and that therapy alone will save all these lives. Therapy saves lives when cancers are found earlier.
I do not support exaggerating the benefits of screening, but Komen's was an advertisement, not a scientific analysis. It is far more egregious when supposed scientists provide, scientifically unsupportable, misinformation in the medical literature to try to deny women access to screening.
References
1. Woolfshin S, Schwartz LM. How a charity oversells mammography BMJ 2012;345:e5132 doi
2. http://www.cochrane.dk/about/AnnRep2011.pdf page 7 last accessed on 8 16 2012
3. Gøtzsche PC. Time to stop mammography screening? CMAJ. 2011 Nov 22;183(17):1957-8
4. Kerlikowske K, Grady D, Barclay J, Sickles EA, Eaton A, Ernster V. Positive Predictive Value of Screening Mammography by Age and Family History of Breast Cancer. JAMA 1993;270:2444-2450
5. Sox H. Screening Mammography in Women Younger than 50 Years of Age. Ann Inter Med. 1995;122:550-552.
6. Kopans DB. The 2009 US Preventive Services Task Force (USPSTF) Guidelines are not Supported by Science: The Scientific Support for Mammography Screening. Radiologic Clinics of North America Volume 48, Issue 5, Pages 843-857, September 2010
7. Kopans DB. Bias in the Medical Journals: A Commentary. Am. J. Roentgenol 2005; 185: 176 - 182.
8. Kopans DB. Informed decision making: age of 50 is arbitrary and has no demonstrated influence on breast cancer screening in women. Am J Roentgenology 2005;185:177-82
9. Welch HG. Should I Be Tested for Cancer? Maybe Not and Here's Why. University of California Press 2004 :126 and 127).
10. Hendrick RE. Smith RA, Rutledge JH, Smart CR. Benefit of Screening Mammography in Women Ages 40-49: A New Meta-analysis of Randomized Controlled Trials. Monogr Natl Cancer Inst 1997;22:87-92.
11. Zahl PH, Maehlen J, Welch HG. The natural history of invasive breast cancers detected by screening mammography. Arch Intern Med. 2008 Nov 24;168(21):2302-3.
12. Jorgensen KJ, Gotzsche PC. Overdiagnosis in publicly organised mammography screening programmes: systematic review of incidence trends. BMJ. 2009;339:b2587
13. Kopans DB, Smith RA, Duffy SW. Mammographic screening and "overdiagnosis". Radiology. 2011 Sep;260(3):616-20.
14. Adair F, Berg J, Joubert L, Robbins GF.Long-term followup of breast cancer patients: the 30-year report. Cancer. 1974;33:1145-50
15. Bock et al Effect of population based screening on breast cancer mortality. The Lancet 2011;378:1775.
16. http://www.cochrane.dk/about/AnnRep2011.pdf page 7 last accessed on 8 16 2012
17. Spivey GH, Perry BW, Clark VA, & et al, Predicting the Risk of Cancer at the Time of Breast Biopsy. The American Surgeon 1982;48 No.7: 326-332
18. Baker LH. Breast Cancer Detection Demonstration Project: Five-Year Summary Report. Ca - A Cancer Journal for Clinicians 1982; 32 No.4:194-225.
19. Kopans DB. Beyond Randomized, Controlled Trials: Organized Mammographic Screening Substantially Reduces Breast Cancer Mortality. Cancer 2002;94: 580-581.
Competing interests: No competing interests
Sir,
In a well-written, succinct and informative article, Woloshin and Schwartz [1] report the case of a charity promoting breast cancer screening by the use of misleading data.
The deception found in the information provided to potential participants of cancer screening is not, of course, confined to charities. Much of the criticism in the article would apply equally to those who should know better – the researchers, academics, officials in the Department of Health, and those who design and implement screening programmes.
In the case of breast cancer, the authors rightly emphasize the importance of lead-time bias and over-diagnosis bias that result in misinterpretation of survival figures. [1] Yet, as they point out, these problems have been known about for many years and continue to be ignored. As we know, there are other tricks to mislead the unwary – the use of relative risk reductions to inflate the perceived size of the benefit, the focus on cause-specific mortality rather than all-cause mortality, and the downplaying of side effects are all ways of presenting screening in the most favourable light. But they are also deception.
What is extraordinary is that, despite years of controversy concerning the benefits and harms of breast cancer screening, the fiasco has been repeated in the case of the bowel cancer screening programme. [2] No lessons have been learned because to do so would be inconvenient.
The advocates of screening believe it is a good idea and so they deliberately choose to disregard unfavourable evidence. And this accepted. After all, nowadays presentation is everything.
James Penston
james.penston@nhs.net
References
1. Woloshin S, Schwartz LM. How a charity oversells mammography. BMJ 2012;345;e5132
2. Penston J. Stats.con – How we’ve been fooled by statistics-based research in medicine. The London Press, November 2010. Chapter IX.
Competing interests: No competing interests
As medical students at Cardiff University, we support the authors' argument.
Mammography is particularly relevant to us due to the recent £10 million investment in Wales to upgrade breast screening equipment[1]. This indicates that there is a significant place for breast screening in the future.
The aspects regarding potential harm from screening do need to be explained to the public too. Throughout our undergraduate training we develop an understanding of epidemiology and the sensitivities and specificities of screening. We are aware that the general public doesn’t always appreciate the difference between screening and diagnosis, and the anxiety that screening may generate [2].
Relevant charitable organisations have a duty to the public to give balanced information regarding screening matters. Not to do so could disempower them from making an informed choice as to whether or not this is the right action for them to take.
1. Bodden T. £10m plan to upgrade Breast Test Wales cancer screening. Daily Post: 2011 January 15th.
2. Hafslund, B, Espehaug, B and Nortvedt, M. Effects of False-Positive Results in a Breast Screening Program on Anxiety, Depression and Health-Related Quality of Life. Cancer Nursing 2011: Vol 0:1-9.
Competing interests: No competing interests
Imaging, as suggested by Richard Gordon, may not be the answer. The earlier breast cancer is detected, the less likely it will develop and the more overdiagnosis and overtreatment there will be. Looking at cells may not enable the vital distinction between progressive and nonprogressive cancers because the critical factor may be outside and inherently unpredictable (say, a subsequent compromise to the immune system, trauma, exposure to toxins, you tell me). Although it would be welcome if it turned out that it could, the only way we can get there is by removing benign as well as malignant tumours, harming women in the process. If this is not prophylactic treatment for those whose risk of cancer is not actually known or calculable on available knowledge, then it is next door to it – which I take to be uncontroversially unacceptable.
Watchful waiting may be angstridden, but not more so than having treatment one cannot be sure is necessary. On balance in my view the latter is more distressing, involving the profound distress of irreparably damaging treatment one cannot know was necessary combined with anxiety about recurrence while the former involves anxiety about occurrence, no less severe, but without the treatment. Mr Gordon trivializes the distress of “minor ablation” and often the ablation is not minor, especially for DCIS which is supposedly early cancer. Better still, don’t screen people and don’t upset them when there is no good evidence that any good can come of it.
As for “being careful in not leaking this information to the public”, I am saddened by Professor Codacci-Pisanelli’s misplaced concern at a time when many other professionals are embracing the values of transparency, respect for humanity and informed consent. That involves allowing for the possibility that “the public” whose bodies, and indeed minds, are in question are in fact capable of drawing the right conclusions from correct, balanced and adequate information. Schwarz and Woloshin’s article draws attention to inexcusable moves by a powerful organization with a veneer of authority to encourage the public by false information to accept a measure involving serious harm and Professor Codacci-Pisanelli appears worried about them finding that out. As for undermining confidence in mammography screening, that is the correct attitude to it; and it is entirely appropriate that this should provide a lesson in caution regarding the scope and limits of imaging in general, and screening in general, which does not entail that no screening can be good, but does demand that it should be shown to be so. There are to my knowledge no better breast screening techniques given that even a technology that could be proven to save large numbers of lives (not the case for any technique that I know of) must also be shown not to create unacceptable collateral damage.
Competing interests: Diagnosed through breast cancer screening
An Italian writer said "le parole sono pietre" [Words are stones]. I am a practising medical oncologist, and a senologist, and mostly a University teacher. I think everybody should be very careful about the words we use. Mammography does not only imply the radiography, but also the awareness in women about breast cancer. These articles are all correct, but let us be very careful when leaking this information to the lay public, because we may lose confidence not only in mammography, but also in other screening techniques for breast, but also for other cancers.
Competing interests: No competing interests
Woloshin & Schwartz have done an excellent job in explaining the lack of a relationship between mammography screening and 5 year survival. So what is next? Given the small positive impact of mammography screening, let alone its downsides, it is time to replace this lead (Pb, not gold) standard. I’ve reviewed the prospects*. The major concept is that it is high time that breast imaging researchers aim at replacements for screening mammography, rather than second class adjuncts to it. This requires pushing imaging approaches to their physical limits. As extrapolations of epidemiological data suggest >99% cure if 100% of tumors were found and destroyed before they reach 2-4mm*, this may be an attainable goal.
One unfortunate consequence of the failure of mammography is that this has colored perception of all breast imaging methods. For example, the National Breast Cancer Coalition and Friends for an Earlier Breast Cancer Test seem to eschew imaging approaches. Another unfortunate consequence is that Woloshin & Schwartz castigate “overdiagnosis”. Of course, many small tumors will not end up killing the asymptomatic patient. But at present we can’t find most of the premetastasis tumors because of inadequate imaging methods, nor would we be able to distinguish which would kill from those that would not. The rational approaches here are: 1) imaging research to seek prediction criteria (downside: politics of redirecting research money); 2) watchful waiting (downside: anguish); 3) ablation or excision (downside: minor discomfort for tiny tumors). The latter is the standard of practice in dermatology (excise on suspicion, then do pathology).
*Gordon, R. (2011). Stop breast cancer now! Imagining imaging pathways towards search, destroy, cure and watchful waiting of premetastasis breast cancer. In: Breast Cancer – A Lobar Disease. Eds.: T. Tot. London, Springer: 167-203.
Contact: DickGordonCan@gmail.com
Competing interests: No competing interests
Re: How a charity oversells mammography
Recent evidence revealed that hundreds of registered Charities mainly use donations and funds to support themselves, their own existence, rather than finance good deeds. [1][2][3]
Their spending patterns suggest that they have direct economic benefits from arbitrarily exaggerating slogans like "early detection", "reduced mortality", "lives saved", "healthy prevention", etc.
Deliberately overselling benefits from diagnostic tests, screening programs, clinical procedures, in order to claim more donations and funds, should be retained a financial criminal offence, and punished accordingly.
References
[1] http://www.telegraph.co.uk/news/uknews/12046438/true-and-fair-foundation...
[2] http://www.independent.co.uk/news/uk/home-news/one-in-five-charities-spe...
[3] http://metro.co.uk/2015/12/13/worried-about-where-your-charity-donations...
Competing interests: No competing interests