For our November Readers' Review: “Dinner at the Homesick Restaurant” by Anne Tyler. As we prepare for holiday gatherings, join Diane and her guests to discuss this master work from the author who has made an art of exploring family love and dysfunction.
It’s been generally accepted that early breast cancer detection and treatment can improve a patient’s prognosis. For decades women have been advised to get an annual mammogram starting at age 40, and now there’s 3-D mammography which can improve chances of spotting something suspicious. 3-D mammography can also reduce the number of women who need to be called call-back for a follow up test, but some say widespread routine screening is leading to unnecessary treatment: Please join us to discuss the benefits and consequences of regular mammograms.
- Dr. Gil Welch professor of medicine at Dartmouth Institute for Health Policy and Clinical Research and internist, VA Outcomes Group
- Dr. Daniel Kopans professor of radiology at Harvard Medical School.
- Shannon Brownlee acting director of the Health Policy Program at New America Foundation.
MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Most doctors say routine mammograms for women over 40 are the best way to beat breast cancer. But erring on the side of caution when it comes to treatment, as many women and their doctors typically choose to do, has some risk as well.
MS. DIANE REHMJoining me to talk about routine breast cancer screening: Shannon Brownlee of the New America Foundation, from a studio in Cambridge, Dr. Daniel Kopans, professor of radiology at Harvard Medical School, and, from a studio in Hanover, N.H., Dr. Gil Welch, professor of medicine Dartmouth Institute for Health Policy and Clinical Research. I look forward to hearing your questions and comments. Join us, 800-433-8850. Send us an email to firstname.lastname@example.org. Follow us on Facebook or Twitter. Good morning to all of you. Welcome to the program.
MS. SHANNON BROWNLEEThank you.
DR. GIL WELCHGood morning, Diane.
DR. DANIEL KOPANSNice to be with you.
REHMDr. Kopans, let me start with you. I know you actually invented 3-D mammography, but tell us about the technique, what it does and how it works.
KOPANSFirst of all, thanks, Diane, for having me on. Just a general statement, I think all major medical groups now agree that mammography screening reduces the death rate from breast cancer. And a number of years ago, we started to try and improve on standard mammography. As you know, digital mammography was developed, and once digital detectors became available, we could apply a technique called tomosynthesis to the breast. As you pointed out -- I need to disclose -- I did invent this, so I'm quite biased.
KOPANSBut essentially, a standard two-dimensional mammogram is like looking at -- for radiologists, it's like looking at a book with clear pages. You can hold the book up to a light and see all the words on the pages, but they are superimposed one on the other. On a standard mammogram, all the breast tissue from one side of the breast is superimposed all the way across the breast, and it can hide cancers or even make it look like someone may have a cancer when it's just superimposed normal tissue.
KOPANSTomosynthesis, by taking a few low-dose images from different angles and having a computer synthesize the pages in the book, allows us to look at each page individually. What that does is two things. First of all, it helps unmask cancers that may be hidden on a two-dimensional mammogram, and the second advantage is that it reduces the so-called false positive rate.
KOPANSIt reduces the findings that we see in a two-dimensional mammogram that we might be concerned about that turn out to be nothing more than normal breast tissues superimposed. Those are eliminated by tomosynthesis. So digital breast tomosynthesis essentially will increase our ability to find small cancers and, at the same time, reduce the false positives.
REHMAll right. Two questions: First, is there additional radiation exposure compared to traditional mammograms? And, second, it there a greater cost to 3-D mammography?
KOPANSWell, at the present time, there is a little bit more of an increased dose because the first company to get Food And Drug Administration approval, the requirement was to obtain the standard two-dimensional mammograms and then, in addition, do the tomosynthesis study. What is right around the corner and actually under review by the Food and Drug Administration now is to eliminate the need for the standard two-dimensional mammograms and basically reconstruct them from the tomosynthesis images, and that looks like it's going to be very, very good.
KOPANSSo ultimately, the dose will not be greater than a two-dimensional standard mammogram. With regard to cost, you know, that's entirely up to the companies and also the insurance companies in terms of what the machines will cost and then what the insurance companies will reimburse. I suspect there'll be an increased cost. It shouldn't be, from my prospective, very much, but that'll be determined by other people. I don't actually -- no one asks my opinion about that.
REHMDr. Daniel Kopans, he is professor of radiology at the Harvard Medical School. He did invent the 3-D technology that allows 3-D mammography. And turning to you, Shannon Brownlee, tell us about the incidence of breast cancer rates today and how those rates have changed over the last couple of decades.
BROWNLEEWell, we've seen an increase in the rate of breast cancer in large measure because we screen for breast cancer. One of the more interesting aspects of that is that the kind of cancer that we're finding increasingly is something called DCIS, ductal carcinoma in situ. And DCIS is really particularly problematic because it's -- it may be a very, very, very early form of cancer that might or might not become an actual cancer. So we are detecting a lot of that, rising rates of DCIS, and don't quite know what to do about it.
BROWNLEEDo you treat it? Do you do surgery on it? And in many cases, the DCIS is sort of scattered across different parts of the breasts. And so it's one the reasons women end up getting mastectomies because it's too hard to take out all of those individual little lesions.
REHMAnd what about the outcomes? Are women in general living longer with the disease?
BROWNLEESo that's a little bit of a misleading way of measuring things. That's called survival. We talk about the five-year survival rate a lot. And survival is affected by how early you detect a cancer. And if you're detecting a lot of cancer, things that we call cancer that didn't really need to be treated, things that would not have bothered the woman over the course of her life, then, of course, your five-year survival rate looks really good.
BROWNLEEA more important measure is the population-based rate of death from breast cancer, and that has been declining. Now, the question is, how much of that is due to screening and how much of that is due to better treatment and how much of it is due to the fact that fewer women are on hormone replacement therapy.
REHMShannon Brownlee, director of the health policy program at the New America Foundation. Turning to you, Dr. Gil Welch, we should say you are not a medical doctor. Is that correct?
WELCHNo, that's not correct. I'm a general internist, and I work at the White River Junction VA.
REHMForgive me. All right. And your study was published in the New England Journal of Medicine last month, which made the claim that the widespread use of mammogram is resulting in overdiagnosis of breast cancer. Explain.
WELCHWell, let me first start about what we're not talking about. We're not talking about diagnostic mammography, and that's the test we order when women become aware of a new breast lump. All doctors agree that's a good test to figure out whether the lump is something to worry about. The debate here is about screening mammography. That's inviting women in who have no reason to suspect anything is wrong and looking hard for something to be wrong.
WELCHAnd one of the things we realize, as we start looking for early forms of cancer, is that a lot of people have them. And we're not sure which ones matter. And so we go ahead and treat all of them. And that's just simply led to a lot more cancer treatment. And in the study in the New England Journal, we were trying to get some sense of the scope of this problem. And for a screening test to work, it must not only find more early stages of cancer. It must also cause fewer late stages of cancer to be found, that is demonstrating its ability to take those bad cancers and move them forward in time.
WELCHNow, what we found is with the advent of screening mammography in women aged 40 and older, we saw a dramatic increase in the number of women told they had cancer. It was about a two-fold increase. Unfortunately, it had little impact on the rate at which women were detected with late-stage cancer. And this combination of finding suggests a tremendous amount of overdiagnosis, that is, women who are told they had early stage cancer, many of whom underwent surgery, chemotherapy and/or radiation for a cancer that was never destined to progress to late-stage.
WELCHIn the last three decades, we estimate over a million women have been overdiagnosed. And despite all of the screening, there's been no change in the rate at which women present with metastatic breast cancer. That's the worst kind. That's -- those are the women we'd most like to help. And this suggests that mammography has little impact on the breast cancer death rate. I want to be clear, as Ms. Brownlee has already pointed out, the breast cancer death rate is falling in the United States. That's good news. Our research suggests how this largely reflects better treatment, not screening.
REHMYou know, it's interesting because recently we've been told that perhaps there's been overemphasis on finding prostate cancer in its early stages and that many older men, upon death, the physicians, the autopsy indicates there has been prostate cancer. I'm not necessarily saying the two are comparable, but it's very interesting. We've got to take a short break here. When we come back, we'll talk further. The voice you've just heard was that of Dr. Gil Welch, professor of medicine at Dartmouth Institute.
REHMAnd just before the break, you heard Dr. Gil Welch, who is a general internist at the White River Junction in Virginia and a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Research, talking about the study he has just completed. And that was published in The New England Journal of Medicine. You completed that by talking about 1 million cases of breast cancer as being over or 1 million women as being overdiagnosed. How do we know that, Dr. Welch?
WELCHWell, overdiagnosis is awfully hard to observe directly. It's a little bit like a black hole. Physicists don't see black holes. They infer what's going on from the processes going around them. And the same is true for overdiagnosis. When we see dramatic increases in incidents, and it's all early-stage disease and we don't see a decrease in late-stage cancer, that's a pretty powerful signal. But I want to be clear. These are estimates. But the main point is this is a common a problem.
WELCHAnd I think for the last two, three decades, we sort of systematically exaggerated the benefit of screening mammography and we downplayed, or worse, we've ignored entirely its harms. And the debate here is less about what women should do and more about whether women should be provided balanced information about the benefits and harms of screening.
WELCHAnd the truth is it's a really close call. You have to screen about a thousand women age 50 for 10 years, and less than one will avoid a breast cancer death. That's the benefit side. It's less than one out of 1,000. And that number is -- assumes even the best benefit found with mammography, about 25 or 30 percent reduction in mortality.
REHMSo let me...
WELCHSo what I want to just say is if only one's helped, I think it's important to at least pay attention to what happens to the other 999. And if I had time, I'll tell you a little bit about that.
REHMWell, here's my question.
REHMDo you believe that breast cancer screening should be reduced in a frequency? Do you believe it should be done away with altogether? Do you think it's a waste of money?
WELCHNo. I don't think it should be done away with. What I think we need to do is tell women the truth, tell them both sides of the story. And there are two sides to the story here. I believe there is the potential for benefit for very few women. And again, I think it becomes relevant for women making this choice to understand who's harmed. And in this country of 1,000 women screened for 10 years, around 250 to 450 will have at least one false positive result. And about half of them will biopsied.
WELCHSome will describe it as the scariest time in their life. Some will have -- never have the issue put to rest. They'll be told they don't have cancer, but they're not normal. They have atypia. They have dysplasia. They need to come back. And then somewhere between four and 10 out of that 1,000 will be overdiagnosed. Now, these women will undergo treatment. They will undergo chemotherapy, radiation and/or surgery for breast cancer that was never going to bother them.
WELCHNow, there's no right answer here. There are choices. And screening has been sort of promoted as a public health imperative, and I think that's been wrong. I think it's wrong to measure doctors on the proportion of women which they are able to persuade or coerce into undergoing screening. I think we need a more balanced discussion about this.
REHMAll right. And to help with that balance, we're now going to hear from Dr. Wendie Berg, professor of radiology at the University of Pittsburgh. Good morning, Dr. Berg. Thanks for joining us.
DR. WENDIE BERGThank you, Diane. This is a very important issue. And I think the most important message that needs to get out to women is that, in fact, mammography screening is still their best opportunity to reduce their risk of dying from breast cancer.
REHMAll right. Let me ask you, from your perspective, what have we actually accomplished by pushing for regular mammograms?
BERGWomen who are screened have at least 20 percent or one in five less risk of dying from breast cancer compared to women who don't have mammography screening. That is true. I think we actually are all in agreement that it is important that women be informed of the risks, the downsides to any screening test. But the fact remains that breast cancer is one of the leading causes of death among young women, women who may not see their child graduate from high school if they are diagnosed with advanced breast cancer.
BERGOne of the things that gets lost in all of this discussion is that out of, on average, 11 women who are diagnosed with breast cancer, one of those will have their life saved because of the mammogram. Eight of those will have cancer diagnosed, but the mammogram will have found it earlier than if they had waited until they felt a lump. And their treatment will be less extensive, less involved, less chemotherapy, less mastectomy than if they had waited and not had screening.
REHMAll right. But that is the question. Is there overtreatment of these extremely early diagnoses?
BERGWell, again, on average, about two out of those 11 do represent overtreatment. And I think one, again, important distinction, we don't know that something we see on the mammogram is cancer or not until we do a biopsy. We see something that's suspicious. We need to make a diagnosis. At that point, we do have a choice, and I think we're being -- we're getting better with the information, the oncologists, and the surgeons have to reduce overtreatment. But really, it's at that point that we make a decision about what needs to happen with that individual's cancer.
REHMThen that's the other question. Do you or have you begun using 3-D mammography?
BERGWe do. We have been using it at the University of Pittsburgh for over a year. And...
REHMAnd do you believe it's assisted you in sorting out those images that you may find which need treatment from those which do not?
BERGAgain, one of -- we use imaging to find cancers, and the decision about how to treat them comes after the finding. It is not possible to distinguish, until a biopsy is done, which cancer needs treating from which does not. And even that is very early. We're very early in the science of reducing the treatment to very early minimal cancers that may not progress.
REHMAll right. So, Dr. Berg, at this point with all the research that has been done with what you've heard this morning, tell me what advice you give to women and why.
BERGI think the most important thing is information. I think we're getting better about informing women of the limitations of mammography, including women who have denser breast tissue, where the mammogram could hide it. Not only 3-D mammography will help with that, but also ultrasound. And in women who are at very high risk for breast cancer, MRI can help us find earlier cancers in those situations.
BERGWe may make a much greater impact in reducing the deaths from breast cancer with this added screening, but it will come at the cost of additional testing and additional biopsies. And I do think this dialogue, this discussion in recognition of the risks of both positives is important. A woman needs that information. She also needs to push that we get better with screening and not back off of something that we know actually helps. We can do better than what we've been doing.
REHMAll right. And now I want to bring Dr. Kopans back into the discussion. Dr. Kopans, you've heard Dr. Welch, you've heard Shannon Brownlee, and what they seem to be saying is that many of these cancers discovered in their very early stages are perhaps being overtreated. What's your reaction to that?
KOPANSWell, I have to say, Diane, it's been a little difficult sitting here, listening to some of the information. The estimates in the New England Journal of Medicine article suggesting massive overdiagnosis are just that. They're estimates, and they're based on assumptions that are incorrect. The amount of overdiagnosis is actually much, much lower. I think Dr. Berg was much more accurate in saying, sure, there are cancers that may never be lethal.
KOPANSWe don't know which ones they are. I think I would agree certainly with Ms. Brownlee that ductal carcinoma in situ is a lesion that has been controversial for many, many years. There's a huge debate going on on how to best to treat it, and I think that's nothing new. The problem with the New England Journal of Medicine paper was that it combined women with ductal carcinoma in situ and women who had early invasive breast cancer.
KOPANSEarly invasive breast cancer, no one debates, is potentially a lethal tumor, and it's the detection of early invasive cancers that saves lives. If the paper, the New England Journal of Medicine, had not grouped ductal carcinoma in situ -- and no one else does that. It was a very unusual thing to do. I don't know why it was published.
KOPANSIf you just look at early invasive cancers and use the correct projected incidence of breast cancer, you know, breast cancer, invasive cancers have been increasing by 1 percent per year since 1940. No one knows why. It was long before there was any screening mammography. And had the New England Journal of Medicine paper used that incidence -- 40 years of increasing at 1 percent per year -- they would have found that, in fact, there's no excess of early invasive cancer.
KOPANSSo the suggestion that there are tens of thousands of cancers that are overdiagnosed, if we exclude ductal carcinoma in situ, that's just not true. So I think we need to start with facts. I completely agree women need to be provided with facts. Facts need to be accurate. I just would make one other point or two other points.
REHMHold on one second.
REHMDr. Kopans, let me just remind our listeners, you're listening to "The Diane Rehm Show." Go ahead, Dr. Kopans.
KOPANSYeah. I think it's important -- again, this paper was based on assumptions and estimates. It was not based on actual direct patient measurements. They don't even know which women actually had their cancers found by mammography. So I think we need to, you know, put that paper aside as not being particularly scientific. A couple of other points.
REHMHold on. I think I'm going to bring in Dr. Welch and let him comment on your statement...
REHM...that this paper is based on assumptions and estimates and not true cases and therefore should never have been published. Dr. Welch.
WELCHWell, I appreciate the chance to respond. Let's make sure we understand what the underlying data are. They're the federal government's data. It is the most carefully collected data on incidence in mortality available really in the world. It's a very good database. Let's deal with just a couple of the concerns raised by Dr. Kopans. One of the major ones is why is ductal carcinoma in situ included?
WELCHIt sounds like he is ready to acknowledge that most of that we already agree is overdiagnosis. Well, if that's true, why are we treating it as invasive breast cancer? 'Cause the data show that, in fact, we are treating ductal carcinoma in situ almost as aggressively as we're treating invasive breast cancer.
REHMAll right. Dr. Welch, I'm going to stop you right there and bring in Shannon Brownlee.
WELCHBut I want to just -- one thing about...
REHMIs that true from your perspective?
BROWNLEEFrom what I understand, yes. DCIS is being treated quite aggressively, and it puts women in a real quandary because, you know, they hear carcinoma and they think cancer. And when their clinician isn't sure about the best way to treat them, the tendency is often to say, let's treat it aggressively as if it were a scary cancer.
REHMAll right. And, Daniel Kopans, why don't you respond to that?
KOPANSYeah. No, I think we're all in agreement that ductal carcinoma in situ is an important question that needs and is being addressed by multiple investigators around the world to try and determine what the best way to treat it is. I think if we eliminate ductal carcinoma in situ from the discussion -- and I think we should 'cause that's been going -- this is nothing new.
KOPANSThis is a major issue in breast cancer care for decades now, and people are working very hard on it. The remainder, where does mammography screening actually benefit women, the main area is in finding early invasive cancers. And I would also take issue with the suggestion that you have to reduce the rate of advanced cancers in order for mammography to be beneficial.
KOPANSMammography does reduce the rate of advanced cancers, and I think in the New England Journal of Medicine paper, they also underestimated that. Again, these were not direct measurements from patients. These are summary data from databases. So we don't know, again, who actually had mammography and who didn't. But the point -- let me just -- let me finish. Can I finish the point?
REHMAll right. I'm going to stop you right there, Dr. Kopans, and let Dr. Welch respond.
WELCHWell, I guess I want to respond to two things. One, we think there's overdiagnosis in invasive breast cancer as well. It's not as large as ductal carcinoma, certainly. But if we assume all ductal carcinoma in situ cases are overdiagnosed, we still would have about half of the early-stage invasive breast cancers representing overdiagnosis. But I just want to step back to this model here that -- where we're always looking for earlier and earlier forms of cancer, and I want to at least introduce some hesitancy about that.
WELCHI have no doubt that we can enhance our technologies and see and find more abnormalities. There's no question we can do that. The question is, is that a good thing? And I think one of the things people are rethinking in cancer screening, is the goal really to find the most cancer, or is the goal to find the right cancer?
REHMDr. Gil Welch, he is a general internist at the White River Junction, Va. He's also professor of medicine at the Dartmouth Institute for Health Policy. Short break, right back.
REHMAnd welcome back. As we talk about the value of mammography, annual screening, less frequent screening, more frequent screening, here's our first email from Mitch, who says, "Would you, please, address the huge investment and large revenues currently linked to providers of screening and treatment services and how that could bias the national discussion?" Wonder if you could address that, Shannon Brownlee.
BROWNLEEYou know, he's absolutely right. We've made an enormous financial investment in both screening for cancer, including breast cancer, and in treatment. Hospitals make a lot of money screening and treating cancer, and I don't think for a second that physicians are saying, oh, I'm going to make more money if do this but because we've also got this enormous intellectual and emotional investment in it. So it's very difficult to imagine doing things differently.
BROWNLEEBut the opportunity cost here, I think, is that in having this enormous investment and looking for sort of sonomammography, more and more and more refined mammography, we may be missing an opportunity to think much more carefully about how not to treat, which cancers we don't need to treat because treatment is expensive, but it also has harms for patients.
REHMAll right. Let's take our first caller, Anne, who's in San Antonio, Texas. Good morning to you.
ANNEGood morning, Diane. In 2011, I was 69 and started to skip my normal annual screening because of a lot of the information. No history on either side of the family. A suspicious pattern was found. I have a needle biopsy, was told everything was normal. My internist said she had never seen the spiculated patterns I had without it being cancer, so she insisted on an excisional biopsy. It was cancer.
ANNEAfter my mastectomy and genetic testing, they discovered I had five small but very aggressive triple-negative breast cancer, which is very unusual for someone in my age. And, of course, I then went on and had treatment. So I am one of the outliers. I am one of the ones that are so grateful that I had this screening.
REHMDr. Welch, do you want to comment?
WELCHWell, I'm -- first, I'm very glad for Anne, and that's great. I think we have to be really careful about the power of individual stories because different stories have multiple interpretations. I certainly hope she was helped by the mammogram, and I really do. But the reality, in general, when we hear survivor stories following mammographic detection, we have to recognize they may actually represent the harm that people who have been told they have cancer unnecessarily.
WELCHI'm not saying that's the case in Anne's case. But as we hear these survivor stories, we have to remember, they may be women who've been helped, they may also be women who would've done just as well with clinical detection or more surprisingly, they may be the women who've been harmed.
WELCHHarmed because they were overdiagnosed. They were treated for a cancer that was never going to bother them.
REHMAll right. Here's an email from Brandi, who says, "I work for a genetics lab. I'm working with oncologists daily. And until we can accurately say who has a dangerous type and who does not because more and more tests are being developed for this, isn't it tough to say who will benefit and who will not?" Dr. Kopans.
KOPANSI think that's a very, you know, accurate statement. What I think may be lost in this discussion is that there's been a huge amount of effort ongoing to try and tailor treatment to an individual's cancer. And it's not just that the breast cancers are different, but our own bodies respond differently to different cancers. And there's a great deal of effort going on to try and, as I say, pick the right treatment for the right cancer.
KOPANSAt this point in time, we're not very good at that. That doesn't mean we should stop saving lives. Mammography screening clearly saves lives as I mentioned, and I -- we don't have time to go into the details. I think the estimates of overdiagnosis are grossly exaggerated if we -- and even DCIS, you know, there's some suggestion that removing DCIS lesions has actually contributed to fewer invasive cancers.
KOPANSMammography screening reduces or finds cancers at a smaller size within stages and that saves lives. All of the data show that it saves lives, and all of our medical treatment, quite frankly, for everything we do, we overtreat, if you will, 'cause we don't know who is going to respond to an antibiotic, for example, whose life will be saved by having an antibiotic versus who may be made sicker by an antibiotic, either an adversary action or some other problems,
KOPANSSo I think -- I hope your audience knows that screening saves lives, and the overdiagnosis rate is pretty low.
REHMAll right. Dr. Welch, earlier I asked you whether there were any parallels between the insistence on PSAs for men to detect prostate cancer and the fact that many people die in old age and prostate cancer is found on autopsy. Is there any parallel here in your own mind?
WELCHAbsolutely. There are parallels. And the general problem of overdiagnosis is best understood in prostate cancer screening. We're just now beginning to recognize it's a more general feature of early cancer detection. Whenever we look hard for early forms of cancer, we find more cancer than we expected. And we now know that many people die with small cancers, not from those cancers. And so it becomes -- it's what makes screening a two-edge sword. It does have the opportunity to help some people, but it also leads others to be treated needlessly.
WELCHAnd that's why we can't always look harder and harder for earlier and earlier forms of disease.
REHMAll right, let's take a...
WELCHI think we've embrace our decision making in men and prostate cancer screening, and we probably should do the same in breast cancer screening.
REHMAll right. Let's take a caller in Boone, N.C. Good morning, Doug.
DOUGGood morning, Diane. Uncle Doug here in Boone, N.C., and I really appreciate this show. My mother is 86 years old. She lives with me. She has dementia and Alzheimer's. She wouldn't have lived this long to have dementia and Alzheimer's if there hadn't been a mammogram test in her 40s. I've got a sister that lives in Destin, Fla. She's had breast cancer twice.
DOUGYou know, those DCIS test, wonderful. Use the tool. But don't ever get rid of the mammogram and do it more frequently. Use all the tools that you have. I mean, you got some callers there or you've got some speakers there that are female and what if they had this and they skipped a mammogram test? You know, we need all the females on planet Earth.
REHMAll right. Thanks for calling. Shannon Brownlee.
BROWNLEEOnce again, you know, anecdotes are very persuasive and emotional. But it's -- you can't say for any individual necessarily that the mammogram is really the thing that should be credited for this man's mother surviving to 86. So we have to really be careful of those anecdotes, number one. Number two, not all women who know a lot about mammograms get mammograms.
REHMWhat do you mean?
BROWNLEEI don't get mammograms. I don't do mammograms. Now, I may do a mammogram or two in my 60s when it looks like the benefit is greatest, but I don't do mammograms. And it's...
BROWNLEE...because I am more worried about being harmed by unnecessary treatment. I'm very worried about being harmed by unnecessary treatment by overdiagnosis.
REHMDr. Berg, what do you say to Shannon Brownlee?
BERGI think one other important piece of information is that, of the women who still die from breast cancer today, three out of four of those women never had screening, and I bet you that each one and every one of those wishes they had.
BROWNLEEThat's more anecdote. It's women wishing...
BERGNo. It's actually based on population studies.
BROWNLEEWell, that's what we're talking about here though...
BERGYes, I know.
BROWNLEE...is the population studies, and so...
BERGDr. Welch did not account for whether those women had screening or did not had screening who had advance disease. And this is one of the issues. Randomized trials have shown that mammography saves lives. Yes, you can't attribute it to a given individual, but you certainly know the population level that it reduced breast cancer mortality. We also know that the women who are still dying from breast cancer, most of those women did not have screening.
REHMAll right. Dr. Welch.
WELCHYeah. I want to bring out the randomized trial issues. And it's true. We have about nine randomized trials involving over a half million women. And their central estimate of the benefit is about a 15 percent reduction in mortality. We'll call it 25 if you want. It's still one -- less than one in 1,000 being screened over 10 years.
WELCHBut we have reason to believe that the randomized trials no longer tell us the current benefit of screening. And the reason is our treatments are better. And, ironically, the better our treatment gets, the less important early detection becomes. That's the reason we don't screen for pneumonia because we can treat pneumonia.
REHMAll right. To Mount Dora, Fla. Good morning, Ross.
ROSSGood morning, Diane. I am thoroughly enjoying this discussion as a physician assistant and a cancer survivor myself. But I've also have a question because I have good friend, a surgeon friend, who says that once you have your hammer, everything looks like a nail. And it would seem that the radiologists in the discussion are saying, oh, yes, we got to have more and better mammography. And others are pulling back and saying, yeah, but what about the negative aspects of overtreatment or overdiagnosis?
ROSSAnd I agree TSA screening is another excellent parallel. But I haven't heard anybody mention the other things that can decrease morbidity and mortality from breast cancer, simply decrease in hormonal birth control or decrease in smoking habits and so on. And I'd like your panel to address these other public health measures, which actually may -- has a greater impact on women's health.
REHMAll right. Sir, thanks for calling. Shannon Brownlee.
BROWNLEEThe caller is absolutely right that we know a few of the things that contribute to a woman's risks of getting breast cancer. One of them being genetics, but also smoking, obesity, use of hormone replacement seems to increase your risk a little bit. So we do have ways of reducing the overall risk of getting it. And, you know, that it's really important to look at the fact that we really do have better treatments. We do have better treatments. And women who get breast cancer are more likely to live in large measure because of that.
REHMDr. Kopans, let me ask you whether through 3-D mammography you are clearly better able to judge which tumors need treatment and which do not. And let me just remind our listeners, you're listening to "The Diane Rehm Show." Dr. Kopans.
KOPANSDiane, just one quick point, and then I'll answer that question.
KOPANSThe argument is being made that it's therapy that's saving lives. And there's no question therapy has improved over the past years. But what you'll find is that there is no major medical oncology group -- and neither Dr. Welch or Ms. Brownlee are medical oncologists. There are no major medical oncology groups that have said, you can stop screening. Therapy will save our lives. Medical oncologists know that therapy saves lives when you find breast cancer early.
KOPANSIn terms of digital breast tomosynthesis, I think Dr. Berg stated it really very clearly that we can see more cancers. We'll find more cancers at a smaller size, but it still requires a pathologist looking under the microscope, at tissue to accurately differentiate a cancer from a non-cancer, and hopefully someday -- and we're not at that point for most cancers -- be able to determine which cancers need what type of therapy.
REHMWhat are the current guidelines, Dr. Berg?
BERGThe current guidelines for screening would be...
BERG...from most of the major medical associations, to start getting annual mammograms at age 40. It's reasonable to discuss with your doctor what the risks are, what the risks of having a biopsy or extra testing is and to continue annual mammograms as long as you're in good health. We don't recommend annual mammograms if a patient has less than five years of life expectancy.
BERGWe can certainly cut down on some of the unnecessary screening in women who are otherwise quite ill. But I think that women who are healthy, who want to reduce their risk of dying from breast cancer should get an annual mammogram starting at age 40.
REHMAll right. Dr. Welch, what would be your recommendation?
WELCHI think this is a choice. I think this is genuinely a close call. And Dr. Kopans appeals to the oncology community. And let's be clear, the oncology community is beginning to be more open to this general problem. Even the American Cancer Society, who is one of the -- been the most aggressive -- one of the more aggressive proponents of screening now recognizes that overdiagnosis is a matter worthy of attention and that women should be informed of the risks and benefits that are associated with cancer screening. So this is a choice. And I think the real goal here is to make sure we don't feel -- make women feel like they have to have this test.
REHMAll right. And...
WELCHThis is not something they have to have.
REHMDr. Kopans, what would be your recommendation?
KOPANSDiane, I've always argued based on scientific evidence. And the scientific evidence clearly indicates that screening beginning at the age of 40 saves lives. I think every medical intervention has risks and...
REHMAnd you're saying an annual mammogram.
KOPANSYes, annual mammography.
REHMAll right. And, Shannon Brownlee, I think I know your recommendation.
BROWNLEEAnd I think this is a choice. I think women need to understand the potential for benefit and the potential for harm, and they need to be able to make the choice that's right for them.
REHMShannon Brownlee of the New America Foundation, Dr. Daniel Kopans, he's at the Harvard Medical School. Dr. Gil Welch, he's a general internist at the White River Junction, Vt. and a professor of medicine at Dartmouth. And, finally, we also have a radiologist who has been with us, Dr. Wendie Berg at the University of Pittsburgh. Thanks to all of you. Thanks for listening. I'm Diane Rehm.
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