THE EVIDENCE AGAINST XRAY SCREENING MAMMOGRAPHY GROWS AFTER 20 YEARS.

 Update 18/10/2011 neil.burman@gmail.com

NATIONAL MAMMOGRAPHY DAY 21 OCT 2011:  WORLD BREASTCANCER AWARENESS MONTH National_Breast_Cancer_Awareness_Month :                                THE DEBATE AGAINST XRAY SCREENING MAMMOGRAPHY OF LOWRISK WELL BREASTS.      MOTIVATION FOR NON-XRAY SCREENING MAMMOGRAPHY:

A medical scheme recently asked for a motivation letter for a member wanting them to fund a non-xray mammogram.

 Thinking women cannot do like a postmenopausal professor in genetics – a senior health lecturer and counsellor no less- shrug off the issue of their blind obedience to medical diktat as “not my field”, when unquestioningly undergoing invasive let alone known hazardous tests like screening xray mammography, and major therapy for asymptomatic hidden lumps, on the say-so of their doctors/ their medical scheme advisors, however great their eminence.

Safety in numbers of eminent opinions is no assurance that the collective conventional wisdom and Guidelines are correct, when such conventional wisdom is as likely as not turned on its head in a few years.

Blind obeisance without careful personal study of the evidence for and against is as foolish as taking the advice of the glib salesman self-promoter in any costly and therefore risky investment, be it in health as in finances, property, a motor car, costly other assetts, a job or a glib new lover.

This week Dr Joe Mercola  highlights the latest reports from USA, the  double disaster of xray mammography increasing the risk of breast cancer in women with a familial risk; and more than half of women xray- screened regularly  over 10 years receive at leat one false-positive recall- with all the extra breast  procedures, and upset, that that entails.

Look at what happened to USA and UK-Europe when they blindly followed the advice of the snakeoil vendors the Bush-Blair Gang in invading Iraq in 2003, and listened to the advice of  their self-enriching financial gurus and bankers that led to the demise of balanced national budgets and the western capitalist system in 2008. The USA has achieved the unthinkable, being downgraded to the most bankrupt country, worse than many southern European nations now are, because Bush for the benefit of his cronies abandoned the common-sense balanced budgets reducing national debt insisted on by Clinton, and plunged USA into multitrillion dollar debt that future generations of taxpayers have to pay. .

In women without breast symptoms or familial risk of breast cancer, regular analysis of evidence  to April 2011  on the pros and cons of SCREENING xray mammography ie breast imaging, showed increasingly the risk but no benefit of such xray screening.

The anonymous Wikipedia review outlines the violently opposing views of the screening mammography issue – from sceptical independent analysts, and from the zealous majority, the lucrative vested-interest screening xray mammography - breast surgery industry, who claim shortterm benefit from emotive early diagnosis and treatment. .

It is a sign of the paradigm shift in medical thinking and dogma when a leading medical school eg Tygerberg Hospital no longer accepts women with a palpable breast mass referred for diagnosticxray mammography, but instead first sees them for careful history, examination and fine needle aspiration biopsy.

Last months’ leading Radiology journal features a debate between the two opposing viewpoints;  ; as does a recent medscape debate; http://www.medscape.com/viewarticle/734977 with Heaod of Radiology  Daniel Kopans at  Harvard spearheading the xray mammographers and breast surgeons argument – Just the facts: mammography saves lives with little if any radiation risk to the mature breast.

and Dr Cornelia Baines from Toronto University joins the European and USA critics of routine screening in exhaustively analysing why so many studies convincingly confirm the original Canadian Breast Cancer Screening Study Miller, Baines ea 2004  evidence against routine xray screening – xray screening did not reduce breast cancer mortality after 13years when compared to routine clinical breast examination;

- and the 2009 recommendation of the US Preventitive Task Force to limit recommendation for xray screening mammography to well women only from age 50 years onwards, and every 2 years not annually. Since April 2011 at least nine more authoritative independent scientific papers listed below detail why routine screening xray mammography of well breasts (in women not at known increased risk) gives no longterm meaningful reduction in either invasive breast cancer or mortality. In fact, there is evidence that such repeated breast trauma- crushing, irradiation, surgery and therapy -  actually increases risks of mastectomy, breast cancer and mortality after 10 years, just as oral xeno-hormone replacement therapy may.

The Dec 2010    UK NHS recommendation brochure  by contrast  limits screening mammography to women over 50yrs up to 70yrs, and only every 3 yrs. Thus the UK recommends only about 7 screening mammograms over her lifetime for well lowrisk women. This contrasts with the pressure on USA women to have screening from age 40 years annually ie four times as many as in UK- about 30 screening mmmograms over her lifetime. …

The latest published study, from the University of California no lessconfirms their earlier 2007 study that the more costly computer-aided detection was not associated with higher breast cancer detection rates or more favorable stage, size, or lymph node status of invasive breast cancer. CAD use during xray screening mammography in the USA is associated with decreased specificity but not with improvement in the detection rate or prognostic characteristics of invasive breast cancer. When previously well women are followed up over decades with xray screening mammography, objective studies of at least thirteen first-world countries – Australia, U.S.A, Norway, Denmark, Sweden, Italy, France, Switzerland, Netherlands, Belgium, U.K, Scotland, Northern Ireland, and Ireland – show no patient benefit from such screening xray in reducing breast surgery, advanced breast cancer, mastectomy, or mortality,.

Such evidence and argument against screening of the asymptomatic male without familial risk has been widely accepted for prostate cancer screening. Why are women with no known increased risk perversely all irradiated about 15 to 30 times from their 40s?

And a new study from Minneapolis finds that lowrisk women ie without dense breasts, symptoms or family history need not have screening xray mammography more than every 3 -4 years. The Mayo Clinic lists simply the obvious risks of xray mammography.

There is yet another obvious reason – conveniently not mentioned by researchers and xray mammographers - why screening xray mammography may miss cancers ie give false negative results: because adult female bosoms are obviously threedimensional, not flat like health mens’.. But xray mammography (unlike CAT or MRI scans) is done in only two – the vertical and lateral planes.

Unlike eg the limbs, spine, chest and head, globular female breasts cannot be xrayed meaningfully in the anterior-posterior plane superimposed on the chest, and thus small breast cancers close to the lateral chest wall or the armpits cannot be xray imaged. By contrast, examination with the hands, with thermography, with ultrasound, MRI and now with (eg SureTouch) mechanical pressure transducers check for suspicious lumps in three dimensions ie also in the anterior-posterior plane.  

3D breast xray imaging is becoming a reality . But it still relies on xray irradiation.

Research PhD Geneticist Dr Natalie Bjorklund-Gordon pleads for altenatives to xray screening mammography, she explains exquisitely why she will not have xray screening mammography (let alone screening colonoscopy) . She pleads for nonxray safe and sure technology for screening.  

But review  shows that proven alternatives are available here and worldwide. Thermomammography is now highly evolved over the past 40 years; and mechanical tactile breast mapping over the past decade.

As these on-line reviews detail, is it ethical let alone cost-beneficial to promote routine screening mammography on women at any age who do not have probable breast cancer?

But for those well women who desire screening mammography for peace of mind, infrared thermomammography is the physiological gold standard that may pick up precancerous increased bloodflow years before a cancer mass is detectable by other ie anatomical mammography methods so as to allow non-interventional preventative steps;

while mechanical tactile mammography (eg SureTouch) as recommended by the Cancer Association of RSA is the safe non-invasive anatomical screening tool of choice.

Yet Curves Tokai is still promoting the pernicious offer of free membership of curves upon production of a recent mammogram – without bothering to warn of the major potential hazards of screening xray mammography.  . So long as the Curves empire is openminded ie accepts the alternatives to xray mammography eg MRI, thermography and Digital Tactile Mammography

For anxious women, third party funders should pay for these safe and at least as specific and sensitive non-invasive investigations (rather than for invasive xray screening mammography at two to four times the cost).

In conclusion: all thinking women hold the primary responsibility for their own and their families’ health. It therefore behoves every woman let alone man to take responsibility for prevention when young for their future health. Like Dr Bjorklund-Gordon, they have to make informed decisions about the risk:benefit of having invasive screening like xray mammography and biopsies – just as they have to about their education, careers, financial management and relationships- about their health choices including screening.

Recent refs.

  1. Oct 2011 Utzon-Frank N, Lynge E ea Cancer Epidemiol.Balancing sensitivity and specificity: Sixteen year’s of experience from mammography in Copenhagen, show that after 14 -16 years of xray mammography every 2 years, the incidence of new breast cancers detected at 14-16years actually rose by 50% compared to in the first 12 years.
  2. Sept 2011 Junod Zahl ea in Investigation of the Apparent Breast Cancer Epidemic in France show 8-fold increase between 1980 and 2000 in the number of xray mammography machines in France. Opportunistic and organised screening increased over time. In comparison to age-matched cohorts born 15 years earlier, recent cohorts had adjusted incidence proportion over 11 years that were 50 (23-76)% higher for women aged 50 to 79 years. Given that mortality did not change correspondingly, this increase in adjusted incidence was considered an estimate of overdiagnosis. Breast cancer may be overdiagnosed because screening increases diagnosis of slowly progressing non-life threatening cancer and increases misdiagnosis among women without progressive cancer. We suggest these effects could largely explain the reported “epidemic” of breast cancer.
  3. Sept 2011 Jorgensen Keen & Gotzsche at the authoritative Cochrane Centre ask Is xray mammographic screening justifiable considering its substantial overdiagnosis rate and minor effect on mortality? They point out that the original Swedish Two-County Trial was the most optimistic and pivotal for the introduction of screening, but subsequent trials of higher quality found smaller effects...
  4. Sept 2011 Suhrke P, Gøtzsche PC, Zahl P ea BMJ note in Effect of mammography screening on surgical treatment for breast cancer in Norway: that the aim of screening xray mammography is to reduce surgery and deaths. But in 35 408 women aged 40-79 with invasive breast cancer or ductal carcinoma in situ treated surgically from 1993 to 2008, xray mammography screening in Norway was associated with a noticeable- 70%- increase in breast cancer surgery in women aged 50-69 (the age group invited to screening) and also an increase in mastectomy rates. Although over-diagnosis is likely to have caused the initial increase in mastectomy rates and the overall increase in surgery rates in those screened, the more recent decline in mastectomy rates has affected all age groups and is likely to have resulted from changes in surgical policy. 

5.  Sept 2011 Haukka J, Autier P ea. University of Finland examine Trends in Breast Cancer Mortality in Sweden before and after Implementation of Mammography Screening. : Incidence-based mortality modelling comparing the risk of breast cancer death in screened and unscreened women in nine Swedish counties suggested a 39% risk reduction in women 40 to 69 years old after introduction of mammography screening in the 1980s and 1990s. Without individual data it is impossible to completely separate the effects of improved treatment and health service organisation from that of screening, which would bias our results in favour of screening. However, our estimates from publicly available data suggest considerably lower benefits than estimates based on comparison of screened versus non-screened women. 

 6. Aug 2011 Int J Cancer. Hofvind S, Graff-Iversen S. ea at the Cancer Registry of Norway- dissect Breast cancer incidence trends in Norway-explained by hormone therapy or mammographic screening? A decline in breast cancer incidence has been observed in several countries after 2002. Reduced use of menopausal hormonal therapy (HT), as a consequence of the publication of results from the Women’s Health Initiative, has been argued to be the main reason. the interpretation of breast cancer incidence trends in Norway from 1987 to 2009 is complicated because the xray breast screening program was introduced during a period with increasing HT use. Both factors likely contributed to the observed trends, and the role of each may vary across age

7. August 2011 Professor of Surgery Michael Baum from University London has argued for years that Breast xray screening should be scrapped.

 8. August 2011 Fenton JJ, Barlow W E ea; J Natl Cancer Inst.Breast Cancer Surveillance Consortium. University of California,examined the Effectiveness of computer-aided detection CAD in community mammography, concludingCAD use during film-screen screening mammography in the United States is associated with decreased specificity but not with improvement in the detection rate or prognostic characteristics of invasive breast cancer. http://www.ncbi.nlm.nih.gov/pubmed/21795668

9. August 2011 Autier P, Gavin A. ea studied Advanced breast cancer incidence following population-based mammographic screening : Breast cancer mortality is declining in many Western countries. If mammography screening contributed to decreases in mortality, then decreases in advanced breast cancer incidence should also be noticeable. They assessed incidence trends of advanced breast cancer in areas where mammography screening has been practiced for at least 7 years ie Australia, Italy, Norway, Switzerland, Netherlands, U.K, U.S.A, Scotland, Northern Ireland, Age-adjusted annual percent changes were stable or increasing in ten areas (APCs of -0.5% to 1.7%). Thus in areas with widespread sustained mammographic screening, trends in advanced breast cancer incidence do not support a substantial role for screening in the decrease in mortality. http://www.ncbi.nlm.nih.gov/pubmed/21252058

10.   July 2011 Autier, Vatten ea in BMJ in Breast cancer mortality in neighbouring European countries 1986-2000 with different levels of screening but similar access to treatment compare Norway with Sweden, Belgium with Netherlands and Eire with Ulster, The contrast between the time differences in implementation of xray mammography screening and the similarity in reductions in mortality between the country pairs suggest that screening did not play a direct part in the reductions in breast cancer mortality. http://www.ncbi.nlm.nih.gov/pubmed/21798968

And finally

11. June 2011: PhD research clinical scientist geneticist Dr Natalie Bjorklund-Gordon details exquisitely “why I am not having screening mammography” (or screening colonoscopy). http://www.science20.com/selective_genetics/why_i_am_not_having_screening_mammogram-79776

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