BREAST SCREENING METHODS COMPARATIVE TABLE

this table shows the relative merits of some different methods of breast imaging. Mechanical Tactile Sure Touch Imaging leads the field by far for combined sensitivity and specificity, portability, all-age utility without problems of breast density interference, cost, risks and reproducible mapping.

Competitor Comparisons Table

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 less – confirms 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

CHRONIC ILLNESS- MANAGED ANTIAGING & GENERAL PRACTICE CLINIC SOUTH AFRICA

update 6 April 2015

In Claremont  Cape Town

A  Specialist Family Internist Clinic offers consultations by appointment especially for managing (and ideally preventing)  the major chronic degenerative diseases of aging  and  maintaining physical, mental (and why not sexual?) vigour to a ripe and healthy old age; as well as preventing and managing acute disease at all ages.

The clinic (a specialist physician and a nutritionalist)  offers all-system evaluation and if available, natural  (as well as essential prescription orthrodox) prevention/treatment including metabolic – weight-endocrine-diabetes; heart-lung -kidney; hypertension; neurological-pain; joint & muscle; abdominal, immune system ie infection, cancer and auto-immune  support;  genito-urinary, & sexual problems;

and appropriate screening – ECG, non-xray ( no-touch thermography- eg thermomammogram;   SureTouch tactile) mammograms, non-xray (ie  ultrasound) BMD ie  bone fracture risk measurement, body composition, and appropriate hormone profiling/replacement.

Phone during office hours for appointment: for Claremont office  ph 021-6717415  or 6831465 (or 083-6299160) – at Grove Medical Bldg 1st floor no 15 (opp ABSA Bank Parkade c/o Grove Ave Pearce Rd)  , or neil.burman@gmail.com ;  or consultation by telephone/Skype or email .

by appointment only:        OFFICE HOURS: by appt: ph office:  9am-5pm weekdays, 9am-1pm Saturdays.  AFTER  HOURS up to 9pm any day generally at office: –  email doctor   neil.burman@gmail.com  or ph 6am to 9pm  0836299160. EMERGENCIES  cannot be dealt with- acute emergencies and trauma, bleeding cases  must go to any  Emergency Unit .

Billing according to means ie specialist professional rates:  eg as a preferred provider for Discovery Health-  consultation procedure  0190; for needy patients, what the medical scheme pays  Detailed medical report and advice protocol provided at R300. Even Hospital Plans have to pay for outpatient consultation for scores of PMBs ie Prescribed Medical benefit conditions like Menopause.

 Needy patients desiring brief consultation can be seen by arrangement at GP rate.    Bone density scan  (covered by some medical schemes)  procedure 3612..  Non-xray mammograms are not yet covered by medical schemes codes: R650 for SureTouch including clinical consultation, R800 for thermomammogram.

MAMMOGRAPHY INCREASES RISK OF BREAST CANCER

neil.burman@gmail.com

Wednesday, 2 December , 2009 by:  S. L. Baker features writer:

“Mammograms cause breast cancer, groundbreaking new research declares , especially in those at high risk with familial (breast/ovarian/ prostate/ uterine/- colonic) cancer.”

A 50% increase in risk is relatively small compared to doubling or five-fold increase in risk as eg smoking may cause. But for cancer that affect perhaps one in ten women, even 20% increase in risk is significant.

But remember that while even appropriate HRT reduces deaths from breast cancer by a third- as with prostate cancer, it seems to reduce the incidence of highly malignant cancer, merely bringing to attention earlier the less serious ones.

So patients starting any HRT should be screened first and then periodically so that the HRT cannot be blamed for having caused the cancer. The recent APHRODITE  trial of testosterone patch in women with androgen deficiency (which this column commented on in August)  only lasted 2 years, which shows the fallibility of screening mammography annually  in missing sleeping  small cancers until they are accelerated by anabolics.

As this column has repeatedly reviewed, all evidence from rodents to primates to humans is that appropriate balanced  physiological testosterone replacement reduces breast proliferation, and thus in the long term reduces the occurrence and risk of breast cancer.

It is common cause that cancers take an average of 20 years from their origin to become clinically evident.

Ultrasound is not as sensitive as xray mammography in detecting cancer.

So until accurate thermal scanning is proven to be anywhere near as specific and sensitive as mammography, the latter remains the best diagnostic tool we have available. For women who already have a suspicious breast lump/pain/discharge, diagnostic mammography remains the gold standard, with ultrasound and MRI as backup aids.

BREAST CANCER OVERDIAGNOSIS BY COMMERCIALIZED SCREENING MAMMOGRAPHY: IS THE DOWNSIDE WORTH IT?

It is a no-brainer that mammography is invaluable diagnostically for

– a new breast lump, pain/discomfort  or bleeding.

– for followup of any pathology already present or likely eg the woman with obvious genetic risk of breast cancer;

– And for monitoring at baseline  and periodically on permanent appropriate physiological  HRT.

Rare women do present with distant spread of breast cancer before such cancer presents in the breast. But the hot chestnut* is:  how many well women  with clinically normal breasts at average risk of breast cancer  benefit or suffer by having screening – their apparently healthy ‘chestnuts’   squashed and irradiated regularly for decades looking for  preclinical cancer?

when the downsides also include time, pain, cost,  possible  increased risk from  cancer by both irradiation, pressure and needling, six unnecessary biopsies for each cancer found, and no clear evidence  that the resultant anxiety and  cancer therapy extends wellness and life?

A *chestnut includes an “old or stale joke (British)”, or ” music of sentimental value”!. The joke may indeed be on average-risk older women who are conned into having repeated- and risky-  screening mammography on their often most cherished ornaments.

The Breast Cancermongers – the screening mammography SMG  activists- now proclaim that 1 in 8 women ie 12.5%  will get breast cancer in her lifetime; but between 40 and 59yrs that number reduces to 1:15 ie about 7%. Without screening mammography of “normal” breasts, does breast cancer  actually present as a disease  in even   5% of sensible average-risk  women in the average at-risk middle decades?  and will prompt removal of such early  cancer before it presents itself to her/ the doctor with lump/pain/bleeding avoid  shortened lifespan  in any asymptomatic woman screened? Especially if appropriate balanced postmenopausal systemic human HRT is  continued lifelong to  reduce by 1/3 the  the far more common other major causes of  disease and deaths as well as deaths from breast cancer?

Note the disturbing figures  from Wiki:  “Of every U.S. woman screened, about 7% will be called back for a diagnostic session (although some studies estimate the number closer to 10%-15%). About 1% of those screened  will be referred for a biopsy; the remaining 6% are found to be of benign cause. Of the 1% referred for biopsy, about 0.35% will have a cancer and 0.65%will not. Of the  0.35% who do have cancer, about 0.2% have a low stage ie noninvasive cancer that will be essentially cured after treatment.” But who is to say that these 0.2% would ever have presented with cancer in their lifetime- ie are these the 2 out of 3 per 1000 overdiagnosed by SMG?

The incidence of BRCA in USA women in the 50-65yr agegroup is claimed to have risen  almost 50%  from 0.23 to 0.33% between 1975 and 2000, and has since fallen back about 25%. That almost 50% increase can only have been from the introduction of almost compulsory SMG. Despite advances in treatment, breast cancer mortality took almost 15years to start falling ie after plateau at about 0.07% for decades  till 1988, it has fallen steadily to 0.045% in 2006. A report in about 2002 says that ‘ Breast cancer incidence increased more or less steadily between 1940 and 1987 and has since stabilized at 0.1%.’

So we have a major credibility gap in reports from the USA: some authority says an overall incidence between 50 and 69yrs of 1%, another  say 0.25%.

More important, in 1999 Mettlin noted that “ some of the decline  in BRCA incidence and mortality is attributable to the lower mortality rates for women born between 1924 and 1938, who have reached the age where their breast cancer mortality experience most affects the overall rate; the  hypothesis being  that  increased fertility rates  following World War II reduced their risk of developing breast cancer and, therefore, of dying of breast cancer.”

The reality, not disease-mongering to promote SMG, was  simply put in 1995: “Between 1940 and 1982, breast cancer incidence rates in the United States increased by approximately 1% per year, largely in women over 40 years old. From 1982 through 1987, the rate of increase accelerated to around 4% per year and then leveled off – the rising rate  mainly attributable to early detection, due to the increase in breast cancer screening. The increase in breast cancer cases (with no change in incidence rates) among women 20 to 39 years old during 1970 to 1990 was due to a shift in the age distribution of the population. However, breast cancer mortality rates have remained fairly stable, with almost no change from 1950 to 1990 [42], increasing only about 0.2% per year [3]”

The issue remains a hot chestnut: like screening  colonic imaging and prostatic screening,  is this massive  universal individual screening of the apparent low-risk good, indifferent or bad for women, their men, families  and whoever has to pay the financial cost?

What the Wiki review does not say is that there are almost 20 000 articles already listed on Medline the past 50 years; and some 400 articles on screening mammography in asymptomatic women since 1966. Yet 60 year after mammography was invented,  the cost-benefit for women of the $billion SMG  industry is being increasingly questioned:

(paraphrased) Editorial “Overdiagnosis and mammography screening” 9 July 2009,    BMJ 2009;339:b1

The UK NHS recently scrapped its leaflet inviting well women to undergo mammography since it failed to mention the major harm of screening—overdiagnosis. The question is no longer whether, but how often, this occurs.

In a  new BMJ special on breast cancer,  Jorgensen  ea, Gotzche ea and Zahl ea,   again discuss evidence that screening has led to overdiagnosis of breast cancer not only in the UK, but also in Canada, Australia, Sweden, and Norway.

Overdiagnosis refers to detection of abnormalities that will never cause symptoms or death during a patient’s lifetime- when the cancer grows so slowly that the patient dies of other causes before it produces symptoms or when the cancer remains dormant (or shrinks).   

Because doctors don’t know which patients are overdiagnosed, we tend to treat them all.

Overdiagnosis therefore results in unnecessary treatment – perhaps in one in two (or even 2 in 3) women.

With   widespread efforts to diagnose cancer earlier, over-diagnosis has become an increasingly vexing problem.

H Gilbert Welch, professor of medicine, USA.