Tag Archives: overdiagnosis

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

THE SCREENING MAMMOGRAPHY TSUNAMI

neil.burman@gmail.com 

The past year has seen not just catastrophic oilleaks, earthquakes  and thus marine and radiation disaster  accross the world, but also in Big-Business -driven campaigns to promote invasive radiation  screening mammography. Is the Disease-industry-driven screening   xray mammography tsunami fearmongering    to inflate the $trillion cancer industry ?

A tsunami is an overwhelming and non-tidal deluge. What does the screening mammogram xray deluge  for ever-younger  women bode for their later years?

Any intelligent consumer, not just a  specialist for 40 years, should  look very critically at all technology marketing  and products, and ignore most as unjustified.

Winifred Cutler from the Athena Institute writes this month: it is claimed that screening xray mammography and early treatment of silent breast (pre)cancer has greatly reduced  breast cancer mortality. But she points out that such mortality has also fallen in unscreened women, and given the incidence of overdiagnosis, “the adjusted mortality reduction that can be attributed to widespread  xray mammographic screening may be even more modest than reported by Kalager and colleagues: instead of the 7.2 reduction per 100,000 person-years that they report, a number somewhere between 5.99 and 5.54 should be compared to the 4.8 reduction per 100,000 person-years found in non-screened women. Hence, between 80% (4.8/5.99) and 88% (4.8/5.54) of the reduction in mortality may be attributable to issues other than mammogram screening”.

Another paper this month   reviews “Antidepressants and breast and ovarian cancer risk  and researchers’ financial associations with industry” – concluding that “Researchers with industry affiliations were significantly less likely than researchers without those ties to conclude that ADs increase the risk of breast or ovarian cancer. (0/15 [0%] vs 20/46 [43.5%] (Fisher’s Exact test P = 0.0012).”  ie in studies independent of AD manufacturers,  there is strikingly significant increase in breast cancer risk in those on antidepressants. With all the focus on the overblown risk of womens’ cancers, and the oft-reported discomforts and recalls from  screening xray mammography, no wonder that depression and breast cancer risk may be increased not just by stress (including the dreaded annual mammogram)  but more so by estrogenic ADs .

In view of the controversies about both necessity for well-breast screening, and patient complaints and cost-benefit doubts about xray mammography,  we consider  two of the options that radiologists dont  generally offer – thermography recommended by a recent patient with her thermography report, and tactile pressure-transducer  mapping recommended and used by CANSA the Cancer Association of South Africa, and the breast clinic at Newcastle-on-Tyne University.  

Both equipment technologies  are approved  in eg USA/ UK/ Europe/ Australia, and have been screened and not disapproved by regulatory authorities since the latter have no experience of such, and they are approved overseas, and there are no usage hazards, and as yet no standards locally, and no claims are made about their efficacy for diagnosis, prevention or treatment.

Thermography is used in clinics around South Africa; while pressure transducer tactile breast mapping is recommended and offered by CANSA for the poor in the main centres. In Gauteng one  radiologist does ultrasound followup in the ~10% of breasts where cancer cannot be confidently excluded.

There are obviously at least three major separate issues:

1.REAL RISKS OF COMMON CANCER?  Is the risk – incidence and mortality- of presymptomatic cancer in well patients without genetic risk of developing breast or prostate cancer high? and does early detection of presymptomatic breast or prostate cancer in patients not at high risk do more good than harm? Careful analysis of all available unbiased data suggests not- in fact such early diagnosis possibly  does more harm than good. 

2. RISKS OF REPEATED INVASIVE XRAY SCREENING: are  the risks of breast cancer increased by repeated xray screening?

3. IS ANY MAMMOGRAPHY METHOD TRULY SUPERIOR OR MORE RISKY?  Are the alternative screening mammography options- MRI, tactile mapping, thermomammography,  ultrasound- significantly different from each other and from invasive xray compression  mammography in risks and in sensitivity/ specificity? The evidence suggests that thermomammo, MRI and tactile mapping are safer and more sensitive and specific than xray mammography, and more sensitive than ultrasound as primary screening.

BACKGROUND:     Screening in medical practice thirty years ago used to refer to xay fluoroscopy – viewing through a fluoroscope screen- as is done of passengers at airports; but now refers to any preventative ie screening tests for silent undetected early disease. The most validated screening for cost-benefit – apart from taking a complete history- remains objective ie electronic bloodpressure monitoring.

However, is there still  justification for ever exposing younger healthy tissue- especially the thyroid, breasts and gonads- to repeated preventative invasive  xray “screening” under any circumstamces including for mammography and bone densometry? Especially not children, and especially not well younger (pre or peri)menopausal women  with already fluctuating endogenous estrogen dominance, who now with safe lifestyles have an average life expectancy ahead of them of perhaps 40 years. And when so many older middle-aged women simultaneously have been exposed needlessly to long-known carcinogenic smoking, alcohol and other oral estrogenics- soya, psychotropes, estrogens and progestins- recent use of oral contraceptives increases the risk of breast cancer. 

 The ongoing argument for and against screening is hotly debated by specialists opposed by the vested interest of the Screening Industry.  

XRAY MAMMOGRAPHY:    A Sherbrooke University Quebec paper published in 2011  seems unique- Irradiation (30Gy) of normal mouse tissue increases by some 30fold  the invasiveness of subsequent subcutaneously injected induced mouse breast cancer cells after 6 weeks  . There is nothing like it before on Pubmed nor apparently on Google – that recent normal-thigh irradiation vanquishes cancer resistance. This may explain why  breast cancer incidence, and mortality,  may be the same, if not higher  than in non-screened women after 10 years of   regular xray screening mammography of healthy breasts (the Norwegian and Danish studies of last year- see below) . The mouse irradiation study tries to simulate with one-off irradiation  the situation in women who have breast cancer removed and then a course of fractionated radiotherapy – which may eradicate most existing cancer but promotes fibrosis, but may promote  growth of metastatic   cancer cells into surrounding previously cancer-free subcutaneous tissue. This correlates with the shrunken hard breast we see in women who have had breast cancer excision and then breast radiotherapy.

Whether this applies to repeated (bi)ennial  screening xray mammography of “well” breasts over many years  with perhaps a few milliGy of diagnostic xray each time remains to be clarified.   Ruth Kleinerman’s followup of children does suggest possible risk,  that modest irradiation for diagnostic or therapeutic purposes with 0.1 to 0.7Gy increases breast cancer risk up to 2.5fold a decade to fifty years later.   This especially when the breast sceening industry claims that breast cancer lifetime risk is already above 10% eg 1 in 10, and increases with aging.

And correlates with work 30 years ago –Brian Henderson ea San Fransisco -that even ‘modest’ dose of another indisputable secondary carcinogen – oral ie megadose xeno-estrogen-progestin eg PremPro – started soon after menopause- progressively increases breast cancer risk when continued ie > 1500mg premarin for much more than a decade . .

Are women   reaping the harvest of liberal combined (post)menopausal oral (in North America, mostly (xeno)-estrogen therapy) – ERT – since the 1990s – ie to women born after WW2 – with liberal screening mammography?  – “a social obligation” according to xray-screened British women recently canvassed by Frances Griffiths ea .

Have either of these universal prescriptions for women ever been justified by independent longterm (ie well over 10 year) cost-benefit trials? since the 1980s Canadian Breast Screening Trial (1990 Brian Miller ea  )  cast doubt on the benefit over 5 years of  Xray screening mammography . . 

 A practicing USA radiologist like Dr Jeff Dach argues realistically against all such screening based on the evidence.  . He says, ‘just switch off the screening imaging machines, stop calling ductal carcinoma in situ of the breast a cancer.’  This may enrage radiologists offering screening xray mammography, and breast surgeons specializing in early breast cancer surgery.

IS RISK INCREASED BY XRAY SCREENING?  OVERDIAGNOSIS BY XRAY MAMMOGRAPHY SCREENING?          Despite numerous modelling studies trying to theorize – model  the safety of xray mammography, eg from Netherlands and Canada , a Spanish study has just confirmed that breast cancer is overdiagnosed by screening mammography by almost 50% in younger women so screened.  This bears out the observed greater Danish decline in overall mortality after about a decade  (2%) in those not screened than in those screened (1%) by Jorgensen Zahl and Gotzche;     and the lack of decline in incidence of breast cancer over the decades from screening mammography in the English-speaking continents, Sweden and Norway,  documented by Jorgensen and Gotzche. These studies contrast with other studies quoted by the mammography industry. Each group disputes the statistics of the other. .

The recent review in NEJM by Kalager ea of screening xray mammography in Norway similarly showed that such repeated breast screening irradiation if anything saves 1 in 40 000 lives from breast cancer, and barely reduces the longterm risk of breast cancer- contrary to what the dominant Xray Screening Industry would have us believe the past 20 years. .

But as Welch’s accompanying editorial on Kalager’s Norway study points out,  (and sent by the South African Menopause Society January 2011 email Menopause Matters newsletter) “The risk of a 50 year old woman dying from breast cancer in the next 10 years of her life is 0.4% (or 40 per 10 000) – this calculation includes (xray) screening. Put in the obverse frame of reference 9 960 per 10 000 will not die from such cause. Screening contributes 10% to this survival so without screening 9 956 women will not die. The number of lives saved by screening is thus 4 per 10 000 women per 10 years of screening. Using “numbers needed to treat” 2 500 women would need to be screened for 10 years to save one life. This is the benefit of screening. The harms are what happen to the 2499 women who are screened that do not die. Depending on screening techniques roughly 1 000 of the 2 499 (ie 40%) can anticipate a false-positive  and some sort of recall for further screening  This number rises with the frequency of mammography and is here calculated on screening every 2 years. Over-diagnosis and over-treatment is more sinister and would occur in 10 of the 2 499 survivors. This is needless (iatrogenic) treatment of a condition that was never going to bother them. False-positive diagnoses and over-treatments are the harms of screening.”

Is there any  objective evidence for the marketing slogan of the American Radiological and Breast Surgeons’ Associations- and the Curves International website-  that Screening Xray Mammography Saves Lives – in order to promote the $8billion a year xray screening mammography industry and the $trillion a year cancer industry?

And it needs to be stressed that the above concerns about screening mammography are directed at XRAY mammography, since due to heavy marketing and promotion,  Xray mammography is the only mammography method in use in all papers and studies of widespread primary screening of well breasts in women not at high risk from eg family history, previous cancer or already having breast lump or bleeding or pain.

It may be asked again: what male doctor would have biennial let alone annual crush xray imaging of his testes from age 40years to reduce his theoretical risk of silently developing testicular cancer, even if the hypothetical risk were 1 in 10?

THERMOGRAPHY:    A practicing academic gynecologist speaks for thermomammography from good  experience for years. Whether his esperience and opinion is  more or less valid that that of breast surgeons  who claim they can run and report xray mammography machines without a radiologist  is as usual a matter of hotly divided opinion.

 Far more important is that recent trials from Cornell , Cambridge UK and Shanghai   universities speak for the comparable effectiveness of thermography .

COMPUTERIZED TACTILE PRESSURE TRANSDUCER BREAST MAPPING  has evolved over the past decade, with applications in prostate and colorectal cancer mapping heavily funded by US Govt agencies. It ( computerized palpation tactile pressure mapping of breasts eg SureTouch) has been validated by academics such as Prof Cary Kaufman  and in controlled studies, at least eight the past decade  eg at the Necastle on Tyne Breast Clinic by Prof Clive Griffith and team (paper under peer review by the British Journal of Surgery). A recent abstract from Griffith(2009) describes study of 137 patients at a UK NHS breast clinic, 66 of whom had palpable breast masses. Seventy-seven of these were chosen at random to have a SureTouch examination in addition to CBE. Use of SureTouch reduced the percentage of missed lesions by senior and junior surgical trainees. The reproducible reports allowed efficient review by examiners with various levels of experience. Authors state that SureTouch imaging improved patients’ safety in breast clinic and likely had a role in the training and assessment of surgical trainees.

All the above options are now accepted in many western countries including South Africa, for both screening and diagnostic breast imaging, since the evidence  supports each of the options.

DEFINITION OF WHAT CONSTITUTES OPTIONS FOR MAMMOGRAPHY:   It is common sense that equipment methods involving the prefix/suffix gram eg ECG/ EKG/EEG/ spirogram/ renogram/ gramradio  often dont involve xrays. Equally, there are many established useful reliable alternative types, options for imaging the heart/lung/ breast. Neither the pre/suffix ‘gram’ nor the prefix ‘mammo’ are exclusive to the xray breast image, there are many established comparable modern breast imaging techniques from physiologicalthermomammography which reflects temperature ie bloodflow,  – to anatomical eg xray, ultrasound; magnetic resonance; and the past decade to computerized palpation tactile  pressure mapping (eg SoftTouch). This is despite van Steen and Van Tiggelen’s semantic  illogic  in regarding only xray breast imaging as mammography in their 2007 Belgian History of Mammography.   Already in 1999, the Dutch used mammography interchangeably for both xray and ultrasound screening.  But the earliest apparent Pubmed reference to ultrasound mammography is in 1982. .

RISK OF BREAST (AND PROSTATE) CANCER: it is common cause that in a first world population- where most die of “natural” degenerative aging diseases rather than classic malnutrition, plagues, exposure and violence –  these cancers cause about 4% of all deaths. But most sufferers do not die from these cancers. Hence their clinical occurrence over a lifetime may be around 10% risk ; although silent – never suspected- cancers may be found in far more people at autopsy. .

With routine repetitive xray mammography screening, the annual risk of breast cancer detection is generally reported  to be about 6 per thousand.

But Winifred Cutlers’ influential Athena Institute group from USA and Switzerland recent study Breast cancer in postmenopausal women: what is the real risk? concluded that regular xray screening of well not-at-high risk breasts, in the 18 published major studies without obvious vested interest bias involving over a million women screened, the annual incidence is more like 1 in a thousand. Her group questtions the bias, data massage of SEER statistics to inflate ie fearmonger. They thus question the cost-benefit of repeated xray screening of all older women from midlife to find 1 silent cancer in every thousand women- many of which cancers may be overdiagnosis since without intervention many will never present clinically diuring lifetime..

But it is also common cause that, apart from those with strong genetic risk (at least 2 close relatives who get one of the five hormonal cancers young ie prostate, colon, breast, ovary and womb),  the risk of cancer lifelong may be 10% or less since without screening, many never present during lifetime and are found incidentally at autopsy. There are many putative avoidable – preventable- causes: obesity, diabetes and bad food choices; and drugs- alcohol; sugar; smoking; aspartame; high cortisol (stress, lack of exercise), and oral estrogenic drugs like unfermented soya, the birth control and hormone therapy pills,. The risk of cancer subsides once these risk factors are minimized – this applies even to the familial cancers- eg after more than 5 years off oral birth control or sex hormone therapy. All diabetics- and all who stay overweight, or have raised cholesterol (mostly caused by insulin resistance) – should take the best preventative all-purpose prescription drug there is, the natural plant extract-  metformin- in appropriate tolerated dose- as well as abundant all-system-protectant antioxidant insulin sensitizer nitric oxide promoting eg vitamins, minerals, biologicals including fish oil; and appropriate human HRT. .

So the only women who justify early and ongoing screening for breast cancer may in fact be those who are at high risk from the above factors; and those who want to use appropriate HRT. For such women, even if if they have no breast symptoms or lumps, thermomammogram and/or tactile breast imaging (SureTouch) screening may arguably  be started young since they are at least harmless, to indicate whether there is need for further screening with ultrasound, xray, MRI etc. . .

Obviously the (Xray and thermo- and Tactile mapping and ultrasound and MRI) mammography machine suppliers and users are not going to fund a head-to-head comparative trial of the five methods . But if we collaborate as Griffith’s Newcastle-on-Tyne group did in an observational study ie recruiting enough women to have two or more of the mammography methods each time they elect to have screening, with screening staff blinded to what is suspected and shown on other and previous mammograms, and have central co-ordination – registration and independent collation- of results, we will soon have answers, as was invaluably shown without error in eg the major longterm Nurses Study.

With already available statistics, it will not take statisticians long to calculate how many women – maybe as little as 100 in each set- will need to have at least a preset minimum of at least two different mammography options, ideally say a year apart for baseline comparison and standardization.. This will be as simple as the Groote Schuur Hospital evaluation of the quantitative ultrasound bone risk system versus xray bone densometry in over a thousand women reported in 2009-  it showed equivalence.

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update Feb 2011: WORLD CANCER DAY DOES NOT MEAN WORLD INVASIVE CANCER SCREENING:   the 2010  World Cancer Day email from the South African Medical Association  claims that “People should get tested by means of screening, it is a simple test that will identify if an individual have an unrecognised disease” ?

Where is cancer screening simple ie no invasive and technological cost? And without false negatives? Even faecal occult blood screening is both distasteful and thus anything but simple to many patients, requires some skill in interpretation, and the test kit has a cost. This SAMA message sounds like the Curves- Breast cancer Industry’s mantra slogan that Xray Mammography Saves Lives?   

 The huge problem is to get people to report and investigate SYMPTOMS, bleeding, bowel changes, lumps promptly.  

 For SCREENING of the well ie those who dont already warrant diagnostic tests due to symptoms or family history-  the definitive diagnostic imaging screens- of cervix,  prostate, colon and breast  –  are anything but simple,   non-invasive , low-cost tests  .   Except in the small minority who have a compelling family history of any of the five interlinked genetic  (breast, womb, ovary; colon; and prostate) cancers, prostate  & breast screening  of the well for early diagnosis of asymptomatic cancer have not proven to make significant difference in long term health let alone survival except create more worry & discomfort when positive?  

Unlike the commonest medical degenerative disease of adults-  vascular disease, hypertension- even breast cancer, the most feared amongst  non-smoking women, is not that common- as the South African Cancer Association says, only “1 in 29 ie 34% of women will present with breast cancer during her lifetime” – not 1 in eight as diseasemongers would have women believe. And “cervical cancer will be diagnosed in 1:35”. And prostate cancer in “1:23 men during lifetime” and  “one in 97 South African men is at risk at getting colorectal cancer while the rate for women is one in 162 “. And of course these risks are far lower in those who do not have bad family history and lifetyle. So the benefit of invasive screening is debatable, the risk of cancer is low in those who live safely, who know they do not have a bad family history or develop symptoms.

 Whether colon imaging (as opposed to faecal occult blood FOB screening) for preclinical diagnosis is any better at truly reducing morbidity and mortality  from colon cancer in low-risk well people is truly better than breast/ prostate screening remains to be validated in the same way  that 10 year retroanalysis has shown up the zero longterm benefit- if not more harm-  of xray screening mammography    

The US Preventative task Force study claims  15% reduction in colon cancer mortality from FOB screening – but all such data from the USA and its trading partners is so  notoriously tweaked to favour diseasemongering , can one believe any of them? Mainstream North American specialists who promote  screening scopes on all  well people naturally believe it is lfe-saving  –  but does it benefit the not-at-risk adult overall except the Screening Industry?  

For universal colon screening, where are objective colon screening studies like the recent Scandanavian breast studies that look at at least 10 year outcomes in the well low-risk population undergoing screening versus the population screened only because of symptoms?   The Wiki review of cancer screening pointedly highlights clear cancer screening benefit only for those at increased risk – which is by definition no longer primary screening for all, only for a small minority.  This seems to be a balanced rational view. Repeated cervix cancer screening is hardly cost-beneficial for the lifelong monogymous couple or ( careful olygamous) woman.

RADIATION DOSE FROM SCREENING XRAY MAMMOGRAPHY OF 50 000 WOMEN TO SAVE MAYBE ONE LIFE

Posted on November 24, 2010     A still practicing radio-oncologist retired professor  writes:

 the new study of  imaging techniques was interesting   MEASUREMENT OF THE RADIATION DOSE AND ASSESSMENT OF THE RISK IN MAMMOGRAPHY SCREENING FOR EARLY DETECTION OF CANCER OF THE BREAST, IN ISRAEL.” by Broisman ea 2010.

“I think (xray) mammography needs to come from a request from a physician following clinical history, i.e risk factors, family at risk, or if for some reason genetic screening found BRCa1 or BRCa 2 genes, or a clinical exam suggests a lump;

Patient insistence may be OK, given informed consent about the controversy about different methods, benefits and risks.

Screening xray mammography implies Xraying all females of a population “at risk”.

 Early detection is based on physician and patient related factors, I would think.

Ben

By contrast, the evidence validating breast screening thermography  – recommended by eg a practicing gynecologist –  has been increasing for fifty years;  and for those who want screening when well, has been reported as a physiological screen with comparable high sensitivity and specificity  (as compared  to anatomical imaging- static xray or ultrasound or MRI or SureTouch tactile devices ) to pick up premalignant hyperperfusion risk about 8 years earlier (than xray mammography)..

In fact, as Dr Kaunitz points out  recently,  from the Norwegian study,  “decline in mortality attributed to screening alone may be as few as 2 deaths prevented/ 100,000 women screened[3]         ie xray mammography screening may save as few as 1 per 50 000 women screened. “

This is indeed a far cry from mammographysaveslives,  when 50 000 women with apparently well breasts   are  denied full knowledge of the actual risks and nett benefits, and driven by fearmongering   to have their breasts crushed and irradiated for decades  –  to  save possibly one  life.

 

THE TRILLION-DOLLAR CANCER INDUSTRY: QUOT HOMINES TOT FEMINA or QUOT HOMINES TOT CANKERI??

neil.burman@gmail.com

 PREFACE:  the conflict  between common sense, conventional wisdom and vested commercial interests:

Throughout the ages, innovators and believers in truth and freedom of thought  have risked if not attained martyrdom for disputing populist or autocratic wisdom or beliefs, from Socrates to Jesus to objectors against prevailing dogma through the past twenty centuries, Martin Luther, Galileo Galilei and in our time  eg Margaret Sanger, Mahatma Ghandi, Linus Pauling, Jack F Kennedy, Nelson Mandela,  Steven Biko, now even medical leaders like Dr David Graham at the Federal Drug And Food Administration itself.

But despite the eternal fact that truth will out, even now the USA and South African governments are determined to suppress truth, making it a jail offence for whistleblowers and media reporters to publicise evidence that exposes (eg medical) fact let alone corruption and worse. Jose Saramago the late Nobel-winning Portuguese author of “Blindness” and “Seeing”.  will be sadly shaking his heavenly locks.  We should heed Saramago’s modern scepticism  about official truths if not his atheism and communism.

Eleven years ago the emeritus professors Sirs  Stuart Cameron(British)  and Bill Hoffenberg (South African) at London University  dared to publish jtaboo questions for ethical debate – The ethics of organ transplantation reconsidered: paid organ donation and the use of executed prisoners as donors. This was still hotly debated in 2003- and remains so in South Africa -ironically after 16 years of ‘democratic’ majority rule  one of the most violent and corrupt countries in the world – where leading private practice doctors and hospitals are being prosecuted for transplanting kidneys from apparently desperate willing sellers to unrelated paying recipients.

The Case of Disease-Mongering?  Screening the well at average (not high) risk for Possible Future Cancer:

 The classic Latin phrase Quot Homines, Tot Sententiae- so many people, so many opinions – refers to the dilemma of which opinion to follow, what to  vote for. Politics aside, never is this more apposite than about confusing men and women about the grave risks  of the overdiagnosis and overtreatment of screening-detected silent cancers.

So perhaps the title should read: Quot Homines Tot Cankeri: not all adults may get crabs, but the screening disease industry posits that  all adults may get cancer and thus should be regularly invasively internally screened. .

We are not talking about investigation directed at a possible cancer that has already grown big enough to be causing relevant symptoms eg a lump or pain etc. It is indeed surely negligent if a health professional fails to recommend such diagnostic investigations in the appropriate clinical conditions.

SCREENING FOR BREAST AND PROSTATE CANCER: A review last month of the massive ( New Jersey Cancer Institute) study of prostate cancer bears out the futility- in fact grave risks- of screening for silent dormant prostate cancer in men without symptoms. This is reinforced by a broader recent Medscape review. 

Wikipedia usefully sums up the dilemma we face 2500 years after Hippocrates.  While Aulus Cornelius Celsus translated the Greek carcinos into the Latin  – to many of us the foods of the gods – Galen 150 years later used “oncos” to describe all tumours, the root for the word oncology; but the more thoughtful Hippocrates had long before distinguished benign tumours oncos, Greek for swelling, from malignant tumours carcinos.

We can fast-forward this distinction to 2010 in Hippocratic terms of both ethics and pathology:

1.should tumours that are histologically “malignant” but clinically static over a usual lifetime – as most asymptomatic prostate and breast “cancers” are ie “oncos” (eg screening-detected ductal or cervix carcinoma in situ) if not stirred up by eg hormone therapy or biopsy- be labelled, diagnosed to the patient as clinically malignant “carcinos” ie a spreading crab? Hippocrates , and later Celsus , were indeed talking about cancers as tumours that were clinically and macroscopically malignant. Silent preclinical cancers that are discovered on screening are rarely so. And therefore

 2.is it ethical to do cancer screening (by blood, digital, xray, ultrasound, biopsy) of all asymptomatic patients? As Shaughnessy and Slawson (1997) so incisively wrote a decade ago, is such commercially lucrative proactivity Patient-Orientated Evidence that Matters ie POEM to the patient? They continued to publicise this theme relentlessly until their last joint Pubmed-listed essay in 2006, arguing trenchantly for valid evidence-based practice rather than as most doctors seem to do, following ex cathedris views and guidelines by ‘experts’ and committees- who are likely influenced by Big Pharma. They (Shaughnessy and Slawson) individually continue this battle until now.

The updated wikipedia review  of xray screening for asympotomatic preclinical cancer including breast cancer, soberly reviews the controversy surrounding the benefits – saving possibly one extra life in 2000 healthy women whose breasts are heavily crushed and irradiated for years for no benefit, for the dozens undergoing recalls and biopsies for lesions found, the handful who may have cancer diagnosed and even surgery and radio/chemotherapy, for mostly early cancers that far more often than not would never have presented during lifetime and death from other causes.

Yet screening breast cancer xray mammography of even millions of asymptomatic women not at familial risk cannot be proven to save even one life let alone lives. The increasing doubts about the costs (both financial and emotional) of such screening versus the benefits of such screening of well persons with low risk factors including family, apply to screening for many relatively common feared cancers eg breast, prostate, testicular, ovary, lung.

SCREENING FOR OTHER CANCERS: So the question may well be asked whether there is overall statistically significant benefit (in lower overall mortality and morbidity) of such invasive screening programs even for the other two commonest cancers of older adults- colon cancer and cervix cancer- in those without significant risk factors- relevant symptoms or infections or family history.

This then extends to the longerm questionable overall benefit versus risk of vaccination especially from preteens against human papilloma virus- again, such vaccination is a trillion-dollar industry when it is decreed compulsory for all children. .  As screening for breast and prostate cancers has shown no clear benefit to individuals or to the population screened – versus the non-screened- on longterm population followup, it will take comparable careful review of results in thousands of initially low-risk well patients for decades to show whether overall mortality and morbidity was indeed lower in average-risk populations that were invasively screened/ vaccinated for eg cervix or colon cancer versus those that were not.

Only such a study will show whether the public has anything to lose by simply being mandated to report to a healthcare professional for relevant investigation when they develop new symptoms eg change in bowel or gynaecological health.   It is damning that on a populist website like Health24, the page on Breast cancer was last updated in 2006, and does not even mention the crucial issue of longterm benefit and risk on those screened. Naturally service providers with vast investments in technology and aggressive management promote screening, as witnessed by national health services, university and private hospitals and high-tech practitioners in all countries. At least the Wikipedia section on breast cancer screening has a lengthy section covering the controversy.  .

 It is now six years since surgery professors Dent and Panieri published an editorial warning about the lack of convincing evidence for population breast cancer screening. And their editorial did not even consider the added risk factor of repeated crushing and irradiation of presumably health breasts.

And a practicing USA radiologist like Dr Jeff Dach argues realistically against all such screening based on the evidence.  .  As he says, just switch off the screening imaging machines, stop calling ductal carcinoma in situ of the breast a cancer. The ongoing argument for and against screening is hotly debated by specialists supporting and opposing the vested interest of the Screening Industry.

 Without more study, it cannot be assumed, proclaimed, taken for granted that the giant resources- costs, risks, and invasion of everyones’ privacy and time,  required for such mass screening and vaccination – are justified. Are they anything more than lucrative disease-mongering? when screening xray mammography alone is already said to  gross almost $10 billion a year in USA (300million people) .

   Extend that to all countries and the five common adult genetically linked cancers,  and the cost of questionable screening (and then managing the discovered cancers) – let alone aging cancer itself) for the whole world of older adults surely  rises to above a trillion dollars a year– a nice coveted annual pot of gold for governments in power and the business moguls, big stakeholders they serve.

As with the spurious decade-long unwinnable invasion of Iraq for fictitious nuclear weapons but in reality for the profits of war and oil,

 and the USA – European Union -WHO declaration of a swine flu pandemic just a year ago so that the NATO business buddies – governments and their funding private megacorporations – could reap billions in immediate rake-off from unproven screening tests and vaccinations and drugs;

and its trillions a year from uncovering and treating all those sleeping cancers, 

 so who cares about the benefits and risks decades down the line for those screened and vaccinated and treated now for disease that is unlikely ever to occur?

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.