Breast cancer being "overdiagnosed"?

[Darth Wong]

http://www.cbc.ca/health/story/2009/07/ ... nosis.html

Breast cancer has high 'overdiagnosis' rate: study
Last Updated: Friday, July 10, 2009 | 2:10 PM ET
CBC News

One in three breast cancers detected by mammogram screening programs may be treated needlessly because they are unlikely to be life-threatening, researchers said Friday.

Writing in the British Medical Journal, Scandinavian researchers who reviewed data on screening programs from five countries, including Canada, found an overdiagnosis rate of 52 per cent for all cancers, including those that have not spread, and 35 per cent for invasive breast cancer.

Overdiagnosis arises since some breast cancers grow so slowly and harmlessly that the patient dies of other causes.

Since it's impossible to tell deadly cancers from harmless ones, doctors treat all breast cancers that are identified. But treatments such as radiation therapy, surgery or drugs can also cause harmful side-effects.

"One in three breast cancers detected in a population offered organized screening is overdiagnosed," Karsten Jorgensen and Peter Gotzsche of the Nordic Cochrane Centre in Copenhagen concluded after looking at trends at least seven years before and after public screening programs began in Australia, Britain, Canada, Norway and Sweden.

"This information needs to get to women so they can make an informed choice," Jorgensen said. "There is a significant harm in making women cancer patients without good reason."

Since screening programs began about two decades ago, more cases of breast cancer have been picked up. If the screening is effective, theoretically it should identify cancer at an earlier, more treatable stage, and eventually fewer numbers of advanced cancers should be found in older women. Mammograms are usually offered for women between the ages of 50 and 69.

Study methods criticized

There is also evidence breast cancer screening saves lives, said Otis Brawley, chief medical officer for the American Cancer Society, who questioned the methodology behind Jorgensen's estimate but noted it raises legitimate scientific questions.

Jorgensen's study did not take lifestyle changes into account that are thought to increase breast cancer incidence, such as women waiting longer to have their first child.

"We have eight high-quality, randomized prospective clinical trials — the gold standard in screening methodology — that consistently show that screening using mammography and clinical breast exams reduces the risk a woman will die of breast cancer by up to 35 per cent," Brawley said.

Likewise, Cancer Research UK's blog also raised concerns about the methodology of the Scandinavian study, noting it also did not take into account use of hormone replacement therapy and was too short to offer a reliable estimate of how many tumours are overdiagnosed or simply diagnosed earlier.

"We therefore do not find the results of this study to be credible," wrote Cancer Research UK's screening expert Stephen Duffy, a professor of cancer screening at the Wolfson Institute of Preventative Medicine in London. "Women should not be put off breast screening, which saves over a thousand lives a year in the U.K."

In an editorial published in the same issue of the journal, Gilbert Welch, a professor at the Dartmouth Institute for Health Policy and Clinical Research in Vermont, said the findings highlighted how mammography is one of medicine's "close calls."

"Mammography undoubtedly helps some women but hurts others," Welch said. "No right answer exists. Instead it is a personal choice."

Last month, Statistics Canada reported that, among Canadian women aged 50-69, the likelihood they had undergone a mammogram in the previous two years was nearly twice the rate in 1990, just after systematic breast-cancer screening was introduced.

Both Statistics Canada and the Canadian Cancer Society say evidence suggests mammography helps reduce mortality from breast cancer.

Such a damned complicated kind of subject. When the cure is as likely to kill you as the cancer, do you treat it?

[Lagmonster]

Such a damned complicated kind of subject. When the cure is as likely to kill you as the cancer, do you treat it?

Breast cancer, according to the article, can "grow so slowly and harmlessly that the patient dies of other causes". To me, that sounds like a case where treatment is unnecessary even though the lethality of the disease isn't in question - it will kill you, just not fast enough. So as long as the quality of life is acceptable while living with the disease, treatment would seem to need to be considered by the patient...even though patients usually ask the doctor what he suggests and then goes with it.

The question would be absolutely different with diseases which weren't life threatening only because the progression was too slow, but for which quality of life was significantly affected. Imagine being suspended upside down with your head in a bucket of water while your feet are set on fire: You will probably drown before you burn to death, but that doesn't mean you wouldn't prefer they put the fire out.

To highlight that kind of choice, my father has a form of leukemia that, in his own words, "Won't kill him before something else does", but it's being treated simply because the quality of his life goes down significantly if its untreated. But by the same token, his treatments do have unpleasant side-effects. But he chose the treatments because the symptoms of living with the disease untreated are more uncomfortable day-to-day than living with the side-effects of the treatment.

[FSTargetDrone]

Such a damned complicated kind of subject. When the cure is as likely to kill you as the cancer, do you treat it?

Speaking of treatment, some women who are at an increased risk of the problem (family history, etc.) have elected to take preventative action by having their breasts removed before any cancer is even detected. It's called bilateral prophylactic mastectomy:

What is preventive mastectomy, and what types of procedures are used in preventive mastectomy?

Preventive mastectomy (also called prophylactic or risk-reducing mastectomy ) is the surgical removal of one or both breasts in an effort to prevent or reduce the risk of breast cancer (1). Preventive mastectomy involves one of two basic procedures: total mastectomy and subcutaneous mastectomy. In a total mastectomy, the doctor removes the entire breast and nipple. In a subcutaneous mastectomy, the doctor removes the breast tissue but leaves the nipple intact. Doctors most often recommend a total mastectomy because it removes more tissue than a subcutaneous mastectomy. A total mastectomy provides the greatest protection against cancer developing in any remaining breast tissue.

[Darth Yoshi]

Wow. Removing most of the breast tissue would certainly reduce risk, but man. It seems pretty drastic, especially since increased risk doesn't necessarily mean that cancer will develop. Unless removing the breast after the occurrence of tumors doesn't work for some reason, I don't see how simply minimizing risk through less invasion methods isn't a better idea. Maybe I'm just misunderstanding and this actually is a last resort procedure (the qualifier "preventative" seems to indicate otherwise).

[FSTargetDrone]

Wow. Removing most of the breast tissue would certainly reduce risk, but man. It seems pretty drastic, especially since increased risk doesn't necessarily mean that cancer will develop. Unless removing the breast after the occurrence of tumors doesn't work for some reason, I don't see how simply minimizing risk through less invasion methods isn't a better idea. Maybe I'm just misunderstanding and this actually is a last resort procedure (the qualifier "preventative" seems to indicate otherwise).

Here is an April 2009 Daily Mail article about a 19-y/o who had the procedure:

The 19-year-old who had a double mastectomy to beat family cancer curse

By Andy Dolan

Last updated at 10:58 AM on 15th April 2009

For most women, it would be an agonising decision, worthy of months of heart-searching and consultation. But 19-year-old Hannah Fitzpatrick was never in any doubt.

Last autumn, she became the youngest woman in Britain to have a double mastectomy in a preventative operation to beat the scourge of breast cancer which has haunted her family.

Now she believes she can look with optimism to a healthy future.

Genetic screening had revealed that she carried the faulty BRCA 2 gene, which meant she had an 85 per cent chance of developing the condition.

It followed the diagnosis of two of her cousins with breast cancer, both in their early twenties - an unusually young age. Both were subsequently found to have the same faulty gene.

Yesterday Miss Fitzpatrick, now 20 and a nursing student, told how two aunts had also been struck by the disease, with one terminally ill.

She said: 'The fact that my cousins got the disease so young, plus one of my aunties being terminally ill, really focused my mind. It made the decision for me, really.

'I know that I am only young, but I would have spent years worrying about falling ill, especially if I ever found a lump.

'Now I can look forward to the future without worrying about it. I have no more chance of developing the disease in future than any other woman.'

The chance of a woman developing breast cancer in her lifetime is one in nine, according to Cancer Research UK.

The cancer history in Miss Fitzpatrick's family stems from her father Michael's side. Mr Fitzpatrick, 49, a Labour councillor, is one of three brothers who along with three of their four sisters all carry the faulty BRCA 2 gene.

Of those sisters, one was diagnosed with breast cancer aged 37 five years ago and is now terminally ill. A second was diagnosed a year ago in her late forties and is receiving treatment.

Miss Fitzpatrick's cousins, daughters of one of her uncles, were diagnosed with breast
cancer just months apart two years ago.

Both are now in remission and have also had double mastectomies to try to prevent the disease from returning.

Miss Fitzpatrick, who lives with her mother Karen, 47, a healthcare assistant, in Burton upon Trent, Staffordshire, gave a blood sample which was screened for the faulty gene two years ago after her cousins were diagnosed.

She had the 11-hour double mastectomy operation at Selly Oak hospital in Birmingham last October.

During the reconstructive part of the surgery, she took the opportunity to increase her bust size from a 34B to 36C.

'I thought I might as well take the chance to make them bigger,' she said.

She has since had another three operations on her breasts, and doctors are monitoring the situation.

She said her parents, who are separated, and boyfriend Martyn Croft had all supported her decision.

Mr Croft, a 23-year-old forklift truck driver, said: 'I think Hannah has been amazing. She has stayed really strong throughout everything.'

Breast cancer is now the most common cancer in the UK, with around 45,000 cases diagnosed each year.

About 100,000 British women are believed to carry dangerous versions of the BRCA 1 and BRCA 2 genes. They can currently decide between a lifetime of regular monitoring or a pre-emptive mastectomy.

The previous youngest woman to have a preventative double mastectomy is believed to be Derbyshire radio DJ Becky Measures, who had the operation three years ago at the age of 24.

At least 14 women in her family had died over the generations.

As you can see, she felt it was worth it.

A more general Reuters' article from this year:

Rates of preventive mastectomy rising in U.S.

Sat Apr 25, 2009 1:27am IST

NEW YORK (Reuters Health) - New research points to a dramatic increase in the number of women diagnosed with the earliest stage of breast cancer in one breast who choose to have both breasts surgically removed.

The rate of so-called "contralateral prophylactic mastectomy" surgery among U.S. women with early breast cancer called ductal carcinoma in situ (DCIS) increased by 188 percent between 1998 and 2005, Dr. Todd Tuttle, from the University of Minnesota, Minneapolis, and colleagues found.

Exactly why more and more women are opting for this treatment, however, is unclear.

"The 10-year survival rate for women with DCIS is 98 percent to 99 percent," Tuttle notes in a university-issued statement. "Therefore, removal of the normal contralateral breast will not improve the excellent survival rates for this group of women. Nevertheless, many women, particularly young women, are choosing to have both breasts removed."

The findings, reported in the Journal of Clinical Oncology, stem from a study of 51,030 women who had one-sided DCIS. Overall, 2072 women chose breast removal surgery for their cancer, the report indicates.

Among all surgically treated patients, the contralateral mastectomy rate climbed from 2.1 percent to 5.2 percent (148 percent) between 1998 and 2005.

For those treated with mastectomy, the rate of double mastectomy increased from 6.4 percent to 18.4 percent (188 percent).

More studies are "critically needed" to evaluate the complex decision-making processes leading to contralateral prophylactic mastectomy," the investigators conclude.

SOURCE: Journal of Clinical Oncology, March 20, 2009.

[Broomstick]

Such a damned complicated kind of subject. When the cure is as likely to kill you as the cancer, do you treat it?

Several years ago my sister the doctor was irate that mom was still being subjected to regular mammograms. Due to mom's other health problems there was no way she could be treated for any cancer found - chemo, radiation, surgery, it would all almost certainly kill her in short order, faster than any cancer would. So why even test for it? Mammograms are somewhere between uncomfortable and painful, mom got dozens of tests a year anyway, it's not like she needed another. The only thing that could be done would be palliative treatment, i.e. painkillers. In which case you might as well wait until it's detectable without x-ray or other imaging technique since, in the end, it wouldn't matter anyhow.

It's just that "test for cancer" has gotten to be so automatic that it continued to be done for woman for whom it was pointless. As it happened, she never did develop cancer (so far as we know - no autopsy was done) but even if she had then most certainly she died of "something else" first.

Certainly for the very elderly, or those with other severe medical problems, treating breast cancer aggressively might actually hasten death. More and more medicine is finding that not all cancers originating in a particular organ are the same. A way of distinguishing aggressive, spreading cancers from those that would grow slowly, perhaps so slowly that death from other causes first is nearly certain, would be invaluable as cancer treatments are not fun and can permanently damage various organs.

Wow. Removing most of the breast tissue would certainly reduce risk, but man. It seems pretty drastic, especially since increased risk doesn't necessarily mean that cancer will develop. Unless removing the breast after the occurrence of tumors doesn't work for some reason, I don't see how simply minimizing risk through less invasion methods isn't a better idea. Maybe I'm just misunderstanding and this actually is a last resort procedure (the qualifier "preventative" seems to indicate otherwise).

In general bilateral mastectomy is offered to women with BRCA1 and BRCA2 genes. Women with the BRCA1 and BRCA2 genes have an 85% chance of getting cancer by age 70. That's an enormous risk, really, if you think about it. They also have a significantly increased risk of ovarian cancer. One option is to wait until the woman finishes bearing children/nursing, then to remove either both breasts or else both breast and both ovaries. By doing this BEFORE cancer occurs you don't have to worry about metastesis, the woman is much healthier (and likely younger than if she waited until cancer arose) so she will tolerate surgery much better, she will recover faster, and any reconstructive techniques will be yield much better results.

This does not remove ALL risk - women with these genes are at higher risk of ALL cancers (men with those genes are, too, including increased risk of breast cancer) and they must still be monitored. By removing tissue that is most likely to become cancerous, however, the chances of her living a normal lifespan are greatly increased.

Needless to say, this is not surgery to have on a whim, but under some circumstances it can be a very rational decision. There are other gene mutations that lead to similar issues. There is, for example, a gene defect that virtually guarantees colon cancer. It is becoming more common for people with this gene to have their colons entirely removed in their early 20's, before cancer actually occurs. It's a drastic step, but many people feel it beats dying in their late 20's or early 30's.

People with these genes also have the dilemma of whether or not to reproduce. Modern medicine provides means to deal with the cancer issue, but there is the question of whether or not it is ethical to perpetuate such genes.

[Darth Yoshi]

Ah, that makes sense. I'd neglected the fact that younger patients have an easier time with surgeries. Color me informed (well, moreso than before, anyway).

[Mayabird]

I'd heard that "monitor and wait" was becoming more common with elderly men diagnosed with prostate cancer for these same reasons - slow-growing ones likely won't kill them before something else does and treatment would be more harmful than nothing.

[Simon_Jester]

Certainly for the very elderly, or those with other severe medical problems, treating breast cancer aggressively might actually hasten death. More and more medicine is finding that not all cancers originating in a particular organ are the same. A way of distinguishing aggressive, spreading cancers from those that would grow slowly, perhaps so slowly that death from other causes first is nearly certain, would be invaluable as cancer treatments are not fun and can permanently damage various organs.

I'd think that would be easy- test twice, a moderate length of time apart. If the tumor isn't getting bigger at a noticeable speed, keep checking but don't apply treatment.

[Broomstick]

The problem is that very aggressive cancers might well spread between the two testing episodes.

What we really need is a test that will identify, at initial biopsy, which cancers MUST be dealt with immediately and which we can watch and monitor in relative safety.