Since the U.S. Preventive Services Task Force (USPSTF) report on breast cancer screening in 2009, articles about the benefits and harms of mammography screening have accelerated. It is remarkable that a technology that women have counted on for decades for the early detection of breast cancer and its subsequent reporting life-saving benefits receive such polar opposite messages and conclusions. While these reports are primarily designed to assist women in making an informed decision about breast cancer screening, they often lead to more confusion about what to do and whom to believe to be protected from late-stage disease.
Breast cancer, next to lung cancer, is the second leading cause of cancer deaths among all races in the United States. Yearly, 230,000 women in the United States are diagnosed with breast cancer and 40,000 die from the disease. It is a substantial public health issue with deadly consequences.
A recent study by Pace & Keating published in JAMA reports that while mammography reduces mortality by 20 percent, it also has "harms" that must be taken into consideration when determining a patient's screening protocol. The authors conclude that mammography screening decisions should be individualized based on patients' risks and preferences.
I am a strong believer in personal responsibility and my ability to make healthful choices to control MOST of my health destiny. No smoking, moving my body daily, an abundance of green hues on my plate and a modest consumption of alcohol (although I have increased my consumption of red "antioxidant" wine since my advanced-stage breast cancer diagnosis); yet in spite of my health-conscious lifestyle with no family history of breast cancer and my relentless yearly mammographic screening appointments, I was diagnosed with advanced stage breast cancer within weeks of my 11th NORMAL mammogram. I only received all the facts of my individual risk of breast cancer AFTER my advanced stage diagnosis as I learned that my extremely dense breast tissue not only can mask cancer on mammography but is an independent risk-factor for breast cancer. Even though the masking and risk of dense breast tissue were reported in the scientific literature for more two decades, not one of my health care providers over a dozen years ever informed me of "all the facts" about the limitations of mammograms and the missed positives caused by dense breast tissue. This harm of dense breast tissue, which is the strongest predictor of the failure of mammography to detect cancer, is seldom discussed in the popular media.
Having a conversation about the harms of over-diagnosis and over-treatment of indolent cancers have little value to a patient when it cannot be precisely determined which cancers will harm and which will not. As Denise Grady aptly reveals about mammography and harms in the Well blog of the New York Times, "So where are these over-treated women? Nobody knows." Additionally, we need better risk models to accurately communicate an individual's personal risk for breast cancer, as indicated by my "low risk" assessment status prior to my advanced-stage diagnosis.
An editorial in JAMA by Elmore and Kramer insists on balanced messaging from health care providers about the facts of mammography, supporting shared-decision making by respecting women's preferences and values. I applaud this recommendation, as all too often I hear from women about how physicians shockingly dismiss their concerns about dense tissue and the likelihood of masked cancers by mammography. Sadly, time, money, inconvenience and health care providers' preferences and knowledge trump "just the facts."
Physicians have an ethical responsibility to truthfully communicate the current scientific facts with their patients. Additionally, they need to listen to and respect patients' preferences even when it may collide with their own preferences. An informed decision about such a personal health issue as breast cancer screening and prevention can only be made after receiving all the facts!