Of Mammograms and Telegrams
The ritual of the yearly mammogram screening has reached epic proportions, with vast numbers of our “over-50-ish” fairer sex trudging down to their family care providers, gynecologists, or radiologists religiously, in order to receive peace of mind for another 365 days. Mammograms were originally conceived of to preclude nasty surprises and their subsequent urgent telephone calls and telegrams. But are they foolproof? Does being a “good girl” and getting one’s annual mammogram avert a worst-case scenario, namely, advanced-stage breast cancer with little chance of cure? Lo and behold, we now learn that no two breasts are exactly alike, and that mammography can detect only about half of all breast cancers in women with dense breast tissue. And how, for that matter, is a woman to know if her breasts are dense? We need to throw some light and accurate medical information on a subject that directly or indirectly affects us all. As products of a mother’s milk, we would be remiss to do otherwise.
Breast tumors are dense and, when coupled with dense breast tissue, make for a difficult game of hide-and-seek, with anatomical camouflage making discovery difficult, at best. To make matters worse, dense breasts are not the exception to the rule and, actually, are quite frequent. The medical literature indicates that half of women under age 50 and one-third over 50 have this density dilemma, if we may call it that. The younger a woman is, the more likely she is to have dense breasts. If that were not all, even if a woman were to be aware of her individual density issue, chances are that she would be blatantly unaware of the fact that her annual mammogram might actually miss its intended target. Were radiologists to inform their patients of this particular, not only would mammograms drop below radar screens and get scratched off shopping lists, but women might protest en masse and further embarrass a health care system already reeling from assaults by Congress, local politicians, the elderly, the poor, and the downright fed-up.
So, in simple terms, one might say that the question is whether or not screening mammograms are worth their weight in biological gold. Do they, indeed, reduce a woman’s chances of dying from breast cancer? If not, why is there so much ado about nothing? In that case, we might be better served by simply moving on to another form of detection, more sensitive and specific than pressing one’s upper torso against a plate. The fact is that mammograms reduce women’s chances of dying from breast cancer by 22% when they are aged 50 and over, and by 15% in those in their 40s. No small numbers, especially when female friends and family members are set adrift in the choppy waters of cancer fear, doubts, and medical misinformation, and cling to the only life preserver and communication beacon heretofore available, namely, the screening X-ray. However, when breast density is thrown into the mix, any attempt at treading water becomes problematic, to say the least. Enter our hero, the breast ultrasound.
While screening ultrasound adds little to the diagnostic picture in women with category 1 (fatty) and category 2 (somewhat fatty) breasts, in whom screening mammography is 98% and 80%, respectively, effective in detecting breast tumors, it can nonetheless commute a death sentence in women with category 3 and 4 (dense) breasts. The latter have only a 50% chance of having their breast tumors detected on a mammogram before they become palpable on physical examination, and ultrasound excels at individuating these silent killers in dense breast tissue. It is not a panacea, however, and with the good comes the bad, and sometimes even the ugly. Ultrasound pinpoints abnormal breast findings 10% of the time that turn out to be benign, when subsequent breast biopsy is done. Not only that, but it is unavailable in many radiology centers and, at a miserly $87 dollars a pop for 20-30 minutes of work, few radiologists are ready, willing, and able to perform it. After all, time is money! Who knows that better than radiologists, who further state that the combination of magnetic resonance imaging (MRI) and mammography is almost twice as effective as ultrasound and mammography at detecting tumors in women with very high breast cancer risks. Those “roentgen masters” are just itching to employ MRI more widely, and being held back only by its $1,000 per test price tag. And when all is said and done, we save the ugly for last. Even were ultrasound to be employed on a large scale, there is no data as yet to tie improved tumor detection with ultrasound to a reduction in deaths from breast cancer. So, currently, an end justifies the means argument cannot be made.
Cancers come, and most often do not go. Until now, their early detection has been the name of the game to improve survival statistics. But what about those lazy, indolent tumors that are so slow-growing that early detection makes little difference, and similar, acceptable survival results can be achieved without a precipitous “jump on the horse,” expensive technology with little financial remuneration for its purveyors, and a rush to judgement? We must ask ourselves whether mammograms, ultrasound, and expensive MRIs influence the survival equation in a meaningful way, or whether cheaper, more patient friendly, and perhaps more delayed detection procedures and devices can achieve equivalent reduction of those fateful telephone calls, letters, and telegrams.
ã 2009, Albert M. Balesh, M.D. All rights reserved.
posted by Dr. Al at
8/09/2009 01:39:00 PM
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