Statement of Position
12% of females in the United States will develop invasive breast cancer over the course of their lifetime. Breast cancer rates began decreasing significantly at the turn of the millennia after increasing for the previous two decades. The reduction is partially attributed to hormone replacement therapy (HRT). The incidence rates have slightly increased in recent years. Screening breast cancer through mammography can result in a reduction in mortality. It can also reduce the harm of over-diagnosis. Screening, however, involves substantial harm of excess identification of more early-stage cancers which is not complemented by a decrease in late-stage cancer. It contributes to a considerable amount of over-diagnosis. The rate of death from breast cancer has decreased substantially but can only be attributed to a combination of screening mammography and improved treatment. There is little evidence that screening mammograms reduce death by breast cancer on a population basis.
Proposed Bill
Caution should be exercised when recommending mammographic screening to women below the age of 50. Individual state mandates should be upheld and full coverage for bi-annual mammography screening for all females of 35 years and older and all females of 20 years and older who have documented breast cancer in an immediate family member amended.
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Analysis
Risk of Death
The probability of women dying from breast cancer is approximately the same for both those who initiate or do not initiate mammography in their forties, according to a 2014 Canadian study. The study followed more than 50,000 women between 40-49 years until the age of sixty. Half of the women were randomly assigned annual mammography while the remaining half did not. Of the 256 deaths from the sample population, 124 were allocated mammography while 122 were not allocated to mammography. This represented a cumulative risk of death as 0.53% and 0.48% respectively (Narod et al. 2014). Mammography was, therefore, associated with a small but non-significant increase in the risk of mortality before the age of sixty. There is a lack of discernible evidence that screening mammograms reduce the risk of death. It may lead to over-diagnosis, overtreatment and may even be responsible for the shortening of the life of some women. If the main reason that regular mammography is done is to reduce mortality from breast cancer there is evidence that its contribution to this is insignificant, there should be a change in the way it handled in the current legislation.
Figure 1. (Narod et al. 2014)
Over-diagnosis
Screening mammograms results in an increased number of breast cancer incidence because of earlier detection of cancers that would have been identified later in life or would not have been detected clinically in a woman’s entire lifetime. The second category is said to have been over-diagnosed. The screened tumor may lack the potential to progress or even regress. The woman may also die from other causes before cancer surfaces clinically. There are various harms associated with the treatment of over-diagnosed breast cancer mainly because it is an unnecessary burden to the patient and a threat to her health and life. Treatment may include radiotherapy, surgery, and chemotherapy. The risk of death from cardiovascular disease is higher in women treated with radiotherapy. It is possible that overtreatment may increase mortality by other causes besides cancer. This is a possible explanation of why there is no reduction in the risk of death in women populations with screening mammography. Most studies estimate over-diagnosis to range from 30% to 54%. This represents a significant number of women with screening mammograms who are at the danger of suffering harms associated with over-diagnosis.
Figure 2 shows substantial jump in the use of screening mammography through the years among women aged forty-years and older (Bleyer & Welch, 2012). It indicates a significant associational increase in the occurrence of early-stage breast cancer due to the increased screenings. Figure 2b shows minimal change in breast cancer incidence among women who were not screened. Figure 2b also suggests that more than 1.3m women were over-diagnosed over a period of thirty years.
Figure 2. (Bleyer & Welch, 2012)
Cost
The Affordable Care Act requires private insurers and Medicare to cover preventive measures without any cost-sharing. Most United States residents are required to cover part of the cost of hospitalization, physician visit, or any other health-related service. Preventive measures are discretionary in the United States. The Affordable Care Act provides for screening without copay or deductible. This is an incentive to increase the number of women turning up for the bi-annual mammography screening. It is a concern, however, since approximately forty percent of women have dense breasts. This often requires them to take a secondary test that insurance companies won’t pay for. Most women are unaware of this and end up footing an extra bill for additional tests. The mammogram cancer detection software costs the $400m to health care spending every year but a recent study has concluded that it does not make any difference in how accurately radiologists detect breast cancer ( Trivedi, 2010). It is seen as a waste of resources according to the study released in the journal JAMA Internal Medicine.
It is time to have a conversation on whether vast resources used in routine mammography can be shifted toward diagnostic workup for women with a change in their breast that fails to leave, surveillance of women at a higher risk for breast cancer, and timely treatment. There are also social, financial, and emotional costs to women and their families that can be mitigated by reduced screening mammography.
Anxiety
False positives and over-diagnoses results in anxiety. An abnormality might be detected in the breast and identified as breast cancer while it is actually not the case. Further testing may cancel earlier findings but the damage at this point is usually already done. This causes anxiety for those involved including the notion that they are at a higher risk for breast cancer. The experience of over-diagnosis has a major impact on women who receive cancer treatment and live with a breast cancer diagnosis in the entirety of their lives. Without screening mammography, these women would not have gone through that experience. Screening mammography has also been associated with an increased incidence of small breast cancers below 2 centimeters. The same does not translate to a decreased incidence of larger breast cancers.
Radiation
Radiation associated with mammography tests and additional tests for false positives carries a considerable risk for women. It also includes radiation treatment for women with over-diagnosed cancer.
Figure 3. (Tabar, et al. 2011)
The flawed study by Tabar et al indicated with a definite finality that the primary factor in the reduced breast cancer deaths was mammography. It erroneously indicated that women screened regularly had a 47% lower risk of mortality from breast cancer within two decades of diagnosis as opposed to those not regularly screened. This is an extremely optimistic figure even for other studies attributing screening mammography to reduction of breast cancer mortality.
Conclusion
The idea that there could be a single answer to breast cancer is appealing but not yet a reality. There is no discernible proof that screening mammograms decrease the risk of death by breast cancer on a population basis. The staunch proponents of screening mammography have turned a well-meaning awareness campaign into a misinformation movement, obscuring screening limits, compromising the country’s decisions about health care, and combining risk with breast cancer. This narrative should change and allow legislation to be based on research to achieve the best possible approach for diagnosis and treatment of breast cancer.
References
Bleyer, A., Welch, G. (2012). Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence. New England Journal of Medicine . https://www.nejm.org/doi/full/10.1056/nejmoa1206809#:~:text=The%20introduction%20of%20screening%20mammography,122%20cases%20per%20100%2C000%20women .
Narod, S., Sun, P., Wall, C., Baines, C. and Miller, A. (2014). Impact of screening mammography on mortality from breast cancer before age 60 in women 40 to 49 years of age. US National Library of Medicine National Institutes of Health . https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4189562/
Plucknette, G. (2013, April 28). The problem with pink . The New York Times. http://www.nytimes.com/2013/04/28/magazine/our-feel-good-war-on-breast-cancer.html
Trivedi, A. (2010) Effect of cost sharing on screening mammography in Medicare health plans. https://www.nejm.org/doi/pdf/10.1056/NEJMsa070929
Tabar, L et al. (2011). Swedish two-county trial: impact of mammographic screening on breast cancer mortality during 3 decades. PubMed . DOI: 10.1148/radiol.11110469 https://pubs.rsna.org/doi/full/10.1148/radiol.11110469
