Overselling and Promoting Over Diagnosis...and the Winner is ?

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Breast Cancer: Komen Oversells Mammograms, Doctors Say By SYDNEY LUPKIN August 2, 2012—

abcnews.go.com

Medical Journal Column Calls Pink Charity Out for Bad Math

Two Dartmouth Medical School professors have called out Susan G. Komen for the Cure, accusing the pink-ribbon organization of overstating the benefits of mammograms in its advertisements.

The accusation comes about six months after the breast cancer charity came under fire for cutting Planned Parenthood funding, which it claimed was not a politically motivated decision. According to the foundation's most recent Form 990, it netted about $114 million in 2010.

The ad in question ran last October in several major magazines, and said, "The five-year survival rate for breast cancer when caught early is 98 percent." Its not. It's 23 percent."

"It sounds like you'd have to be crazy not to get screened. It sounds like a huge benefit," said Dr. Steven Woloshin, co-author of the article in BMJ, the British medical journal. "The statistic is totally distorted."

The problem is that a five-year survival rate is easy to manipulate, he said. The ad compares five-year survival rates for early-stage cancers and late-stage cancers, which Woloshin said is not a meaningful way to measure the benefits of screening. Here's why:

Suppose three women are diagnosed with breast cancer at age 67 when a doctor finds a small lump, and they die of the disease three years later, when they're 70. That five-year survival rate is a miserable zero percent because no one lived five years past their diagnosis dates.

Now, suppose the same women were diagnosed when they were 64 because the cancer showed up on mammograms, but they still die of breast cancer at age 70, he said. The new five-year survival rate is a triumphant 100 percent, even though the women actually survived cancer the same length of time. They just didn't know how long they had it.

"If there were an Oscar for misleading statistics, using survival statistics to judge the benefit of screening would win a lifetime achievement award hands down," Woloshin and his co-author Lisa Schwartz wrote.

More useful numbers, he said, are derived from randomized trials. They show that 0.53 percent of women in unscreened trial groups died over 10 years -- compared with 0.46 percent of the women who were screened. That's not much of a difference, the authors said.

This problem is further exacerbated by overdiagnosis, which happens when mammograms detect cancers that never grow or cause symptoms, he said.

For every woman saved by an early screening, two to 10 are falsely diagnosed, the authors wrote. This means patients endure biopsies, chemotherapy and radiation even though they don't have a threatening cancer.

"There's no way for an individual to know they've been overdiagnosed," Wolostin said, explaining that the only way to tell whether this has happened to a specific person is if that person is diagnosed, does not seek treatment and eventually dies of something else.

Doctors have seen evidence of overdiagnoses in long-term follow-ups to randomized trials and analyses of population data, he said.

In response to the article, Komen's Vice President of Research, Chandini Portteus, stood by the foundation's stance on mammograms, calling the screenings "the best widely available detection tool that we have today."

She said Komen has contributed funds toward even earlier detection.

"We think it's simply irresponsible to effectively discourage women from taking steps to know what's going on with their health," Portteus said, adding that the foundation is also funding research to determine which tumors will spread.

Woloshin said his article is not saying mammograms are bad.

"Some people benefit while other people are harmed," he said. "If you don't know, you can't make an informed decision."

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What this article, as well as Komen do not express, is that mammograms can also be ineffective as a diagnostic tool. My form of b.c., invasive lobular - which started as a nearly imperceptible node, was consistently misdiagnosed as "fibrous breast tissue" for years before it grew to 6.2 cm and a biopsy followed by a MRI confirmed its true nature. My history of mammograms gave both my doctor and myself a false sense of health. Until the tumor insisted on recognition.

Additionally, this article and Komen do not address the cumulative nature of radiation - which is the energy behind mammograms; and our bodies inability to naturally purge this and all of the other daily exposures to radiation we encounter. All of which create a toxic environment within our bodies where cancer can happily proliferate.

I personally know many women who have been "diagnosed," via mammograms, with stage -0- / in-situ carcinoma (a pre-breast cancer state). With this diagnosis they have gone on, with full encouragement of their medical teams, to undergo the slash/burn/poison protocol. Their outcome: "cured." Yet, they all seem to be experiencing some after"gift" of their treatments -- no one should leave a party empty-handed. It begs the question: what were they actually cured of?

And, if they and their medical team had not relied so heavily on mammograms, would they have made a different choice?
                                                                                                    ~ TC

Nurse Tracy Calling

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Four Winds Oncology, can you hold?

Of course

May I help you?

May I speak with one of Dr. Obenchain’s nurses?

I’m Nurse Tracy, I can help you.

Oh hi Tracy. I don’t believe we have met before. This is “TC” I got a letter from SMIL stating they it was imperative they do additional studies, to supplement my breast MRI last Tuesday. I have called them. They want to do a mammogram on my right breast and an ultrasound on my left. They will need the doctor to fax over orders. But, I have a couple of questions that I need answered before we proceed.

Of course. Tell me what they are and I will talk to doctor and get back with you, and I will talk to her about the orders.

Thank you, my questions…concerns, rather are (1) since the MRI is a more comprehensive diagnostic exam than either an ultrasound or mammogram – even a diagnostic mammo, why do we need to do either? SMIL said that the MRI images were perfect in clarity; and (2) what is SMIL seeing on the MRI that makes them (a) want to do additional exams, and (b) what less comprehensive exams tell us that the MRI can’t?

I can’t answer those questions, I will have to request the report, have doctor review it and call you back.

Yes, I realize that, thank you. I would appreciate you following up with the doctor, thank you.

4 hours later….

Ms. TC, this is Nurse Tracy calling from Dr. Obenchain’s office. I have your answers. SMIL says that they do not have a current mammo on your right breast and want it for their records, so that is the reason for that follow up exam. Regarding the ultrasound, because the scar tissue from the sentinel node biopsy is greater in size than your last PetScan they want to make sure of what is there. That is the reason for the ultrasound request. The doctor said that's fine, and I am preparing the orders to fax over to the lab now.

Oh. What about my initial question?

What was that?

My question of necessity. Since the MRI is a more comprehensive diagnostic exam than either an ultrasound or mammogram– even a diagnostic mammo, why do we need to do either?

Oh, as I said, because SMIL says that they do not have a current mammo on your right breast and need it for their records. And, because the scar tissue from the sentinel node biopsy is greater in size than your last PetScan they want to make sure of what is there.

Right, I understand what you are relaying as SMIL’s reasons, but isn’t it true that the MRI, that was just conducted 6 days ago, is a more comprehensive diagnostic exam than either an ultrasound or mammogram– even a diagnostic mammo. And as such, that it should give both SMIL and Dr. Obenchain the information they need to determine what is going on with the scar tissue as well as the status of the right breast?

Ms. TC, you haven’t had a diagnostic mammogram on the right breast in over a year. With your history, you need to have a diagnostic mammogram at least annually.

Tracy, I don't think I agree. I am not so sure that is necessary, in light of my history. The mammograms are not as effective as detecting ILC as an MRI.  My individual history includes the sequence of diagnostic events, in order of certainty, as: (a) diagnostic mammogram; (b) ultrasound; (c) biopsy; and (d) MRI. Knowing all this, I raise the question - isnt doing a mammogram now going backward, diagnostically speaking? And, therefore unnecessarily exposing me to radiation?

Ms. TC, radiation exposure to mammograms is minimal. You got significantly more radiation exposure with the MRI.

Um…Tracy. I don’t believe that is completely accurate. My understanding is that an MRI does not involve exposure to ionizing radiation. Doesn't an MRI use magnetic fields and radio frequency pulses – not radiation. Mammograms, on the other hand, do indeed use ionizing radiation – I know the radiation levels are not astronomical but it is certainly higher than an MRI. Besides, aren’t there more risks of false positives with mammograms than MRIs?

(Pause...heavy sigh...) Ms. TC, it is your choice as the patient, if you do not want to have the mammogram that is just fine. I will note that you are declining the mammogram here in the file. Is there anything else, otherwise I do need to attend to other patients.

What about the necessity of the ultrasound? My understanding is that the MRI would be more conclusive in determining what is going on with the scar tissue than an ultrasound.

Again, Ms. TC, it is your choice if you do these exams or not. Doctor has signed the orders. Just let our office know what you decide. Have a good day.

I hung up and immediately started writing. Since the beginning of this journey I have always kept a journal when meeting with or talking to any and all medical professionals. There is too much information and bias that is thrown out there, and taking notes is the only way I can properly process and distill everything in my own time and context. With the second conversation, four hours later, I was keeping copious notes. I wanted to confirm for myself whether or not my questions had indeed been answered - or not. It is entirely possible that I am suffering some residual effects from last week’s concussion and was just not "hearing" Nurse Tracy. Though, I am fairly certain - upon review, that the substance of my questions were never addressed.

Thank you, Nurse Tracy, you have a good day too!