By LUCY ORMONDE
At 25, I’m not in the right age bracket to line up for a mammogram but when my GP asks me if I want a breast exam, I’m all for it. Poke ‘em, prod ‘em, touch away! I don’t care. Because it’s better to be safe than sorry, right?
Maybe.
Researchers are now suggesting that breast screening could be causing more problems than it’s actually solving. They say that women are being ‘over diagnosed’ and subsequently treated for breast cancer unnecessarily.
The Sydney Morning Herald reports:
While Australia’s BreastScreen program is believed to be saving hundreds of lives each year, researchers now estimate about a third of cancers it detects would not make them ill. This means thousands of women are potentially being diagnosed and treated for breast cancer unnecessarily.
Writing in the Medical Journal of Australia this week, epidemiologist Alexandra Barratt and GP Paul Glasziou said Australian women were not at present providing informed consent for mammograms because they were being given inadequate information about the potential for ”overdiagnosis”.
Professor Barratt of the University of Sydney and Professor Glasziou, of Bond University, said that although some researchers were still debating the rate of overdiagnosis, there was enough evidence now to decide if policymakers, experts or the women targeted for screening should judge whether the benefits outweigh the harms.
But how can there even BE such a thing as being overcautious when it comes to your health?
Breast Screen Victoria has weighed in on the debate. According to their website:
Overdiagnosis is a current topic of debate in the media.
The BreastScreen Australia Evaluation Report June 2009 concluded that the program has been successful in reducing mortality from breast cancer at the current participation rate of 56% in the target age group of 50 – 69 years by approximately 21 to 28%. It is acknowledged that this benefit is a result of routine screening combined with significant improvements in surgery and drug treatments.
However, all population screening programs acknowledge that a small percentage of the cancers detected would not have led to death or caused symptoms if left untreated. Overdiagnosis is the term applied to these cancers. Some people debating this issue say that the diagnosis and subsequent treatment of these cancers is harmful. In an effort to reduce their risk of a life threatening cancer in the future, some women receive treatment that might not have been necessary and so for them, the harm could outweigh the benefits.
A few years ago, a Government review of Australia’s breast cancer screening program found that “while the program was saving lives and should continue, it should be closed to women aged 40 to 44 and to those over 75 because of doubts about the balance of benefits and harms for them.”
While there has apparently been little or no action from the Government is response to that review, debate on the issue has not stopped.
We’re keen to know your thoughts.
How often do you have a breast screen? Do you think women should be informed about the risk of ‘over diagnosis’? Should the Government alter the age bracket for who is eligible to have breast screening so that women in low risk age-groups are not being ‘over diagnosed’?
Comments
42 Comments so far
New research that suggests the risks of breast screening exceed the benefits when you factor in deaths caused as a result of over-treatment. (unnecessary radiation, chemotherapy and surgery)
http://www.bmj.com/content/346/bmj.f385
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Perhaps slightly off-topic, but at 28 and with a family history of breast cancer I was disappointed to find out that I wasn’t old enough for the BreastScreen opportunity. I appreciate resources can be stretched, but plenty of women in their 20′s are faced with breast cancer prognosis’ every year. Let’s just hope there’s not something m missing n my self examinations hey…
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I was lucky do be working in South Africa when I discovered a sore that was not healing and went to the doctor. Fortunately the incidence of penile cancer is substantially higher there than in Australia. I’d rather see an “over diagnosis” than what happens with penile cancer where due to “male sensitivities” and lack of knowledge there is a 25% mortality rate, much of which could be prevented. Us blokes need to become as body aware as our partners….
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http://www.cochrane.org/news/blog/mammography-screening-ten-years-reflections-decade-2001-review#comment-1242
This has a link to the NCI brochure.
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I had a mammogram at 40 at the insistence of my GP whom is a very caring and non corporate type GP. There is no breast cancer in my family and I was sure I would be cleared as I had no Lumps or any other symptoms. My breasts appeared absolutely normal. This was simply a screening mammogram mainly to appease my GP whose sister had died from undiagnosed breast cancer in her thirties.
My first standard public health screening mammogram at 40 led to several biopsies and a diagnosis of high grade DCIS (Ductal Carcinoma In Situ) in two quadrants of my breast. DCIS can’t be felt or seen, even by the best specialists. It is only detected by a mammogram. This diagnosis resulted in two lumpectomies and then a mastectomy and reconstruction which all happened in just 3 weeks. I am very lucky!! If I had not had a free standard screening mammogram when i turned 40,by the time a Lump was noticeable, the cancer would have most likely have spread to the lymph nodes and I would have needed chemo and had a much poorer prognosis. Instead I had surgery, have a 98% survival percentage 15 years post surgery and needed no other treatment. Nearly four years on I am still clear. It is never too early to check and I for one, will be having a yearly mammogram and ultrasounds which I don’t find at all painful. It is important to mammogram, 9 out of 10 women diagnosed with breast cancer have no family history. Younger women also tend to have much more aggressive breast cancers. Whilst screening can create over diagnosis and treatment it also saves lives!
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Until someone comes up with some way of telling which cancers are going to stay small and cause no symptoms or death, and which ones are going to grow, metastesize and ultimately kill if left untreated, the issue of ‘overdiagnosis’ is just theoretical. Things like this make me think the mainstream media should not have access to medical research. They go and report what they think it means (in the process putting their own spin on it), rather than what it actually means.
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I’ve known about this for a few years, I don’t accept a word coming from BreastScreen or Papscreen, both groups have political goals and neither in my opinion, respects our legal right to make an informed decision about testing – neither program provides women with “real” information – most of it is misleading or even incorrect and their aim is to herd women into screening to achieve govt-set targets. It’s a numbers game for them…
The AMA and ANZCOG remain silent while this goes on – no one protects women in this country.
Fortunately, other countries have doctors and other advocates watching these programs and ensuring they remain current and focused on what’s best for women. The Nordic Cochrane Institute, an independent medical research group, have reviewed all of the evidence on breast screening – “The risks and benefits of mammograms” is at their website. This is an excellent source of real information. Also, articles and interviews by Prof Michael Baum, UK breast cancer surgeon. I’ve declined breast screening, an informed decision.
Beware of pap testing as well…
Our cervical screening program seriously over-screens women and this means high over-treatment/excess biopsy rates for NO additional benefit. (lots of false positives) (cervical damage can mean cervical stenosis, cervical incompetence, infertility, premature babies, c-sections etc)
The Finns and Dutch have evidence backed programs – 7 pap tests, 5 yearly from 30 to 60 and the Dutch are moving with the evidence again – their new program will be 5 hr HPV primary triage tests offered at ages 30,35,40,50 and 60 and only the roughly 5% who are HPV positive and at risk from cc will be offered a 5 yearly pap test – these are the only women with a small chance of benefiting from pap testing. The vast majority of women will be HPV negative and are not currently at risk, they will be offered the HPV primary testing program or can test themselves with the Delphi Screener. Those HPV negative and confidently monogamous or no longer sexually active can forget all further testing. This program will better protect all women, the small number at risk (it’s more likely to prevent these rare cancers) and the vast majority, those HPV negative, who can only be harmed and worried by pap testing, false positives and over-treatment. This program will see pap testing and over-treatment rates plummet…it’s smarter testing.
Our program generates huge profits for vested interests and with no critical scrutiny the program has remained unchanged…excessive and harmful – NOT in the interests of women. Our GPs also receive target payments for screening 70% of eligible women – so instead of protecting women, they profit from this outdated program. (the target was recently increased to 70%, so expect more pressure in the consult room)
Note: a Finnish woman is offered 7 pap tests, an Australian woman 26 or more pap tests….the Finns have the lowest rates of cc in the world and send far fewer women for potentially harmful over-treatment.
I think both of these programs reflect very poorly on our medical profession – they have a duty to women, not to the govt, these programs, profits and vested interests. The silence from our doctors is deafening and shameful….
I’d urge every woman to rip up any “information” provided by these programs and go straight to real information. Informed consent for women in cancer screening is a joke in this country.
By the way, clinical breast exams are not recommended, there is no evidence they help, but they lead to excess biopsies.
I have always declined pap testing (as a low risk woman) – if I were concerned about this cancer, I would not agree to a pap test without first establishing I was HPV positive and at risk…I also rejected breast screening when I turned 50 – I have real concerns when it comes to benefit and it leads to significant over-diagnosis. I practice breast awareness, taking note of the look and shape of my breasts in the mirror every morning after I shower…I’ll see my GP if I notice any changes.
It’s great the truth is finally emerging here, but after years of misinformation, many women simply won’t believe it.
The review of our cervical screening program has just begun…more delay while they continue to over-screen and over-treat women – there is nothing to discuss – the evidence has been clear for many years – no woman benefits from over-screening or from early screening. The only women who can benefit from a 5 yearly pap test are those aged 30 and over who are HPV positive – they have a small chance of benefiting.
I’d urge women concerned about this rare cancer to look at programs in the Finland and the Netherlands.
The tragedy is…there was never a need to worry and harm so many women if screening had been placed in ethical and responsible hands. Women have a right to make up their own minds and that means providing them with all of the evidence, good and bad, and allowing them to make up their own minds. Time to drop the spin, scare campaigns, misinformation, target payments and just expect women to file in like ignorant sheep – we’re adults, not targets!
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I agree with everything you say in principle. However telling women to seek real information is problematic. Many people have no idea where to go and turn to mainstream media, and (my favourite) Dr Google for their medical advice. There does need to be a universally available source for up to date evidence based health information that lay people can understand, and access for free.
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Karen, it’s easy with breast screening – the Nordic Cochrane Institute have reviewed all of the evidence for breast screening. Their leaflet should be given to every woman, but that won’t happen because the program is chasing a govt-set target – 70% of women aged 50 to 69 and don’t want to give them anything that might put them off testing. It’s a denial of informed consent – if you have to hide some of the facts, inflate the benefits etc – then you have to ask yourself whether it’s an ethical screening program.
There is also an excellent book written by the doctor who heads up the NCI – it will shock you, I knew things were bad, but had no idea how far vested interests will go to protect their profits. See:
Dr Peter Gotzsche, “Mammography Screening: Truth, lies and Controversy”.
It’s trickier with cervical screening, the facts have been hidden for decades, misinformation is the norm here…but take a look at the new Dutch program. “HPV Today for the Netherlands” sets out the new program and you’ll find it on the website of the Health Council of the Netherlands. Also, the Delphi-Bio-science site explains how the HPV self-test option works…
Australian women are told there is no point testing for HPV as it’s a common virus, there is no cure and it usually goes away on it’s own, all true, but the BIG fact is not mentioned – HPV negative women, most of us, cannot benefit from pap testing, biopsies or over-treatment – they don’t want us to know that…instead they prefer to pap test and over-treat vast numbers of women who are not even HPV positive – who are not at risk from this rare cancer.
When you know the facts, the misinformation and deception is breathtaking and quite frightening.
“Time to Change the Policy” by Dr James Dickinson goes back to 2002 now…so Karen, head over to the NCI site, it’s my first port of call when I want real evidence backed information. Good luck!
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I am 45 and one week ago was diagnosed with breast cancer and I underwent double mastectomy and lymph node removal on one side due to abnormal cells (yesterday)
My last scan and mammogram at 44 detected cysts in both breasts that did not require treatment.
It is quite concerning to me because I’ve had several mammograms since my mid 20′s not routine ones but due to lumpy breasts.
I agree with previous commenters like Ellie that Chemo and radiation therapy are not offered on the basis on mammogram detection alone. Only after other testing including biopsy and usually surgery .
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Wishing you all the best for your recovery Trish. x
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I’m 44 and have a mammogram every 2 years. Breastscreen NSW doesn’t actively promote to under-50s, but I choose to have one because of my naturally lumpy E cup boobs.
I can see a few flaws in this article*.
Firstly, women don’t get subjected to chemo or radio treatment purely on the basis of the mammogram result. They get referred to a specialist, who will probably do more scans and a biopsy, then see what the pathology result is before deciding on treatment. My mother got the all-clear from the pathology result, so still has her breast and got nothing worse than a local anaesthetic and a biopsy.
Secondly, Breastscreen NSW is only available for women 40+ and only marketed to women 50+; ie as a 44 year old I do not receive and marketing or reminder letters. Any women younger than that will need a doctor’s referral to a breast clinic for reasons such as family history or a lump found – not just because they want it. Apparently younger women aren’t routinely eligible because the risk of finding a cancer is even smaller than the risk of the mammogram causing a cancer.
I guess it’s probably true that some cancers won’t progress into anything – the same happens in prostate cancer, I understand – but how do we know which is which? Can the doctors even tell us? Better safe than sorry.
* I’m a medical receptionist, my boss has had breast cancer and my mother a near-miss, and my sister is a doctor.
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Im the same as you, except for the E cup, more like B cup, lol. My grandmother had agressive breast cancer in her 20s and survived a long time after a radical mastectomy. I also have regular paps because I’m HPV positive, lucky me. As a very fair skinned child of the 60s & 70s, I also get my skin checked regularly. I think we probably are over screened and wish our govt would seriously look at reviewing the overseas research and reviewing our screening programs, but until then, I’ll screen, because having had a major health scare, I realise that not every problem comes up and whacks you on the face with it and you don’t properly appreciate your health until its at jeopardy.
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these kind of articles make me nervous. Will young females consider regular check-ups unnecessary after reading this article due to the possible risks of over diagnosis involved? I’m constantly stunned by the amount of my friends who already fail to regularly get their breasts checked, surely an article like this can’t help?
I’m 24, and as my mother had breast cancer at 36 and a single mastectomy as a result, I get checked over by the doctor every year – which often leads to referral for an ultrasound (and once a biopsy) as my breasts are filled with fibroadenoma’s.
Yes the experience is intrusive, costly and with the biopsy, painful, but its better to be safe than sorry, IMO
While were on the topic, i’m interested to know what other MM readers think of the test you can now undertake that determines whether you carry the breast cancer gene. I recently read a book about a woman in the US who had a double mastectomy after learning she carried the gene.This got a few girlfriends and I talking about what we would do if we had this test and the results came back positive – instantly I said i would have them lopped off – as did another girlfriend whose Aunty has also had BC. Some said they wouldnt as they loved their boobs. I could imagine it would be a pretty traumatic experience so am interested to hear other’s opinions on the issue. thoughts?
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Hi Megs, I found out that I had two mutations of BRCA1 after being diagnosed with breast cancer in 2010 aged 29. Subsequently we found that my sister, my mother AND father (one in 500,000 chance of a marriage where both partners have a mutation), aunts all have the mutation. I chose to have a mastectomy to treat my cancer, and when I found out I had the gene I chose to have a prophylactic mastectomy of the remaining breast. As the gene also has implications for ovarian cancer (increases the risk from the 4% population lifetime risk to 40% lifetime risk) I will undergo a prophylactic removal of my ovaries in the next few years (I hope to have another child). My thoughts were that they are only breasts, and I wanted to know that I had done everything possible to reduce my chance of cancer recurring. (I also had chemotherapy FYI). It was not a traumatic decision at all for me. In my mind my breasts had turned against me and they had to go. The hardest thing was being told “You must stop breastfeeding today so we can operate next week” as I had a six month old baby at the time.
My understanding is that genetic testing is offered to people based on their family cancer history and risk factors. The type of cancer that I had, in combination with family history and my age made me a high priority for testing, but other women I went through treatment with had to wait for their testing due to limitations on funds for this. I am not sure if it is available to patients who want to pay for it themselves?
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Hi Megs. I had the test for mutations BRCA 1 and 2 in 2009, aged 19. My mother, maternal aunt and great aunts all had breast cancer so I was offered the test as part of KConFab research into familial breast cancer (you can find their website pretty easily if you’re interested).
The tests were positive so I was in the predicament you describe above. I’m 22 now and not going to get my breasts removed any time soon. I have a prevention plan which was created by the geneticist, my GP and a surgeon who specialises in mastectomy, which involves breast exams every 6 months, pelvic ultrasounds yearly and a breast MRI yearly. That gives me peace of mind for the moment but in the future I probably will have them removed.
I try not to think about it all too much, I don’t let it take over my life. I do have a wonderful support network of family and friends though and I think that makes all the difference
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Hi Megs,
Check out Pink Hope, it’s an organisation created to inform and support women at high risk. Filled with useful info.
Also, Mamamia has in the past interviewed the founder of Pink Hope, Krystal Barter on site about the organisation, and also Jackie Cross, both of whom have BRACA genes and who have had this surgery. Well worth a look.
x A
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Sorry, this article is misleading. You say you are 25 and go on to talk about breast exams, which is a manual examination. This is NOT the same as breast screening, which are mammograms – x-rays – and possibly ultrasounds. (or maybe an MRI if your doctor recommends one.)
Mammograms should be used VERY carefully in young women as exposure to x-rays is in fact a cause of breast cancer. My experience is a young woman would not be routinely given a mammogram unless she has a worrying family history of breast cancer and presents with something suspicious.
Yes, you are correct that you are not the target of the screening program – Breastscreen’s own information says women aged over 50 are at highest risk of breast cancer. Breastscreen doesn’t recommend women under 40 have regular mammograms.
Manual examinations present NO health risk and are recommended by all health professionals. When I was diagnosed with breast cancer at 37, it was because I discovered my own lump.
Please don’t conflate these issues. Having said all this, it is very concerning that women are having unnecessary treatment for small cancer that may resolves themselves. I wouldn’t want any women to lose her breast and go through chemotherapy if it wasn’t necessary.
So I guess it up to all women to be informed and vigilant. Get the facts on your actual risk, DO examine your own breasts especially if you are younger – and grill your doctor about their recommendations if they are packing you off to a mammogram regularly. I can’t stress enough that you the more active you are in your health management, the better outcomes.
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If nothing else, I’ve learned there is such a thing as non-harmful cancers. Or that they could not lead to death. I would never have envisaged those words could be grouped together.
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Apparently this happens in prostate cancer too – they can either be aggressive and fatal, or so slow-growing that you’ll die with them rather than of them.
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I am going to continue my annual mammograms regardless.
I dont care that I could be over diagnosed. If there is a tumor in my body that may or may not become malignant I want it out. Period.
I would much rather have an early diagnosis and then less invasive treatment, even if it might never become full blown cancer. Why would I take that risk? I have two children and there is no way I would risk them losing their mother to cancer if there was something proactive I could do about it.
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Because unneccesary mammograms can cause cancer. Can you have yearly ultrasounds instead? They’ll still ID what’s there, but are less invasive.
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Yes, wouldn’t ultrasounds be the better alternative??
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Mammograms and physical examinations done by a GP are two different things and shouldn’t be confused……
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I don’t know about you but I’d prefer anything that’s been medically classified as a cancer or likely to turn into cancer be removed from my body, malignant or not!
There have been similar articles about pap smears which I personally found concerning as I have recently had an op to remove some serious cell changes at age 25 – what do this arguists suggest I do, leave them in and wait for the ‘luck of the draw’ as to whether they turn malignant?
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Melissa Sweet, the journalist who writes the excellent Croakey (Crikey’s health blog) has been writing a lot on overdiagnosis lately. Here’s her take on the latest interest in this area: http://blogs.crikey.com.au/croakey/2012/06/14/have-we-reached-a-critical-tipping-point-with-healthcare/
Highly recommend a read if you are interested on how society is turning perfectly healthy people into patients.
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Women need to be informed about their health, and have the opportunity to undergo whichever tests they need – inclusive of mammograms at any age.
My mum found a lump in her breast when she was 24 and told not to worry about it as she was “too young to have breast cancer”. 6 months later the lump was still there and she went back to her GP insisting that it be investigated further. Within a week she had a mastectomy to remove cancer. Perhaps if action were taken sooner she would not have died from breast cancer?
As for me, naturally I am very, very proactive about my health – especially when it comes to my breasts.
Andrea
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The reason you can’t have a mammogram at any age is because the evidence shows there is no benefit below 50. Young women have low rates of breast cancer and different breast tissue density . Allowing anyone to have a mammogram would lead to high rates of over diagnosis and unneeded investigation, not to mention the cost to the healthcare system.
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Mammograms are less effective on younger breast tissue because it’s denser, but they are not ineffective. They’re viewed as less neccesary as a first step than ultrasounds – but if you have a lump or abnormality identified through an ultrasound they’ll do a mammogram. I’ve had two mammograms by 25 because I have very lumpy breast tissue (according to doctors), so I know from experience that this is the case.
Technically the “golden rule” for any breast lump or abnormality in a woman (young or old) is ultrasound, mammogram, fine needle biopsy. This information is from expert evidence reports I have to read for work…although I know from experience (as mentioned above) that most doctors don’t actually do this in practice.
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Dear ‘Anonymous’,
Yes, young women have lower rates of breast cancer, but they still can get it – which was my point.
I get the other points you are making, and while I don’t necessarily agree with them, I think perhaps making them in response to my comment was a little insensitive.
Andrea
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Over-diagnosed!!??? What the hell!! I wish I was overdiagnosed at 42 when I first presented with a fibroadonema and not left till I was 49 to find breast cancer!!
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I want to know that my mum, my sister, my grandma – every woman I know – has access to breast screening if and when she wants it, and even if it’s just for peace of mind.
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My mum thinks that mammograms cause cancer due to the squashing of her boobs in the torture machine.And she thinks squashing spreads the cells. I know – sounds ridiculous!
If only there was a better way to find out if there is cancer in the booby area!
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There is. You can also ask to have a breast ultrasound. I had a lump detected this way.
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Thanks for that!
I never knew you could have an ultrasound instead of a mammogram. My mum will be so pleased to know! We have often discussed how it would be much nicer to just go over it with an ultrasound than the boob squasher. I assumed that the pictures wouldn’t come out so clear, and that was why they mammogram and not ultrasound it.
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Generally (speaking in my own experience) you have both mammogram & ultrasound. I am due to go back for a follow up mammogram (they detected an abnormality in December). The abnormality did not show on the ultrasound. I am not looking forward to it (hurts – A LOT!), but I will do it.
They recommended just keeping an eye on it and re-test in 6 months, which is what I will be doing shortly.
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Hi Amanda – I’ve actually been refused mammoagrams because I’d already had one in the 12 months (following an unusual result on an ultrasound). So they insisted on just doing an ultrasound rather than a mammogram for the next check up (because of the radiation risk).
It probably varies between each patient and doctor, so Happymum it’s definitely worth telling your mum to ask for an ultrasound instead!
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I don’t agree that there can be too much screening. However, what there may need to be is a better approach once someone IS diagnosed. Which comes back to what the specialists can advise, and what treatments are available. If they can tell that one person’s cancer is not harmful to their long term health, then surely they can tailor treatments to that?
Personally, I will be proactive, and aggressive, with anything that will impact on my long term health.
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Haha, you and me both, probably for the same reason.
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I can maybe see an argument for some elderly people – my grandmother has cancer and can’t be treated as she’s too frail. She probably would never have known if it wasn’t for routine screening.
Then again, my grandfather also has cancer at 86 and has been given radiotherapy to help with the pain – it’s slow growing bone cancer – and his life has been much improved, although he won’t be cured.
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Wow. Who knew? I’m 48 and have my mammogram every two years to the date.
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My sister had her fist breast screen at the age of 40 and was diagnosed with breast cancer. No such thing as too much screening IMO.
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