Friday, December 7, 2012
Nearly one-third of breast cancer diagnoses are wrong and the system has been faulty for decades.
That conclusion, reported in the Nov. 22 issue of the New England Journal of Medicine, carries such serious implications that I have chosen to put the planned column on hold to address it.
If you are one of the women who wonders whether you were treated for something that wasn’t cancer, I share some degree of your concern. I may have been one of your doctors.
The lead author of the article was Dr. Archie Bleyer. I met Bleyer when I worked at the University of Washington. He was respected as a clinician and researcher. He went on to head one of the nation’s biggest programs and to serve in a high position with the American Cancer Society.
More recently, he has investigated lifestyle issues and cancer development. It would have been easy to discount the claim, were it not for the credibility of the authorship and acceptance by one of the world’s most discriminating and respected journals.
How could it be possible that medicine could have been so wrong?
First of all, I could be the one who has this all wrong and the authors might have missed something.
Here’s the basis of the conclusions that, “in 1978 breast cancer was overdiagnosed in more than 70,000 women.” I’ve written recently in this space that we diagnose cancer by looking at cells and recognizing patterns that are the same in a biopsy specimen that we see in known malignancies.
It is reasonable and disconcerting that the entire system may have been faulty. Inherent in the problem is the fact that we never felt that we could look at a pathology report and decide to wait and see if it might be wrong. Looks like cancer? Let’s get rid of it and let’s do it now.
Radiologists have been under pressure to be sure they never underdiagnose. Society and its lawyers aren’t tolerant of missed diagnoses.
A pathologist suffers from the same unrealistic expectation. Never miss a cancer. If a pathologist labels something as a cancer, and it would have never killed the patient, no one will ever know and it counts as a cure.
The issue is complex and it points to the reality of uncertainty in life and science. It doesn’t say that your physician was incompetent or uncaring. If you want to understand the study and make your own decision, check out the NEJM, and/or read my summary.
Technical zone: The national data collection system, SEER, is based on data that is imperfect. The local contribution is from The Blue Mountain Oncology Program, which is carefully collected and reported.
The study in the NEJM evaluated the cancer incidence information in women over 40 years old, from 1976 to 2008.
We would expect that screening would do two things. There would be “early” cases diagnosed and the number of advanced cases should decrease. The last half of that equation was almost nonexistent.
In fact late stages decreased by only 8 percent. Meanwhile the number that were called “Early cases,” more than doubled, from 112 cases per 100,000 population to 234. Another way to ask about the efficacy of screening is to look at the death rates over that period of time. Death rates from breast cancer have decreased, but they improved more for women under age 40, who were not screened. We can reasonably conclude that better survival resulted from better treatments and not screening.
What else can we conclude?
Mammograms appear much less effective than we have believed.
Fear of cancer may commit a huge number of women to treatment that has serious consequences for management of non-existent threats.
Patients should talk with physicians about the risks and benefits. Be smart.
Be realistic that some organizations have committed their resources to promoting mammography. People have committed their lives to promoting it. Industrial giants have billions invested and they support the organizations that do the promotion. They know how to sell an idea.
When the government looks at costs of care, it will face a storm of opposition challenging payment for interventions, even if they might cause more harm than good. The battles will continue for a long time.
Doctors and some of their professional organizations are trying to deal with these problems and the state medical association is working on outcome determined decision making.
Science is addressing the issue of better ways to know how to identify obligate malignancy, those cells that are certain to become invasive. The answer may be in the DNA.
Alternative medicine offers many ways of redefining cancer. Don’t be fooled.
Eat right and exercise. Stay slim. Reduce your risks.
Dr. Larry Mulkerin is a retired clinical professor. He can be reached at email@example.com.