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Experts fear breast screenings more harmful than helpful

Breast density law

The flip side to overdiagnosis is underdiagnosis — when women learn they have late-stage breast cancer despite mammograms that were clean, medical experts say.

Pennsylvania is one of 14 states with a breast density law, which took effect in January. The law requires mammography facilities to inform women if they have dense breast tissue and to make them aware of the potential need for additional screening.

Dr. Wendie Berg, a radiologist at Magee-Womens Hospital of UPMC, said a mammogram might not reveal a cancerous mass in a woman with dense breast tissue. As many as 10 percent of women have dense breasts, according to the American College of Radiology.

Ultrasounds can screen for irregularities in a painless and relatively inexpensive way, although such tests might require a needle biopsy.

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Sunday, March 2, 2014, 10:40 p.m.

Barbara Downing believes she is one of the lucky ones.

After undergoing surgery to remove a breast lesion three years ago, she began receiving annual mammograms.

The screenings found nothing.

Much to her surprise, Downing discovered a suspicious lump in October. She did so on her own, making her wonder whether all the mammograms were justified.

“Mammograms are a tool, but you can't rely solely on that,” said Downing, 48, a school guidance counselor from Jefferson Hills.

Not wanting to risk a recurrence of cancer, she underwent a bilateral mastectomy in December, hoping to avoid chemotherapy and radiation. “I think the answers are out there, but you really have to educate yourself.”

The decades-old recommendation that women get mammograms every two years has recently come under scrutiny in the medical community. Though the screenings can be helpful, some medical experts argue that an X-ray of the breast might detect cancers that would never show symptoms.

Studies suggest women could be overdiagnosed and treated sooner than necessary.

“We know we cure some people who don't need to be cured,” said Dr. Otis Brawley, executive vice president of the American Cancer Society. He said some women run the risk of overdiagnosis, subjecting themselves to treatment without having symptoms of cancer.

The Canadian National Breast Screening Study released data last month suggesting that annual screenings do not reduce deaths from breast cancer. The 25-year survey of more than 89,000 women found that 22 percent of screens that detected invasive cancer were considered overdiagnosed because they involved tumors that didn't cause disease.

Most doctors, Brawley said, “don't have the guts” to consider letting something that turns up as cancer go untreated. And most patients aren't comfortable playing the odds when the research to figure out which cancers can go untreated is evolving.

“We don't have clear, 100 percent evidence that the treatment is unnecessary for everybody who gets it,” Brawley said. “At this juncture, we need to support research so we can develop the tests that figure out what needs to be treated and doesn't need to be treated.”

Without knowing who early detection helps, mammograms remain the best tool available, said Pat Halpin-Murphy, founder of the PA Breast Cancer Coalition.

“I do not know of one woman who says, ‘I have a breast cancer tumor I don't want to be treated,' ” Halpin-Murphy said. “I have not come across that woman.”

A December study published in the Journal of the American Medical Association by Dr. H. Gilbert Welch, a professor of medicine at Dartmouth Institute for Health Policy & Clinical Practice, found that mammograms will save up to three lives by preventing a death from breast cancer among 1,000 American women 50 or older. The study found that about half of women will have at least one false alarm, and three to 14 women will be overdiagnosed and treated needlessly.

Welch, who specializes in researching overdiagnosis, said all early detection strategies involve trade-offs.

“Whenever we look for early forms of cancer, we end up finding some that never go anywhere,” Welch said. “So we treat everyone.”

Breast cancer is a spectrum of conditions with varying degrees of aggression, said Dr. Wendie Berg, a radiologist at Magee-Womens Hospital of UPMC.

“For better or worse, breast cancer is far from a single entity,” she said. Cancer discovered as a lump, an irregular mass on ultrasound, or a group of calcifications seen on mammography could carry different levels of aggression, she said.

The controversy about overdiagnosis comes down to discussion about treatment, Berg said. Doctors can trace tumor markers to gauge whether a cancer might be aggressive and require high-level treatment, such as chemotherapy, Berg said, but such tests are still developing.

“Right now, we still have challenges in identifying — reliably — which lesions do not require aggressive treatment,” she said.

Dr. Adam Brufsky, co-director of the Women's Cancer Center at Magee, said advanced genomics and cell testing can help determine what kind of cancer someone has to better align treatments.

One such test, Oncotype DX, examines tumor tissue at the molecular level. Doctors can glean information on the likelihood of cancer reoccurrence or the effectiveness of chemotherapy.

Brufsky said treatment advances improved the chances of surviving breast cancer, including late-stage diagnoses.

Survival depends on when the illness is diagnosed. If it is found before it has spread to the lymph nodes, the survival rate is nearly 100 percent. The five-year survival rate for all women is 85 to 90 percent.

“The vast majority of women diagnosed with breast cancer are going to survive,” Brufsky said. “Now what we're doing is figuring out what you need to survive.”

Melissa Daniels is a Trib Total Media staff writer. Reach her at 412-380-8511 or




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