Educate for the Cure

I agree with Peggy Orenstein (NYT 4/25: Our Feel-Good War on Breast Cancer) that the pinking of America is largely a superficial marketing ploy. Instead of racing for the cure and wearing pink bracelets, women must become more educated about their individual risk profile and how they can best utilize the tools available for breast cancer diagnosis. I have seen tragic cases of late stage diagnosis which might have been found earlier, at a curable stage, had the women understood their risk profile and the all the screening options available to them.

Breast Imaging modalities, including mammography, Ultrasound, Molecular imaging and MRI, work differently and used in combination at different intervals depending on the patient’s individual risk profile, give us the most accurate method of finding breast cancer.

Results of The American College of Radiology Imaging Network (ACRIN) 6666 trial, presented at the Radiological Society of North America’s 2009 Scientific Assembly and Annual meeting, showed that annual screening done every year for 3 years with mammography and physician-performed ultrasound found 29% more cancers, and 34% more invasive cancers, than mammography alone. ACCRIN 6666 also screened a subset of 612 patients with MRI in year 3 of the study and found that MRI increased the detection of breast cancer another 56% in that subgroup of patients, and increased the detection of invasive cancers by 67%.

Orenstein questions the value of early detection but carefully conducted studies demonstrate that early detection of invasive breast cancer reduces mortality (death) and morbidity (complications of disease requiring more treatment).

A study by the Swedish Organised Service Screening Evaluation Group, found a 40% to 45% reduction in incidence-based breast cancer mortality among mammography screened women (Cancer, June 1, 2007).

A review by Dr. Judith Malgram of 2,000 women diagnosed with breast cancer in their 40s, found that women with mammogram-detected breast cancer required less treatment. Furthermore, as the rate of early stage mammogram-detected cancers went up, the incidence of later-stage cancers went down (Radiology, March 2012).

Orenstein wants women to express outrage about diagnosis and treatment that may not have been necessary. What about necessary treatment that was not given? Here’s an example of how outrage can fuel positive action. Until recently, mammogram providers have been required to inform physicians when their patients have dense breast tissue but no one was required to tell the patients. Women whose cancers were missed on a mammogram but may have been found with Ultrasound expressed their outrage by advocating for legislation that requires radiologists to inform both patient and physician when they find dense tissue. Several states now have those laws on the books. One is winding its way through the New Jersey Assembly. Women throughout the country are benefitting from that outrage by becoming better educated about the cancer risk of breast density, enabling them to take action which may save their lives.

We can feel outrage that every tumor found is removed even though it may not hurt us. But outrage doesn't help here. We don't yet have the ability to know which tumors are potential killers until they are taken out and analyzed.

Screening tools for breast cancer aren't perfect and neither are the treatments available. But we have come a long way in developing individualized plans that more closely match individual requirements. There is a place for outrage about many issues. Promoting early detection of breast cancer isn't one of them.

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