Monthly Archives: December 2011

And the mammogram nonsense goes on …

Given my previous curmudgeonly rants about the general uselessness of mammograms I was pleased, nay, delighted when when the Canadian Task Force on Preventive Health Care issued new guidelines – ever-so-gently suggesting that perhaps this pop culture myth that ‘mammograms save lives”, especially that of younger women, is a crock. Naturally they phrased it in dry, epidemiologic language, but you’d thought the poor geezers had suggested women shouldn’t be allowed to vote.

The response, anecdotal, I’ll grant you but shrill, emotive and generally overwhelming was: Well! How dare you condemn women to death you dreadful guideline-writing scum you. Letters poured into newspapers and editorials pilloried the Task Force – the inevitable line was “having a mammogram saved my life”.

Politically incorrect and uwomanly of me it may be, but my first thought was, ‘Really?! How do you know? Given that a teensy mass that couldn’t even fill the head of a pin is now called a cancer and the person who’s had it a survivor?’

Perhaps less vocal people felt relieved that the Task Force had articulated what they had thought all along, that it may not be such a splendid thing to squish your breasts between two metal plates once a year even as you ended up dosed with radiation but I don’t know.

As far as I’m concerned the Task Force didn’t go far enough. They clearly stated that women who had the BRCA1 and 2 genes or had a family history continue to have regular mammograms, even as early as 40 and added that older women, those over 70, should also be screened. They politely did not say, trust us, if you have cancer you’ll know it. Ideally, a mammogram will find a fast-growing cancer early. By and large, it won’t. What it will find is what all those cancers that don’t want to be found, the bits and pieces of slightly abnormal tissue we all have – and which will be found if we go looking for trouble. Which is essentially what screening is.

Alas, screening is all too often confused with ‘cure’. Or ‘treatment’. Which screening simply cannot be. Screening is a way to make obvious something that was there that we didn’t know about, theoretically to ‘catch’ something dangerous early. As if.

But, hey, we’ve got the runs for the cure and all those pretty celebrities (and nonentities) going on the telly to lecture us on how we should all be focused on preventive care and take our radiation. Or have someone thrust a sharp object up our colon. Yes, sharp. The kind of thing that can slip and perforate the bowel and have you in the ICU faster than you can say colonoscopy.

But I wax incoherent.

So, once again, a brief lesson in how cancerous cells evolve. Cells divide over the course of their and our lives; with each division the odds of a ‘mistake’ increases. Which is why cancer is generally a disease of old age. The more those cells divide the greater the odds that something will go askew and result in what, if found, we will call cancer or pre-cancer or some damn fool thing. (Of course as we get older our cells divide more slowly which is why most older people die with cancer not of it.)

Then we attack what we’ve found with all the tools of the early 20th century: radiation, surgery and harsh drugs. True, a handful of cancers are actually treatable with some new meds, usually fairly rare cancers, and a few drugs can increase life span. We are better at targeting and focusing and not killing quite so many non-cancerous cells. But the reality remains that we’re still focused on zapping and poisoning and cutting out cancers, just as they were in close to a hundred years ago and, barring the smoking/lung cancer connection, no closer to understanding why some people get cancer and others don’t.

That’s the question we should be asking and flinging money at, not mammograms.

Of course why the guidelines come as a shock to anybody I do not know, since we’ve known, definitively, since the 90’s that mammography is a crude screening tool at best. Plus, for women under 50 the risk benefit ratio is beyond ridiculous. (What we really mean by that, of course, is women who have not yet gone through menopause not women under 50 but we do love our decimal groupings – maybe it’s that counting-on-ten-fingers thing, so much easier). In other words, the number of false positives, biopsies to confirm one does not have cancer and actual false diagnoses are phenomenally high. (That last one, by the bye, simply refers to the women who end up being told they have cancer when they do not and end up in that most dismal of all “treatment” regimens for no reason at all.)

We have also known for a long time that not all cancers want to be found; that in fact over-diagnosing and over-treatment are rife when public policy institutionalizes screening, whether it’s PSA testing or colonscopies or mammograms.

But the emotional anecdotes continue to mount as individuals tearfully ask why the rest of us (and that nasty Task Force) would condemn them to death. Ah, easy there sport. Nobody’s condemning you to anything. Yes, women do get breast cancer. We have all had a friend or relative die of the disease. (Yes, including me. I sat with her as she died.) But simply because something happens does not mean it’s an epidemic or a scourge.

Finally, health policy is not clinical practice. Policy, guidelines, are simply a way for institutions to recommend what appears to be best practice. This does not mean that individual women cannot have mammograms or that individual doctors cannot counsel individual patients to have them. It simply means that a blanket policy recommending all women over a certain age undergo a procedure that is neither benign nor risk free is not a good idea.

Furthermore, something the Task Force did not mention, probably because they did not know it, is that women prior to menopause go through a phrase of life called perimenopause. Perhaps you’ve heard of it. It’s the years leading up to the cessation of the menstrual cycle when some women have hot flushes and mood swings and can get depressed and irritable. Estrogen levels fluctuate during this time and estrogen, boys and girls, is a hormone that causes cells to proliferate. It does that in the uterus during the menstrual cycle and also in the breast. So, the risk of a false positive raises commensurately for perimenopausal women because higher estrogen = lumpy breasts. More often than not these will resolve, go away, with time as an elegant Scandinavian study demonstrated some years ago.

So tell me again why women in their 40’s would want to subject themselves to this? Oh yes, because they believe in the medical model and the linear nature of physiology. Worst, we have all been subjected to such a barrage of pink ribbons and nonsense about prevention that women honestly believe the dratted technology actually works.

For my part, a certain weariness sets in as I watched this play out, not to mention the inevitable expert huffily saying, look, it’s science and you can’t argue with that. Actually I can. But this is one time the best-guess statistics, hypothesis testing, and empirical data all back up the physiology and common sense.

But I guess a lot of women have decided that the Forces of Evil want to take their mammograms away. How does one explain the Forces of Evil have a lot more on their mind these days than women’s breasts?