December 8, 1995
The cost of saving a single life, using mammography, is
well over a million dollars for the mammography alone.
The last column that I wrote about breast cancer advised women over 50 to have an annual mammogram in addition to monthly breast self examination. In doing so, I was following the advice of the "authorities" on the subject, the National Cancer Institute and the American Cancer Society. Now I am beginning to have some doubts about how good that advice was. Do I now dare question such formidable people as these, as well as Hillary Clinton?
First, everything that we know to date points to the fact that the chance of a cure, if you get breast cancer, is related to the size of the tumor when it is removed; the smaller the tumor the better the odds. In a large test, women over 50 who had annual mammograms along with an annual physical, did not die as readily of breast cancer as did those who had the usual annual physical. The validity of those data remain. So why the doubts?
The doubts relate to a number of events that I have observed. For one thing, I went to a surgeon who, after examining a lump in my breast, asked me if I wanted a mammogram. Why in heavens name would I want a mammogram? And how would you get my small breast into the machine? I got out of there in a hurry and found a surgeon with some common sense. I talked to a woman with small breasts, who complained of the pain of the mammogram. Besides, a woman with small breasts should be able to detect a tiny tumor much more easily than a woman with large breasts. Does she really need a mammogram? Is there any point at all to a mammogram when someone has already detected a tumor? If the tumor is going to be removed anyway, I doubt it. Should the tumor be cancer, it might be a good idea to do mammograms on the other breast.
I heard about a woman who got a number of mammograms at different facilities because she figured that the chance of detecting cancer was better. She was unaware that the chance of causing breast cancer with the X-ray was also increased. Besides, if she located the best mammography lab, there is no point in being checked by worse facilities. She was not only wasting time and money, but she was increasing her risk of getting breast cancer.
I once heard a radiologist remark that it made little difference if the X-rays caused a few cancers provided that they were detected and removed. He might change his mind if he ever had a modified radical mastectomy himself, or even that breast-sparing lumpectomy and radiation.
I don't know too many women, but out of those I know, three of them have had positive findings on mammography that turned out to be nothing. The worry and trouble is of considerable consequence. True, it is better than dying of cancer, but that suffering should also be part of the equation.
Does a woman need a mammogram every year? Why one year? Why not every 6 months? Why not every two years, or three? No one knows because that hasn't been tested. Some physicians have even questioned the wisdom of an annual physical. They say that if a person is in good health, an exam every year might well be a waste of time and money.
I think that bromides like "always do this," or "never do that," are not such a good idea unless they are tempered by some common sense. The conventional wisdom, if it is not to cause more pain and suffering than it prevents, has to be tempered with a good deal of judgment on the part of a woman and her physician. Breast cancer is not like acute appendicitis. There is no need to treat it as an emergency. More suffering might be caused by haste than by moving with deliberation.
The only problem is that common sense is an uncommon commodity.