July 11, 1997
As to diseases, make a habit of two things --to help, or at least to do no harm.
Hippocrates, 460?-377? B.C.
In the April 6,1997 issue of the Santa Rosa Press Democrat, the following sad letter to the editor appeared:
Like a good little soldier, I have marched off to get my mammogram every two years since the age of 38 (I am currently 44). I don't drink; I don't smoke; I eat a low-fat diet; I exercise like a fiend. I don't have any first-line relatives with a history of breast cancer. Friends describe me as "the healthiest woman I know." Last month I discovered a lump in my breast. My gynecologist sent me off to get a mammogram which showed nothing; even ultrasounds showed very little. A subsequent biopsy showed a large, malignant tumor, and the cancer had spread to my lymph nodes. I now face some pretty drastic treatment and, statistically speaking, a lower rate of survival. This is directly due to my reliance on mammograms as a reasonably accurate diagnostic tool. I encourage women to get mammograms also encourage them not to be lulled into a false sense of security by the results. By the way, I am not an anomaly, by any means. Kara Jacobs.
She doesn't say how long the interval was between feeling the lump and the biopsy.There is only one way to determine whether a lump is cancerous -a biopsy and examination by a pathologist. A mammogram just won't do it.
It is well established that x-rays, particularly the "soft" x-rays that are used in mammography, can cause breast cancer. The writer of the letter states that she had her first mammogram at age 38 and had regular mammograms at 2 year intervals until the age of 44 when she developed breast cancer. It is quite possible that she would have developed the cancer without the mammograms. It is also possible that the x-ray actually caused her breast cancer. There is no way to tell whether a cancer has been caused by x-ray or any other carcinogen, or is unrelated to anything like that.
Another unknown is why some cancers will grow slowly and others will grow very rapidly; some will stay in one place for a long time, and some will spread. Occasionally a cancer will have spread before the original tumor gets large enough to detect.
Some day our wonderful engineers may develop something like Magnetic Resonance Imagery(MRI) that will do what mammography now does, without exposing the patient to ionizing radiation. For now, because x-ray will cause cancer, the risk has to be weighed against the benefits. To date, the benefits outweigh the risks only in women over 50 years of age: post-menopausal women.
The debate still rages about women between 40 and 50. A number of years ago, a panel that was organized by the National Cancer Institute(NCI),in the face of strong opposition from the mammography evangelists, concluded that it is not a good idea for women under 50 to have routine mammograms.The true believers were outraged. I use the term "mammography evangelists" advisedly. Ever since Phil Strax was head of the American Cancer Society(ACS), the organization has been pushing mammography to the point where a woman feels that she is neglecting her health if she doesn't have one once a year. Strax is a radiologist who believed with a fervor that mammography was the answer to breast cancer. Now, even The President and The First Lady have gotten into the act.
The National Cancer Institute recently put together a new panel to decide whether to recommend mammography to women between the ages of 40 and 50. Their conclusions were that nothing has changed since they recommended that it not be done because there was little detectable benefit. They softened their recommendation to say that the decision should be left to the patient and her doctor -which really says nothing at all. Most of the commentators on TV news sounded either disappointed or outraged. The institute told the truth, and it is not the first time that people have been outraged by the truth. Now, as a result of political pressure, the NCI now recommends regular mammography for women between the ages of 40 and 50.
I wonder what kind of physician would order mammograms on young women, thereby putting them at increased risk of developing breast cancer, when the benefits are questionable?
Unfortunately, all of the efforts of the American Cancer Society and the media have been dedicated toward convincing women to get regular mammograms. It is not surprising, therefore, that many women of all ages feel that they should have regular mammograms. I have rarely heard the caution that mammograms are for older women only, and I have only heard it said once on television or radio, that x-rays can cause breast cancer. Nor do the ads for mammography mention age.
The majority of breast cancers are still not detected by doctors or mammograms, but by the women themselves who feel a lump in their breasts. Virtually all breast cancers in men are detected that way. Physicians usually don't even bother feeling men's breasts.
It is a good idea for both men and women to know their own bodies. Most diseases are first detected when someone notices that something has changed.
In a future article, I will consider the cost in money, and in the suffering caused by false positive mammograms, as well as unnecessary surgery.