Mammogram Controversy Continues
Tuesday, February 1, 2011
We'll discuss the case for mammography screenings for women beginning at 40 and find out the latest on breast cancer treatment.
The shock waves from a 2009 recommendation on the usefulness of mammograms for younger women is still resounding in the medical community. That federally-funded task force says mammograms should be optional for women under 50. The recommendation was based on data that suggests that mammograms are not that reliable at picking up cancers in younger women.
The controversy resulting from the study illustrates that breast cancer remains not only a deadly disease that claims too many women's lives but also a deeply emotional issue for women.
Dr. Laszlo Tabar is known by many as "the father of mammography. " He's here from his practice in Sweden to speak at UCSD Moores Cancer Center.
Dr. Anne Wallace is Professor of Clinical Surgery and Director of the UCSD Breast Care Unit.
CAVANAUGH: The shock waves from a 2009 recommendation on the usefulness of mammograms for younger women is still resounding in the medical community. That federally funded task force says mammograms should be optional for women under 50. The recommendation was based on data that suggests that mammograms are not that reliable in picking up cancers in younger women. The controversy resulting from the study illustrates that breast cancer remains not only a deadly disease that claims too many women's lives, but also a deeply emotional issue for women. Joining me to talk about breast cancer treatment are my guests -- Dr. Laszlo Tabar. He is known by many as the father of mammography. He's here's from his practice in Sweden to speak this week at UC San Diego Morris Cancer Center. Dr. Tabar, welcome.
TABAR: Thank you very much.
CAVANAUGH: -- And Dr. Anne Wallace is Professor of Clinical Surgery and Director at the UC San Diego Breast Care unit. Dr. Wallace, good morning.
WALLACE: Good morning.
CAVANAUGH: Now, we are inviting our listeners to join this conversation. Are you confused about when to start having regular mammograms? Are you concerned about the relatively low rate of breast cancer prevention? Give us a call with your questions and your comments, our number here is 1-888-895-5727. That's 1-888-895-KPBS. Dr Tabar, we're told that many of the technicians over at the Morris Cancer Institute do call you the father of mammography. How did you get that appellation?
TABAR: Well, probably because of the very hard work I was doing the in the past 42 years in the field. But it's certainly a great honor to hear this.
CAVANAUGH: I'm wondering, since you are well known in this field for, as you say, 40 years, when should women begin to get mammograms as part of their annual exam.
TABAR: In those age groups where we have scientific evidence, and those age groups are 40 to 74.
CAVANAUGH: I see. So why don't the screenings actually begin before 40? I mean, women who do contract breast cancer before the age of 40, right?
TABAR: For three reasons. One, we don't have the scientific evidence -- we have never screened women under 40. Second, the reliability, sensitivity, of today's methods are decreasing rapidly, with decreasing age.
CAVANAUGH: Uh-huh. Why is that?
TABAR: Because of the kind of arch enemy of imaging, namely dense breast tissue.
CAVANAUGH: I see.
TABAR: And the third one is that the incidence drops dramatically under 40. However, unfortunately, if you look at the past 20 or 30 years, it's rapidly increasing, the incidence. This disease just doesn't want to go away, and it creeps down in age, any clinician like Dr. Ellis and myself, and many of those working in the diagnostic and therapeutic field are shocked about the many young women with very often fatal cancers. But that does not justify straight up, straight down screening of 20 or 30-year old women. And again, I really stick to the strict evidence-based medicine. We need scientific evidence.
CAVANAUGH: What about breast self examination? There have been some issues surrounding the usefulness of self examination as well. What do you think about that, Dr. Tabar?
TABAR: There are two parts of this question. Every woman should perform breast self examination at regular intervals in their fertile age, the week after the menstruation because, especially in dense breasts, they are and they can be very skillful in finding something we might not see on imaging. The other part of the question is -- and unfortunately people mix these two -- breast self exemption as a sole screening tool: now, that doesn't seem to work. There are two scientific studies that fail to prove that only self examination moves the time of diagnosis forward sufficiently. So I would really ask everybody to split these two. If somebody recommends women not to perform breast self examination, that person makes a professional mistake.
CAVANAUGH: I'm speaking with Dr. Laszlo Tabar, he is known by many as the father of mammography. He's known as an international expert, here from Sweden to speak this week at UC San Diego Morris Cancer Center. I’d like to bring Dr. Anne Wallace now into our conversation, she’s Professor of Clinical Surgery and Director of UC San Diego Breast Care Unit. And I'd like to also offer once again, you can join the conversation at 1-888-895-5727. I want to go back to what I was talking about in the very opening of our discussion, and that is this 2009 recommendation that sort of sent a shock wave through the community of when women should start to have regular mammograms, and I wonder if you could comment on what kind of confusion you think that's caused.
WALLACE: Well, basically, the recommendations that were made were based on large meta-analysis that looked at what the survival benefit was in screening women every year for ten years, between the ages of 40 and 50. And the task force did recognize that lives were saved. But what they thought was that it was such a small number of lives saved that the amount of call backs, and the amount of anxiety, and the amount of biopsy, and really there was no mention made on the amount of cost, but that’s one of the things people were afraid of. That maybe over all that risk didn't outweigh the benefit of one life per 1900 screened over ten years. So because of that, they said that our recommendations are that it can become the standard of care that you can start screening over 50, and start every other year, instead of between 40 and 50. So they never actually said that lives weren't saved. They just said that there were so many other risks that were created by those lives being saved. Now, the American Cancer Society, the American College of Surgeons, the Radiologic Society never embraced these recommendations because we did recognize that there were flaws in the recommendations that were made. So the recommendations still hold, for all the cancer groups, that women should get screened between 40 and 50, and they should continue it every year.
CAVANAUGH: But what about that rate of false positives? What about women who have had biopsies on tumors that are not cancerous, or perhaps as recent study might have indicated, might have gone away on their own? Is that actually a risk to women?
WALLACE: It is a risk that women will get unnecessary biopsies. We have what's called BIRADS categories, and that's how mammograms are read, and category 4 and 5 are the ones where biopsy is recommended. Category 4 generally only has about a 20 to 25% risk that is going to be cancer. So that means out of of a hundred women who are recommended for biopsy, only 20 to 25 will be cancer. And some of those cancers are going to be extremely low grade, that maybe we didn't need to know about it at all, believe it or not, or maybe we didn't need to know for many years. But certainly it means that 75 out of a hundred women will get a biopsy, that they didn't necessarily need. And that's the controversy. And I think that this is where we shouldn't be ordering any test without explaining to our patients what the risks and benefits are. And let the patient decide: if I have a one in 1900 chance of my life being saved because I do this, but I might get a biopsy and that biopsy might lead to an infection, it might lead to some scar tissue, it might cost me money, do I make that choice and. So I think it's our job to explain the numbers to the patients.
CAVANAUGH: We are talking about breast cancer treatment on These Days, the number is 1-888-895-5727. Courtney is calling us from Oceanside. Good morning, Courtney, welcome to These Days.
NEW SPEAKER: Hi, thank you for having me on. My question is, I know we are spending a lot of money on waiting until cancer makes an appearance, and then therefore trying to treat it after the fact. I've met a lot of groups and organizations that have been working on not only prevention through, let's say, the Cancer Project, is working on prevention through nutrition. Letting you know that there's a strong link between the ingestion of meat and getting cancer. And also the I Love Food Project, which has been going through the fact that in women's beauty supplies is a great factor, sodium lauryl sulphate, methylparabens have also been linked to cancer. My questions for the doctors are: did you think we should be putting our money more towards prevention and getting the word out, that we need to stop this where it is, instead of just waiting until cancer manifests, and then trying to do all these interventions that could lead to decreased health and taking off the breasts and people dying from chemo and thing like that.
CAVANAUGH: Thank you, Courtney. And Dr.Tabar wants to respond.
TABAR: Well, that was a very interesting, a very important question. Because this is really in women's minds. But please split the word prevention. There is primary prevention, which we just heard about. Unfortunately I have to disappoint women. Breast cancer is not one disease. There are 20 or 25 different diseases we call breast cancer. So I really do not believe we will ever be able to prevent breast cancer. Secondary prevention is what we are very good at. We let the cancer grow to a certain size, ideally smaller than ten millimeters, and then we strike. And that's called screening. You know, cervix cancer screening is going to succeed in two levels. We know that 80 percent of the cervix cancers are caused by Human Papilloma Virus. Today’s young girls are vaccinated --that's the answer to her question, but unfortunately, that doesn't work in breast cancer. Because cervix cancer is more or less one disease in 80% of the cases, so primary prevention is going to work. And also in cervix cancer, the secondary prevention screening works. But in breast cancer you cannot tell women what they should eat, what they should drink, should not eat, and should not drink. We have to resort to the secondary prevention, it's called cancer. So I would very much like to encourage women to go to a very good high quality breast center yearly for their yearly mammogram, when they are 40 and above.
CAVANAUGH: Let me bring -- you brought up that idea of the Pap smear resulting in a reduction of deaths from cervical cancer. There's a 90 percent reduction of deaths from cervical cancer reported from pap smears, there’s a 60 percent reduction of deaths reported from colon screening, but most experts agree, that's just a 30 percent reduction in deaths that comes from mammograms. First of all, do you agree with that statistic, and number two, doesn't that mean that we need a better screening?
TABAR: Be careful with the statistics. When we run randomized trials, we never test screening. We test invitation to screening. Very few people understand. That is that randomized control trials do not talk to the individual women. They give the inclination result to the politicians. If I put in so much money to screen a given population, of which 30 percent might not come, but their results and mortality result is mixed together with this screening. So now we have other publications when the results speak to the individual women. What if I am going to come at a regular interval? Tell me what the benefit for me is meant to be. And now we are up at 45-50 percent. So be careful with the statistics. You know? That's where, for example, the task force made a humongous mistake. They looked at the meta-analysis, which did not pool the screening results. But the intention to treat, as the professional expression that is invited to screening, a certain percentage doesn't come. In the United States, 30-40 percent don’t come. So the results originating from screening, plus originating from those who have been invited but didn't show up, are put together, because that's what science is all about.
CAVANAUGH: I understand. Dr. Wallace, you wanted to comment.
WALLACE: Yeah, one of the things that I did like about what came out with the task force is the recognition that in cancer, it is not always about how early and how small you get something. So the data with mammography, is what it is, because often mammogram does pick up that slightly slower growing breast cancer, that estrogen-receptor positive breast cancer that kills a lot less frequently and a lot slower. The what we call triple negative breast cancer ,which is the one that we're just behind the eight ball on in breast cancer, that can kill at half a millimeter. So much there's really almost no screening technique that's gonna pick that up before it can be deadly. So a lot of it is understanding the biology and understanding how we can biologically attack these things, as opposed to trying to find an even better screener for those, because they're bad from the get-go.
CAVANAUGH: We have to take short break. When we return, we will continue to talk about breast cancer treatment and also talk about Dr. Laszlo Tabar's long view of breast cancer, and what he sees as an overview of the progression of this disease. We're taking your calls at 1-888-895-5727. You're listening to These Days on KPBS.
CAVANAUGH: I'm Maureen Cavanaugh, you're listening to These Days on KPBS. We're talking about breast cancer treatment and mammography. My guests are Dr. Laszlo Tabar, he is here from his practice in Sweden to speak at the UC San Diego Morris Cancer Center. And Dr. Anne Wallace is Professor of Clinical Surgery and Director of the UC San Diego Breast Care unit. We're taking your calls at 1-888-895-5727. In fact, let's start with a call, there are a lot of people who want to join us. Pat is calling from the college area. Good morning, Pat, welcome to These Days.
NEW SPEAKER: Good morning, I have two questions. One is a follow-on from one previous caller about prevention. And I did hear the doctor say that we can't force women to eat or not eat things. People to eat or not to eat. But I do think that if we could show research links between a certain chemicals and the increase in cancer, that would help and we could regulate those chemicals. I'm particularly interested in the increased use of hormones in animal and dairy foods over the years and looking to see if there's a correlation between that and the increase in cancers in general. Especially breast cancer. My second question is -- I happen to have only two sisters, they both had breast cancer, and in both cases, they were having mammograms once a year, and in both cases, the tumor was visible on the mammogram the year before they actually identified the larger tumor. In one case, the sister needed to have chemo, the other one didn’t. They're both okay. But the chemo has dramatically affected the health of the sister who had to have that. So I went to my HMO, and I said should I have mammograms twice a year, should I have MRIs? I obviously have a high risk. So my question would be, in the case where you know you have a high cancer risk, should you have MRIs, and how often should you have mammograms?
CAVANAUGH: Thank you for that question. Dr. Tabar, would you like to take that?
TABAR: These are very good questions, both of them. You know, we are talking again about the primary prevention of breast cancer. The person who called in has a point. There are certain subtypes of breast cancers that have something to do with hormones, and certain subtypes of breast cancers might be caused by chemicals like pesticides and so on. But what about the remaining 20? That's the problem. Certainly we are doing the research on every field, but we don't want today's women to die from breast cancer. That's why we say go for screening. While we are doing research on every bit, subtype. The second comment, well, you know, I already mentioned that if you are a woman, you should really check out what kind of place you go to. American College of Radiology approved, and a place where - double reading is systematic in Europe, not exactly in the United States. And you are right on here, partly to give lectures at the breast center, but mostly on giving it for the course, a teaching course for radiologists coming from seven different countries, teaching, training, further education is what we are dealing with. When it's concerning plastic surgery or radiation, or mammography or MRI. And specifically answering your question, if somebody really runs a very high risk of developing a breast cancer, then one method is not enough to examine that woman. We call it a multi-modality approach. That is, if she happens to be young, very dense breasts on the mammogram, then very thorough ultrasound examination is a must, and yearly MRI examination.
CAVANAUGH: And would you agree, Dr. Wallace?
WALLACE: Well, the first thing that I would do with two sisters with breast cancer, and I assume that they were fairly young because you sound fairly young, is have them see the genetic counselor to see if they carry the gene for breast cancer. Because if they do, then you would want to be tested and you may not carry the gene. So then your risk actually is not as elevated as you think, it goes back down to a normal woman. So I would encourage your sisters to go in and speak to a genetic counselor. If there is a gene for breast cancer or one is not identified in your two sisters, then, yes, you have elevated risk, you can actually plug your risk into statistical models and you come over twenty percent because of the two first degree relatives. And in that situation right now, MRI yearly is -- it's not a hard and fast recommendation, because MRI is still fairly new, and it's also controversial how each center does it -- but it's at least recommended and should be something that you talk about. MRI also has a very high false positive rate, and can result in a lot of unnecessary biopsies too. But it sounds like, in this particular case, it wasn't so much that mammogram missed your sisters' cancer, but that it was there, and maybe someone didn't quite see it as early as they could have.
CAVANAUGH: Let's take another call. Joyce is calling from Point Loma. Good morning, Joyce, and welcome to These Days.
NEW SPEAKER: Yes, good morning, I'm gonna try to get through this without getting too emotional, because I had breast cancer last year. And if I hadn't had the mammogram, which I almost skipped, because I was a very healthy 52 year-old, and found out a young cousin, 39, was diagnosed with cancer, I decided to go get my mammogram. And luckily my doctors really looked at the mammogram closely, and called me back and did more testing and then did sonogram, and then the biopsy, and I was diagnosed with breast cancer. And no doctor could ever feel my lump.
CAVANAUGH: Right. It had to be the mammography that caught it.
NEW SPEAKER: The mammography caught it. And then they did the MRI, and they thought I was really early stage, but when they did the surgery, thank goodness they do the sentinel biopsy because it had already gone into one lymph node. I've had mammography every year since I was 40.
CAVANAUGH: And how are you now?
NEW SPEAKER: I finished my radiation November 19th, and I'm cancer free.
CAVANAUGH: Well, thank you for calling. And I'm very glad to hear the outcome of that. And Dr. Tabar, you must hear from many women with similar stories.
TABAR: I really would like to comfort her. She shouldn't be depressed, her cancer -- her doctors stole time from the cancer, let's say that way. And that time might have been life saving. So I think she should really try to live a normal life.
CAVANAUGH: You know, Dr. Wallace, breast cancer is -- remains one of the most common types of cancer that women get. And the second most deadly form of cancer for women in the United States. What strides have we made in recent years, for early detection, even understanding the cause of cancer?
WALLACE: Oh, we've made a lot of strides. And actually the incidence is kind of stabilized and the mortality has actually gone down and we’ve made tremendous strides in what we call the estrogen-receptor positive tumors. Those are tumors that have good targets, and probably one of the biggest strides that we made in the last decade is the first biologic, that we learned can actually really save lives and that's Herceptin. So that started us on --
CAVANAUGH: What -- stop – what’s a biologic?
WALLACE: Chemotherapy kind of slashes and burns the cancer, while it actually kills a lot of other cells, and makes people very sick, et cetera. Biologics actually go against targets on the cancer cell itself. One of the first ones in breast cancer is called Herceptin, which is almost like an antibiotic, like a monoclonal antibody that targets directly against that receptor on cancer cells and dramatically changed the face of what about 30 percent of women have, which is called HER2/neu positive breast cancer. Those women used to die of their disease, now most of them don’t. Most of them completely live. And and that was all out of clinical trials that we learned that. So that has led in the last decade to many other biologic agents that specifically go after - like Dr. Tabar said - 30 different kinds of breast cancer, at least, that we have, that all have different targets. If we can find specific targets for each patient, then we can customize care, which is what we didn't do 20 years ago, and now we are starting to do. So we actually are starting to win the battle a little bit. I completely agree this we still see way too many women with this disease, and way, way too many die of the disease, but we are starting to understand it a little bit better.
CAVANAUGH: Now, you made the comment, Dr. Tabar, earlier, that you're seeing maybe younger women with more frequency getting breast cancer, and you made the comment that this disease just simply doesn't want to go away. What do you mean by that?
TABAR: Right, the incidence is increasing, all over the world. But as Dr. Wallace very correctly mentions, mortality goes down. And that's the result of a joint effort of earlier detection, better treatment, more custom tailored treatment, and that's where we really have to work together, the diagnostic and the therapeutic teams. The best and most ideal situation is when there is only one focus. Can you imagine a field of green grass, and one tulip, and the surgeon goes in and takes the tulip, and looks back and there is nothing left? In these cases, I might be visionary, but I would question the value of any kind of adjunctive treatment, radiation, Tamoxifen, whatnot. Unfortunately, however, in 40 percent of the cases, there are many tulips out there opened and not opened, we call it in-situ and invasive, so in 40 percent of the cases, the extent of the disease is larger than 4 or 5 centimeters, and here is a tiny focus, and there is a tiny focus, and they end up so the tumor burden is going to be big. So these are the definite, let's say research target subgroups, where we have to put everything together. Research, pharmaceutical industry, a better preoperative determination of the true extent of the disease. So Dr. Wallace doesn't need to go back and cut again, and back and cut again. That's where MRI has a fantastic role in the preoperative staging, so to speak. There is a lot of hope, and if you have just one moment…
TABAR: I would like that say that the very first breast cancer was described, call it published, exactly 5000 years ago.
CAVANAUGH: 5000 years!
TABAR: I have a beautiful slide of a five meter long papyrus and the first breast cancer was described then. But you know, absolutely nothing happened for 4970 years. So women should be extremely happy for what we have been doing in the last 30-35 years, both in concerning diagnosis as well as treatment.
CAVANAUGH: And when it comes to treatment, and this is something very deeply personal for women going through breast cancer treatment, Dr. Wallace, it's interesting to note that not only are you Professor of Surgery and Director of the UC San Diego Breast Care unit, you’re also Chief of Plastic Surgery. So when you treatment a woman's breast cancer, you also, at the same time, also reconstruct her breast?
CAVANAUGH: I do. So for me, I was very fortunate to have this position developed for me over the last 15 years, and the conversation goes circular, one minute we're talking about the cancer, and the next minute we’re talking about how we’re going to put it back together. In the future, it's my job to hopefully cure the patient, but also recognize that she needs to be a “girl” again, and she needs to feel good about herself. So even though she'll say to me, I don't care about that at all right now, I know that it's gonna be important for her. So we kind of go all around with the discussion.
CAVANAUGH: Let's take another call. David is calling from San Diego. Good morning, David, and welcome to These Days.
NEW SPEAKER: Hello.
NEW SPEAKER: I was wondering how effective ultrasound is, and at what point it becomes effective. Is it diagnosis, is it screening, is it after a mammogram, before a mammogram or MRI? And I can take the answer off the air.
TABAR: That's a very good question. You understand that after all this, that breast cancer is a heterogeneous disease, and there are so many benign cancer-mimicking breast diseases. So just don't say that we are doing unnecessary biopsies, because there are a lot of benign breast diseases. You put a needle in, and they never see Dr. Wallace. Now, if there are as many different diseases, benign and malignant, as we know, then one method, one tool will never be able to image them perfectly. That's why we worked out, we developed with the help of industry, another method. For example, the mentioned ultrasound, and the MRI, and the other different interventional methods. And isotopes, and so on. However I think he also pointed out very, very clearly that -- or correctly -- that unfortunately in screening, we only have one method. And it should be changed. That is, we use the multi-modality approach to assess the lesion, to make the diagnosis, and we became so good at it, but in screening, we have to add ultrasound to mammography, in order to compensate for the less sensitivity in the dense portion of the breast. And that must not be today's ultrasound as we know it. But it has to be an ultimated ultrasound, out in screening, in mobile units, whatnot, and industry is working on it. And we are putting this new tool to a tremendous scrutiny, just like we did through the years with mammography. So if I can answer David this question, in the near future, we hope that we are going to use multi-modality approach, both in screening as well as in diagnosis.
CAVANAUGH: And do you see that, Dr. Wallace, as becoming part and parcel of standard screening in the United States? In perhaps the foreseeable future?
WALLACE: I think, you know, this is something that actually has been addressed for quite a number of years in the United States, and I believe that parts of of Europe actually do this better. Ultrasound is very good at picking up solid masses, the problem is, in this country, so far the standard of care – anything solid seen gets a biopsy, whereas places like Germany, and, I believe, Sweden are actually a little bit better at kind of trying to figure out what solid is suspicious and what's not. And so what's been the fear in this country is it would raise biopsy rates if we screen with ultrasound. But I rely on my practice on ultrasound so much for all kinds of things that we see in field.
CAVANAUGH: Now, I have to tell you both that we are out of time. And I want thank all the people who called in. If you still would like to comment, please go on line, KPBS.org/These Days. And I think probably the comment we should end on is yours, Dr. Tabar, that women have a lot to be hopeful for in terms of breast cancer research.
TABAR: Absolutely. This is the first generation of women and physicians that can hope that we are going to have a significantly better control over the breast cancer than any other generation of physicians or women in the past 5000 years.
CAVANAUGH: Taking the long view, things sound very good. Thank you, Dr. Laszlo Tabar, thank you so much. And Dr. Anne Wallace, thank you for speaking with us today.
WALLACE: Thank you.
TABAR: Thank you.
CAVANAUGH: Now, coming up, we'll talk to the author of this year's One Book, One San Diego selection. That's as These Days continues here on KPBS.
To view PDF documents, Download Acrobat Reader.