No refunds or returns for advanced disease
Without a shift to a personalised breast cancer screening programme, participation rates in mammography screening may further decline.
As i said goodbye to another Christmas season and headed to the mall and my local post office to exchange a gift with one that fits or is more apropos to my personal needs, I was reminded of my more than a decade-old desire to exchange the term ‘mammography’ screening with‘breast cancer’ screening—after all we do not screen for mammography but screen for breast cancer. I want a breast cancer screening programme that is personalised, based on the unique risks and personal preferences of women who choose to participate in
screening. Without a shift to a personalised breast cancer screening programme, Participation rates in mammography screening may further decline.
In the last decade, there is increasing news about the overdiagnosis of mammography screening and its harms compared to its benefits. This month another headline greeted women across the globe about the overdiagnosis and ineffectiveness of mammography screening from a study published in the BMJ (Autier et al. 2017). the study, which analysed the mammography screening programme in the Netherlands from 1989 to 2012 concluded that the Dutch programme had little impact on the burden of reducing advanced disease, suggesting a marginal effect on mortality. Additionally, the authors concluded that half of screening detected cancers represent overdiagnosis.
Radiologists and supporters of mammography screening are yet again tasked with counteracting the growing trend of studies in peer-reviewed journals touting the harms of mammography. often criticising the faulty analysis of the most recent study and fiercely questioning the elaborate claims of overdiagnosis, the cheerleaders of mammography screening defend the importance of its role in finding early cancers and at the same time acknowledging an insignificant rate of overdiagnosis.
Overdiagnosis is defined as the detection of tumours at screening that might never have progressed to become symptomatic or life-threatening in the absence of screening. the challenge that currently exists is that we cannot discriminate between which cancers are progressive and potentially deadly.
Since my advanced stage breast cancer diagnosis in 2004, after never missing my mammography screening, I have studied the research of mammography screening and its impact on mortality. given my significant diagnosis and that my faithful mammography screening did not benefit me but caused me harm and still may cost me my life, I should be the least enamoured advocate of mammography screening. However, the impact of early detection by screening mammography, although not perfect, is beneficial to many women with its impact to reduce mortality from breast cancer. Coincidentally, a 2015 study from the Netherlands found that even in light of new treatments, the size of the cancer and how far it spread remains vital to surviving the disease (Saadatmand et al. 2015).
I am personally aware that mammography is not an equal opportunity technology for access to an early diagnosis for many women with dense breast tissue. When a woman’s cancer is not detected at an early stage, even after faithfully participating in mammography screening, there are no refunds or returns. the benefits of early detection by mammography have failed these women. They are left with the harms of a later stage diagnosis, aggressive treatment options, quality of life issues and a greater likelihood of dying from breast cancer. In our state advocacy efforts, we still encounter physician-trade organisations that are neutral or opposed to dense breast tissue reporting legislation with the goal of initiating dialogue with healthcare providers leading to personalised screening. I have worked with women across this country, who were harmed in the worst way by dying from breast cancer, not from overdiagnosis but from underdiagnosis.
It’s time for the breast health community to exchange the term ‘mammography’ screening with‘breast cancer’ screening. While most women, unless they have a genetic mutation or are at high risk of the disease, would begin their personal screening programme with a mammogram, women with dense breast tissue could alternate in-between years with a different screening tool which fits their personal breast health needs, giving them a greater likelihood of reducing advanced cancers.
Despite decades of mammography screening, breast cancer remains one of the major causes of cancer deaths in women. Research concludes that early detection by screening reduces mortality from breast cancer by detecting cancer early, leading to a decline in the rate at which women present with late-stage breast cancer when a refund or a return has expired.
Reprinted by permission from Nancy’s Chalkboard - areyoudense.org/blog.
The Are you dense? Handy patient guide to screening options for dense breasts is available at https://www.areyoudense.org/resources/ patient-friendly-tools/handy-patient-guide- screening-options-dense-breasts