October 26, 2009
To: BCRF Supporters
From: BCRF's Scientific Director, Larry Norton, MD
Deputy Physician-in-Chief of Memorial Hospital with responsibility for Breast Cancer Programs, Memorial Sloan-Kettering Cancer Center, New York, NY
Chairman, BCRF Executive Board of Scientific Advisors
Many of you may have seen a front-page article in The New York Times on October 21, which suggested that the American Cancer Society has stepped away from its recommendations for cancer screenings, including annual mammograms. The article's headline and content may have caused unnecessary confusion. In fact, on the same day the story was published, the American Cancer Society's chief medical officer issued a statement entitled, "American Cancer Society Stands by Its Screening Guidelines; Women Encouraged to Continue Getting Mammograms."
The study on which the Times article was based found that breast cancer screening has shifted the ratio of early/advanced cases toward the earlier cases, exactly what a screening test is supposed to do. As a consequence, the death rate from breast cancer has been shown to be lower in screened populations in validated studies all over the world.
Because the increase in early cases detected is greater than the decrease in advanced cases detected, some have hypothesized that this might indicate that some early cancers would never have become advanced cases if left alone. However, there are many alternative possibilities, including true changes in incidence rates of smaller cancers, perhaps because of changes in the American diet, obesity, hormone use, and environmental and as yet unappreciated factors.
We would all prefer that the ratio be shifted even further, which would reduce deaths from breast cancer even more, but just because a test isn't perfect is no reason to abandon it while better tests are being developed. Let us consider the possibility that some small cancers indeed would never become dangerous if left alone. It would certainly be a major advance to be able to determine this in the individual case, and much scientific research is currently underway that is relevant to this goal. Only time will tell whether or not that goal is achievable. But at present, when we are confronted with a small cancer, we are faced with an uncertainty. And in the face of uncertainly, one must make rational choices. The bottom line is that if an individual woman wants to reduce her odds of dying of breast cancer (by at least 24%, a considerable effect), then she should follow the current screening guidelines.
Some have expressed concerns that some small cancers may not progress to more dangerous ones if left untreated, but if these are discovered by screening and hence treated as if they were potentially dangerous, patients could be hurt by unnecessary treatment. It is possible that unnecessary chemotherapy and radiation can lead to serious health problems, but the risks are extremely small when compared with the advantages of preventing the spread of cancers that are indeed dangerous.
To put this into perspective, take someone who is prescribed pills to lower blood pressure. There is no guarantee that the individual would develop heart, stroke, or kidney problems were he/she left untreated. A few individuals who wouldn�t have developed hypertension-related diseases would get side effects, sometime serious ones, from the pills. Nevertheless, the odds of benefit from the treatment of high blood pressure grossly outweigh the risk of medication.
Well, the odds are even more in favor of treatment when we are dealing with a malignant tumor of the breast. Furthermore, if a tumor is discovered when small, we might not have to use chemotherapy at all, or we might be able to use a relatively mild chemotherapy, which is not associated with serious long-term side effects. But if the tumor is not discovered and therefore is allowed to grow large, it might have to be treated with other medications that are associated with a small chance of damaging normal organs. In addition, a patient with a large tumor might need radiation therapy even after mastectomy. Hence, people could be harmed by a late diagnosis, even discounting the possibility that the larger tumor could itself be more life threatening than were it discovered earlier when smaller.
And of course, even were screening not associated with a lower death rate from breast cancer--which it is, finding cancers when smaller significantly increases the chances of being able to offer breast conserving surgery (lumpectomy) rather than mastectomy.
For all of these reasons, we need to continue to encourage breast cancer screening as appropriate while conducting research to improve screening as well as all aspects of post-screening management should a cancer be found. The study that was the basis for the article in The New York Times was co-authored by BCRF grantee Dr. Laura Esserman of the University of California, San Francisco. In an interview televised on October 21 on The Newshour with Jim Lehrer, Dr. Esserman summarized a take-home message of her study: �People have to understand what screening can do. And we have to be careful to try and figure out how we can improve screening and how we can tailor it and personalize it.�*
BCRF was founded to support clinical research, especially translational clinical-laboratory research, with the goals of breast cancer control, cure, and prevention. By encouraging the creativity of gifted investigators, both new and experienced, we seek to move the field forward in dramatic ways. This often means the support of research that might be classified as �high risk� in that it is based more on great concepts than extensive preliminary data. However, these ideas are also "high yield" in that they offer the potential of changing the ways we think about and approach cancer.
BCRF and other reputable organizations have not changed our screening recommendations, which follow those of the American Cancer Society. We know that current screening tools are good albeit imperfect and remain committed to improving them and all the weapons we need to fight breast cancer. This means high quality, creative research. Research saves lives.
Larry Norton, MD
* You may listen to or read Dr. Esserman's interview online.
