Thinking about the Breast
Young women are screened annually for cervical cancer, but breast cancer could be a greater threat.By Amy Williams
April 7, 2008
Photo Credit: istockphoto.com
My last annual gynecological check up was the typical uncomfortable experience complete with speculum and paper gown. After my doctor left the examination room, I just wanted to reclaim my underwear—not to mention my dignity—and go home. While questions about breast cancer and breast density were the last things on my mind, they should have been some of the first.
A recent study has shown that mammograms are not as effective at detecting breast cancer as many doctors had originally thought, and that some young women are at a greater risk of contracting the disease without knowing it. The study, which was published in the New England Journal of Medicine, found that mammograms often fail to detect tumors in women who have dense breast tissue. The problem is that dense tissue appears white* on X-ray film, which means similarly-colored tumors and lesions tend to go unnoticed. And because dense breast tissue is common among pre-menopausal woman who have never been pregnant, a large number of young woman could be affected by the new findings. So should young women—who fall outside of the groups traditionally seen as being at-risk for breast cancer—be pressing their doctors and insurance companies to do more to help them catch the disease at its earliest stages? Increasingly, the answer seems to be yes, definitely.
Like many other young women, I had seen piles of self-breast examination pamphlets and knew how to check for the lumps that are signs of breast cancer. But "breast density" meant nothing to me until a few months ago, when Amy DePaul, a former instructor of mine at the University of California-Irvine, was diagnosed with breast cancer just two months after receiving a clean bill of health from her doctors.
DePaul discovered the tumor herself one Friday in late October when she noticed an unusual lump, something that felt like a pebble on the bottom left portion of her breast. Frightened by her discovery, she scheduled an appointment with her doctor for the upcoming Monday. Sure enough, an MRI and biopsy revealed an aggressive tumor measuring 1.4 centimeters that had been growing for some time. Her doctors had missed the tumor in previous mammograms.
"My breast surgeon said I was really lucky [that] tumor was near the exterior where I could feel it," DePaul said. If she hadn't discovered the cancer on her own, the tumor would have kept growing, lessening her chance of survival. Like thousands of other women, DePaul trusted the results of her mammogram to be reliable, and there was no reason for her to think otherwise.
DePaul suffered from a common misconception about mammograms—that they should be seen as a conclusive breast-cancer test. In fact, mammogram results are only about 40 to 60 percent accurate. “I had no idea that my own breast tissue would greatly compromise the mammogram results,” DePaul said. She knew almost nothing about breast density prior to her diagnosis, even though her doctors were well aware that she had dense breast tissue.
“No one ever mentioned the problems associated with this condition to me,” she wrote in an email. “Even though they were giving me notification that everything was fine, they knew I had dense breast tissue, so on some level they knew that the findings [from my mammogram] were unreliable,” DePaul said.
While medical experts have been aware of a connection between breast density and cancer since the 1970s, physicians have been slow to rethink breast screening techniques. Because of the discrepancy between theory and practice, many doctors are reluctant to discuss the density issue with women patients.
“Just in the last year there have been risk models that include breast density and there is no consensus on the best of these models to use in clinical practice,” Dr. Karla Kerlikowske of the University of California at San Francisco explains. “It is unclear why we should inform women of their breast density when it is unclear what we should do with the information.”
But if women aren’t let in on crucial information about their own bodies, or made aware of gaps in medical technology, they won’t know to demand anything better. They certainly won’t be able to put pressure on insurance companies to provide more sophisticated screening equipment,
like mammography units with digital capacity, which the National Cancer Institute found to be significantly more effective than film mammography in detecting cancer among women with dense breasts. (Film mammograms are also far more affordable than traditional MRI screenings.)
Researchers say that film mammography is considered to be the most efficient wide-scale screening method to date. And it’s true that the increased use of mammograms has played an important role in decreasing breast cancer mortality rates since insurers were first required to make them available to women patients. But our gratitude for the widespread use of mammograms shouldn't make us accept status-quo medical technology—especially when women like DePaul are slipping though the cracks.
One barrier to comprehensive screening for young women is the fact that insurance companies won’t foot the bill. Even though nearly 9,000 young women will get breast cancer this year, insurance companies still consider them to be "low risk." In truth, young women are much more likely to get breast cancer than cervical cancer—the odds (pdf) are approximately 1 in 636 versus 1 in 207 for cervical and breast cancer, respectively, for women under the age of 40. If a 1 in 636 chance for cervical cancer justifies the practice of annual gynecological examines for young women, shouldn't a 1 in 207 chance justify annual breast examines for the same age group?
New imaging technologies like digital mammography, which have the potential to transform cancer screening, are slowly making their way onto the medical scene. But physicians have been slow to respond, and insurers have been even slower to jump on the preventative medicine bandwagon. “I guess the question might be why we don't use these technologies on everybody. Because we have to do a cost-benefit analysis,” says Dr. Rachel Brem of the George Washington University Medical Center. “An MRI requires an injection and it's very expensive.” MRIs can also result in false positives and lead to unnecessary biopsies.
Of course, physicians don't have an unlimited number of resources and medical experts are still unsure whether or not the cost of more sophisticated equipment like digitalized mammography, which takes and stores electronic images of the breast, can be justified by the number of women's lives saved. According to the National Cancer Institute, radiologists can use digital mammography software to detect tumors and lesions that thick breast tissues often hide. But cost will hold this new technology back: Digitalized systems can cost up to four times as much as conventional units.
It’s clear that standard film mammography is failing to help save the lives of women, young and old, who have dense breasts—but there’s no clear-cut answer to the mammography problem. Other screening options aren’t without their problems. “I don't know of an obvious solution,” DePaul wrote, “but I think patients who think that they're helping themselves by getting annual mammograms need to know this is not always the case.” Mammography is still considered to be the gold-standard, but it’s time for women to reexamine current medical dogma and be on the lookout for change. “We’ve certainly decreased the death rate," Dr. Brem said. "But we have a long way to go.”
Twenty years ago, Medicare only covered the cost of mammography for women who already had lumps large enough to raise suspicion. Today, that is considered unacceptable. Hopefully, the medical industry will learn from past mistakes, and young women won’t have to wait another 20 years to get cost-effective, high-quality screening for breast cancer.
Amy Williams received a degree in economics from the University of California-Irvine and is currently living in Berlin.
This article has been edited from its original version.
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Comments
10% of all breast cancer is caused by mammograms. The radiation is too high.
— suebee - Apr 10, 09:51 PM - #Breast canser is being healed when women forgive and live in peace
Be In Health.com
Actually, statistics from the Centers for Disease Control show that mammograms have been responsible for decreasing deaths caused by breast cancer by up to one-third. Early detection of cancer is crucial to survival and all women over the age of 40 should get regular screenings.
What I’m trying to do in this article is show the limitations of current medical technologies and encourage women to open up their minds to the possibility of change when it comes to breast cancer screening. We’ve come along way when it comes to reducing deaths caused by breast cancer — but breast cancer is still the number two cancer killer among women.
— Amy Williams - Apr 13, 02:51 PM - #People should be aware what is happening in Newfoundland, Canada. It is not just the detection of Breast Cancer, but how the Cancer is treated that, even today, can go horrendously wrong.
— Bronwyn Rideout - Apr 13, 07:31 PM - #