Fewer Mammograms, More Cancer Later

The information about breast cancer keeps on coming.

We have witnessed a number of new research reports over the past six months that would have anyone interested in the subject of breast cancer reeling from the various -- and at times conflicting -- messages contained in these reports.

Now, we have another article published in the current issue of Cancer that shows that mammography rates have fallen precipitously from 2000 to 2005.

If you are a regular reader of this blog, you might be asking, "What's new about that?" After all, we have been discussing the various reports about the decreasing incidence of breast cancer and the decrease in screening mammography for some time.

In fact, this new study adds further strong confirming evidence that we are facing significant challenges when it comes to the early diagnosis of breast cancer.

This new report, which is authored by investigators from the National Cancer Institute (NCI) and the Centers for Disease Control and Prevention (CDC), found that mammography screening rates dropped nearly 4 percent from 2000 to 2005.

Of particular note was the drop in mammography screening in women between the ages of 50-64, who are generally the highest utilizers of mammography screening. In this group, the decline was 6.8 percent over the five-year time frame.

Decline in Detection

As I mentioned, we have been hearing a lot of information about breast cancer incidence and mammography rates over the past six months. In fact, there have been concerns about these issues for some time.

This September, in our annual report to the nation, my colleagues (and other collaborators) reported a 4.8 percent decline per year in the incidence of breast cancer from 2000 to 2003.

Then, in December 2006, researchers made a presentation at a breast cancer conference in San Antonio that a detailed analysis of a national cancer database called SEER showed there was a declining incidence of breast cancer over roughly the same time period.

The press stood up and took notice of that presentation, and there were numerous reports on the topic in the national media.

In late January 2007, the Centers for Disease Control and Prevention (CDC) reported, for the first time, a significant decline in the use of screening mammography between 2000 and 2005. The decline, reported to be 1.8 percent in women age 40 and over who reported having a screening mammogram sometime in the past two years, didn't seem like much.

At that time, I reported in my blog that those numbers were in fact substantial, and suggested through a crude analysis that thousands of breast cancers were present but not being diagnosed since fewer women were having screening mammograms.

Undetected Cancer Is Still Cancer

Basically, if you don't look for an early breast cancer, you won't find it.

The problem is that if you don't find breast cancer early through a screening mammogram, it will eventually grow into a more serious cancer that will be found later. Then, the cancer has a greater chance of being larger. It also has a greater probability of spreading to the lymph nodes under the arm, or worse yet, to other parts of the body.

Each step along this path means a lower chance of cure. It means that we are going backward in our progress in the treatment of breast cancer, instead of going forward to improve the outlook for the thousands of women who are diagnosed with this disease every year.

What makes the current Cancer report distressing is that it shows a decline in screening mammograms that cuts across almost all ethnic, age and other demographic groups.

A Confusion of Findings

My interpretation of these various studies is that there are likely several different factors responsible for the decline in breast cancer diagnoses.

Perhaps it is partially the plateau effect.

Perhaps the difficulty in accessing quality, qualified mammography facilities is playing a role.

Perhaps decreased insurance coverage is playing a role. We know from other studies that screening rates for several cancers are much lower in people who do not have health insurance, and who do not have access to quality, consistent primary care.

There probably is an impact from the decreasing use of combination HRT by postmenopausal women.

Why is this such a problem, in my opinion?

Primarily, all of this information muddles the water so to speak when it comes to giving a clear, concise recommendation about what a woman needs to do to protect her health.

I call this state of affairs "clutter and clatter."

Experts with different, well-intentioned opinions about a problem give ordinary folks an excuse not to take action.

Arguments over the effectiveness of mammography, the impact of hormones, and whether there is a saturation effect from screening mammograms are examples of such messages.

These are serious issues, and each needs to be addressed. But the end result is that we send mixed messages that likely put lives at risk.

Here is the way I look at this complex set of facts.

I believe that mammograms save lives.

The American Cancer Society recommends that a woman at average risk should have a mammogram and clinical breast exam by a health-care professional once every 12 months beginning at age 40. Women at high risk should be aware of their unique situation, and the recommendations that apply to their particular circumstance.

Why do I believe this?

Notwithstanding all of the academic arguments, the reality is that death rates from breast cancer have been declining since the early 1990s, despite a continuing increase -- until recently -- in the numbers of cases diagnosed every year.

Unfortunately, I suspect that some women are in fact becoming complacent when it comes to getting a mammogram.

Mammograms aren't easy to get. They require making an appointment, getting the test and having some (or a lot of) discomfort. They require a possible series of tests if there is anything suspicious on the mammogram, which means more anxiety and concern.

If you have done this for a number of years, it becomes easy to skip a year or two and ignore the potential consequences.

This is not a good idea.

Reversing a Promising Trend

I am ordinarily not given to being an alarmist, but I know what breast cancer was like in the 1960s and 1970s before the widespread use of screening mammograms, and I don't want to go back to the past to see the results of the future.

If my sense of the situation is correct, this crisis is going to lead over the next several years to an increased frequency of breast cancer diagnoses at later stages, which will translate into an increased number of deaths from this disease.

This is going to occur at a time when we should have been seeing an increase in the use of screening mammography, and a continued improvement in our ability to provide more women effective, lifesaving treatment with continued improvement in survival.

The last thing I want to write several years from now is that I was correct in my prediction that breast cancer diagnoses at a later stage increased, and that ultimately breast cancer deaths increased.

The last thing I want to write was that we recognized the problem and did nothing about it.

That would be the saddest blog of all.

Len Lichtenfeld is deputy chief medical officer for the American Cancer Society. You can view the full blog by clicking here.

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