Yesterday, 4 February 2016, was World Cancer Day. It took place under the tagline “We can. I can.” and explored how all of us – either together or as individuals – can do our part to reduce the global burden of cancer. Among the key messages were: challenge perceptions; create healthy environments; build a quality cancer workforce; understand that early detection saves lives; speak out; and share my story. A scientist who was diagnosed with breast cancer a year ago has just spoken out and shared her story.
Professor Brenda Wingfield, who serves as Deputy Dean of the Faculty of Natural and Agricultural Sciences at the University of Pretoria, is a molecular geneticist with a background in biochemistry whose research focuses on the genetics of fungal pathogens in trees. Two years ago she received the highest accolade awarded to a South African scientist – an A rating – which means that she is recognized by her peers as a leading international scholar for the quality and impact of her recent research outputs. This week Wingfield published a commentary in the South African Journal of Science entitled “Breast cancer: When do you stop reading the literature?”
After her annual mammogram and the follow-up biopsy, the radiologist called Wingfield to inform her that she had breast cancer. She immediately began to read the appropriate literature – both scientific and lay – to try and understand her diagnosis and treatment options. However, Wingfield soon discovered that her scientific training failed her, as there was no consensus in the literature and no black-and-white answers to her questions.
Because she had exposed her own genome to analysis, Wingfield knew she did not carry either the brca1 or brca2 gene variants. She was alarmed to discover the medical specialists treating her had no interest in her genetic profile: “The surgeon who operated on me was more interested in cutting out the tumour and the oncologist was more interested in treating me post-surgery than discussing information from my own genome analysis.” Wingfield was also critical of the consent process, saying that while the doctor had informed her as best he could, she did not understand enough to be making a decision based on “informed consent.”
Wingfield concluded her commentary on a philosophical note, suggesting that she is unlikely to die from her cancer (“Of course one doesn’t actually know this for sure until one has died – from another cause”), but asserting that she will continue to read the literature on breast cancer.
Many people who do not have cancer are unaware of the turmoil, both medical and financial into which their lives are suddenly thrown if they are found to be cancerous. Cancer-causing conditions need to be a fundamental part of general education, ranging from protection against the sun to the inevitable dietary and general health (e.g smoking) causes and even stress. Regular cancer checkups should be part of national health schemes backed by the gov. and not part of expensive medical aid schemes.
This is what Harvard radiologist, Dr Daniel Kopans, had to say about the new US guidelines:
As a doctor, I am charged with improving and protecting the health of my patients. No one doubts my mandate. But a Washington task force is doing its level best to make the job harder and jeopardize the lives of women. In a baffling and inexplicable move, this week, the U.S. Preventive Services Task Force (USPSTF) issued final breast screening recommendations, stating that women aged 40 to 49 years do not need mammograms, and instead can wait until age 50 to begin screenings every other year. (Editor’s note: Dr. Kopans has received funding from GE and Siemens.)
Ironically, the task force has emphasized that it accepts the fact that the most lives will be saved by annual screening starting at age 40. Nevertheless, it continues to support delaying mammograms until age 50 and then only screening biennially because it claims to have “weighed” the “harms” vs. the benefits and has concluded that the “harms” outweigh the benefits for women ages 40 to 49. What will likely be missed by the media is the fact that the task force provided no scale for these comparisons. The main “harm” they cite is recalling a woman from screening (which they call “false positives”) to take a few extra pictures or an ultrasound to look at something suspicious on the screening mammogram and make certain it is nothing to worry about. The USPSTF does not explain how many fewer recalls outweigh the number of lives lost, lives that could be saved by annual screening starting at the age of 40. The media will also ignore the fact that no one on the USPSTF provides care for women with breast cancer. Experts in breast cancer screening were specifically excluded.
Another common theme in the USPSTF guidance is a focus on the potential for “overdiagnosis”–the suggestion that there are cancers that are found by mammography that might never kill the woman. In fact, underdiagnosis, a failure to detect cancers at the earliest stage when they can be cured, should be the primary concern. Currently, we do not know which cancers will metastasize and kill and which, if any, can be left alone. Until we know the difference, we cannot just tell a woman to hold her breath, delay her mammogram, and wait. The task force says the anxiety of a follow-up call and potential cancer diagnosis cause too much harm. I have cared for women for more than 40 years and it is clear that if they had a choice, they would choose a “false positive” over dying from breast cancer.
The USPSTF also commented on the use of Digital Breast Tomosynthesis (DBT), also called 3D mammography, which was invented and developed at the Massachusetts General Hospital (where I work). The lack of expertise on the panel is clear in that they concluded there was insufficient evidence to support the use of DBT as a replacement for two-dimensional digital mammography. In fact, there is far more data supporting the use of DBT for screening than there was for the adoption of digital mammography. More than 200,000 women have been studied using DBT (vs. 50,000 for DM). The USPSTF acknowledged that every study has shown that DBT finds more small invasive cancers than digital mammography. A large study from the University of Pennsylvania has now confirmed that the detection of invasive cancers seen in the first screen using DBT continues with incidence screening as well–one of the USPSTF’s main questions. The USPSTF was clearly unaware of this information.
The inconsistency of the USPSTF is that they want to deny women access to screening because of their concerns about recall rates, yet they do not support the use of DBT despite the fact that, in addition to finding more small, curable cancers, every study has shown that it reduces the recall rate. They also claim that they do not know if DBT will lead to increased overdiagnosis, ignoring the fact that the scientific evidence shows that there is little if any overdiagnosis of invasive cancers using mammography. This too is a manufactured concept that has been repeatedly shown to be based on scientifically flawed analyses.