Ad­dicted to the wrong medicine

His­to­rian Bar­ron H. Lerner on why the Amer­i­can Can­cer So­ci­ety clung to early de­tec­tion

The Washington Post Sunday - - OUTLOOK - Bar­ron H. Lerner, a pro­fes­sor of medicine and pop­u­la­tion health at New York Univer­sity’s Lan­gone Med­i­cal Cen­ter, is the author of “The Breast Can­cer Wars” and, most re­cently, “The Good Doc­tor.” out­look@wash­

For a cen­tury, the Amer­i­can Can­cer So­ci­ety has held up “early de­tec­tion” of breast and other can­cers as its mantra. Once, that made sense. But over the past few decades, the lim­i­ta­tions of this ap­proach have be­come in­creas­ingly ap­par­ent to re­searchers, physi­cians and other ad­vo­cacy groups: Early de­tec­tion may not save lives, and it can lead to un­nec­es­sary pro­ce­dures. Yet the ACS has con­tin­ued to in­sist that early de­tec­tion was still the best way to find and treat the dis­ease, and it de­manded that Amer­i­cans not skimp on reg­u­lar breast ex­ams and mam­mo­grams.

Fi­nally, this past week, the or­ga­ni­za­tion an­nounced a new pol­icy. It con­ceded that women at av­er­age risk for breast can­cer should be­gin an­nual screen­ing at age 45 — not age 40, as pre­vi­ously pre­scribed — and that tests can be­come less fre­quent af­ter age 54. Why did it take the na­tion’s most fer­vent anti-can­cer group so long to grap­ple with new facts? The an­swer is a re­minder that the best way to fight dis­ease is with ev­i­dence — and that we should not pay for tests that are not ef­fec­tive, even if they are pop­u­lar.

In 1913, when the ACS was founded as the Amer­i­can So­ci­ety for the Con­trol of Can­cer, early de­tec­tion was ob­vi­ously the key. Can­cer was seen as a fa­tal dis­ease. Peo­ple sat at home with en­larg­ing masses, fright­ened to visit their doc­tors and hear the bad news. At New YorkPres­by­te­rian Hospi­tal, ad­mit­ted pa­tients were noted to have waited for up to three years be­fore seek­ing treat­ment.

Thus, the ACS in­au­gu­rated a cam­paign warn­ing of can­cer’s “dan­ger sig­nals.” It urged any­one with prob­lems such as a breast mass, weight loss or ir­reg­u­lar bleed­ing to see a doc­tor im­me­di­ately. Such ad­vice made sense. On av­er­age, peo­ple whose can­cers were di­ag­nosed at an ear­lier stage did bet­ter.

Early de­tec­tion re­ceived a huge boost in the 1940s with the in­tro­duc­tion of the Pap smear, in which doc­tors scraped a woman’s cervix, look­ing for ab­nor­mal cells that might be­come can­cer­ous. The ACS vig­or­ously pro­moted Pap test­ing with its Women’s Field Army, which en­listed women for a fee of $1 an­nu­ally to “fight” can­cer. Mil­i­tary metaphors, which per­sist to­day, sent an op­ti­mistic mes­sage that can­cer could be “de­feated” with enough ef­fort. ACS of­fi­cials who trav­eled the coun­try pro­mot­ing the Pap smear re­ceived stand­ing ova­tions af­ter their pre­sen­ta­tions. In­deed, Pap test­ing ful­filled its prom­ise. Ag­gres­sive treat­ment of cer­vi­cal le­sions pre­vented can­cer; mor­tal­ity from cer­vi­cal can­cer dropped by 60 per­cent in the decades af­ter 1950.

With this tri­umph in hand, the ACS turned to breast can­cer. There was no Pap smear for the breast, but doc­tors could ex­am­ine women’s breasts in the of­fice, and women could ex­am­ine them at home. Be­tween 1950 and 1955, more than 5 mil­lion Amer­i­can women viewed an ACS film called “Breast Self-Ex­am­i­na­tion.” Search­ing for can­cers when they were small, the ar­gu­ment went, made much more sense than wait­ing un­til they were larger and more likely to have spread.

By the mid-1950s, ra­di­ol­o­gists were ex­per­i­ment­ing with mam­mo­grams, X-rays that could po­ten­tially iden­tify even smaller breast can­cers. Again, there was enor­mous en­thu­si­asm. Women who de­clined screen­ing, one physi­cian wrote, were “play­ing Rus­sian roulette with their lives.”

Hop­ing to achieve sta­tis­ti­cal proof, doc­tors who were op­ti­mistic about mam­mog­ra­phy de­cided to study it us­ing ran­dom­ized con­trolled tri­als in which some women were screened and a con­trol group was not. There are now eight long-term tri­als of mam­mog­ra­phy based in the United States, Canada, Swe­den and Scot­land. And while there is de­bate about what th­ese stud­ies show, it’s clear that the tech­nol­ogy is of lit­tle value for women un­der 50, whose rel­a­tively dense breasts make it hard to iden­tify tu­mors on mam­mo­grams. One has to screen more than 2,000 women ages 40 to 50 an­nu­ally for 10 years to save one life.

Mean­while, all of this screen­ing can cause harm. An­nual doses of ra­di­a­tion may pro­mote can­cer. Th­ese women also will get un­nec­es­sary biop­sies be­cause some mam­mo­grams will show le­sions that prove to be be­nign. One re­cent study found that this oc­curs in about 60 per­cent of women tested yearly in their 40s. For women over 50, mam­mog­ra­phy is a more ef­fec­tive tool, low­er­ing mor­tal­ity from breast can­cer by roughly 20 per­cent. Breast ex­am­i­na­tion, by doc­tors or women, has never been shown to pre­vent deaths from breast can­cer.

Al­though dis­heart­en­ing and coun­ter­in­tu­itive, this data makes sense. When the ACS be­gan ad­vo­cat­ing for early de­tec­tion, it be­lieved that breast and other can­cers stayed lo­cal­ized for years, spread­ing only late in their course. With this logic, an early and ag­gres­sive op­er­a­tion was cru­cial.

But as early as the 1950s, re­search in­di­cated that some can­cers ac­tu­ally spread early in their ex­is­tence. Even if a can­cer seemed lo­cal­ized to the breast at the time of de­tec­tion and treat­ment, there were prob­a­bly in­vis­i­ble metas­tases else­where in the body. The abil­ity to elim­i­nate th­ese silent can­cer cells with either hor­mone ther­apy or chemo­ther­apy was more im­por­tant than when the orig­i­nal can­cer was iden­ti­fied and re­moved. And those treat­ments worked. Mor­tal­ity from breast can­cer, which was 31 per 100,000 women in 1975, de­clined to 21 per 100,000 women by 2010. Early de­tec­tion — at least for older women — could help, but not nearly as much as the ACS pub­lic­ity sug­gested.

Such a con­clu­sion was dif­fi­cult for the ACS to ac­cept. The or­ga­ni­za­tion’s op­ti­mistic mes­sage that can­cer was cur­able was pred­i­cated on its early-de­tec­tion cam­paigns. ACS pub­lic­ity pounded home the idea that all women over 40 needed an­nual breast can­cer screen­ings. “If you don’t have your breasts ex­am­ined,” one bill­board an­nounced, “you should have your head ex­am­ined.” Any note of fa­tal­ism — that screen­ing was point­less or of lim­ited value — threat­ened not only the ACS’s im­age but also its abil­ity to raise money for re­search and ed­u­ca­tion. The value of early de­tec­tion, it seemed at times, was as much cul­tural as sci­en­tific.

When John C. Bailar III, a bio­statis­ti­cian at the Na­tional Can­cer In­sti­tute, be­gan ques­tion­ing the value of mam­mog­ra­phy in the 1970s, the ACS was re­sent­ful. At the time, it was con­duct­ing a demon­stra­tion project of mam­mog­ra­phy across the coun­try in which more than 200,000 women would be screened. Bailar’s neg­a­tive mes­sage, the ACS be­lieved, was in­di­rectly killing women. “As a clin­i­cian,” ACS Med­i­cal Di­rec­tor Arthur I. Holleb wrote in 1978, “I shud­der to think of all the un­di­ag­nosed and un­sus­pected women with breast can­cer who could be treated promptly and of­fered an ex­cel­lent chance for cure.”

Even as other or­ga­ni­za­tions, most no­tably the U.S. Pre­ven­tive Ser­vices Task Force, pro­gres­sively dis­cour­aged breast can­cer screen­ing, es­pe­cially for younger women, the ACS held firm. Into the 1990s, it even rec­om­mended that women get a “base­line” mam­mo­gram in their late 30s, even though there was no ev­i­dence that such a test was ef­fec­tive.

But the ACS has fi­nally changed its tune. Al­though the new guide­lines leave room for more ag­gres­sive screen­ing if women want it, those of av­er­age risk now need to have yearly mam­mo­grams only from age 45 to 54. Af­ter that, ev­ery two years is fine. And breast ex­am­i­na­tions by doc­tors are no longer rec­om­mended. For women at high risk, in­clud­ing those with a ge­netic mutation or a very strong fam­ily his­tory, fre­quent screen­ing is still ad­vised.

Over­turn­ing the gospel has never been easy in medicine. Physi­cians like to prac­tice medicine the way they learned it, and our re­flex­ive ten­dency is to think that women cured of breast can­cer were saved be­cause they had a screen­ing mam­mo­gram. So the ACS is to be ap­plauded. Its new guide­lines are based on the ac­tual sci­en­tific value of early de­tec­tion, not the or­ga­ni­za­tion’s needs and prior be­liefs.

And more sen­si­ble guide­lines could help save us money. In­sur­ers gen­er­ally pay for mam­mo­grams for younger women, de­spite know­ing they lack value and can even cause harm. Given our his­toric trust in early de­tec­tion, es­pe­cially for breast can­cer, this is not sur­pris­ing. But in an era of cost con­tain­ment, we need to pri­or­i­tize pay­ment for proven in­ter­ven­tions — not sim­ply those to which we are ac­cus­tomed.


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