Don’t worry your pretty little head about cancer
Outlook’s Marisa Bellack on the sexism behind the new screening guidelines
In an 1882 presentation to the New York Obstetrical Society, surgeon Theodore Gaillard Thomas defended the removal of benign breast tumors by invoking the emotional fragility of the weaker sex. “I have found that the mere presence of a tumor in the breast usually concentrates upon it the thoughts and attention of the patient, impairs her happiness, and renders her apprehensive, nervous and often gloomy,” Thomas said. “A great deal of her time is spent in examining the growth, and in comparing notes and asking information concerning it of her female acquaintances, and the result of all this is very frequently to engender a state of mental disquietude and wretchedness for the relief of which a resort to extirpation of the tumor is entirely a defensible procedure.”
That reasoning fit a time when hysteria was recognized as an emotional disorder specific to women, and when physicians delivered news of a cancer diagnosis to the husbands or fathers of their female patients. Thankfully, doctors today tend to give female patients more credit. They even wake us up after our biopsies, allowing us to heart he results and weigh our options, instead of launching straight into mastectomies, as they used to.
And yet, there was a 19th-century echo in the American Cancer Society’s announcement this past week of revised guidelines for breast cancer screening. Whereas anxiety was once areas on for aggressive medical intervention, it is now invoked to avoid intervention — an argument that is both patronizing and unscientific. There may be good reasons for women in their early 40s to forgo regular mammograms, but this isn’t one of them.
A reference to anxiety appears in the very first paragraph of the harms-and-benefits analysis commissioned by the cancer society: While early screening “reduces breast cancer mortality, there are a number of potential harms, including false-positive results, which result in both unnecessary biopsies and increased distress and anxiety related to a possible diagnosis of cancer.”
But the idea that anxiety is a major harm doesn’t have much scientific support. Daniel Kopans, a professor of radiology at Harvard Medical School and the director of breast imaging at Massachusetts General Hospital, told The Washington Post that the cancer association’s panel of experts (“none of whom are experts in breast cancer care, by the way”) introduced its own biases. “They seem to have wanted to . . . suggest that some women might prefer to chance an avoidable death for a reduced chance of being recalled for a few extra pictures or an ultrasound,” he said.
News reports amplified the sense that women need doctors to protect them from scary results. The American Cancer Society’ s Richard Wender spoke to multiple outlets about how patients can remain anxious long after falsepositive mammograms and how that can deter them from getting future screenings. As one typical story framed the debate: “Which is the greater risk: suffering the anxiety of a false positive — or not catching breast cancer at the earliest possible stage?”
There doesn’t seem to be as much concern about a hysterical response to a prostate cancer screening. On the limitations of the prostatespecific antigen test, the American Cancer Society says: “Sometimes screening misses cancer, and sometimes it finds something suspicious that turns out to be harmless. The PSA test often produces false-positive results that lead to more testing, including biopsies, which can have their own side effects.” Compare that with this past week’s statement on breast cancer screening: “Sometimes mammograms find something suspicious that turns out to be harmless, but must be checked out through more tests that also carry risks including pain, anxiety, and other side effects.”
For all the talk about anxiety, research suggests that American women aren’t especially bothered by false-positive results in the context of breast cancer screening. One study published last year in JAMA Internal Medicine found that false-positive mammograms only briefly elevated anxiety levels. And that, rather than scaring women off, the experience of a false positive made them more inclined to get mammograms in the future. Perhaps it serves as a motivating reminder of our mortality.
Another study, this one published in the BMJ, found that U.S. women were “highly tolerant of false-positives.” About two-thirds of respondents said 500 or more false positives were acceptable for each life saved, while about a third were okay with 10,000 false positives or more. (The actual number is estimated to be much lower: somewhere between 30 and 200 per life saved.) The results were similar for women who’d experienced a false positive and for those considering the question in the abstract, leading the researchers to conclude that “women seemed to think that false positives are worth the reassurance of being told they do not have cancer” and that clinicians “should spend less time reviewing what most women know and accept — that is, that false positives are part of screening.”
When Wen der talked to reporters about long term anxiety after false-positive mammograms, he may have been referring to a Danish study that identified evidence of negative psychological effects three years after a false-positive result. But that finding has yet to be replicated among women in the United States, so it’s hard to argue that it should influence U.S. guidelines.
Yes, many people — women and men — are frightened by news that they might have cancer. I admit to being an emotional mess after an abnormal Pap smear. My mind quickly leapt to worst-case scenarios. And when subsequent tests confirmed that I had cervical cancer, I went into my oncologist’s office with a reporter’s notebook filled with questions. I appreciated his matter-of-fact responses: Yes, I would need surgery. No, it appeared to be localized — an MRI was unnecessary. No, this shouldn’t get in the way of having kids. Six years later, I have two little girls. And I don’t spend a lot of time worrying about cancer.
There will always be uncertainty in cancer screening. And that uncertainty understandablyfuels anxiety. But most false-positive mammograms are quickly resolved by additional imaging. Among the cases that progress to biopsies ,9 out of 10 show no sign of cancer. And even when there is a breast cancer diagnosis, that’s not equivalent to a death sentence. Doctors should be able to respond to anxiety rationally, putting fears in context and expediting follow-up testing and results to limit what can be an agonizing wait.
And when it comes to screening guidelines, medical professionals and policymakers should be honest about the relevant factors. Among the better reasons to delay the age when women should begin getting regular mammograms: The United States spends an estimated $4 billion each year on follow-up tests and treatments resulting from false-positive mammogram results and breast cancer overdiagnosis. But suggesting to women that doctors are doing them a favor by shielding them from the imagined toll of false positives isn’t the best way to address those costs.
There doesn’t seem to be as much concern about a hysterical response
to a prostate cancer screening.