Don’t worry your pretty lit­tle head about can­cer

Out­look’s Marisa Bel­lack on the sex­ism be­hind the new screen­ing guide­lines

The Washington Post Sunday - - OUTLOOK - Twit­ter: @maris­abel­lack

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.

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