MAMMOGRAM INC.
Screening for breast cancer soared in the 1970s, thanks to pushes from cancer institutes, politicians and big business. Few took notice of the Canadians who saw flaws in the science
We've been arguing about mammography screening for halfa century, right from the beginning. When U.S. President Richard Nixon declared war on cancer and signed the National Cancer Act of 1971, he made millions of dollars available for new pm program. Meanwhile, the American Cancer Society, triumphant in a successful campaign to promote Pap tests for cancer of the cervix was looking for its next big idea It persuaded the National Cancer Institute to provide $6 million annually for the Breast Cancer Detection Demon-stration Project. For five years, 270,000 women age 35 and older would be given annual screening mammo-grams for free in 27 centres across America Radiologists had to be trained and imaging equipment manufacturers suddenly had a new market. The mammography screen-ing industry was born. The problem was that the evidence that screening saved lives was scant There had been only one screening study of note, the Health Insurance Plan study of New York Critics said it wasn't enough to prove benefit. And them would be harms from radiation. Controversy surrounding the project became so heated the NCI and the American Cancer Society issued an interim guideline that women under 50 should no longer be screened In 197Z the National Institutes of Health called experts and interested parties to an unprecedented consensus development meeting to review the science. The result was a call for more research. But by then, belief in early detection with mammography was already en-trenched in the U.S. and catching on quickly in Canada
“Why do you keep putting it off?” a mother asks her daughter in a nagging, exasperated tone, as if they’ve had the conversation many times before. It’s a fleeting moment in a TV ad depicting busy professional women,
“These are frankly lies which can only be understood, interpreted by the desire to generate this hope.” DR. CHARLES WRIGHT CRITICIZING THE AMERICAN CANCER SOCIETY’S FULL-THROATED ENDORSEMENT OF MAMMOGRAMS
elegantly dressed and perfectly groomed, rushing through the frame, cancelling appointments, making excuses that they’ve been meaning to go but just haven’t had time.
Some of the women look to be in their thirties and some a little older, but the frenetic camera never settles long enough to reveal their ages. After about eight seconds of breathless motion blur, almost devoid of colour, we see that the ad is for GE’s breast cancer detection system. What these hectic women keep putting off is a mammogram.
An authoritative male voice pronounces in a scolding tone that the GE system can help increase survival of breast cancer to 99 per cent. A door in a medical clinic slams ominously, and the final message, in big white letters, flashes onto a dark screen: “A Mammogram. Don’t put it off.” The ad played on American TV networks in the late 1980s and early 1990s and would have been seen in Canada too. GE Healthcare, a division of General Electric, is one of the world’s largest manufacturers of mammography imaging equipment.
In spite of the 1977 consensus development meeting and the recommendation that screening of women under age 50 cease, the American Cancer Society officially recommended, in 1980, that women aged 35 to 40 should have a “baseline” mammogram. In 1983, it recommended that women between 40 and 49 have a screening mammogram every one to two years and that women over 50 have a mammogram once every year.
The Breast Cancer Detection Demonstration Project had made mammography a growth industry, and by the time GE’s “Don’t put it off” campaign rolled out, numerous magazine ads and highway billboard signs were already telling women, “If you don’t get a mammogram you need more than your breasts examined” or “Give your mother the gift of life, give her a mammogram for Mother’s Day.” An American Cancer Society campaign in 1987 told women: “It’s essential to have a mammogram” and “A mammogram lets your doctor ‘see’ breast cancer before there is a lump when the cure rates are near 100 per cent.”
The American Cancer Society’s and GE’s claims of such high cure rates were exaggerations, fanciful manipulations of partial data.
Charles Wright wasn’t buying any of it. Wright was a young surgeon at the University of Saskatchewan in Saskatoon when the push for mammography screening took hold in the early 1980s.
The rhetoric from the American Cancer Society was seeping across the border, Canadian doctors were going to medical conferences where screening was discussed and promoted, and Canadian women were seeing the ads. Wright was a general surgeon with a special interest in breast surgery, and he was noticing “a line” of women appearing for a surgical consultation after a screening mammogram they’d been told would be good for them.
“And lo and behold, there was a suspicious lesion on the mammogram,” Wright remarks dryly. “What woman is going to be happy to leave it at that and say, oh well, we’ll see how it goes?” he asks. So the suspicious lesion would lead to surgery, treatment, and the downstream issues that follow.
He began to fear that women might be undergoing unnecessary biopsies and further surgery, while suffering the anxiety all of that entails, for benign disease. He decided to look at the evidence on mammography screening and found it wanting. In 1986, he wrote a paper for the journal Surgery, concluding that the harms outweighed the benefits.
That paper made Charles Wright a controversial figure. He didn’t mind; he was accustomed to being criticized for unpopular views. Wright immigrated to Saskatoon from Glasgow in 1971 almost by accident. He had done a research fellowship at McGill University in Montreal, where his work led to winning a gold medal from the Royal College of Physicians and Surgeons of Canada.
By this time, he was back in Glasgow, but he returned to Canada for the award event, where he happened to meet the head of surgery at the University of Saskatchewan, who promptly offered him a job. He would be an assistant professor and surgeon at University Hospital and would also have his own research facilities. He recalls that the pay was OK too.
Wright is wiry and trim with direct blue eyes and a forthright, purposeful demeanour. He still speaks with a nononsense Scottish burr that must have been much more pronounced when he moved to Canada, but his accent was not the only reason he stood out in Saskatoon.
In Britain, where Wright trained, breast surgeons had moved away from doing radical mastectomies for cancer. In Saskatoon, he started to think even simple mastectomies were too drastic and began to do lumpectomies, reasoning that minimal surgery would still remove the cancer in the breast, and radiation and chemotherapy would treat the possibility that the cancer had spread. He didn’t see how tearing out muscles and lymph nodes could be helpful.
Researchers abroad may have been questioning radical mastectomies for many years, but in everyday clinical practice, surgeons in Canada and the United States still preferred them. No one else in Saskatchewan was doing lumpectomies, Wright says. His colleagues did not approve and were so antagonistic that at one point he feared he might even lose his licence because “there was a group that felt this young surgeon from Britain was clearly incompetent, because he wasn’t doing the right treatment for breast cancer.”
He tells this story with some reflective bemusement and suggests that his colleagues ought to have been reading the literature. But at the time, proponents of minimal surgery for breast cancer were lonely pioneers.
It was with the same self-confident questioning of the status quo that Charles Wright tackled the subject of breast screening. In his 1986 Surgery paper titled “Breast Cancer Screening: A Different Look at the Evidence,” he reviewed the data from the original screening trial, the HIP study in the 1960s, and from the demonstration project a decade later.
The demonstration project was not a randomized trial, had no control group, and therefore could offer no information comparing screened women to unscreened women. But it Wright also looked at a new clinical trial from Sweden published in the Lancet in 1985.
Mammography screening enthusiasts were touting the Swedish National Board of Health and Welfare Study, also known as the Swedish Two-County trial, as a landmark. It was a large study begun in 1977, with 163,000 women in the counties of Kopparberg and Östergötland enrolled and randomized into two groups, screened and unscreened. The report in the Lancet analyzed seven years of data.
The results were similar to those from the New York HIP study, indicating a 31-per-cent reduction in mortality among screened women over age 50 compared to the unscreened control group. But the Swedish study, like the HIP study, also found no reduction in mortality in women aged 40 to 49.
When Wright looked at the demonstration project data, he found that 3.58 per cent of women screened were referred for surgical consultation and 0.54 per cent were found to have cancer, meaning that 3.04 per cent had biopsies that turned out to be negative. When he looked at the mortality statistics from the Swedish and HIP studies, he saw that, yes, there did appear to be a 25- to 30-per-cent reduction in mortality in screened women over 50. But that’s the relative number.
To put it in a different context, Wright looked at the absolute number, asking, 25 to 30 per cent of what? To figure that out, he looked at the actual number of deaths. Ten-year data from the HIP study found 146 deaths among the 33,000 women in the screened group and 192 deaths in the same number of women in the control group. So there was a difference of 46, which is roughly 25 per cent of 192. But in absolute numbers, 46 lives saved out of 33,000 is 0.144 per cent of all the women screened.
The absolute numbers in the Swedish study revealed an even smaller reduction in mortality, only 0.049 per cent in the screened group. Another way to express it, Wright wrote in his paper, was that one in 694 in the HIP study benefited from screening and one in 2,041 benefited in the Swedish study. Calculating that the harm far outweighed the benefits, he wrote that the American Cancer Society’s recommendations should be ignored and that only women at high risk for breast cancer should be screened.
Soon after the article’s publication, Wright accepted an invitation to a conference on mammography at Johns Hopkins University in Baltimore. He has a vivid memory of what happened.
“They had a whole day of people telling this large national audience how wonderful mammography was, then I was there with a contrary opinion, with evidence I thought was fairly strong. I presented this paper which was greeted with a deathly silence, and lots of people were visibly upset.”
A coffee break followed his talk, and he was standing around, avoided by everyone except the organizer of the conference, “who felt he had to look after me,” Wright guesses. Then “a very angrylooking elderly radiologist came up and sort of punched me in the chest with his finger and said ‘You don’t understand, boy; you’ve got your hand in our pockets.’ ”
The radiologist needn’t have feared for his pockets. Charles Wright continued to speak out about screening, but he was no match for a mammography machine gaining momentum.
In October 1987, an announcement from the White House ensured that the momentum would gather force: Nancy Reagan was about to have surgery for breast cancer. The first lady had had an annual checkup and a screening mammogram. When the nurse who did the mammogram said she needed to do a few X-rays over again, Reagan’s stomach knotted.
After the additional tests, White House physician John Hutton came into the room with the grim news. “We think we’ve seen something,” he said. “We think it’s a tumour of the left breast. We’ll need a biopsy.” The next day, a cancer specialist told Reagan she had a choice of a lumpectomy to remove the tumour and a little surrounding tissue or a modified radical mastectomy.
Even though lumpectomies were becoming popular, she chose the mastectomy, not wanting to interrupt her busy schedule with the weeks of radiation that a lumpectomy would necessitate. Also, she was afraid that she’d never stop fretting about what might have been left behind if they didn’t take the entire breast. Just 11 days after her mammogram, she entered Bethesda Naval Hospital for surgery.
The surgeon planned to do a frozen section biopsy first. If the tumour were malignant, he would immediately pro- ceed with a mastectomy. “Please don’t wake me to have a conversation about it. Just do it,” Reagan commanded.
It turned out that the first lady had a tiny, non-invasive tumour, only seven millimetres in diameter, confined within a milk duct. About the size of a lemon seed, the width of a pencil, it was about the smallest tumour a mammogram could detect. When a White House press briefing released the details, some experts were critical of such an extreme response to so tiny a cancer.
Journalist and advocate Rose Kushner, who would have been disappointed that Reagan acquiesced to the one-step mastectomy she’d been fighting so long to stop, accused her of “setting women back 10 years.” But it was an incredible news story and a triumph for mammography.
When asked about the mastectomy, Reagan said the decision felt right for her, but she wasn’t trying to influence other women to do the same. She defended it as a feminist choice, hers to make. On the subject of screening, however, she was adamant that every woman should have an annual mammogram beginning at age 40. She became a mammography ambassador, actively participating in an American Cancer Society promotional campaign. Millions of women witnessed a serene Nancy Reagan, perfectly coiffed and wearing a simple grey dress, staring directly at them through their TV screens. She urged them to know one word: mammography. There could not be a more powerful endorsement.
The American Cancer Society was intent on convincing women that with early detection, breast cancer could be almost 100 per cent curable, although it had no evidence that was true. Charles Wright took note of its commercials and collected its magazine ads. In an interview for a CBC documentary in 1991, he accused the American Cancer Society of leading a conspiracy of hope.
“These are frankly lies which can only be understood, interpreted by the desire to generate this hope and there are certain medical, financial, political implications in all of this too of course.”
When he gave that interview, Wright had recently moved away from Saskatoon and from surgery to become vicepresident of medicine at Vancouver General Hospital. In1995, he moved into another administrative role as director of the Centre for Clinical Epidemiology and Evaluation at the University of British Columbia. He eventually stopped talking about mammography, frustrated that no one seemed to be listening.
“You don’t understand, boy; you’ve got your hand in our pockets.” AN ANGRY RADIOLOGIST CONFRONTING CHARLES WRIGHT
Excerpt from Chapter 4 “Conspiracy of Hope,” originally published in Conspiracy of Hope: The
Truth About Breast Cancer Screening copyright 2018 by Renée Pellerin. Reprinted by permission of Goose Lane Editions.