Los Angeles Times
It isn’t uncommon for cancer survivors to write letters reacting negatively (and passionately) to articles questioning the usefulness of certain treatments or screening methods. What is unusual is for doctors to react with zeal in letters to the editor when one of their colleagues presents a contrarian opinion.
That’s exactly what happened with Dr. H. Gilbert Welch’s op-ed article on Sunday saying regular mammograms for woman over 40 may cause more harm than good, and that we should be performing fewer of them. On Tuesday, The Times published two letters — one from a doctor and one from a cancer survivor — in response to Welch’s piece; since then, several more physicians (many of them experts in breast imaging) have sent us letters. Their reactions range from clarifying the opinions held by the majority of physicians who treat breast-cancer patients (they say women should still get screened regularly starting at age 40) to questioning Welch’s science and motivation.
Dr. Kenneth Offit of the Memorial Sloan Kettering Cancer Center in New York City says mammography, though imperfect, is an important tool in fighting breast cancer:
While Dr. Welch raises
important questions regarding breast cancer screening, the vast majority of cancer care physicians endorse screening when our patients ask us whether they should have mammograms. We remain impressed by the evidence that mammography screening saves lives.
As observed in the editorial accompanying Dr. Welch’s most recent scientific publication, it remains impossible to predict when an individual mammogram will result in “overdiagnosis” of a cancer that might never progress. While newer methods of risk assessment using genomic and other markers should allow adjustment of type and timing of breast cancer screening, until then, mammography remains a reliable and proven means to detect cancers at their earliest, most curable stages.
Dr. Dana Smetherman, a radiologist in New Orleans, says finding those “small breast cancers” is precisely the goal of screening:
Dr. Welch is correct that “over time and over place, the findings are consistent: Screening is good at finding small breast cancers.” This is actually the goal of screening — identifying early-stage disease when it is most likely to be cured with the least aggressive treatment.
As noted by the United States Preventive Services Task Force, the number of lives saved from death by breast cancer is maximized when annual screening mammography begins at age 40. Suggesting that women cannot judge for themselves whether “harms” (like anxiety) from a false positive outweigh the risk of dying from breast cancer smacks of paternalism.
Also, stating that women are treated for cancers that are “not destined to cause symptoms … or be lifethreatening” wrongly implies that doctors can currently predict which cancers will become lethal.