Screen it or Skip it?

Dr Laura J Esserman,a breast surgeon from the University of California,San Francisco,and author of a report in The Journal of the American Medical Association that touched off the latest debate about mammography,described breast cancers as slow,medium or fast in growth rate and aggressiveness.
She said screening seemed to be good at finding the slow ones,which probably didnt need treatment,but might not catch the aggressive and deadly types before they began to spread. But it also picks up the medium ones,and in that case,women may benefit most. Again,more research is needed to figure out which kind of tumour a patient has.

The first thing to talk about is whos helped and whos not, Dr Esserman said. In her view,women over 70 or 75 can stop being screened,because no studies have shown that it helps them. If they do develop breast cancer,it is likely to be a slow-growing type that will not kill them.
Like many other researchers,she said evidence was also lacking for a benefit in screening women from 40 to 50unless they have a strong family history of breast cancer or a mutation in a gene called BRCA,which greatly increases the risk.

For women 50 to 70,Dr Esserman said,the story is different. In that age range,there is good evidence that screening can reduce the risk of death from breast cancer by 20 to 30 per cent.
Also,she said,women should try to get a sense of their own risk,and if it is high,talk to a doctor about taking tamoxifen or raloxifene,drugs that can lower the risk.

One risk factor is having dense breast tissue,which is a double threat: cancer is more likely and harder to detect,because X-rays do not penetrate this tissue as well as they pass through fat. The only way to find out whether you have dense breasts is with a mammogram,and the radiologist8217;s report should mention density,Dr Esserman said.
Other risk factors include taking hormones to treat menopause symptoms; having a history of biopsies,no pregnancies before 30,or a mother or sister with breast cancer; and ageing.

Younger women,said Dr Susan Love,a breast surgeon and researcher in Santa Monica,California,are less likely to have cancer,and they tend to have dense breast tissue,so mammograms are more likely to miss tumours. For them,she said,its radiation without much benefit.
In European countries that screen every other year,she said,the breast cancer death rates are no higher than in the United States. She added that women from ages 50 to 70 should find out whether they have dense breasts,and those who do not could probably get by with less frequent mammograms.

But some researchers say that the benefits of yearly screening far outweigh the risks,and that if women skip it,gains against breast cancerdeath rates have declined in recent yearscould be undone.
Dr Larry Norton,deputy physician-in-chief for breast cancer programs at Memorial Sloan-Kettering Cancer Center in Manhattan,said by e-mail: Just because a test isnt perfect is no reason to abandon it while better tests are being developed. Say,someone fires a gun at you,and you know that there is a 30 per cent chance that the bullet is a blank. Do you not still duck?

Dr Norton also emphasises that finding tumours when small,which mammograms can do,increases the odds that the patient will be able to avoid mastectomy and chemotherapy.
But Dr Silvia C Formenti,the chairwoman of radiation oncology at New York University Langone Medical Center,said: I dont think there is enough debate. Screening does not pay off the way we expected.
Dr Formenti said she was concerned about finding tumours in older people that would probably not kill them. But the diagnosis turns them into cancer patients and erodes their peace of mind forever.

We take away the innocence of being healthy and not having to worry about cancer, she said. The psychological cost of becoming a cancer patient is underrated. Dr Formenti said the emphasis on screening has misled the public into thinking that screening could prevent cancer. Its a giant misconception, she said.
Nonetheless,she said,between 50 and 60 is a good time to be screened and women over 60 may still benefit,though the evidence is not as strong. But she emphasised that women of all ages needed to assess their risks when making decisions about being screened,and that all should have their breasts examined once a year by a doctor to check for lumps or other abnormalities. An experienced doctor can feel lumps one centimeter and larger,she said,noting that even masses as large as five centimeters can still be removed by lumpectomy.
_Denise Grady,NYT