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How To Avoid Overdiagnosis And Overtreatment Of Breast Cancer

This article is more than 8 years old.

One way a woman can avoid the reported risks of breast cancer overdiagnosis is by not getting screened. That way, there’s little chance she’d find out she has breast cancer, even if she does have breast cancer, until the lump or irregular mass gets so large that she can feel it, or notices it ulcerating through skin, or she experiences pain (a late sign).

Waiting until breast cancer becomes obvious would, entirely, eliminate the risk of overdiagnosis.

It takes about a billion cells for a tumor to reach the size of one centimeter, less than half an inch, in diameter. So if a woman goes unscreened for a few years, a breast cancer might remain out of sight and out of mind, happily, while it gains several billion cells or more, acquiring occasional mutations as those cells divide, fast or slow, and with increasing probability over time, spread to the lymph nodes in the armpit, and then to other body parts.

Not to scare you, or anything, but I’m worried about underdiagnosis, an under-reported complication of not getting screened for breast cancer.

The problem is, first, that breast cancer is not rare. Far from it (see below). Second, breast cancer kills many people (ditto). Knowing how much progress there’s been, and the differential survival by stage (with metastatic disease, 5-year survival is 26 percent), I can’t fathom how anyone would think it OK not to remove, or not to want to remove, an invasive breast cancer found in a woman who’s generally healthy, in her forties, fifties or sixties, and possibly older, before it spreads.

Here’s a better way to avoid overdiagnosis and overtreatment of breast cancer:

1. Have screening performed only by breast imaging specialists.

Radiologists vary in their skills (like surgeons). Experience matters. (One limitation of “ecological” and other population-based studies of breast cancer screening is that these don’t evaluate outcomes after mammograms performed in well-equipped facilities, or by individual radiologists, some of who have much larger practice volumes and knowledge than others.)

Radiologists who've seen more breast images are more likely to distinguish probable breast cancer from spots that aren’t likely to be cancer. For this reason, it makes sense for mammograms to be taken and interpreted, possibly exclusively, by breast imaging sub-specialists. This sort of limitation, a restriction on who can perform mammography, should increase screening’s accuracy and lower the false positive rate. It’s a change that would not necessarily be welcome in radiology circles.

But as millions of screening mammograms are performed each year in the U.S., and these are elective procedures, there is no reason why a general radiologist should step in, or make it her business, to perform these evaluations. (There's enough work in this field to keep sub-specialists busy.) And if the images need be sent electronically to a specialized center for further interpretation or an expert opinion, why not? If a sonogram or other supplemental studies, such as MRI or MBI are considered, those too should be evaluated by doctors who have completed extra training in breast imaging. If a biopsy is needed, a woman might have to travel to a specialized center, to have it performed under local anesthesia with ultrasound or other guidance, with a needle.

Given the numbers of screening mammograms performed, and occasional biopsies, there’s no reason why every U.S. state can’t have several centers for breast imaging where these procedures would become routine. It would be worth it – not just to lower the rate of false positive results leading to biopsy – but to improve the detection rate (lower false negatives) and to get the biopsy samples, all, to modern pathology labs.

2. Realize that “overdiagnosis,” if it exists, is not the same as overtreatment, and can be remedied by better education of physicians.

Overdiagnosis of cancer refers to detection of tiny or slow-growing malignancies that are unlikely to cause harm. But finding an early-stage tumor or pre-cancerous condition is fundamentally no different than obtaining other medical information of uncertain significance, such as an abnormal genetic test result. It can be unsettling, and cause worry, but the information in itself is not harmful. The key is not overreacting.

If overtreatment is really the problem – due to fear and overreaction after finding low-grade tumors –the solution is not by avoidance of breast cancer detection, but by better education of physicians and patients. It’s crucial that doctors be knowledgeable about modern pathology, so that they can help patients interpret results and choose the best and most appropriate treatment, which could be minimal, depending on the condition found. Continuing education of practicing physicians, about molecular diagnostics and cancer subtypes, should be required for oncologists, breast surgeons, gynecologists, radiologists, primary care physicians and all others involved in advising women what to do about breast biopsy results.

3. Invest in better screening.

Every day, women are dying from breast cancer. It would be great if there were a blood test for detecting breast cancer, but there isn’t. It would be fantastic if we could prevent it, but as we still don’t know what causes breast cancer in most cases, that’s improbable by 2020 or the foreseeable future. Meanwhile a woman might choose to get screened by the best method available.

To promote quality screening – accurate and safe detection of early breast tumors – means investing in current technology and providing universal access, for women in all regions in all U.S. states, to MQSA-accredited, well-run and modern breast imaging facilities. By maintaining high standards in radiology, women could, instead of being dissuaded by alarmist headlines about screening’s alleged hazards, be reassured about the low doses of radiation involved in this procedure, which can in most cases – especially if performed by an expert radiologist – be performed every other year, safely, and well.

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Of course, no one should be forced to get a mammogram. There are women who prefer not to know if they have breast cancer. Some are terrified of screening. Either way, each woman, and the doctors she might ask about mammography, should be aware of current technology and facts:

Invasive breast cancer is common. The chances of an invasive breast cancer diagnosis are well-documented for U.S. women, and increase with age: ages 20 – 29 years, 1 in 1,732; ages 30 – 39, 1 in 228; ages 40 - 49, 1 in 69; ages 50- 59, 1 in 43; ages 60 – 69, 1 in 29; ages 70 – 79, 1 in 26; (lifetime risk, 1 in 8). Another way of considering these numbers, for possible screening, is that invasive breast cancer affects 1.45 percent of women in their forties, 2.3 percent in their fifties, and 3.5 percent in their sixties. Depending on the accuracy of the test, you might consider that Bayes’ theorem kicks in – when the likelihood of a positive test revealing true disease is high enough to justify screening – starting at age 40 years.

Breast cancer can be fatal. Nearly all deaths from breast cancer occur in patients with advanced, metastatic disease. In the United States, over 40,000 people die from breast cancer per year, which is nearly 110 deaths per day. According to the U.S. Centers for Disease Control, cancer is the leading cause of death in women between the ages of 35 and 64. For those under age 60 years, breast cancer is the leading malignant killer. Despite a rise in invasive breast cancer cases (not just DCIS), deaths have dropped since 1989, by 34 percent – as considered here.

Overall – and when considered in the context of long-term survival trends over decades – the favorable trends cannot be explained away by lead-time bias. With a diagnosis of metastatic breast cancer, the 5-year survival rate is 26 percent; for breast cancer that hasn’t spread to the lymph nodes, relative 5-year survival is 98 percent. At 15 years, relative survival for all women diagnosed with invasive breast cancer exceeds 78 percent.

There is no question that finding breast cancer early has an enormous impact on treatment options and survival. Perhaps, you might wonder, if screening – done better, everywhere – could reduce health care costs.

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