A breast imager's response

It's always difficult when I see a patient present with metastatic breast cancer who has missed a year of screening. Last week as I was performing biopsies on my patient for her tumour in the breast and the enlarged lymph node in the armpit, an unspoken question hung between us. If she had come for her mammogram last year, would her tumour have been diagnosed before it spread outside the breast?

That coincided with Peggy Orenstein's article in the New York Times in which she wondered whether the baseline mammogram she had in 1996 had in fact saved her life. Her mammogram was a "screening" mammogram, in other words, she was not feeling a lump. Every person's course is unique; I don't know Ms. Orenstein's situation, but to me, finding breast cancer in an otherwise healthy 35 year old has to be better than not knowing about it. 

I respect Ms. Orenstein's personal perspective; she has been through a major health concern. Much of her article asks whether screening all women over 40 on an annual basis is worth it.  My worry is that the science that demonstrates the value of screening is not being presented and represented clearly. Full disclosure: statistics has never been my strong suit, but I certainly know that several large trials and numerous population based studies have proved that mammography screening saves lives from breast cancer.  We can definitely debate whether as a society we want to pay for mammography screening, and whether the number of lives saved is enough to justify the cost. But if we don't screen, there will be women whose breast cancers are not diagnosed until they are palpable (able to be felt) and are larger than they would have been had they been picked up on mammography. 

Ms. Orenstein was unhappy with the response of Nancy Brinker from the Komen Foundation and tweeted me about that. Nancy Brinker makes the point that mammography is not perfect, but is still the best screening test available to us. As a breast imager, who also finds cancers on ultrasound and MRI that are invisible on mammograms, I could not agree more. But mammography is a widely available and relatively inexpensive way to find disease before it presents clinically. It also needs to be stressed that breast cancer is a disease where earlier treatment leads to better outcomes. That's the definition of a good screening test; you find it, and you can intervene and, thus alter the natural history of the disease.

When I tweeted about the article originally I said: "Ask your doctor if she still gets a mammogram every year, I bet she does". I do.