Reply #19: I'm not sure.

[bluedawg12]

But, I'll give this another try.

>>No one is saying that. Even if up to 80% (the figures vary) of ductal carcinoma in situ will not be ultimately life-threatening, most women, of course, once diagnosed would not want to wait around and hope for the best. But what harm - both psychological and physical - is being done to the up to 80% that didn't need aggressive treatment? - JenniferJuniper <<

I’m not talking about treatment at all. I am talking about having as many tools as possible to monitor breast health. I am talking about getting to the point of knowing if there is or is not a tumor and then, determining what the tumor is and how it will likely behave.

Whether to treat it or not, or to treat it aggressively is not the discussion we are having.

The discussion was about mammography.
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JenniferJuniper (697 posts) Sat Mar-07-09 04:10 PM
4. Mammograms do not prevent cancer so the statement that undergoing fewer of them might cause higher rates of cancer is misleading.


bluedawg12 (1000+ posts) Sat Mar-07-09 11:07 PM
Response to Reply #4
7. Mammograms are a diagostic tool for early detection of breast cancer
early detection means that when the diagnosis is made it is less likely to be in a later stage with metastasis.
The correct statement should have read:"Research has shown that lesbians undergo fewer mammograms than heterosexual women and perhaps as a consequence, may suffer higher rates of late stage breast cancer , she said.
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>>Point one is that mammograms (and for different reasons, MRIs) are a lousy screening tool for many reasons which I won't further delineate here. - JenniferJuniper <<

OK, that’s disappointing, because it started to get interesting, because, while most people would know that they are not 100% able to detect all forms and all stages of breast cancer, is the issue then that there is something better, or that, in your opinion they are minimally effective, or not at all effective? That’s disappointing that you would not delineate.

>>Leading into point two - which is where we started - does early detection really as much good as claimed in the case of most breast cancers? Yes, lives are saved. - - JenniferJuniper <<

“ Lives are saved,” that’s pretty much my area of interest in this discussion. Are lives saved? Are lives saved at a rate that makes the screening what? Cost effective? Or is it that the yield of diagnosis is so low that it is medically meaningless? What are you saying?

>>And this must be balanced with an understanding of the harm that over-diagnosing and over-treatment can cause. - JenniferJuniper <<

This is true and this is phase two and as I said earlier, making a diagnosis is the first step. A very personal step and one that is mitigated by unique personal health history and a discussion with your health care provider.

Please note, I have not made any suggestions about who should get mammograms, how often, or why, because that is a personal decision made with your health care provider.

OK, for the sake of discussion, let’s assume there is a diagnosis, then what is to be done?

Well, my first thought is that a mammogram alone is not sufficient to make a diagnosis, so one of several things will happen.

a.) Do nothing, observe and perhaps repeat the mammogram in six months, a year or two. Again many variables.

b.) Recommend an additional test. Perhaps an ultrasound or MRI.

c.) Recommend a biopsy.

My thought, at each step of the way, from a through c, ask for a diagnosis in writing and if necessary a second opinion from either an oncologist or breast surgeon. Or, simply take the piece of paper home with the diagnosis and look up the diagnosis and educate yourself on the term, including the various types of breast cancer, their diagnoses, symptoms, tests and treatments.


The same thing holds true in the event that G-d forbid a histopathologic diagnosis is made and confirms one of the variety of breast cancers. Take the path report home and get a clear diagnosis in writing, and go home and read as much as you can to be self informed before deciding on treatment. A few days of rest away from a clinical setting, a chance to think calmly and a chance to study the options and then, a return appointment to finalize things.


>>Just a few weeks ago, a new (and controversial) study found that up to 22% of breast cancers will resolve on their own. You can read about it here: http://www.medpagetoday.com/HematologyOncology/BreastCa... - JenniferJuniper<<


No this is completely false. The study did not find that up to 22% of breast cancer will resolve on their own. Here is the abstract for that study and what they conclude. Please note, that “appears” and “that some cancers” and the words “raises the possibility” that
“the natural course of some screen-detected invasive breast cancers is to spontaneously regress.”

That is not at all what you assert: “the study found that up to 22% of breast cancers will resolve on their own. - JenniferJuniper”

That’s wrong and misinformation for any woman reader who may see this and be misled.

Here's what they said:

“Because the cumulative incidence among controls never reached that of the screened group, it appears that some breast cancers detected by repeated mammographic screening would not persist to be detectable by a single mammogram at the end of 6 years. This raises the possibility that the natural course of some screen-detected invasive breast cancers is to spontaneously regress.” (1)

This is a preliminary study and they didn't even know the type of cancers they were speculating about.

I hope their research is fruitful. I would like to thin that 20% of any and all breast cancer regresses, but, that is not what that paper said.

Also, you never provided any citations for your generous statement that 80% of ductal carcinoma will not be life threatening. Would you kindly provide a reference for myself and other readers?

“Even if up to 80% (the figures vary) of ductal carcinoma in situ will not be ultimately life-threatening, most women, of course, once diagnosed ...But what harm ...is being done to the up to 80% that didn't need aggressive treatment?”

The journal article I cited, showed that about 50% will likely recur.

“This makes the assumption that all DCIS will inevitably progress to invasive carcinoma; however, much about the behaviour of DCIS is still poorly understood because opportunities to study its natural history are limited.

Over recent years, large clinical trials and follow-up on several important studies in which patients received diagnostic biopsy alone as treatment for their DCIS have provided further insight into the behaviour of this disease.

The latter studies, which are biased towards lower-grade lesions, show that, untreated, up to 50% of DCIS lesions progress to invasive disease, and that the time for progression may be up to four decades <4,5>.

Conversely, this also indicates that half of these lesions do not progress to invasive disease within a woman's lifetime. The challenge is to define better ways of quantifying the risk of progression for individual lesions in order to better tailor treatment decisions.”(2)

It’s not starting at four decades, recurrence can occur in under six years:

“Bijker and colleagues <11> followed up 775 cases of DCIS as part of a randomised clinical trial of breast conserving surgery for DCIS with or without radiotherapy. Recurrence was detected in 125 cases at a median follow-up of 5.4 years: 65 developed recurrent DCIS whilst 60 developed invasive breast cancer.” (2)

You raised some interesting points and did not elaborate.

>>“But I reiterate that we should be demanding more. More focus on TRUE prevention. Better screening tools. And better information and education about the over-diagnosis scenario.” - JenniferJuniper<<

I am asking this on the assumption that you do care, that you may some serious information to impart and that being aware that this is a public forum where you and I are not chatting in private, if you do have some good information on prevention and diagnosis I would ask you to share that for myself as well, as for other readers.

What is TRUE prevention?
What are better screening tools.

I agree about the education regarding over-diagnosis scenario.

Finally, here is a 2008 peer reviewed paper from the UK that found: “The results suggest that the National Breast Screening Programme in East Anglia is achieving a reduction in breast cancer deaths, which is at least consistent with the results from the randomised controlled trials of mammographic screening.” (3)

However, as with most things in medicine, I can also find you one from the year before that says it’s unproven. There are no cook book answers.

Here is a site that covers the different diagnostic techniques:

http://www.radiologyinfo.org/en/sitemap/modal-alias.cfm?modal=MAMMO


Citations:

(1) Arch Intern Med. 2008 Nov 24;168(21):2311-6.

The natural history of invasive breast cancers detected by screening mammography.Zahl PH, Maehlen J, Welch HG.
VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT 05009, USA.

BACKGROUND: The introduction of screening mammography has been associated with sustained increases in breast cancer incidence. The natural history of these screen-detected cancers is not well understood. METHODS: We compared cumulative breast cancer incidence in age-matched cohorts of women residing in 4 Norwegian counties before and after the initiation of biennial mammography. The screened group included all women who were invited for all 3 rounds of screening during the period 1996 through 2001 (age range in 1996, 50-64 years). The control group included all women who would have been invited for screening had there been a screening program during the period 1992 through 1997 (age range in 1992, 50-64 years). All women in the control group were invited to undergo a 1-time prevalence screen at the end of their observation period. Screening attendance was similar in both groups (screened, 78.3%, and controls, 79.5%). Counts of incident invasive breast cancers were obtained from the Norwegian Cancer Registry (in situ cancers were excluded). RESULTS: As expected, before the age-matched controls were invited to be screened at the end of their observation period, the cumulative incidence of invasive breast cancer was significantly higher in the screened group than in the controls (4-year cumulative incidence: 1268 vs 810 per 100 000 population; relative rate, 1.57; 95% confidence interval, 1.44-1.70). Even after prevalence screening in controls, however, the cumulative incidence of invasive breast cancer remained 22% higher in the screened group (6-year cumulative incidence: 1909 vs 1564 per 100 000 population; relative rate, 1.22; 95% confidence interval, 1.16-1.30). Higher incidence was observed in screened women at each year of age. CONCLUSIONS: Because the cumulative incidence among controls never reached that of the screened group, it appears that some breast cancers detected by repeated mammographic screening would not persist to be detectable by a single mammogram at the end of 6 years. This raises the possibility that the natural course of some screen-detected invasive breast cancers is to spontaneously regress.

(2) http://www.pubmedcentral.nih.gov/articlerender.fcgi?art...

Breast Cancer Res. 2006; 8(2): 204.
Published online 2006 April 21. doi: 10.1186/bcr1397. PMCID: PMC1557717

Copyright © 2006 BioMed Central Ltd
Overdiagnosis and overtreatment of breast cancer: Progression of ductal carcinoma in situ: the pathological perspective
J Louise Jones1
1Tumour Biology Laboratory, Institute of Cancer, Queen Mary's School of Medicine and Dentistry, Charterhouse Square, London, UK

(3) Br J Cancer. 2008 Jan 15;98(1):206-9. Epub 2007 Dec 4.
A case-control study of the impact of the East Anglian breast screening programme on breast cancer mortality.Allgood PC, Warwick J, Warren RM, Day NE, Duffy SW.
Cancer Research UK Department of Epidemiology, Mathematics and Statistics, Wolfson Institute of Preventive Medicine, Charterhouse Square, London EC1M 6BQ, UK. [email protected]

Although breast cancer screening has been shown to work in randomised trials, there is a need to evaluate service screening programmes to ensure that they are delivering the benefit indicated by the trials. We carried out a case-control study to investigate the effect of mammography service screening, in the NHS breast screening programme, on breast cancer mortality in the East Anglian region of the UK. Cases were deaths from breast cancer in women diagnosed between the ages of 50 and 70 years, following the instigation of the East Anglia Breast Screening Programme in 1989. The controls were women (two per case) who had not died of breast cancer, from the same area, matched by date of birth to the cases. Each control was known to be alive at the time of death of her matched case. All women were known to the breast screening programme and were invited, at least once, to be screened. There were 284 cases and 568 controls. The odds ratio (OR) for risk of death from breast cancer in women who attended at least one routine screen compared to those who did not attend was 0.35 (CI: 0.24, 0.50). Adjusting for self-selection bias gave an estimate of the breast cancer mortality reduction associated with invitation to screening of 35% (OR=0.65, 95% CI: 0.48, 0.88). The effect of actually being screened was a 48% breast cancer mortality reduction (OR=0.52, 95% CI: 0.32, 0.84). The results suggest that the National Breast Screening Programme in East Anglia is achieving a reduction in breast cancer deaths, which is at least consistent with the results from the randomised controlled trials of mammographic screening.

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