Breast Cancer Screening

Do I have breast cancer?

Report of the Task Force on Preventive Health Care

Breast cancer incidence, that is the chance of getting breast cancer has increased enormously since the war. From 1 in 50 back in the early 1950’s to 1 in 7-8 now (StatsCan).  It is true that we live much longer now after diagnosis (albeit with lots of misery…), because of tremendous advances in Molecular Cell Biology and other treatments.  Still, because of the 7-fold increase in incidence, the chances of dying from breast cancer today are essentially the same as back in the 50’s, at the time when even the double-helix of DNA was not discovered yet…

The key to survival is early detection.  Nobody seems to  disagree about that.  There has been a substantial progress in that front in recent years, with mammograms, ultrasound imaging and MRI, let alone our trained fingers.  Therefore, the guidelines released in December 2018 from the Canadian Task Force on Preventive Health Care (CTFPHC) recommending against screening for women in their 40s, against self-exam, against clinical exam, and the use of ultrasound and MRI came as somewhat of a surprise…

The Public Health Agency of Canada (PHAC, French: Agence de la santé publique du Canada) is an agency of the Government of Canada. PHAC is responsible for public health, emergency preparedness and response, and infectious and chronic disease control and prevention. It was formed by legislation that came into force in 2006.  The PHAC head is the Chief Public Health Officer of Canada, who reports to the Minister of Health.

PHAC funds the Task Force which is an independent panel of methodologists tasked with developing clinical practice guidelines to support family doctors in delivering preventive health care.  https://canadiantaskforce.ca/guidelines/

Besides breast cancer screening, the Task Force is tasked with making guidelines for 18 conditions, ranging from Hepatitis C, Prostate and ovarian cancer, to cognitive impairment and diabetes. The Task Force guidelines on breast cancer screening are to be used by 36,000 family doctors in their interactions with 9 million women aged 40-74 of average breast cancer risk.

According to their website, the Task Force consists of 14 members:  Seven family doctors, one occupational therapist, one chiropractor, one nephrologist/health economist, one epidemiologist, one Emergency doctor, one pediatrician/epidemiologist and the chair who is a psychologist (see the list below). One would think that, since the committee is charged to decide on policy on breast cancer screening, it should consist, at least in part, of breast imaging experts, but there is not a single radiologist or imaging expert in sight…

The absence of experts was intentional according to their website.  The reason offered is troubling: radiologists or breast imaging specialists have a “conflict of interest.” I fail to understand, are specialists so conflicted by greed, that their knowledge and experience are completely worthless and unwelcome?  Besides, are radiologists short on customers? Aren’t there long lines for mammograms even, never mind ultrasounds or MRI’s?  It took two full weeks for my mammogram to be scheduled, as the cancer may have been spreading!  Even so, whom are you going to consult for example for the strength of a bridge or a roof, if not an engineer?  Why consult non-imaging-experts for such an important matter?  Is the real reason to reduce access to care?

The Task Force released a report in 2011 and an update in December 2018 [1]. The report advises no screening for women 40-49 years old, although one sixth of breast cancer deaths and 24% of the years of life lost to breast cancer are in women diagnosed in their 40s. As a result, 4,000 Canadian women will die unnecessarily over the next decade if this recommendation is followed [7].

One reason offered in the report is that not much information can be gained from a mammogram. However, according to 130 breast cancer experts who signed a letter protesting the report, including Dr. Martin Yaffe, the Task Force relied heavily on old randomized clinical trials of mammography performed between the 1960’s and early 1990’s.  The methodology in these studies has been widely criticized in many publications [8-10]. The equipment used during that time was x-ray film mammography, which is outdated and obsolete.  It has been replaced globally by digital mammography and increasingly in the USA by digital breast tomosynthesis (3D mammography). The newer technology is better at finding cancers AND has fewer false alarms. Besides, if cancer is found early there are many more treatments today than back in the mid-nineties (eg Herceptin).

More recent evidence, that was ignored by the Task Force, shows significant mortality reduction from screening starting at age 40 [2,3].  In fact, women having mammograms are 44% less likely to die from breast cancer.  Actually, the most lives are saved when screening starts at age 40 and is performed annually [4]. A major methodology flaw of the Task Force guidelines is the fact that they do not consider the harm that can ensue from not screening. Recent studies show that not participating in screening mammography leads to a 60% higher chance of dying from breast cancer [3].

image of old breast cancer screening
image of current breast cancer screening technology

As a survivor, I would like to stress that death is not the only thing to consider.  What about the misery of radiation, surgery, aggressive chemotherapy, lymphedema, and above all, the threat of an early death hanging above your head?  Besides, the older studies did not even consider the years of life saved; it is more than obvious from the health economist’s point of view that when cancer is found early in younger women, more years of life are saved, than when found in older women [5].  And when found early, cancer can be treated with less aggressive therapy: lumpectomy instead of mastectomy, sentinel node biopsy instead of axillary dissection, and less or NO chemotherapy [6].

The report advises doctors to engage in shared decision making with the patient about having a mammogram or not.  But, nobody wants to risk death.  In order to decide, a woman needs accurate information first and foremost, but this is totally lacking.

A so-called harm of screening cited by the Task Force is the potential for false positives and the need to “avoid anxiety.”  Well, burying your head in the sand works better, ask any ostrich. Not knowing provokes the worst anxiety, and for a good reason…

Interestingly, the report also advises against self-examination. I fail to understand, what is the harm of simply trying to feel a lump?  The Canadian Cancer Society advocates to “know your body.”  How can you do that if you don’t even try to feel?

To top it off, the guidelines ignore the risks of breast density, that have been known for 40 years. Having dense breasts increases the risk of developing breast cancer and the risk that cancer will be missed on a mammogram. The guidelines advise against ultrasounds or MRI’s, which are the way to detect cancer early in the 40% of women with high breast density.

I had a mammogram 11 months before I discovered the lump that can kill and it did not show anything, it was supposedly “normal”. I am left to wonder if an ultrasound might have caught the devil at the in situ stage, so that I would not need to worry if I would see my kids grow up…

Of course, the Task Force would be tasked to find ways to contain costs. However, a cancer diagnosed after it has spread is far more expensive to treat, ie more money is spent, not less. Besides, the loss of a mother is not just her salary; you cannot give 10,000$ to a baby and tell him to grow up…

I have to add BCAK’s own story:  We lost a friend to breast cancer a few years ago. She was an athlete and a beautiful soul.  She went to her family doctor with a lump but he said it is “nothing”.  From that moment on she was doomed, because a young, healthy and strong person who can do twenty push-ups in one breath, will not suspect that this lump, that causes no pain, no fever, no discomfort of any kind, may kill her… Six months later, “it is getting bigger”, but again he said “it is nothing, don’t worry” etc. Well, she was diagnosed a short time after this and died two years later with metastases. We are left to wonder if her doctor had just been following these “guidelines”…

Being in good health is no protection from breast cancer. Actually, breast cancer is often more aggressive in young women…

In short, get your annual mammogram starting at 40 and keep doing self exams every month. There is a guide on our website under resources>self-education>breast self-examination, on how to do it right. If you feel any change ask for a mammogram, keeping this report in mind. If your breasts are dense ask for an ultrasound, or MRI.

 

This is the advice that the breast cancer experts are giving.

Please Note:  BCAK has always advocated for breast self-examination. We give out models of a breast with cancer lumps for free to health practitioners for training and demonstration purposes.

 

Aftermath:

 

The composition of the committee for 2018 is as follows:

Chair:  Brett D. Thombs, PhD, psychologist

Ainsley Moore, MD, MSc, CFCP, family physician

Heather Colquhoun, PhD, OT Reg. (Ont.), occupational therapist

Roland Grad, MDCM, MSc, FCFP, family medicine, McGill.

Stephane Groulx, MD, CCFP, FCFP, family physician

Michael Kidd, AM FAHMS,  Family Medicine

Scott Klarenbach, MD, MSc, FRCPC nephrologist

Eddy Lang, MDCM CCFP(EM) CSPQ,  Emergency Medicine

Nav Persaud, Msc, MD, CCFP,  Family Medicine

John Leblanc,  MD, MSc, FRCPC, FAAP,

Donna L. Reynolds,  MD, MSc, FCFP, FRCPC, Family Medicine

John Riva,  DC, MSc (epi), Family Medicine

Guylène Thèriault, MD, CCFP, Family Medicine

Brenda Wilson, MB ChB, MSc, MRCP (UK), FFPH, Public Health, Preventive Medicine

 

The Guidelines can be found here:

https://canadiantaskforce.ca/guidelines/published-guidelines/breast-cancer-update/

 

[1].  Klarenbach et al.  Recommendations on screening for breast cancer in women aged 40-74 years who are not at increased risk for breast cancer. (2018) Canadian Medical Association Journal, 190:E1441-E1451.

[2]. Coldman A et al. Pan-Canadian Study of Mammography Screening and Mortality from Breast Cancer. Journal of the National Cancer Institute, Volume 106:1-7. (2014). https://academic.oup.com/jnci/article/106/11/dju261/1496367

[3]. Tabar L et al. The Incidence of Fatal Breast Cancer Measures the Increased Effectiveness of Therapy in Women Participating in Mammography Screening. Cancer. 125:515-523 (2019). https://www.ncbi.nlm.nih.gov/pubmed/30411328 

[4]. Patel SB. (2018). Estimated Mortality of Breast Cancer Patients Based on Stage at Diagnosis and National Screening Guideline Categorization. Journal of the American college of Radiology 15:1206-1213. https://www.ncbi.nlm.nih.gov/pubmed/29793836

[5]. Hendrick ER et al. (2014). Implications of CISNET Modeling on Number Needed to Screen and Mortality Reduction With Digital Mammography in Women 40–49 Years Old. AJR Am J Roentgenol. 203:1379-81. https://www.ncbi.nlm.nih.gov/pubmed/25415718

[6]. Ahn S et al. (2018). Impact of Screening Mammography on Treatment in Women Diagnosed with Breast Cancer. Ann Surg Oncol. 25:2979-2986. https://www.ncbi.nlm.nih.gov/pubmed/29987612

[7].  Yaffe MJ, Mittmann N, Lee P, et al. Clinical outcomes of modelling mammography screening strategies. Health Reports. 2015 Dec 16;26(12):9-15. PMID: 2667623.
SM Moss, C Wale, R Smith, A Evans, H Cuckle, SW Duffy. Lancet Oncol 2015; 16: 1123–32. https://www.ncbi.nlm.nih.gov/pubmed/26206144

[8] Boyd NF et al (1993). A critical appraisal of the Canadian National Breast Cancer Screening Study. Radiology 189:  https://doi.org/10.1148/radiology.189.3.8234686

[9] Heywang-Köbrunner et al (2016). Conclusions for mammography screening after 25-year follow-up of the Canadian National Breast Cancer Screening Study (CNBSS).  European Radiology 26:342–350  https://link.springer.com/article/10.1007/s00330-015-3849-2

[10]. Kopans DB (2014). The Canadian National Breast Screening Trial Had So Many Flaws That Its Results Should Not Be Used to Guide Screening Recommendations. The ASCO post. April 15, 2014.  http://www.ascopost.com/issues/april-15-2014/the-canadian-national-breast-screening-trial-had-so-many-flaws-that-its-results-should-not-be-used-to-guide-screening-recommendations/