One person's positive mammogram test

"A health journalist who has written about changing guidelines for breast cancer screenings finds herself caught between statistics and personal decisions."

In a previous blog post, I mentioned that there is some debate over when to begin mammogram screening for breast cancer. The U.S. Preventive Services Task Force (USPSTF) recommends that mammograms begin at 50, whereas the American Cancer Society (ACS) recommends that mammograms begin at 40. In the post, I referred to new research that showed that the majority of breast cancers deaths (71%) in the study occurred in women who had not undergone breast cancer screening, thus arguing for earlier screening.

Last week the Boston Globe ran a story by a health journalist who had previously written about this debate. She herself began mammogram screening when she was 40; the positive test occurred when she was 46.

Her reaction: "Phew."

The diagnosis was ductal carcinoma in situ (DCIS) which is the most common type of noninvasive breast cancer and is considered the earliest form of breast cancer (stage 0). A key point is that DCIS is noninvasive so that it hasn't spread out of the milk duct to invade tissue in other regions of the breast. It accounts for about 60,000 (30%) of the country’s 200,000 breast cancer diagnoses annually.

However as the author points out the prevalence DCIS is an important reason why researchers argue for delaying mammograms:

"One reason a growing number of researchers discourage early mammograms is that many more women will be diagnosed with DCIS and, they argue, get needless, invasive treatment. In an estimated 70-80 percent of DCIS cases, the cancer cells will never leave the ducts, never metastasize into the rest of your body, and never kill you. Had I waited until I was 50 to get my first mammogram, it’s likely doctors would have found the very same DCIS — still sitting demurely inside my ducts — and we could have dealt with it then."

Yet there is a compelling counter-argument:

"But it’s also possible I would have been among the smaller percentage for whom DCIS cells become more aggressive, nudge their way out of the ducts and become invasive. Since there’s currently no clinical test to tell who is in which group, most oncologists assume you’re at the highest risk and treat accordingly. That approach jibes well with my own worldview — namely, that there’s no such thing as overtreatment when the person being treated is you."

Most women with DCIS are effectively treated with breast-conserving surgery (lumpectomy) and radiation, and in some cases hormone treatment with tamoxifen. The alternative is total mastectomy (removal of breast), but this has not been shown to be significantly more effective than the lumpectomy. The author elected for the lumpectomy with radiation treatment overcoming her reservations about the radiation:

"In women with DCIS, she pointed out, the 12-year likelihood of recurrence — either DCIS again or invasive cancer — went from 31 percent without radiation down to about 16 percent with radiation."

There are risks associated with the radiation treatment including damage to the heart and lungs but they are considered minor.

Interestingly, the author also chose the tamoxifen treatment:

"Studies show that about 9 percent of women with my grade of DCIS, after lumpectomy and radiation, still get invasive cancer within five years. That number goes down to about 5 percent among those who take Tamoxifen. Was that statistical boost worth the small but scary risks of Tamoxifen, including stroke, blood clots, and uterine cancer? Not to mention the menopausal-like hot flashes and night sweats that some women report?"

On a personal note, I would add that one of my close relatives was diagnosed with DCIS. She chose a lumpectomy with radiation treatment but no tamoxifen.

Every breast cancer story is a little different, and every person's reaction will be different. But it is important to pay close attention to the numbers to make the best possible decisions for your own case:

"It’s indoor track season now, and between my son’s events, as I nurse my irradiated skin and push through the fatigue, I’ve had a lot of time on the bleachers to think. I finally realized that I can only do so much to minimize risk; either I get cancer again or I don’t, no matter what the numbers say. Nor can I eliminate worry; that’s who I am, and what I do. But by over-analyzing each statistic, driving my doctors crazy, and accepting my own psychological comfort level, I feel I’ve done all I can to minimize regret."

Figure 1. Freelance writer Karen Brown and her husband, Sean Norton, organize paperwork related to Brown’s cancer treatment at their home in Northampton (Matthew Cavanaugh for the Globe).