Recently I had the unsettling experience of being called back for additional views of my left breast after my screening mammogram. I had questions for the radiologist prior to consenting to the additional views and he had one for me, where had I gotten last year’s mammogram? I replied I hadn’t as I was following the U.S. Preventive Services Task Force (USPSTF) recommendation that average-risk women get mammograms every 2 years. Many doctors, particularly radiologists, don’t buy into the recommendations and advocate for yearly mammograms. The radiologist implied if I’d had a mammogram last year, we’d know more about the suspicious finding on this year’s mammo. In other words, if something was wrong, it was my own damn fault. Call me cynical, but any group that makes a steady income on screening procedures isn’t likely to agree with a recommendation that will cost them business.
I choose to follow the guidelines because I’m a little suspicious of the entire screening mammography experience, particularly when the National Cancer Institute website points out “Potential harms of screening mammography include false-negative results, false-positive results, overdiagnosis, overtreatment, and radiation exposure.”
As medical science looks at cancer more closely, it turns out that some abnormalities labeled as cancer are not a threat to a women’s health and will not lead to death (A similar conclusion was reached after screening males for prostate cancer became widespread and led to overdiagnosis and overtreatment). The New England Journal of Medicine recently reported on breast cancer overdiagnosis, defined as cancer that doesn’t need treatment. The study found that up to one third of breast cancer diagnoses, between 50,000 to 70,000 cases annually, don’t need treatment. Experts even debate whether one type of cancer, DCIS (ductal cancer in situ), should even be called cancer. In a 2006 study founded by the Susan G. Komen foundation, they estimated that 90,000 diagnoses of DCIS were actually misdiagnosed because of pathologist error, leading to incorrect treatment. So medicine is really great at FINDING cancer, not so good at figuring out whether it needs to be treated.
Cancer treatment comes with it’s own set of risks. Errors involving chemotherapy and radiation treatment helped to define the patient safety movement. When 32 year old health columnist Betsy Lehman died after receiving a massive overdose of chemotherapy four days in a row in 1994 at Dana Farber, institutional policies changed to include double checking of medication calculations and closer supervision of physicians in fellowship training. Even so, a second patient subsequently suffered a chemotherapy overdose of the same medication. Radiation treatment holds the same risk of the cure being worse than the treatment. In 2007 a man with tongue cancer died of a radiation treatment overdose that left him deaf, partially blind, unable to swallow, and caused his teeth to fall out. Even after the cause of his radiation overdose was identified, other patients around the country suffered a similar fate.
When all was said and done, my repeat mammogram turned out to likely be a cyst and a six month view of the breast should bear that out. If the diagnosis had been different, how would it have felt to challenge the doctors treating me? Asking for a second, independent pathology review, double checking all medication calculations, and, in the case of radiation, learning about the equipment and asking questions to ensure it was properly calibrated and set up all seems like a large burden for someone coping with cancer. Even more troubling is the thought that questioning the supposed experts could lead to an adversarial relationship with the medical team. It’s too easy in healthcare to label someone a bad patient or noncompliant when they question the doctor.
The problem is that many of the truths that medicine hold true aren’t true at all. Receiving a cancer diagnosis must be hard enough. Having to question it’s validity and treatment is a burden no one should have to bear.