tag:theconversation.com,2011:/global/topics/breast-cancer-screening-8214/articlesBreast cancer screening – The Conversation2024-03-19T14:07:42Ztag:theconversation.com,2011:article/2258602024-03-19T14:07:42Z2024-03-19T14:07:42ZWhat breast cancer risk assessments can tell you<figure><img src="https://images.theconversation.com/files/582489/original/file-20240318-22-a2250w.jpg?ixlib=rb-1.1.0&rect=0%2C5%2C3589%2C2495&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">After her doctor calculated her breast cancer risk, Munn went on to have further tests which ultimately revealed her cancer.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/olivia-munn-23rd-annual-critics-choice-1020846856">Tinseltown/ Shutterstock</a></span></figcaption></figure><p>Actress Olivia Munn recently shared on social media that she had undergone a double mastectomy after being diagnosed with <a href="https://www.bbc.co.uk/news/entertainment-arts-68554938">luminal B breast cancer</a>. In <a href="https://www.instagram.com/p/C4dXfrULDdJ/?img_index=1">an Instagram post</a>, Munn explained how she had been diagnosed with the fast-growing cancer.</p>
<p>The actress had initially undergone genetic testing in an effort to be proactive about her health. Munn tested negative for mutations of the BRCA gene, which is associated with a <a href="https://www.nature.com/articles/nrc2054">much higher risk of breast cancer</a>. Still, Munn’s doctor decided to calculate her “Breast Cancer Risk Assessment Score” by looking at other factors known to increase risk of the disease. </p>
<p>The test revealed Munn had a 37% risk of developing breast cancer in her lifetime. Munn subsequently decided to undergo further testing, which revealed she had cancer. Many people reading this story may be wondering whether they should also have a breast cancer risk assessment done – and what this would entail.</p>
<p>In general, a breast cancer risk assessment involves evaluating various factors that can contribute to a person’s likelihood of developing breast cancer. Some factors that would be taken into consideration include: </p>
<h2>1. Age</h2>
<p>Age is a major risk factor for breast cancer. The older you are, the more likely you are to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4491690">develop breast cancer</a>.</p>
<p>About 80% of breast cancer cases occur in woman over 50, who have been through the menopause. This is one reason why all women aged 50-71 should be <a href="https://www.nhs.uk/conditions/breast-screening-mammogram/">screened for breast cancer</a> every three years. </p>
<h2>2. Family history</h2>
<p>Having a mother, sister or daughter (referred to as a “first-degree relative”) diagnosed with breast cancer approximately <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8428369/">doubles the risk of breast cancer</a>. This risk is even higher the more close relatives you know who have had breast cancer, or if a relative developed breast cancer under the age of 50. </p>
<p>While family history of breast cancer on your mother’s side is associated with greater risk, history of breast cancer on the father’s side shouldn’t be <a href="https://pubmed.ncbi.nlm.nih.gov/12697961/">dismissed</a> either. </p>
<h2>3. Genetic mutations</h2>
<p>Mutations in genes such as <a href="https://www.nature.com/articles/nrc2054">BRCA1 and BRCA2</a> are associated with a higher risk of breast cancer and ovarian cancer, with these cancers occurring at younger ages.</p>
<p>About <a href="https://pubmed.ncbi.nlm.nih.gov/33301022/">10-13% of women will develop breast cancer</a> at some point in their lives and most of these cases do not have predisposing mutations, <a href="https://pubmed.ncbi.nlm.nih.gov/32710860/">such as changes in BRCA1 or BRCA2 genes</a>. By contrast, most women who inherit a harmful BRCA1 or BRCA2 gene variant <a href="https://pubmed.ncbi.nlm.nih.gov/30572612/">will develop breast cancer</a> by 70-80 years of age if they aren’t followed up and treated properly, for example with bilateral (meaning both sides) mastectomies.</p>
<p>But these may not be the only genetic mutations which increase breast cancer risk. In Munn’s case, although she didn’t have a BRCA mutation, she may have had other genes which we’re now understanding have a role – such as the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8152746/">ATM gene</a> or the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7066089/">CHEK2 gene</a>. </p>
<p>Importantly, genetic tests are now much quicker and easier to access than they used to be – and <a href="https://www.nice.org.uk/guidance/cg164">can often be accessed</a> on the NHS. </p>
<h2>4. Medical history</h2>
<p>Previous breast biopsies and benign breast conditions (such as fibroadenomas or pre-cancerous lesions in the breast tissue) would all be taken into account as they can be associated with an increase breast cancer risk. </p>
<figure class="align-center ">
<img alt="An older woman and her female doctor both look down at a clipboard the doctor is holding." src="https://images.theconversation.com/files/582493/original/file-20240318-30-uxd635.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/582493/original/file-20240318-30-uxd635.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/582493/original/file-20240318-30-uxd635.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/582493/original/file-20240318-30-uxd635.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/582493/original/file-20240318-30-uxd635.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/582493/original/file-20240318-30-uxd635.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/582493/original/file-20240318-30-uxd635.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Your doctor would also take her medical history into account when assessing risk.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-doctor-sits-her-desk-chats-1679462023">Lordn/ Shutterstock</a></span>
</figcaption>
</figure>
<p>A doctor would also look at a person’s hormonal and reproductive health, looking specifically at when they had their <a href="https://pubmed.ncbi.nlm.nih.gov/23084519/">first period</a>, when they had their <a href="https://linkinghub.elsevier.com/retrieve/pii/S030146810960579X">first full-term pregnancy</a> and if they were <a href="https://pubmed.ncbi.nlm.nih.gov/19450345/">pre or post-menopausal</a>.</p>
<p>Research <a href="https://www.nature.com/articles/s41467-023-40608-z">published by my team</a> explored the mechanisms by which delaying a first pregnancy to the late-30s increases the <a href="https://www.telegraph.co.uk/news/2023/09/06/breast-cancer-risk-pregnancy-older-mothers-age-mutation/">risk of breast cancer</a>. We discovered that changes that occur in the breast’s tissues during pregnancy can ultimately trigger more mutations to occur in the breast’s tissue over time.</p>
<h2>5. Breast density</h2>
<p>Having very dense breasts is a risk factor for breast cancer and is associated with a <a href="https://pubmed.ncbi.nlm.nih.gov/36183671/">doubling of risk</a>.</p>
<p>A person is considered to have <a href="https://www.cancer.gov/types/breast/breast-changes/dense-breasts">dense breasts</a> if they have high amounts of glandular tissue and connective tissue and low amounts of fatty breast tissue. <a href="https://www.cdc.gov/cancer/breast/basic_info/dense-breasts.htm#:%7E:text=Women%20with%20dense%20breasts%20have%20a%20higher%20chance%20of%20getting,%2Ddense%20(fatty)%20breasts.">Breast density</a> can only be seen on mammograms. </p>
<h2>6. Lifestyle</h2>
<p>Factors such as whether a person <a href="https://pubmed.ncbi.nlm.nih.gov/25307527/">smokes</a>, what their <a href="https://pubmed.ncbi.nlm.nih.gov/31277273/">diet is</a>, how <a href="https://pubmed.ncbi.nlm.nih.gov/17130685/">physically active</a> they are, if they’re <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6437123/">obese</a> and if they take <a href="https://pubmed.ncbi.nlm.nih.gov/12927427/">hormone replacement therapy</a>, may all linked with greater risk of breast cancer. Your doctor will take all of these into account when assessing your risk.</p>
<p><a href="https://www.nature.com/articles/s41416-021-01492-w">Alcohol consumption</a> is a particularly important factor, as excess alcohol use is associated with greater risk. Even moderate alcohol consumption can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3832299/">increase the risk by 30-50%</a>.</p>
<h2>7. Radiation exposure</h2>
<p>Having previously <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1895063">undergone radiation therapy</a> for lymphoma, especially during childhood and adolescence, may increase the risk of breast cancer – though this is rare.</p>
<p>It’s important to note that this is only referring to radiation treatment. Routine X-rays should not increase your breast cancer risk.</p>
<h2>Caveats and limitations</h2>
<p>This isn’t an exhaustive list and other factors can be important. For example, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1895063/">diabetic women</a> are up to 20% more likely to develop postmenopausal breast cancer than older, non-diabetic women – but this may be related to obesity.</p>
<p>Calculating breast cancer risk typically involves integrating these factors into risk assessment models – sometimes called risk calculators. These models use statistical algorithms to estimate a person’s likelihood of developing breast cancer over a period of time by giving the average risk of breast cancer for a group of women with similar risk factors.</p>
<p>For example, say it gives a woman a five-year risk of 1%. This means the tool estimates 1% of women who have similar risk factors will develop breast cancer over the next five years. However, it can’t predict which of these women will get breast cancer. </p>
<p>While these risk assessment tools can provide valuable information, they are not perfect predictors. Personalised medical advice should always be sought from healthcare professionals, and you should have more than one discussion before undergoing any preventative treatment.</p><img src="https://counter.theconversation.com/content/225860/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Justin Stebbing does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Olivia Munn recently shared on Instagram that she’d had a double mastectomy after being diagnosed with luminal B breast cancer.Justin Stebbing, Professor of Biomedical Sciences, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2019512023-04-07T12:16:57Z2023-04-07T12:16:57ZThe FDA’s rule change requiring providers to inform women about breast density could lead to a flurry of questions<figure><img src="https://images.theconversation.com/files/519672/original/file-20230405-1759-sbi3a7.jpg?ixlib=rb-1.1.0&rect=107%2C71%2C7832%2C5225&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Breast density is one of the factors that can influence whether people should pursue supplemental screening. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/female-doctor-talking-to-her-patient-and-adjusting-royalty-free-image/1221770065?phrase=mammogram&adppopup=true">andresr/E+ via Getty Images</a></span></figcaption></figure><p><em>The U.S. Food and Drug Administration <a href="https://public-inspection.federalregister.gov/2023-04550.pdf">finalized a regulation</a> in early March 2023 that updates mammography reporting requirements. The new regulation goes into effect on Sept. 10, 2024, and will require that all women receive information about breast density following a mammogram. It will also require they be told in their mammogram report that dense breast tissue can mask cancer and make cancer more difficult to detect.</em></p>
<p><em>The Conversation asked <a href="https://www.rad.pitt.edu/profile-detail.html?profileID=311">Dr. Wendie A. Berg</a>, professor of radiology at the University of Pittsburgh School of Medicine, to explain how the rule change could affect screening recommendations as well as the way people interpret their results.</em></p>
<h2>What is breast density and why does it matter?</h2>
<p>All breasts are made up of a mix of fat, milk glands and ducts. The glands are supported by fibrous tissue and ligaments, collectively called “fibroglandular tissue.” The more fibroglandular tissue a woman has, the “denser” her breast tissue. </p>
<p>When a woman has a mammogram, the radiologist reviewing it will describe her breast density using one of four categories: A) fatty, B) scattered tissue, C) heterogeneously dense or D) extremely dense. Categories C and D are considered “dense” whereas categories A and B are “not dense.” </p>
<p>Dense breasts are <a href="https://doi.org/10.1093/jnci/dju255">normal and common</a>. Over 50% of women have dense breasts before menopause, as do about 40% of women in their 50s and 30% of women in their 60s. Breasts can become less dense after menopause, but a woman with extremely dense breasts will likely continue to have dense breasts all her life.</p>
<p>Breast density matters for two reasons. Most importantly, dense breast tissue can hide cancer on a mammogram. About 40% of breast cancers will go unseen on mammography in the densest breasts, labeled “extremely dense breasts,” and about <a href="https://doi.org/10.7326/m14-1465">25% will go undetected in heterogeneously dense breasts</a>. </p>
<p>Secondly, dense tissue also increases the risk of developing breast cancer, with about <a href="https://doi.org/10.1158/1055-9965.epi-06-0034">fourfold the risk of breast cancer in extremely dense breasts</a> compared with fatty breasts, and about <a href="https://doi.org/10.1016/j.breast.2022.09.007">twofold the risk compared to breasts with scattered tissue</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/519670/original/file-20230405-24-mpiqoo.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Mammography comparison of cancer easily seen in a a fatty ('not dense') breast on the left and hard to see in a 'dense' breast on the right." src="https://images.theconversation.com/files/519670/original/file-20230405-24-mpiqoo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/519670/original/file-20230405-24-mpiqoo.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/519670/original/file-20230405-24-mpiqoo.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/519670/original/file-20230405-24-mpiqoo.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/519670/original/file-20230405-24-mpiqoo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=539&fit=crop&dpr=1 754w, https://images.theconversation.com/files/519670/original/file-20230405-24-mpiqoo.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=539&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/519670/original/file-20230405-24-mpiqoo.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=539&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Dense breasts not only make cancer harder to spot, they also increase the risk of developing cancer.</span>
<span class="attribution"><span class="source">DenseBreast-info.org and Dr. Wendie Berg</span></span>
</figcaption>
</figure>
<h2>What does the FDA ruling entail?</h2>
<p>Until now, <a href="https://densebreast-info.org/legislative-information/state-legislation-map/">38 states plus Washington, D.C.</a>, have had varying laws about what to tell women about breast density. This has resulted in inconsistent levels of information being provided to U.S. women depending on where they live. </p>
<p>Beginning in September 2024, the <a href="https://public-inspection.federalregister.gov/2023-04550.pdf">FDA’s final rule</a> creates a uniform national standard requiring that all women be informed in the mammogram results letter that their breasts are either “dense” or “not dense.” They will be told that dense tissue can hide cancer on a mammogram and that it also raises the risk of developing breast cancer.</p>
<p>The new regulations require that the specific density category be included in all mammography reports that go to the referring health care provider. Some states require the specific density category also be included in the patient results letter, and this information can be included, but must be separate from the language required by the FDA. The FDA notification cannot be altered in any way.</p>
<p>The FDA requirement also includes this sentence in the letter to women with “dense” breasts: “In some people with dense tissue, other imaging tests in addition to a mammogram may help find cancers.” Such “supplemental screening” deserves discussion.</p>
<h2>How might this affect how patients respond to mammogram results?</h2>
<p>Without some guidance on what to do about it, there is the potential for this information to cause some confusion and worry. </p>
<p>3D mammograms, also known as tomosynthesis, are becoming standard and are slightly <a href="https://doi.org/10.1148/radiol.221571">better at detecting cancer, with fewer callbacks</a> for extra testing for findings that turn out not to be cancer. Women with dense breasts should make sure to have routine screening with a 3D mammogram.</p>
<p>Deciding whether to pursue supplemental screening beyond an annual mammogram starting at age 40 depends on several considerations. These include breast density and other risk factors, potential benefits, downsides – such as additional testing for findings that turn out not to be cancer – insurance coverage and costs. </p>
<p>By age 30, <a href="https://doi.org/10.1016/j.jacr.2017.11.034">all women should discuss their risk factors</a> with their health care provider and consider genetic testing, if appropriate. This is because women considered to be “high risk” should start screening earlier and have MRI screening in addition to mammography, regardless of breast density. </p>
<p><img src="https://cdn.theconversation.com/static_files/files/2615/BIRADS_Cancer_%281%29.gif?1680793880">
</p><figure><figcaption><span class="caption">Breast density is described as one of four categories in the mammogram report. The denser the breast, the harder the cancer is to see on a mammogram.</span></figcaption></figure><p></p>
<p>Here is a list of some of the factors that would make a woman “high risk,” and good candidates for yearly screening with MRI up to ages 70 to 75, depending on overall health.</p>
<ul>
<li><p>Women with disease-causing genetic variants, such as BRCA1 or BRCA2, or who have a mother, sister or daughter with a disease-causing variant, should start having yearly <a href="https://doi.org/10.3322/canjclin.57.2.75">screening with MRI by age 25-30</a>, and add mammography screening once they turn 30. </p></li>
<li><p>Women who received radiation therapy to the chest for prior cancer – usually Hodgkin lymphoma – before age 30 should start MRI screening eight years after treatment – but not before age 25 – and add mammography by the time they’re 30. </p></li>
<li><p>Women with an estimated lifetime risk of breast cancer of at least 20% should have annual MRIs, in addition to mammography. The most accurate estimates are from the <a href="https://ibis.ikonopedia.com/">Tyrer-Cuzick or IBIS model</a> and include weight, height, breast density, family history, biopsy history and other risk factors. AI-based processing of mammograms alone may be even <a href="https://doi.org/10.1200/jco.21.01337">more accurate than risk models</a> at predicting who will develop breast cancer in the next one to five years.</p></li>
<li><p>Annual MRI screenings are also recommended for women <a href="https://doi.org/10.1016/j.jacr.2017.11.034">diagnosed with breast cancer prior to age 50 or women with dense breasts</a>.</p></li>
<li><p>The European Society of Breast Imaging recommends that <a href="https://doi.org/10.1007/s00330-022-08617-6">women with extremely dense breasts</a> add MRI screening every 2 to 4 years from age 50 to 70 (with mammograms every 2 years).</p></li>
</ul>
<p>Women with dense breasts, especially if they also have other risk factors such as family history of breast cancer or prior atypical biopsy, should consider adding screening MRI to their annual mammogram. But MRI requires lying in the tunnel of the magnet, which can be <a href="https://doi.org/10.1148/radiol.2541090953">difficult for women with claustrophobia</a>. It also requires intravenous contrast injection. Cancers become more visible with contrast because they have more and leakier blood vessels than normal tissue. </p>
<p>For women who cannot tolerate or access MRI, adding ultrasound to mammography can be considered, but <a href="https://densebreast-info.org/screening-technologies/cancer-detection-by-screening-method/">MRI finds more cancers than ultrasound</a>. <a href="https://doi.org/10.1016/j.ejrad.2022.110513">Contrast-enhanced mammography</a> is being evaluated as an alternative to MRI.</p>
<h2>Will insurance cover additional screening tests?</h2>
<p>Currently 15 states plus D.C. have <a href="https://densebreast-info.org/legislative-information/state-legislation-map/">laws requiring insurance coverage</a> for supplemental breast cancer screening, but only New York, Connecticut and Illinois require such coverage without copays. </p>
<p>A federal insurance bill, the <a href="https://densebreast-info.org/legislative-information/find-it-early-act/#">Find It Early Act</a>, is being reintroduced by two U.S. representatives. This measure would ensure all health insurance plans cover screening and diagnostic breast imaging with no out-of-pocket costs. </p>
<p>This would include supplemental screening for women with dense breasts or at a higher risk for breast cancer, in accordance with National Comprehensive Cancer Network guidelines and the <a href="https://doi.org/10.1016/j.jacr.2021.09.002">American College of Radiology’s Appropriateness Criteria</a>.</p><img src="https://counter.theconversation.com/content/201951/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Wendie A. Berg receives funding from the Breast Cancer Research Foundation and Pennsylvania Breast Cancer Coalition. She is voluntary Chief Scientific Advisor to <a href="http://www.DenseBreast-info.org">www.DenseBreast-info.org</a>. </span></em></p>Dense breast tissue is common and normal, but it can make cancer more difficult to detect. FDA requirements going into effect in September 2024 will dictate that patients be better informed about it.Wendie A. Berg, Professor of Radiology, School of Medicine, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1858242022-07-08T12:17:05Z2022-07-08T12:17:05ZBiopsies confirm a breast cancer diagnosis after an abnormal mammogram – but structural racism may lead to lengthy delays<figure><img src="https://images.theconversation.com/files/472092/original/file-20220701-16-qwlz5x.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2122%2C1410&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Black patients are more likely than other racial and ethnic groups to have a biopsy delay of 90 days or more after an abnormal mammogram.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/nurse-with-patient-signing-consent-for-mammogram-royalty-free-image/141089953">Yellow Dog Productions/The Image Bank via Getty Images</a></span></figcaption></figure><p>While mammograms are often the first step to detecting breast cancer, patients need additional tests after an abnormal screening result. Further imaging can determine if a finding is truly suspicious for cancer, and sometimes a biopsy is required to confirm a diagnosis. But biopsy delays reduce the benefit of early detection, putting patients at a higher risk of treatment failure and lowering their chances for survival.</p>
<p><a href="https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/breast-biopsy.html">Breast biopsies</a> involve removing a small piece of tissue from a suspicious area and examining the sample under a microscope. Once doctors are able to confirm the presence of tumor cells and what type they are, they are then able to devise a treatment plan.</p>
<p>Much <a href="https://doi.org/10.1038/s41416-020-01038-6">prior research</a> has looked at disparities in breast cancer care, including potential factors underlying <a href="https://doi.org/10.1001/archinte.166.20.2244">diagnostic and treatment delays</a>. On average, <a href="http://doi.org/10.1001/jamasurg.2017.0005">Black patients</a> are more often diagnosed with late-stage breast cancer, have higher mortality rates and are less likely to receive guideline-recommended treatment compared with white patients. <a href="http://doi.org/10.1001/jama.2014.17322">Hispanic and South Asian patients</a> are also more often diagnosed with late-stage breast cancer compared with non-Hispanic white patients.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/472557/original/file-20220705-24-c1s9pw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Diagram of ultrasound-guided breast biopsy" src="https://images.theconversation.com/files/472557/original/file-20220705-24-c1s9pw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/472557/original/file-20220705-24-c1s9pw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/472557/original/file-20220705-24-c1s9pw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/472557/original/file-20220705-24-c1s9pw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/472557/original/file-20220705-24-c1s9pw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=533&fit=crop&dpr=1 754w, https://images.theconversation.com/files/472557/original/file-20220705-24-c1s9pw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=533&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/472557/original/file-20220705-24-c1s9pw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=533&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">One breast biopsy method involves using ultrasound to guide a needle to a suspected cancer mass in order to take a sample for further analysis.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/biopsy-the-breast-cancer-cell-royalty-free-illustration/1003502426">Tsezer/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<p>But previous studies have not looked at how multiple factors, including at the neighborhood and institutional level, can affect breast cancer care across diverse groups in different geographic locations. And not many studies have evaluated the disparities that may occur within the time-sensitive period between routine screening and an official diagnosis.</p>
<p>As radiologists who study <a href="https://rad.washington.edu/radiology-personnel/mblawson/">health disparities</a> and <a href="https://scholar.google.com/citations?user=wADZtfAAAAAJ&hl=en">population health</a>, we wanted to fill in this research gap. Our <a href="https://doi.org/10.1001/jamaoncol.2022.1990">recently published study</a> found that patients from racial and ethnic minority groups are more likely to have significant delays in getting a diagnosis-confirming breast biopsy after a mammogram compared with white patients.</p>
<h2>Racial and ethnic differences in biopsy delays</h2>
<p>We wanted to investigate potential reasons why some patients experienced a delay between when they received an abnormal mammogram result and when they underwent a diagnostic biopsy. So we used data from the <a href="https://www.bcsc-research.org/">Breast Cancer Surveillance Consortium</a>, a network of imaging registries researching ways to improve breast cancer detection. We collected the demographic information of 45,186 patients in six states across the U.S. and analyzed their risk of not receiving a biopsy within 30, 60 or 90 days after getting an abnormal mammogram.</p>
<p>We found that all racial and ethnic minority groups experienced a higher risk of having a biopsy delay of over 30 days compared with white patients. Asian patients had the highest increased risk; they were 66% more likely to get a biopsy more than 30 days after their mammograms. When we looked at biopsy delays of 90 days or more, however, we found that only Black patients had a significantly increased risk – they were almost 30% more likely to experience extended delays compared with white patients.</p>
<p><iframe id="8wLwZ" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/8wLwZ/3/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Factors behind biopsy disparities</h2>
<p>To figure out the potential reasons for these differences, we statistically accounted for other factors that may contribute to racial and ethnic differences in biopsy delays. These included individual-level factors, such as age and family history of breast cancer; neighborhood-level factors, such as area median income and education; and screening facility factors, such as academic affiliation and availability of on-site biopsy services.</p>
<p>We found that which screening facility a patient went to had the biggest effect on biopsy delays. This suggests that there are health care setting differences that could be contributing to longer wait times for nonwhite patients. These health care setting differences could include a number of factors, including whether there is a robust <a href="https://www.cancer.org/latest-news/patient-navigators-can-help-when-live-disrupts-cancer-care.html">patient navigation system</a> to provide guidance throughout the care process or the availability of same-day biopsies.</p>
<p>Our analysis suggests that nonwhite patients were still at higher risk of breast biopsy delays, even when we compared white and nonwhite patients with similar individual, neighborhood and screening facility characteristics.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/_rdOjtVi56w?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Structural racism plays a significant role in long-standing public health disparities in the U.S.</span></figcaption>
</figure>
<p>This persistent difference in risks suggests that unmeasured factors such as <a href="http://dx.doi.org/10.1377/hlthaff.2021.01466">structural racism</a>, or ongoing policies and practices that lead to inequitable resource distribution for racial and ethnic minority communities, could also account for these differences. This could include health care coverage inequities with higher out-of-pocket costs, or policies that restrict access to higher quality care. </p>
<p>Structural racism may also have contributed to the facility-level disparities we saw. For example, facilities where more white people went to may have had additional resources allocated to patient navigators and same-day services that would have facilitated more timely biopsies.</p>
<h2>Reducing the diagnostic gap</h2>
<p>Long diagnostic delays after an abnormal screening mammogram can <a href="https://doi.org/10.1158/1055-9965.EPI-17-0378">reduce the benefit</a> of early cancer detection. Consequently, racial and ethnic differences in timely biopsy scheduling may exacerbate existing disparities in breast cancer diagnosis, treatment and survival – especially for Black patients.</p>
<p>While we were unable to identify more specific drivers behind these differences, we found that screening facilities do contribute to differences in biopsy delays among racial and ethnic groups. Our future work will focus on identifying facility-specific factors that may affect timely diagnosis after abnormal screening results. Our goal is to eventually be able to target these factors with interventions that reduce racial and ethnic disparities in breast cancer outcomes.</p><img src="https://counter.theconversation.com/content/185824/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marissa Lawson receives funding from grant number T32CA09168 from the National Institutes of Health. </span></em></p><p class="fine-print"><em><span>Christoph Lee does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Early detection of breast cancer is critical to improving chances of survival. But racial and ethnic minority patients systematically have delayed diagnoses that reduce the benefits of screening.Marissa Lawson, Medical Fellow in Radiology, School of Medicine, University of WashingtonChristoph Lee, Professor of Radiology, School of Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1595292021-04-23T05:46:13Z2021-04-23T05:46:13ZCOVID vaccine may lead to a harmless lump in your armpit, so women advised to delay mammograms for 6 weeks<figure><img src="https://images.theconversation.com/files/396434/original/file-20210422-23-11wdpg4.jpg?ixlib=rb-1.1.0&rect=7%2C1%2C991%2C589&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-woman-having-mammography-scan-hospital-1334759717">from www.shutterstock.com</a></span></figcaption></figure><p>Australian women are being asked to think about the timing of breast cancer screening as they prepare to receive their COVID vaccine.</p>
<p>This is in light of <a href="https://www.sciencedirect.com/science/article/pii/S0899707121000206">US evidence</a> that a normal consequence of COVID vaccination, temporary swelling of the lymph nodes in the armpit, <a href="https://www.ajronline.org/doi/10.2214/AJR.21.25688">may interfere</a> with how doctors interpret mammograms.</p>
<p>So women <a href="https://www.ranzcr.com/documents-download/professional-documents/position-papers/5272-position-statement-on-covid-vaccines-and-breast-screening">have been advised</a> to either have a mammogram first, or delay it until six weeks after vaccination, to avoid any confusion.</p>
<p>This advice is particularly relevant now we are <a href="https://www.abc.net.au/news/2021-04-22/national-cabinet-over-50-vaccination-mass-hub-astrazeneca/100087334">preparing to vaccinate the over-50s</a>, the key target age for routine breast cancer screening under Australia’s <a href="https://www.health.gov.au/initiatives-and-programs/breastscreen-australia-program">BreastScreen program</a>.</p>
<h2>What’s all this about lumps?</h2>
<p>When people have vaccines in their upper arm, it’s normal for the lymph nodes in the armpit on that side of the body to be activated and swell. It’s your body preparing a protective immune response.</p>
<p>After their COVID shot, some people develop more severe swelling in the armpit than others. While <a href="https://www.cdc.gov/vaccines/covid-19/info-by-product/pfizer/reactogenicity.html">estimates vary</a>, only <a href="https://www.ajronline.org/doi/10.2214/AJR.21.25688">about one in ten people</a> vaccinated can feel a lump there, and it’s not always painful. </p>
<p>It’s important to stress these lumps are not breast cancer, and are not harmful. They also disappear within one or two weeks of vaccination.</p>
<hr>
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<strong>
Read more:
<a href="https://theconversation.com/explainer-how-does-the-immune-system-work-27163">Explainer: how does the immune system work?</a>
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</p>
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<p>However, a swollen lymph node can affect imaging such as breast cancer screening by mammography or ultrasound. This is because it <em>looks like</em> breast cancer that has spread (metastasised) from the breast to the lymph node. This can have important consequences.</p>
<p>An enlarged lymph node may cause a woman to have further testing to confirm or rule out breast cancer. This can lead to further imaging, invasive procedures such as biopsies, and patient anxiety.</p>
<p>So it’s important to note this potential impact of COVID vaccination on mammography, ahead of Australia ramping up its vaccine rollout, especially in the over-50s.</p>
<h2>So what’s behind the new advice?</h2>
<p>Reports of COVID vaccine-related swollen lymph nodes <a href="https://www.sciencedirect.com/science/article/pii/S0899707121000206">emerged from the United States</a>, where <a href="https://ourworldindata.org/covid-vaccinations">almost 90 million people</a> have been vaccinated with the Pfizer or Moderna vaccines.</p>
<p>This led to <a href="https://www.ajronline.org/doi/10.2214/AJR.21.25688">swollen lymph nodes showing up</a> on breast imaging, including mammography and ultrasound.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1368203896456441857"}"></div></p>
<p>According to the Royal Australian and New Zealand College of Radiologists, this type of swelling has not been reported <a href="https://www.ranzcr.com/documents-download/professional-documents/position-papers/5272-position-statement-on-covid-vaccines-and-breast-screening">with the AstraZeneca vaccine</a>. This is the vaccine earmarked for the over-50s in Australia from May.</p>
<p>However, as activating the immune system is how all vaccines work, we’ve seen similar swelling after vaccines <a href="https://www.sciencedirect.com/science/article/pii/S0899707121000206">other than COVID</a>. So it’s likely we’ll also see it with other COVID vaccines. However, we have yet to see published data from the United Kingdom and other countries that have more experience administering the AstraZeneca vaccine to confirm this.</p>
<p>Nevertheless, the college <a href="https://www.ranzcr.com/documents-download/professional-documents/position-papers/5272-position-statement-on-covid-vaccines-and-breast-screening">has recommended</a> women have their mammogram before their COVID vaccine, or six weeks after vaccination, without specifying any particular COVID vaccine.</p>
<p>Others have proposed a more pragmatic approach of monitoring any suspected case of a swollen lymph node in the armpit on the side of the injection, and <a href="https://www.ajronline.org/doi/10.2214/AJR.21.25688">only investigating further</a> if the swelling doesn’t go down after six weeks.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/women-should-be-told-about-their-breast-density-when-they-have-a-mammogram-66125">Women should be told about their breast density when they have a mammogram</a>
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</em>
</p>
<hr>
<h2>Why is this so important?</h2>
<p>It’s essential for both COVID vaccination and mammography screening of women without symptoms to continue.</p>
<p>While it is important screening identifies women with breast cancer, it is also important not to over-investigate otherwise healthy women. So it makes sense to delay the screening of otherwise healthy non-symptomatic women for a short time, and to not over-investigate women who do not have cancer.</p>
<p>It’s also important for women with breast cancer symptoms to seek medical advice immediately, and for the appropriate diagnostic imaging to take place.</p>
<p>However, in light of the recent advice, women should mention their COVID vaccination status to their health-care team — GP, radiographer and specialist doctor — so they can take this into account when interpreting imaging. That’s whether or not their mammograms are part of the breast cancer screening program.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-causes-breast-cancer-in-women-what-we-know-dont-know-and-suspect-86314">What causes breast cancer in women? What we know, don't know and suspect</a>
</strong>
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</p>
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<img src="https://counter.theconversation.com/content/159529/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rik Thompson is affiliated with the Clinical Oncology Society of Australia, which has recently developed a Fact and Issues Sheet on Mammographic/Breast Denisty. He has received research support from the Princes Alexandra Research Foundation for studies on Mammographic density. </span></em></p><p class="fine-print"><em><span>Thomas Lloyd is a Senior Staff Specialist, Department of Diagnostic Radiology, Princess Alexandra Hospital, Metro South Health and a Visiting Radiologist Breastscreen Queensland.</span></em></p>As Australian women over 50 prepare to have their COVID shot, they need to factor in timing of their mammogram. Here’s why.Rik Thompson, Professor of Breast Cancer Research, Institute of Health and Biomedical Innovation and School of Biomedical Sciences,, Queensland University of TechnologyThomas Lloyd, Adjunct Professor, Radiology, Faculty of Health, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1277912020-01-26T19:06:45Z2020-01-26T19:06:45Z29,000 cancers overdiagnosed in Australia in a single year<figure><img src="https://images.theconversation.com/files/307817/original/file-20191218-11924-3kufdx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Men are 17% more likely to be diagnosed with cancer than they were 30 years ago.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/frustrated-older-mature-retired-man-feeling-1185179038">fizkes/Shutterstock</a></span></figcaption></figure><p>Almost one in four cancers detected in men were overdiagnosed in 2012, according to our new research, published today in the <a href="https://www.mja.com.au/">Medical Journal of Australia</a>. </p>
<p>In the same year, we found that approximately one in five cancers in women were overdiagnosed. </p>
<p>Overdiagnosis is when a person is diagnosed with a “harmless” cancer that either never grows or grows very slowly. These cancers are sometimes called low or ultra-low-risk cancers and wouldn’t have spread or caused any problems even if left untreated.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-it-time-to-remove-the-cancer-label-from-low-risk-conditions-101331">Is it time to remove the cancer label from low-risk conditions?</a>
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</em>
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<p>This level of overdiagnosis means Australian men are 17% more likely to be diagnosed with cancer in their lifetime than they were 30 years ago, while women are 10% more likely. </p>
<p>Cancer overdiagnosis can result in people having unnecessary treatments, such as surgery, radiotherapy and hormone therapy. Being diagnosed with cancer and having cancer treatments can cause physical, psychological and financial harms.</p>
<h2>How many cancers were overdiagnosed?</h2>
<p>In 2012, 77,000 cancers were diagnosed among Australian men. We estimated that 24% of these (or 18,000 in total) were overdiagnosed, including:</p>
<ul>
<li>8,600 prostate cancers</li>
<li>8,300 melanomas</li>
<li>860 kidney cancers</li>
<li>500 thyroid cancers.</li>
</ul>
<p>Some 55,000 cancers were diagnosed in women; 18% of them (11,000) were overdiagnosed. This includes:</p>
<ul>
<li>4,000 breast cancers</li>
<li>5,600 melanomas</li>
<li>850 thyroid cancers</li>
<li>660 kidney cancers.</li>
</ul>
<p>These calculations are based on changes since 1982 in the lifetime risk of cancers, after adjusting for other causes of death and changing risk factors.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Mammograms sometimes detect cancers that wouldn’t grow, spread, or cause the woman any harm.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-40s-about-undergoing-mammography-test-195635468">GagliardiPhotography/Shutterstock</a></span>
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</figure>
<p>Because they are more common, prostate and breast cancer and melanoma accounted for the greatest number of overdiagnosed cancers, even though larger percentages of thyroid cancers were overdiagnosed. </p>
<p>In women, for example, 73% of thyroid cancers were overdiagnosed, while 22% of breast cancers were overdiagnosed.</p>
<p>The harms to patients come from the unnecessary surgery, and other treatments, as well as the anxiety and expenses. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/29042396">Three in four patients with thyroid “cancers” that are overdiagnosed</a>, for example, will almost all have their thyroid completely removed, risk complications, and have to take replacement thyroid medication for the rest of their life. </p>
<p>In addition, there are substantial costs to the health system, and delays in necessary surgery. </p>
<p>Some “good news” is that overdiagnosis appears to be largely confined to the five main cancers mentioned above. </p>
<h2>What causes cancer overdiagnosis?</h2>
<p>The cause of overdiagnosis differs for each cancer. </p>
<p>For prostate cancer, the cause is the quest for early detection of prostate cancer using the prostate specific antigen (PSA) blood test. A downside of PSA testing is the risk of detecting large numbers of low-risk prostate cancers which may be overtreated. </p>
<p>For breast cancer, the cause is also early detection, through mammography screening which can detect low-risk cancers. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/five-warning-signs-of-overdiagnosis-110895">Five warning signs of overdiagnosis</a>
</strong>
</em>
</p>
<hr>
<p>Likewise, detection of low-risk melanoma accounted for most of the melanoma overdiagnosis we observed. Early detection activities again are the likely cause, with many times more skin biopsies being done today than 30 years ago.</p>
<p>Overdiagnosis of kidney and thyroid cancer is due largely to “incidentalomas” – abnormalities found incidentally on imaging done for other reasons – or through over-investigation of mild thyroid problems.</p>
<h2>What can we do about it?</h2>
<p>Some level of overdiagnosis is unavoidable in a modern health-care system committed to screening to reduce the disease and death burden from cancer.</p>
<p>We want to maximise the timely detection of high-risk cancers that allows the best chance of cure through early surgery and other treatments. </p>
<p>But this is still possible while taking measures to prevent overdiagnosis and overtreatment of low-risk cancers that are better left undetected. </p>
<p>Take South Korea, for example. Following the introduction of a screening program for thyroid cancer, the country saw a <a href="https://www.nejm.org/doi/full/10.1056/NEJMc1507622?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed">15-fold increase</a> in small, low-risk thyroid cancers. Then it cut back on early detection. This led to a major drop in thyroid cancer rates without any change in death rates. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Rates of PSA testing are comparatively high in Australia.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-laboratory-during-blood-research-68481031">ariadna de raadt/Shutterstock</a></span>
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<p>Rates of PSA testing in Australia are <a href="https://cancercouncil.com.au/wp-content/uploads/2015/03/World-Journal-of-Urology_2015_Prostate_mortality-AUS.pdf">among the highest in the world</a>. Countries where there is less PSA testing, such as the <a href="https://researchonline.nd.edu.au/cgi/viewcontent.cgi?article=1777&context=med_article">United Kingdom</a>, detect less low-risk prostate cancer, and therefore have less overtreatment.</p>
<p>Rather than simply accepting PSA testing, a wiser strategy is to <a href="https://www.bmj.com/content/362/bmj.k3581.full">make an informed decision whether to go ahead with it or not</a>. Tools to help you choose are available <a href="http://psatesting.org.au/info/?utm_source=pcfa&utm_medium=redirect&utm_campaign=pcam19">here</a> and <a href="https://www.racgp.org.au/download/Documents/Guidelines/prostate-cancer-screening-infosheetpdf.pdf">here</a>.</p>
<p>A <a href="https://ses.library.usyd.edu.au/bitstream/2123/16658/1/2017%20updated%20breast%20screening%20DA%20%28Hersch%20et%20al%29.pdf">decision aid</a> is also available for Australian women to consider whether to go ahead with mammogram screening or not.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/three-questions-to-ask-about-calls-to-widen-breast-cancer-screening-82894">Three questions to ask about calls to widen breast cancer screening</a>
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<p>Trials to wind back treatment of low-risk prostate cancer have resulted in <a href="https://www.nice.org.uk/guidance/ng131/chapter/Recommendations#localised-and-locally-advanced-prostate-cancer">clinical practice guidelines</a> which recommend men with low-risk prostate cancer be offered active surveillance as an alternative to immediate surgery or radiation therapy. </p>
<p>Trials to evaluate less treatment for low-risk breast cancer are now under way and should help wind back breast cancer overtreatment one day.</p>
<p>New screening tests that identify clinically important cancers, while leaving slow- and never-growing cancers undetected, are the holy grail. But they could be some time coming. </p>
<p>In the meantime, health services need to be vigilant in <a href="https://annals.org/aim/fullarticle/2724039/recognizing-potential-overdiagnosis-high-sensitivity-cardiac-troponin-assays-example">monitoring new areas of overdiagnosis</a>, particularly when investing in new technologies with potential to further increase overdiagnosis.</p><img src="https://counter.theconversation.com/content/127791/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alexandra Barratt receives funding from NHMRC. She is a lead investigator on Wiser Healthcare, an NHMRC funded research collaboration to reduce overdiagnosis and overtreatment. </span></em></p><p class="fine-print"><em><span>Katy Bell receives funding from NHMRC. She is Chief Investigator on an Investigator Grant "Using early detection tests to benefit health without causing harm" and a member of the Wiser Healthcare research collaboration that aims to reduce overdiagnosis and overtreatment. </span></em></p><p class="fine-print"><em><span>Paul Glasziou receives funding from an NHMRC program grant on overdiagnosis and overtreatment.</span></em></p><p class="fine-print"><em><span>Mark Jones and Thanya Pathirana do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New research estimates 24% of cancers in men that were detected in 2012 were overdiagnosed, meaning they never would have caused harm if left untreated.Alexandra Barratt, Professor of Public Health, University of SydneyKaty Bell, Associate in Clinical Epidemiology in the School of Public Health, University of SydneyMark Jones, Associate Professor, Biostatistician, Institute for Evidence-Based Healthcare, Bond UniversityPaul Glasziou, Professor of Medicine, Bond UniversityThanya Pathirana, Senior Lecturer, School of Medicine, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/976862018-06-04T10:58:25Z2018-06-04T10:58:25ZMany women with breast cancer may not need chemo, but beware misleading headlines<figure><img src="https://images.theconversation.com/files/221491/original/file-20180604-177134-r2yc9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Breast cancer tumours behave, and are treated, differently. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>Findings from a <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1804710?query=featured_home">major international clinical trial</a> suggest a significant number of women with the most common form of early-stage breast cancer do not need chemotherapy after surgery.</p>
<p>The results of the so-called <em>TAILORx</em> trial were presented yesterday at the annual meeting of the <a href="https://am.asco.org">American Society of Clinical Oncology</a> and concurrently published in the <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1804710">New England Journal of Medicine</a>. </p>
<h2>Breast cancer types</h2>
<p>The study looked at over 10,000 women with one specific type of breast cancer known as hormone-receptor–positive, human epidermal growth factor receptor 2 (HER2)–negative, lymph node–negative breast cancer.</p>
<p>Not all breast tumours behave the same way, with a number of different subtypes of breast cancer defined by genetic and protein markers. There are five to six main subtypes, depending on the classification system used. But with genome sequencing it’s becoming apparent each patient’s disease has subtle differences at the molecular level. These <a href="https://www.cancer.gov/types/breast/patient/breast-treatment-pdq">different subtypes are treated differently</a>, and can have significantly different outcomes for patients.</p>
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Read more:
<a href="https://theconversation.com/what-causes-breast-cancer-in-women-what-we-know-dont-know-and-suspect-86314">What causes breast cancer in women? What we know, don't know and suspect</a>
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<p>The subset of breast tumours that form the focus of this study are driven by hormones (oestrogen), do not respond to drugs such as <a href="https://canceraustralia.gov.au/affected-cancer/cancer-types/breast-cancer/treatment/what-does-treatment-breast-cancer-involve/targeted-therapies/types-targeted-therapy/trastuzumab-herceptin">trastuzumab</a> (also known as Herceptin - an engineered antibody that targets HER2), and haven’t yet spread to the lymph nodes. They represent roughly half of the more than 17,000 new cases of breast cancer <a href="https://www.aihw.gov.au/reports/cancer/breast-cancer-in-australia-an-overview/contents/summary">diagnosed in Australia every year</a>.</p>
<p>Patients with these kind of tumours typically undergo surgery followed by treatment with drugs that target rapidly dividing cells (chemotherapy) and drugs that block the production or action of the hormone oestrogen (endocrine therapy, such as the drug Tamoxifen).</p>
<p>Results from this study suggest many women with this specific type of tumour do not receive any additional benefit from having chemotherapy in combination with endocrine therapy, compared to endocrine therapy alone. This has the potential to spare thousands of women from the awful side effects of chemotherapy, including nausea, hair loss, and heart and nerve damage.</p>
<p>This study used a genetic test (called “Oncotype DX”) to measure a panel of 21 genes that help predict risk of cancer recurrence. Importantly, chemotherapy still showed some benefit in women with higher Oncotype recurrence scores, and in some women under the age of 50.</p>
<p>Although mortality rates have decreased significantly over the last few decades, breast cancer is estimated to cause more than <a href="http://globocan.iarc.fr/old/FactSheets/cancers/breast-new.asp">half a million deaths globally</a> every year. Breast cancer remains the <a href="https://www.aihw.gov.au/reports/cancer/cancer-compendium-information-and-trends-by-cancer-type/report-contents/breast-cancer-in-australia">second most common cause of death from cancer</a> among females in Australia.</p>
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Read more:
<a href="https://theconversation.com/my-cancer-is-in-remission-does-this-mean-im-cured-95429">My cancer is in remission – does this mean I'm cured?</a>
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<h2>Hope and hype</h2>
<p>Cancer is complex and challenging to study, and news reporting on the disease easily lends itself to hype, contradiction and misinterpretation. Clearly communicating research findings are important for helping patients make informed decisions about treatment and modifying risk.</p>
<p>Poor reporting may have serious consequences for public and scientific communities alike. Some of the reports and headlines on this trial have been a little misleading, feeding on an understandable fear. They could potentially encourage patients to incorrectly avoid or stop treatment - with potentially tragic consequences. </p>
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<p>False or unmet expectations can also seed disappointment and an eventual loss of trust in science. Another, more sinister, aspect to these headlines is the potential to fuel myths and conspiracy theories about the effectiveness of chemotherapy. </p>
<p>One of the most exciting aspects of this trial is the emergence of robust, large-scale data supporting the use of “<a href="https://theconversation.com/its-2030-and-precision-medicine-has-changed-health-care-this-is-what-it-looks-like-90539">precision medicine</a>” - using genetic profiles to dictate treatment and predict outcomes in cancer. Trials like this are critical in balancing the significant hope and hype of precision medicine.</p>
<p>This study supports sparing thousands of women from the sometimes nasty side-effects of chemotherapy, but we must be crystal clear that it applies to a very specific (and significant) subset of women. Patients should not make any changes to their treatment based off this study, and should always consult their doctors. </p>
<p>And while celebrating this genuine advance, we should remember just how far we have to go in finding effective therapies for metastatic breast cancer, and other breast cancer subtypes for which treatment options are still limited. </p>
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Read more:
<a href="https://theconversation.com/how-likely-is-my-breast-cancer-to-recur-and-spread-7715">How likely is my breast cancer to recur and spread?</a>
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<p class="fine-print"><em><span>Darren Saunders receives funding from the US Dept of Defense, and is the secretary of Science and Technology Australia.</span></em></p>Headlines that 70% of women with breast cancer don’t need chemo need to be heeded with caution: it’s a very specific (but substantial) subtype that was studied.Darren Saunders, Associate professor, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/963142018-05-09T10:59:18Z2018-05-09T10:59:18ZWas anyone harmed by the breast cancer screening scandal?<figure><img src="https://images.theconversation.com/files/218253/original/file-20180509-34015-jxgilx.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C995%2C573&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/289309139?src=gHLDkqVT1WtS_rJpR1i7nQ-1-17&size=medium_jpg">Guschenkova/Shutterstock.com</a></span></figcaption></figure><p>When the UK health secretary, Jeremy Hunt, admitted that, due to an IT error, up to 270 women may have died prematurely because they were not invited to their final breast screening <a href="https://www.theguardian.com/society/2018/may/02/jeremy-hunt-to-launch-inquiry-into-450000-missed-breast-cancer-screenings">appointment</a>, politicians and commentators expressed shock. Janet Street-Porter exemplified the anger about a scandal that affected “those who complain the least and do the most in our society: ordinary middle-aged and older <a href="https://www.independent.co.uk/voices/nhs-breast-cancer-screening-scandal-jeremy-hunt-janet-street-porter-experience-a8336176.html">women</a>”. </p>
<p>A few days later, a group of senior medics wrote to <a href="https://www.thetimes.co.uk/past-six-days/2018-05-05/comment/frictionless-travel-and-uk-transport-policy-zkljr5xbf">The Times</a> that “women aged 70 to 79 who are being offered a catch-up appointment by Public Health England would be well advised to look this gift horse in the mouth”, because the breast cancer screening programme does “more unintended harm than good”. </p>
<p>For some, failings in the screening programme are a scandal that harm innocent women. For others, the scandal is that we are screening at all because doing so harms innocent women. Oddly enough, both sides of this debate might be right.</p>
<p>The logic behind screening is simple. Many diseases, such as cancer, are easier to treat the earlier they are detected, so it makes sense to test people without symptoms in higher risk groups to see if they have the disease. Unfortunately, it can be hard to detect early-stage disease with accuracy, and even harder to know that our interventions will actually benefit patients. Screening saves lives, but also leads to <a href="https://www.ncbi.nlm.nih.gov/books/NBK430655/">overdiagnosis</a> and <a href="https://www.cancer.gov/publications/dictionaries/cancer-terms/def/overtreatment">overtreatment</a>. </p>
<p>In introducing a screening programme for a disease such as breast cancer, then, we face two kinds of questions. First, what are the programme’s likely effects? How many lives will be saved? How many women will receive a diagnosis of cancer when, in fact, they don’t have the disease (so-called “false positives”)? How many women will have unnecessary mastectomies? </p>
<p>These questions are notoriously difficult to answer. For example, many of the most malignant cancers grow so quickly that they may develop and metastasise in the periods between routine check-ups, such that screening programmes are most likely to detect relatively benign <a href="https://en.wikipedia.org/wiki/Length_time_bias">lumps</a>. </p>
<p>Even if we can resolve these scientific uncertainties, we face a second question: all things considered, does the programme do more harm than good? Ultimately, this is an ethical question that requires us to judge how benefits to some people should be weighed against harms to others. We don’t have “net benefit-ometers” that tell us precisely how many unnecessary mastectomies are worth saving one life. Health economists and policymakers have ways of answering these questions, but they are, of course, <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1088-4963.2006.00067.x">controversial</a>.</p>
<p>Given both scientific and ethical uncertainty, it should be no surprise that cancer screening is contested. How, though, can both sides be right? </p>
<h2>It depends which direction you look in</h2>
<p>The concept of harm is <a href="https://www.sciencedirect.com/science/article/pii/S0091743511002702">ambiguous</a>. To see why, imagine that the sceptics are right and that, overall, screening women of 70 does more harm than good. This conclusion implies that, for any random 70-year-old woman, getting screened is not in her interests. </p>
<p>In a forward-looking sense, screening her causes harm. What it doesn’t imply is that every 70-year-old would end up suffering harm as a result of screening. Rather, the programme would help some women by allowing for detection and removal of tumours that would, otherwise, have killed them. </p>
<p>In this backward-looking sense, the programme helps these women. If we go ahead with the programme, some women will both be harmed in the first sense and benefited in the second. Bearing these ambiguities in mind, the IT error may have harmed some of the affected women, even if a well-functioning programme would have harmed all of the affected women.</p>
<p>Must we choose between these senses of harm? Not necessarily. The forward-looking sense might be important for some purposes, such as designing ethical policies, and the backward-looking sense for others, such as awarding compensation. </p>
<p>Normally, we don’t need to distinguish these senses of harm, because decisions about screening programmes deal with statistical data, not claims about individuals. We can say that a certain proportion of mastectomies were probably unnecessary, but not that any individual’s mastectomy was unnecessary. </p>
<p>What makes the current controversy so tricky is that this uncertainty has been removed. We can point to people who did lose out as a result of the IT error. Our instinctive human sympathy for these identified <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/hast.13">victims</a> should not blind us to the fact that all screening programmes – whether functioning as planned or not – will have “winners” and “losers” in the backward-looking sense. Even if we don’t know the identities of these statistical <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/hast.13">victims</a>, they are, nonetheless, real people.</p><img src="https://counter.theconversation.com/content/96314/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen John has previously received funding from the Early Detection programme at the Cambridge Cancer Centre</span></em></p>Unfortunately, there is no net benefit-ometer for breast cancer screening.Stephen John, Senior Lecturer in Philosophy of Public Health, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/841102017-10-01T23:09:50Z2017-10-01T23:09:50ZRoutine mammograms do not save lives: The research is clear<figure><img src="https://images.theconversation.com/files/188098/original/file-20170928-1483-g9qngk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A recent Canadian trial reports breast cancer over-diagnosis rates of up to 55 per cent, from routine screening mammograms.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>As breast cancer awareness month kicks off, all women should know something: there is no reliable evidence that routine mammograms for healthy women save lives.</p>
<p>There is good evidence that such mammograms can cause harm. </p>
<p>And yet there are 12 breast-screening programs in Canada, each offering routine mammography screening to well women. Most of them offer mammograms to women of 50 to 74 years of age every two to three years. These programs were set up based on evidence produced in the 1970s and 1980s — that detecting breast cancer early through a mammogram would save many lives. </p>
<p>The <a href="https://canadiantaskforce.ca/guidelines/published-guidelines/breast-cancer/">Canadian Task Force on Preventive Health Care</a> also still recommends that women aged 50 to 74 get regular mammography screening. They are updating their breast-screening recommendations this year; hopefully they’ll reflect the latest evidence.</p>
<p>I have been looking at breast-screening evidence for more than 20 years.</p>
<p>I was part of a small group of individuals who started the breast-screening program in Newfoundland and Labrador. My job was professional and public education, including recruitment of women. </p>
<p>Over time there was increasing evidence that mammography screening may not be as beneficial as once thought. As the daughter of a woman with pre-menopausal breast cancer, I was also interested in the evidence on breast self-examination and clinical breast examination in screening.</p>
<p>If you are a woman who is considering having (or continuing to have) routine mammography screening, here is some information you need to know.</p>
<h2>1. Screening mammograms do not reduce death from breast cancer</h2>
<p>There is no reliable evidence that having a screening mammogram reduces death by breast cancer on a population basis. The <a href="http://dx.doi.org/10.1002/14651858.CD001877.pub5">Cochrane Collaboration</a> reached this conclusion after taking a good look at the original randomized trials. A <a href="http://dx.doi.org/10.1136/bmj.g366">recent Canadian trial</a>, considered the best mammography trial, supported this finding for women aged 40 to 59. This is important evidence that needs careful consideration.</p>
<h2>2. Routine mammograms over-diagnose cancer</h2>
<p>The Cochrane Collaboration also reported on harms associated with mammography screening. The most important of these is over-diagnosis. That is, the diagnosis of breast cancers in healthy women that would never have become clinically detectable without screening or would have caused harm to the woman in any way.</p>
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<span class="caption">Woman receives a mammogram.</span>
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<p>Estimates of over-diagnosis vary from 30 per cent in the Cochrane Collaboration 2013 report to 55 per cent in the <a href="http://dx.doi.org/10.1016/j.ypmed.2016.06.033">2016 update from the Canadian trial</a> and 54 per cent by the <a href="https://www.cancer.gov/types/breast/hp/breast-screening-pdq#link/_13_toc">United States National Cancer Institute</a>. </p>
<h2>3. Treatment for over-diagnosed cancer is harmful</h2>
<p>Women with over-diagnosed breast cancer receive the usual breast cancer treatments including lumpectomy, mastectomy, radiation and hormonal therapy. All treatment for over-diagnosed cancer is harmful. This means that, because of mammography screening, many women are diagnosed with a breast cancer that might never have become apparent, and they undergo unnecessary treatment.</p>
<h2>4. False positives and over-diagnosis cause anxiety</h2>
<p>Another harm associated with mammography screening is <a href="http://dx.doi.org/10.1136/bmj.g366">false positive findings</a> — when an abnormality is detected that might be breast cancer but, after further testing including more mammography, is found not to be. Having additional testing causes significant anxiety for some women, including the belief that they are at higher risk for breast cancer. </p>
<p>In addition to the significant anxiety some women feel because of a false positive finding, consider the experience of a woman who is over-diagnosed, receives cancer treatment and lives with a breast cancer diagnosis for the rest of her life — a diagnosis that might never have occurred without mammography screening.</p>
<h2>5. Radiation from screening can also kill</h2>
<p>Radiation associated with mammography screening, additional mammography for false positives and with radiation treatment for overdiagnosed breast cancer carries significant risk for women. </p>
<p>A study done for the United States Preventive Services Task Force estimated that radiation exposure from screening and diagnostic workup <a href="http://dx.doi.org/10.7326/M15-1241">causes 27 breast cancers and 4 deaths</a> for every 100,000 women aged 50 to 69 screened every two years.</p>
<h2>6. Screening directs resources away from treatment</h2>
<p>There are significant harms associated with mammography screening and no reliable evidence of benefit. It is time to discontinue routine mammograms for all healthy women of a particular age. Resources should be shifted toward surveillance of women at higher risk for breast cancer, diagnostic workup for women with a change in their breast that does not go away and for ensuring that women receive timely treatment for a confirmed invasive breast cancer. </p>
<p>Population-based mammography screening has opportunity costs for the health care system, not to mention the social, financial, interpersonal and emotional costs to women and their families.</p>
<h2>7. Public information is not balanced</h2>
<p>It’s important that women are told — in plain language — about the potential harms and benefits of mammography screening so they can make an informed decision about being screened or not. I was involved in a recent review of the websites of 12 breast screening programs in Canada. Our results (accepted for publication) show that no program is offering balanced information on their website to support an informed decision.</p>
<p>It’s time to change the conversation in Canada about how to reduce the significant illness and death associated with breast cancer. Population-based mammography screening is not the way. We need to continue to research better early detection methods, including breast self examination and clinical breast examination.</p><img src="https://counter.theconversation.com/content/84110/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anne Kearney received funding from Government of Newfoundland and Labrador for a current project related to non-nursing duties (not-related). I have held other funding in the past but none that puts me in a conflict of interest.</span></em></p>October is breast cancer awareness month. Women should know there is no reliable evidence that routine mammograms reduce death from breast cancer, and there’s good evidence that they cause harm.Anne Kearney, Associate Professor of Nursing, Memorial University of NewfoundlandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/828942017-08-30T06:29:50Z2017-08-30T06:29:50ZThree questions to ask about calls to widen breast cancer screening<figure><img src="https://images.theconversation.com/files/183898/original/file-20170830-5012-ykfmzz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">More mammography, for instance, starting at a younger age or screening more often, isn't necessarily better.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/560294245?src=YLhWfkj2eWvoidSYttzpMQ-1-2&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>It’s easy to assume the earlier women are screened for breast cancer, the better. And a <a href="http://onlinelibrary.wiley.com/doi/10.1002/cncr.30842/abstract">recent US study</a>, which found screening women with mammography from the age of 40 saved the most lives, <a href="http://www.sbs.com.au/news/article/2017/08/21/us-study-revives-mammogram-debate">generated</a> <a href="http://www.smh.com.au/national/mammograms-from-age-40-would-save-more-lives-study-finds-20170821-gy0uqo.html">headlines</a> <a href="https://news.google.com/news/story/dU4hXdrjI3KNgFMfdLIBRKOKZeOTM?ned=au&hl=en-AU">around the world</a>. </p>
<p>We need to be cautious, however, when interpreting studies like this and the media reports they create. That’s because with screening, its benefits – less risk of dying of cancer – are clear, and are easily exaggerated. But the potential harms of screening are harder to recognise and readily overlooked.</p>
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Read more:
<a href="https://theconversation.com/when-talking-about-cancer-screening-survival-rates-mislead-30395">When talking about cancer screening, survival rates mislead</a>
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<p>The <a href="http://onlinelibrary.wiley.com/doi/10.1002/cncr.30842/abstract">recent US study</a> compared an intensive screening strategy (strategy a) of annual mammograms for women starting at age 40 all the way to 84 years of age, with two less-intensive screening strategies.</p>
<p>Strategy b) offered annual mammograms from 45-54 years, then every two years until age 79. Strategy c) offered mammograms every two years from 50-74, the <a href="http://cancerscreening.gov.au/internet/screening/publishing.nsf/Content/breast-screening-1">same screening policy we have in Australia</a>.</p>
<p>Strategy a) has become known in the media as “screening from age 40” but it is really screening more often, and until an older age (when breast cancer is more common), as well as starting earlier. It prevented the most deaths, according to the modelling. But at what “price”?</p>
<p>By screening longer and more often, the more intensive strategy a) required women to have three times as many mammograms. It caused three times as many false positives or false alarms (when women didn’t end up having a breast cancer despite an abnormal mammogram), as the least intensive strategy c). In a major omission, the authors did not address potential harms of overdiagnosis and overtreatment (more below).</p>
<p>So what questions do you need to consider when reading reports about studies like this?</p>
<h2>1. Who’s giving the advice?</h2>
<p>Three specialist radiologists and a medical physicist, all employed by departments of imaging or radiology, authored this study. Screening mammography in the US is big business. The total annual cost of screening mammography there was estimated to be <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4142190/">US$7.8 billion in 2010</a>.</p>
<p>So, why should we be concerned? Because previous research has found financial conflicts of interest <a href="http://www.nejm.org/doi/full/10.1056/NEJM199308193290812">increase the risk of bias</a>, and lead committees towards recommendations that are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5441061/">more favourable towards mammography screening</a>.</p>
<p>Non-financial conflicts of interest can also affect recommendations. Guideline panels with radiologist members are <a href="https://www.ncbi.nlm.nih.gov/pubmed/22498428">more likely to recommend screening for women from age 40 years</a> than recommendations issued by panels without radiologist members.</p>
<h2>2. What aren’t they telling me?</h2>
<p>A mammogram may seem harmless, but it can cause long-term problems that many people would never think of. An important one is finding harmless, idle or dormant cancers, a major factor in overdiagnosis.</p>
<p>Overdiagnosis is common not just in <a href="http://jamanetwork.com/journals/jama/fullarticle/1722196">breast cancer, but in screening for prostate, thyroid and lung cancer</a>.
How common? When a UK panel carried out an <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61611-0/abstract">independent assessment</a> of the benefit and harms of screening mammography, it found the chance of a woman being overdiagnosed by screening was three times greater than the chance screening would save her from dying of breast cancer.</p>
<p>Even the chief medical officer of the American Cancer Society urges accepting <a href="http://annals.org/aim/article/2597574/accepting-existence-breast-cancer-overdiagnosis">overdiagnosis and overtreatment as harms</a> of breast cancer screening.</p>
<p>Yet the authors of this latest US study didn’t consider overdiagnosis and overtreatment when concluding annual screening from age 40-84 years is best.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/five-commonly-over-diagnosed-conditions-and-what-we-can-do-about-them-82319">Five commonly over-diagnosed conditions and what we can do about them</a>
</strong>
</em>
</p>
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<p>Overdiagnosis is important because it isn’t a good idea to have cancer treatments (surgery, radiotherapy and antihormone pills) for a harmless cancer (overtreatment).</p>
<p>Each of these treatments comes with risks of side-effects, as UK woman Elizabeth Dawson <a href="https://olot1.wordpress.com/2015/11/04/a-mammogram-may-break-your-bones/">describes in her blog</a>. Two and a half years after starting treatment she was still wondering whether the cancer that was found by screening was overdiagnosed or not, and whether she needed all, or even any, of the treatments she’d had. She hates that the drugs she’s still taking to prevent a recurrence make her bones frailer. She’s been told not to go out when it’s icy because she might fall and fracture, but she hates the idea of being housebound at 56 when she feels so well and active.</p>
<p>The US study did include false positives in its calculations, but may not have recognised fully the impact. Being recalled for an abnormal mammography is scary. But what is less well known is that even three years after being declared free of suspected cancer, women with false positives consistently report <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3601385">worse psychosocial outcomes</a>; they report feeling more dejected and more anxious, and report worse sleep and negative impacts on sexuality than women with normal mammograms.</p>
<p>Mammography uses radiation, so <a href="http://annals.org/aim/article/2480762/radiation-induced-breast-cancer-incidence-mortality-from-digital-mammography-screening">there’s a small chance</a> the screening process itself may induce cancers over time. But starting screening from 50 and screening every two years is estimated to reduce the number of induced cancers <a href="http://annals.org/aim/article/2480762/radiation-induced-breast-cancer-incidence-mortality-from-digital-mammography-screening">five-fold</a> compared to annual screening from age 40.</p>
<h2>3. What’s the health-care context?</h2>
<p>The US has a very different health-care context to Australia. In the US, mammography screening costs are paid by many different organisations. So debates over recommendations may <a href="http://www.stoptheguidelines.com/">have implications</a> for whether health plan organisations cover services or not. </p>
<p>In contrast, as part of our national cancer screening programs, <a href="http://cancerscreening.gov.au/internet/screening/publishing.nsf/Content/breast-screening-1">BreastScreen Australia</a> provides mammograms in a national, publicly funded program that offers high-quality screening to eligible women, for free.</p>
<p>The health-care context is also relevant when we consider an individual woman’s risk of breast cancer. This debate (about when to start screening and how often) is relevant to women at average risk of breast cancer. For women with a strong family history, or who know they carry a breast cancer genetic mutation, <a href="http://www.genetics.edu.au/individuals-and-families/cancer-in-the-family">screening more intensively offers greater benefits</a>.</p>
<h2>So which strategy really is best?</h2>
<p>The ultimate aim of screening is to reduce deaths from breast cancer. Yet, whichever screening strategy we use, screening is not 100% effective.</p>
<p>It probably reduces the risk of dying from breast cancer <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61611-0/abstract">by about 20%</a>, at most <a href="http://journals.sagepub.com/doi/abs/10.1258/jms.2012.011127">by 40%</a>, and perhaps as little as only <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1792915">a few percent</a>.</p>
<p>So we must balance this limited benefit with a clearer picture of harms like overdiagnosis and overtreatment to avoid tipping over into net harm.</p><img src="https://counter.theconversation.com/content/82894/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alexandra Barratt receives funding from NHMRC. She is a member of the Public Health Association of Australia, and of the Australasian Epidemiological Association. </span></em></p>Calls to routinely offer breast cancer screening to more women might sound like a good idea, but can harm. Here are three questions to ask when figuring out whether more screening really is better.Alexandra Barratt, Professor of Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/670472016-10-16T19:08:22Z2016-10-16T19:08:22ZBreast self-examination: should you really ‘pledge to check’?<figure><img src="https://images.theconversation.com/files/141708/original/image-20161014-3944-5bi62g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's normal for breasts to be a little bit lumpy.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-201864136/stock-photo-breast-cancer-self-check-healthy-lifestyle-concept.html?src=DFhSlgOWfekGxs2kfXaGOw-1-13">9nong/Shutterstock</a></span></figcaption></figure><p>Shopping at my local pharmacy last week, I was taken aback by a product on the counter: <a href="http://www.egopharm.com/qv-self-check-breast-cream/">“self check breast cream”</a>. Sorry, what? Breast self-examination cream? Is that even a thing?</p>
<p>Looking closer at the <a href="https://twitter.com/drgrinzi/status/784315845421912064">bright pink display</a>, I discovered a sales campaign in full swing, seemingly timed to coincide with <a href="https://canceraustralia.gov.au/healthy-living/campaigns-events/breast-cancer-awareness-month">“breast cancer awareness month”</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/141701/original/image-20161013-3985-1jw5kjm.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/141701/original/image-20161013-3985-1jw5kjm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/141701/original/image-20161013-3985-1jw5kjm.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=250&fit=crop&dpr=1 600w, https://images.theconversation.com/files/141701/original/image-20161013-3985-1jw5kjm.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=250&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/141701/original/image-20161013-3985-1jw5kjm.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=250&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/141701/original/image-20161013-3985-1jw5kjm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=314&fit=crop&dpr=1 754w, https://images.theconversation.com/files/141701/original/image-20161013-3985-1jw5kjm.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=314&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/141701/original/image-20161013-3985-1jw5kjm.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=314&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><a class="source" href="https://qvskincare.com.au/promotions/breast-cream/">QV Breast Cream screen shot.</a></span>
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</figure>
<p>Two dollars from each tube sold was going to <a href="http://www.mcgrathfoundation.com.au/">a breast cancer charity</a>, and there was a ready-to-use social media hashtag – #<a href="https://www.twitter.com/search?q=%23IPledgeToCheck">IPledgeToCheck</a>. In large font was the message “self checking your breasts is important”.</p>
<p>This is a fairly familiar message. But is it true? The evidence is surprisingly complicated.</p>
<h2>Breast cancer screening</h2>
<p>Breast cancer is a common and important disease. Affecting about one in eight women at some point in their lives, it is <a href="http://www.aihw.gov.au/publication-detail/?id=10737423008">the second most common</a> cause of cancer death in Australian women. I’ve seen it profoundly affect many people, including several of my general practice patients. Preventing this would be wonderful.</p>
<p>Cancer screening means looking for cancer in people without symptoms. An established (though <a href="https://theconversation.com/growing-uncertainty-about-breast-cancer-screening-15997">still controversial</a>) example is <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/breast-screening-1">mammography</a>: breast X-rays. Another less established method is breast self-examination.</p>
<p>At first glance, being offered a chance of finding cancer early sounds like a good thing. But it’s more complicated than that. Some screening tests, despite good intentions, fail to help, or even cause harm.</p>
<p>There are various ways screening can mislead us. Screen-detected cancers often show better survival rates than other cancers, but this doesn’t mean the screening is saving lives. </p>
<p>It can instead mean we’re just detecting the cancer earlier <a href="https://theconversation.com/when-talking-about-cancer-screening-survival-rates-mislead-30395">without changing its course</a>, or that the screening is picking up some so-called “cancers” that would <a href="https://theconversation.com/whats-in-a-name-why-we-need-to-reconsider-the-word-cancer-16606">never have caused symptoms</a> (this is called “overdiagnosis”). </p>
<p>Screening can also cause problems by raising false alarm – discovering a lump that resembles possible cancer, but after a worrisome round of tests turns out not to be.</p>
<p>To best measure the effect of a screening program, we need large “randomised controlled trials” of screening. These are studies in which people are randomly allocated to either screening or normal care, and followed over time to see what happens.</p>
<h2>The paradox of breast self-examination</h2>
<p>Two large trials of breast self-examination measured important outcomes such as harms and death. In these trials, study staff taught groups of women how to examine their own breasts in a careful, structured manner. Monthly self-examination was encouraged. </p>
<p>These women were followed up and compared to other women who had no training or encouragement in self-examination.</p>
<p>The results of these studies have been brought together and meta-analysed (mathematically combined) in order to summarise our best evidence on the effectiveness of self-examination. </p>
<p>The <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003373/abstract">combined results</a> from nearly 400,000 women are disappointing: encouraging women to examine their own breasts does not prevent any deaths from breast cancer, but does cause false alarm and an increase in the need for biopsies (involving needles or surgical excision).</p>
<p>But here’s the apparent paradox: despite this lack of effectiveness of breast self-examination in these trials, most breast cancers are still discovered because women notice a change in their breasts.</p>
<p>Trying to put these seemingly contradictory facts together can be headache-inducing. How can this all be true? </p>
<p>It must be that significant breast cancers are likely to be detected spontaneously or accidentally by women in the course of normal life, even without self-examination. Adding structured, monthly self-examination sounds wise, even noble, but sadly our best evidence finds it is unhelpful and leads to false alarm.</p>
<p>Why the false alarm? Because it’s normal for breasts to be a little bit lumpy, as firmer glandular breast tissue sits suspended amongst looser fatty tissue. Picking the “signal” of cancer from the “noise” of normal lumpiness can be tricky.</p>
<h2>So what should we do?</h2>
<p>Authors of breast cancer guidelines have tried to resolve the apparent paradox. They recognise the ineffectiveness of formal regular self-examination, but they also don’t want women to completely ignore their own breasts. </p>
<p>As a sort of compromise, guidelines now talk about <a href="https://canceraustralia.gov.au/publications-and-resources/position-statements/early-detection-breast-cancer">breast awareness</a> – having some self-awareness of one’s breasts, and knowing the importance of presenting quickly to a doctor if a change is noted. </p>
<p>This is a prudent message, and it is one I share with my patients. But it’s still unclear exactly where the sweet spot lies between too much self-examination and too little awareness.</p>
<p>These evidence-based uncertainties and nuances are often lost in media messages about breast awareness, and they seem thoroughly lost in this moisturising cream’s marketing campaign. On <a href="https://twitter.com/egoeveryday/status/783891677668790273">Twitter</a> and <a href="https://www.youtube.com/watch?v=zbPkFZtvwgs">YouTube</a>, the manufacturer actually encourages women to perform <em>daily</em> self-checks, “by making it part of their every day skincare routine”.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"783891677668790273"}"></div></p>
<p>To be fair to the manufacturer, the “daily routine” phrase is echoed by <a href="https://canceraustralia.gov.au/affected-cancer/cancer-types/breast-cancer/awareness/what-can-you-do-find-breast-cancer-early/50-74-years-old">Cancer Australia</a>. But Cancer Australia seem more relaxed about the process, stating that no special technique is necessary and suggesting that a more casual awareness in the shower or in the mirror may suffice. </p>
<p>I haven’t found any evidence to show that using a moisturising cream is necessary or helpful in cancer detection. So it’s not at all clear that this cream will save anyone from bad cancer outcomes, and there’s a real possibility of causing false alarm. While sales help raise money for a worthwhile charity, it’d be more efficient to <a href="https://www.mcgrathfoundation.com.au/Donate.aspx">donate directly</a>.</p>
<p>Is it possible, behind all the pink-tinted pledge-gathering, that the main goal of this campaign is simply to sell moisturising cream?</p><img src="https://counter.theconversation.com/content/67047/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brett Montgomery is a general practitioner working academically and clinically. In his clinical work he sometimes treats people who have breast disease.</span></em></p>Women are told it’s important to self-check their breasts. But is this true?Brett Montgomery, Senior Lecturer in General Practice, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/661252016-10-03T19:16:27Z2016-10-03T19:16:27ZWomen should be told about their breast density when they have a mammogram<figure><img src="https://images.theconversation.com/files/139540/original/image-20160928-736-273r8y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Breast density appears white or bright on mammograms – so do breast cancers. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-196939097/stock-photo-x-ray-mammogram-image-of-breast-with-cancer.html?src=pp-same_artist-196939100-1&ws=1">Tomas K/Shutterstock</a></span></figcaption></figure><p>Women with higher breast density for their age are more likely to develop breast cancer. High breast density also makes it harder for doctors to detect breast cancer on a mammogram. But Australian women are not routinely tested for and told about their level of breast density when they undergo a mammogram. </p>
<p>A woman’s breasts are made up of dense breast tissue and fatty breast tissue. Almost <a href="http://jnci.oxfordjournals.org/content/106/10/dju255.short">8% of women aged between 40 and 74 years</a> have extremely high breast density. This means they have more connective tissue and less fat surrounding their glands. </p>
<p>Breast density can’t be determined just from looking at or physically examining the breasts; it’s measured from a mammogram, an X-ray of the breast. Breast density appears white or bright, while non-dense breast tissue appears dark.</p>
<p>Breast cancers also appear white on a mammogram. So having high breast density can mask or hide the cancer, making early detection more difficult. This is especially important because women whose breast cancers that are found within 24 months of a “clear” mammogram tend to have poorer outcomes.</p>
<p>Across the population, a woman has a 12.5% chance of getting breast cancer in her lifetime. Women who have high breast density for their age and body mass index (BMI) have a <a href="https://www.ncbi.nlm.nih.gov/pubmed/16775176">four to six-times higher</a> risk of developing breast cancer in the future compared to women with low breast density. </p>
<p>We are a group of breast cancer scientists concerned that Australian women are not being made aware of the significance of breast density in the diagnosis and prevention of breast cancer. We want to start a conversation about what density is, even though we don’t yet have all the answers.</p>
<p>We would like to see health professionals (including researchers, radiologists, GPs and BreastScreen) begin talking with women about the best way to measure and report breast density. </p>
<h2>What can women do about it?</h2>
<p>A woman’s breast density is established at the time her breasts form, and is largely determined by genetic factors. </p>
<p>“Environmental” factors then can modify breast density over time. This includes having children, which reduces breast density, and taking certain hormone therapies: hormone replacement therapy increases density, while the drug <a href="https://www.ncbi.nlm.nih.gov/pubmed/21483019">Tamoxifen</a> decreases density.</p>
<hr>
<blockquote>
<p><strong>Further reading:</strong> <a href="https://theconversation.com/how-does-breast-density-impact-on-cancer-screening-34700">How does breast density impact on cancer screening?</a></p>
</blockquote>
<hr>
<p>We don’t yet have a straightforward answer about what women with high breast density for their age should do. </p>
<p>Being “breast aware” is important for all women, but particularly women with higher breast density. Get to know how your breasts feel and check them regularly for changes. </p>
<p>Mammography is the best breast cancer screening test for women aged 50-74 who aren’t showing any symptoms. Early detection improves the outcomes for women with breast cancer, as therapies are more effective at early stages of disease and chances of survival are increased. </p>
<p>For women aged 40 to 49 and over 75, the research is less clear about the benefits of breast screening. </p>
<p>Supplemental screening options such as ultrasound and MRI (magnetic resonance imaging) are available for women with high breast density. However, these also have a number of limitations and are not covered by Medicare for this purpose. </p>
<p>Ultrasound often results in high rates of false positives, indicating that breast cancer is present when it is not. A false positive can be a distressing experience, with additional tests sometimes being required such as a breast biopsy. </p>
<p>MRI does not lead to higher false positives, but it is not a feasible option for a population-based screening program because of the high costs and insufficient MRI resources (equipment and trained staff). </p>
<p>A further problem is there are few options to reduce breast density once it is detected. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/21483019">Tamoxifen</a> is a drug used to prevent or treat breast cancer that reduces breast density and breast cancer risk. But it has significant side effects such as hot flashes, vaginal dryness, low libido, mood swings and nausea, which need to be considered on a patient-by-patient basis. </p>
<p>In counselling women about their breast cancer risk and screening options, clinicians will also ask about a women’s other breast cancer risk factors, particularly family history of the disease.</p>
<h2>What might be available in future?</h2>
<p>Researchers and clinicians have been investigating breast density for around 40 years. But there is still a lot we do not know. </p>
<p>The long-term goal of our research – in Australia and abroad – is a tailored screening program where women undergo good-quality screening measures based on their levels of breast density and their breast cancer risk. </p>
<p>First, we need to determine if women with higher breast density would benefit from supplemental screening mentioned above, or annual mammograms. </p>
<p>Our research teams are currently investigating:</p>
<ul>
<li><p>the underlying biology of breast density to inform the development of new drugs to decrease density </p></li>
<li><p>the optimal methods of measuring breast density across the population and in younger women, for whom mammography is not recommended</p></li>
<li><p><a href="http://www.lifepool.org/">breast cancer risk prediction models</a> to determine the individual likelihood of developing the disease or having it go undetected </p></li>
<li><p>breast density in <a href="http://crowdresearch.uwa.edu.au/project/are-your-breasts-dense/">Aboriginal women and younger women</a></p></li>
<li><p>and the genetic determinants of breast density and breast cancer risk to inform individual risk prediction models.</p></li>
</ul>
<p>We don’t want to scare women that have higher breast density for their age. Rather, we want to inform them about their risk of breast cancer and the additional care they should take until we find treatments that can reduce density and breast cancer risk. Not all women with high breast density will develop breast cancer, but they should be aware that they are at an increased risk.</p>
<hr>
<p><em>For more information on breast density, visit the <a href="http://www.informd.org.au">INFORMD website</a>.</em></p><img src="https://counter.theconversation.com/content/66125/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kara Britt receives funding from National Breast Cancer Research Foundation of Australia and the Peter MacCallum Cancer Research Centre. She is a member of INFORMD (Information FORum on Mammographic Density), an Australian alliance of breast cancer researchers who aim to increase awareness of the importance of breast density in screening, diagnosis and prevention of breast cancer.</span></em></p><p class="fine-print"><em><span>Honor Joy Hugo has received funding from the National Breast Cancer Foundation, Victorian Cancer Agency and is currently funded by a Translational Research Institute SPORE grant and a National Breast Cancer Foundation collaborative research grant called EMPathy. She is a member of INFORMD.
</span></em></p><p class="fine-print"><em><span>Jennifer Stone received grant funding to conduct breast density research from The National Breast Cancer Foundation, Cancer Australia, Cancer Council Western Australia, Cancer Council Victoria, National Health & Medical Research Council, Royal Perth Hospital Medical Research Foundation, Breast Cancer Research Centre Western Australia, Victoria Cancer Agency, and the Victorian Breast Cancer Research Consortium. She is a member of INFORMD.</span></em></p><p class="fine-print"><em><span>John Hopper receives funding from the NHMRC, Cancer Australia, the National Breast Cancer Foundation, the National Institutes of Health and Cancer Council Victoria. He is a member of INFORMD. </span></em></p><p class="fine-print"><em><span>Pallave Dasari receives funding from The Hospital Research Foundation. She is a member of INFORMD.</span></em></p><p class="fine-print"><em><span>Rik Thompson has received funding from the St Vincent's Hospital Research Endowment Fund, the Princess Alexandra Hospital Foundation, the Victorian Breast Cancer Research Consortium and the Translational Research Institute. He is a member of INFORMD.</span></em></p><p class="fine-print"><em><span>Wendy Ingman receives funding from the National Health and Medical Research Council, the National Breast Cancer Foundation and The Hospital Research Foundation. She is a member of INFORMD.</span></em></p>Women with dense breasts are more likely to develop breast cancer. Density also makes it harder for doctors to detect breast cancer on a mammogram.Kara Britt, Senior Research Fellow at Peter MacCallum Cancer Centre; Adjunct Lecturer, Monash UniversityHonor Joy Hugo, Postdoctoral Research Fellow, Queensland University of TechnologyJennifer Stone, Senior Research Fellow, Centre for Genetic Origins of Health and Disease, The University of Western AustraliaJohn Hopper, NHMRC Australia Fellow, The University of MelbournePallave Dasari, Australian Breast Cancer Research Postdoctoral Fellow, The Queen Elizabeth Hospital and The Robinson Institute, University of AdelaideRik Thompson, Professor of Breast Cancer Research, Institute of Health and Biomedical Innovation and School of Biomedical Sciences,, Queensland University of TechnologyWendy Ingman, Associate Professor, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/442572015-07-08T15:02:53Z2015-07-08T15:02:53ZCelebrity campaigns are a distraction from the real risks of cancer screening<figure><img src="https://images.theconversation.com/files/87596/original/image-20150707-1297-36xxpi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Unnecessary worry?</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>You may have read stories about people who believe their <a href="http://www.telegraph.co.uk/finance/personalfinance/insurance/privatemedical/8813595/When-it-pays-to-go-private-500-test-saved-my-life.html">lives were saved</a> because of a routine screening for a disease such as cancer. Or you may have heard of people who feel they were let down because they <a href="http://www.mirror.co.uk/news/uk-news/sophie-jones-petition-cervical-screening-3253376">didn’t receive such screening</a>. While they make compelling media stories, this kind of media coverage of screening is often incomplete and misleading.</p>
<p>It has helped to create unrealistic expectations of what screening programmes are and what they can deliver. On the one hand, there is a <a href="http://jnci.oxfordjournals.org/content/101/17/1216">mistaken belief</a> that screening only offers benefits. On the other, there is the myth that screening is only offered to certain age groups due to <a href="http://www.thescottishsun.co.uk/scotsol/homepage/2153672/NHS-screening-cuts-betrayed-women-like-Jade-says-Sun-Columnist-Jane-Moore.html">financial restrictions</a>.</p>
<p>This superficial view has real and lasting implications for citizens, patients and health care professionals, leaving many people confused about screening. It needs to change.</p>
<p>Screening involves testing apparently healthy people to see if they have a higher risk of a disease. This means you can offer treatment or advice at an earlier stage, giving a greater chance of successfully dealing with or preventing the condition. Screening programmes are based on careful calculation, including who will benefit, what treatments are available and the level of accuracy of the tests.</p>
<p>Each screening programme is targeted to a specific subset of the population. For example, screening for diabetic eye disease only involves people with diabetes. Other effective screening <a href="http://www.nhs.uk/Livewell/Screening/Pages/screening.aspx">programmes in the UK</a> include looking for cystic fibrosis in newborn babies, or Hepatitis B and HIV in pregnant women.</p>
<p>But despite what you might read or hear, there are real risks of screening programmes, even in well-established programmes such as mammography. Sometimes screening produces false negative results, where people are mistakenly told they don’t have the disease. More common are the false positives, where people are mistakenly told they have the risk marker when they don’t, or when the condition that is identified would not have progressed, or was harmless. This means that any treatments they were then offered and underwent were unnecessary, with all of the emotional and health consequences that this brings.</p>
<h2>Risk versus benefit</h2>
<p>There is <a href="http://www.dailymail.co.uk/health/article-2958333/Would-mammogram-number-women-screened-breast-cancer-falls-year-new-study-reignites-debate-benefits-risks-test.html">heated debate</a> about the harm this causes. <a href="http://bit.ly/1TirDPu">For example</a>, in the case of UK women aged 50 screened for breast cancer for the next 20 years, <a href="https://www.harding-center.mpg.de/de/system/files/media/pdf/cee0305337891f79c011e70d3879c2e1/mammography_en_11-2014.pdf">one death</a> is prevented for about every three over-diagnosed cases identified and treated. And there is <a href="http://archinte.jamanetwork.com/article.aspx?articleid=2363025">no impact</a> on death overall from all causes.</p>
<p>I am saddened when I hear people discuss their distress about their own or their family member’s “cancer” diagnosis via screening when, for example, the breast cancer cells discovered haven’t developed the ability to spread. These “DCIS” cells look like cancer down a microscope but they don’t behave like cancer and might never have led to a problem.</p>
<p>Women are then put into a terrible dilemma. Do they live with uncertainty, or do they live with life-changing treatments? Would they have ever have started this journey had they realised the uncertainty? How do they get off the conveyor belt now they are on it? In many cases, they <a href="http://archinte.jamanetwork.com/article.aspx?articleid=1754987&resultClick=3#Discussion">do not even realise</a> that the life-changing mastectomy (or double mastectomy) was an adverse consequence of being screened. It seems counter-intuitive, but <a href="http://www.bmj.com/content/343/bmj.d4692">there is evidence</a> a mastectomy is less likely if you wait for symptoms instead of being screened </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/87597/original/image-20150707-1297-169yr3s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/87597/original/image-20150707-1297-169yr3s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/87597/original/image-20150707-1297-169yr3s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/87597/original/image-20150707-1297-169yr3s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/87597/original/image-20150707-1297-169yr3s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/87597/original/image-20150707-1297-169yr3s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/87597/original/image-20150707-1297-169yr3s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Unbearable decision.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Some men may have a prostate blood test that leads to a biopsy and then an operation that produces impotence. Were these operations necessary? How unbearable to wonder. Many of the screeners these men and women will meet on their journeys are also <a href="http://archinte.jamanetwork.com/article.aspx?articleid=1754987&resultClick=3#Discussion">not fully informed</a> about the limitations. Before starting on any screening journey, everyone should be told about the real risks and benefits in order to make their own, informed decisions.</p>
<p>The question of who should be invited for screening generates some of the most emotive and often misinformed discussion. <a href="http://www.itv.com/news/wales/2015-05-27/teenage-cancer-survivor-campaigns-to-lower-age-for-cervical-cancer-screening/">Campaigners and</a> <a href="http://www.reuters.com/article/2015/04/09/us-people-taylorswift-idUSKBN0N025U20150409">celebrities call for screening</a> in more people, more diseases and for longer with no mention of the impact and potential harms of doing so. It is vanishingly rare that they have any expertise in biology, medicine, science or uncertainty and yet their opinions that “more should be done” or “more could have been done” are given a great deal of airtime.</p>
<p>The conversations surrounding cervical screening are no exception. Currently cervical screening in the UK is only offered from the age of 25, but <a href="http://www.bbc.co.uk/news/uk-northern-ireland-foyle-west-29814206">media coverage</a> <a href="http://www.mirror.co.uk/news/uk-news/sophie-jones-petition-cervical-screening-3253376">and petitions</a> have demanded the cervical screening age be lowered to 20. But research has shown that screening this younger age group is ineffective. It <a href="http://www.bmj.com/content/339/bmj.b2968">does not prevent deaths</a> from cervical cancer and results in many false positives and overdiagnosis. </p>
<h2>No short cut</h2>
<p>Treatment of more and more women with minor cellular abnormalities in the cervix will lead to <a href="http://www.bmj.com/content/349/bmj.g6223">surgical damage</a> and to some cases of premature and damaged babies being born. The cervical screening programme on offer, as with all others, should be based solely on the balance of benefit and harm. It should not be unduly influenced by public discussion that only promotes a one-sided story of benefits. </p>
<p>Screening is not a short cut to health. It should not be for everyone. It should not be for all diseases. It should not be about screening more people for longer. It should only be offered when there are more benefits than risks. </p>
<p>The charity <a href="http://www.senseaboutscience.org">Sense About Science</a> has launched a new edition of <a href="http://www.senseaboutscience.org/pages/making-sense-of-screening.html">Making Sense of Screening</a> to tackle the widespread myths about screening programmes. I hope it will be shared among clinicians, health professionals and anyone interested or concerned about screening so that more people understand that simplistic calls for more screening are wrong. Harms always need to be weighed against benefits when making decisions about screening, whether at national programme or individual level.</p><img src="https://counter.theconversation.com/content/44257/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Bewley is a trustee of HealthWatch, a charity 'for science and integrity in medicine' and contributed to Sense About Science's 'Making Sense of Screening' guide.</span></em></p>Screening may save lives but it comes with a cost - and sometimes unbearable decisions - that shouldn’t be underestimated.Susan Bewley, Professor of complex obstetrics, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/422252015-06-01T05:17:20Z2015-06-01T05:17:20ZHow understanding breast cancer at a molecular level is revolutionising our thinking<figure><img src="https://images.theconversation.com/files/83245/original/image-20150528-31337-1kdfzft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The many presentations of breast cancer. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-128042738/stock-photo-close-up-topless-woman-body-covering-her-breast-with-hand-color-processed.html?src=PLpv-uwjPddclgmb5dZtWw-1-18">Breast cancer by Shutterstock</a></span></figcaption></figure><p>The evolution of past and modern therapies in breast cancer has been an inspiring illustration of the progress that has been made towards cancer cures. Breast cancer makes up a quarter of new cases worldwide and is <a href="http://www.wcrf.org/int/cancer-facts-figures/worldwide-data">the most common cancer in women</a>. </p>
<p>While the number of people with breast cancer <a href="https://theconversation.com/hard-evidence-are-we-beating-cancer-20870">has been increasing</a> fewer people are dying from the disease, potentially because of <a href="http://www.cancerscreening.nhs.uk/breastscreen/">better screening</a> and diagnosis at an early and more curable stage. Thanks to better treatments, more people are also surviving five years after diagnosis, but this wouldn’t be possible with the strides that have been made in understanding breast cancer at a molecular level. </p>
<p>Breast cancer was long considered as a tumour with an underlying relationship with oestrogen. Instead, driven by a greater understanding of the molecular basis of breast cancers, we now see a more complex picture. We now know breast cancer to be an umbrella of different diseases – as many as ten different types – with a number of subtypes.</p>
<p>And although a number of factors can contribute towards developing breast cancer, there is no single agent or cause. A closer look at cancer detection, molecular biology and progression is telling us more about the underlying factors in breast cancer development and spread.</p>
<h2>No one breast cancer</h2>
<p>Despite the uncertainties of what exactly causes breast cancer, there is abundant <a href="http://www.ncbi.nlm.nih.gov/pubmed/23543779">evidence for hormonal</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/12133652">reproductive factors</a>. A number <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470027">of environmental factors</a> may also lead to mutations in DNA, such as exposure to radiations, chemicals and alcohol. However not all of the mutations are environmentally induced – some occur spontaneously. Other factors that increase risk of developing breast cancers are age, gender, family history and certain medical conditions. </p>
<p>A wide range of genes and proteins may contribute towards the development of breast cancer or fail to prevent it; these can be either involved in regulating the cell cycle, promoting the growth of tumour cells (known as oncogenes) or suppressing tumour cell growth (known as tumour suppress genes). There are also genes that are involved in <a href="https://theconversation.com/how-self-destructing-cells-may-hold-key-to-cancer-cure-31707">promoting cell death</a> along with genes involved in DNA repair. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/83249/original/image-20150528-31319-8ej7je.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/83249/original/image-20150528-31319-8ej7je.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=722&fit=crop&dpr=1 600w, https://images.theconversation.com/files/83249/original/image-20150528-31319-8ej7je.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=722&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/83249/original/image-20150528-31319-8ej7je.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=722&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/83249/original/image-20150528-31319-8ej7je.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=907&fit=crop&dpr=1 754w, https://images.theconversation.com/files/83249/original/image-20150528-31319-8ej7je.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=907&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/83249/original/image-20150528-31319-8ej7je.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=907&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">BRCA1.</span>
<span class="attribution"><a class="source" href="http://commons.wikimedia.org/wiki/File:BRCA1_en.png">Kuebi = Armin Kübelbeck</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<p>For example, inherited breast cancers can involve mutations in BRCA1 and BRCA2, genes that are crucial in DNA repair. Mutations in these genes result in incorrect repair of DNA damage which in consequence increases risk of further mutations occurring that may then lead to cancer. Genetic tests <a href="https://theconversation.com/greater-access-to-genetic-testing-in-nhs-will-help-cancer-fight-14448">are now available</a> to test for such genes, which are known to increase the risk of developing breast cancer by 40-90%. </p>
<h2>Four subtypes</h2>
<p>Gene expression <a href="http://www.news-medical.net/health/What-is-Gene-Expression.aspx">is the process</a> in which genetic instructions are used to make gene products, mainly proteins that function as enzymes, hormones and receptors. Gene expression profiling is a technique that allows scientists to determine the expression levels of hundreds or thousands of genes within a cell. </p>
<p>Breast cancer cells <a href="http://www.macmillan.org.uk/information-and-support/breast-cancer/treating/treatment-decisions/Understanding-your-diagnosis/receptors-for-breast-cancer.html">have receptors</a> that other hormones or proteins can attach to and stimulate the cancer to grow. These receptors include the hormones oestrogen and progesterone, and human epidermal growth factor 2 (HER2), a protein. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/83247/original/image-20150528-31319-mjyoy1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/83247/original/image-20150528-31319-mjyoy1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/83247/original/image-20150528-31319-mjyoy1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/83247/original/image-20150528-31319-mjyoy1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/83247/original/image-20150528-31319-mjyoy1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/83247/original/image-20150528-31319-mjyoy1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/83247/original/image-20150528-31319-mjyoy1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Expression of oestrogen sulfotransferase 1E1 and steroid sulfatase in breast cancer.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-128042738/stock-photo-close-up-topless-woman-body-covering-her-breast-with-hand-color-processed.html?src=PLpv-uwjPddclgmb5dZtWw-1-18">Libertas Academica</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>The expression of breast cancer receptors has led to the molecular classification of breast cancer into four distinct subtypes: basal type or triple negative breast cancers (TNBC), HER2 positive breast cancers, Luminal A and Luminal B breast cancers – each with a different combination of positive/negative receptor interactions. </p>
<p>A Luminal B type cancer will be positive and/or negative for oestrogen receptors and positive for HER2, for example, while triple negative breast cancers are those that do not have receptors for either HER2 or for the hormones oestrogen and progesterone, and affects about a fifth of women with breast cancer.</p>
<p>Establishing the presence of these receptors can allow clinicians to make more accurate prognosis and work out which treatments will be more effective for particular patients. For example, <a href="http://www.ncbi.nlm.nih.gov/pubmed/23320171">20-30% of breast cancers</a> are known to be HER2 positive, which indicates a poorer prognosis with a reduced overall survival rate.</p>
<p>Some breast cancers are more common in particular populations, for example the occurrence of triple negative breast cancers is thought <a href="http://annonc.oxfordjournals.org/content/23/suppl_6/vi7.long">to be three times higher</a> in women of African descent and usually more aggressive than in European women, there is <a href="http://www.nature.com/nrc/journal/v15/n4/full/nrc3896.html#close">still some debate</a> over wheather this is due to lifestyle (enviromental) factors or biological reasons.</p>
<h2>Targeted therapies</h2>
<p>Targeted therapies tend to target a specific protein or receptor found in tumour cells making the treatment selective and more effective. So while HER2 positive breast cancers have a poorer prognosis, treatment has improved through targeted therapies such as Herceptin, which fights against cancer cells by suppressing the function of HER2 to prevent tumour growth.</p>
<p>Unlike chemotherapy and radiotherapy, which affects both normal and cancerous cells, using targeted therapy reduces overall side effects. But it isn’t perfect – some patients still don’t respond to targeted therapy and there can be resistance to the drug in some cases. <a href="https://theconversation.com/cutting-edge-particle-physics-could-bring-cancer-therapy-home-13765">New technology</a> such as proton beam therapy may provide a more targeted form of radiotherapy. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/83242/original/image-20150528-31296-1txk2v6.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/83242/original/image-20150528-31296-1txk2v6.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=431&fit=crop&dpr=1 600w, https://images.theconversation.com/files/83242/original/image-20150528-31296-1txk2v6.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=431&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/83242/original/image-20150528-31296-1txk2v6.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=431&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/83242/original/image-20150528-31296-1txk2v6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=541&fit=crop&dpr=1 754w, https://images.theconversation.com/files/83242/original/image-20150528-31296-1txk2v6.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=541&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/83242/original/image-20150528-31296-1txk2v6.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=541&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Internal radiotherapy for breast cancer.</span>
<span class="attribution"><a class="source" href="http://commons.wikimedia.org/wiki/File:Diagram_showing_how_you_have_internal_radiotherapy_for_breast_cancer_CRUK_159.svg">Cancer Research UK/Wikimedia Commons</a></span>
</figcaption>
</figure>
<h2>The gene trail</h2>
<p>In addition to BRCA1 and BRCA2, <a href="http://www.breastcancer.org/risk/factors/genetics">a number of genes</a> – though rarer – that increase the risk of breast cancer when faulty have been identified. These include the ATM gene – which helps repair damaged DNA, the CDH1 gene – which makes a protein that helps cells join together to form tissue, and the CHEK2 gene – which helps create instructions for a protein that stops tumour growth. A paper in Nature Genetics recently <a href="http://medicalxpress.com/news/2015-04-breast-cancer-gene.html">identified a new breast cancer gene</a> called RECQL, mutations in which are associated with breast cancer. </p>
<p>There may yet be more. Around 5-10% of all breast cancer cases <a href="http://www.breastcancer.org/risk/factors/genetics">are hereditary</a>, and while diagnostic or genetic tests are available for some genes, there are yet to be any for some of the others already identified.</p>
<p>Although molecular subtyping of breast cancer has been proven to be useful with more patient-specific treatments, the techniques used to classify breast cancers into these subtypes can vary from place to place. Triple negative breast cancers may be the most reliably classified and identified, whereas other subtypes may have some variance. Changes in receptor status, for example, can also occur throughout the progression of the disease and in some cases equivocal results – which is seen in some HER2 testing – can make it uncertain what subtype the patient belongs to and what treatment they should have, or what the results might be.</p>
<p>Understanding breast cancer at a molecular level opens up the way for better treatments, but we’re also discovering just how complex these cancers are. In the long run, the more detailed knowledge we have the better.</p><img src="https://counter.theconversation.com/content/42225/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Haroon Hussain does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Long gone are the days when breast cancer was seen as a tumour with an underlying relationship with oestrogen. The picture is much more complex.Haroon Hussain, PhD Student, Brunel University LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/418892015-05-20T20:02:50Z2015-05-20T20:02:50ZMost people want to know risk of overdiagnosis, but aren’t told<figure><img src="https://images.theconversation.com/files/82156/original/image-20150519-25400-1dalg0u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An independent UK inquiry estimated that perhaps one in five of the cancers detected via breast cancer screening are overdiagnosed. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/armymedicine/14917131905/">Army Medicine/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>An <a href="http://dx.plos.org/10.1371/journal.pone.0125165">Australian survey released today</a> has found a large majority of people report they’ve never been told by doctors about the danger of being overdiagnosed – and an equally large majority say they want to be informed.</p>
<p>This is the first time anywhere in the world the general community has been asked about their knowledge and views on the “<a href="http://archinte.jamanetwork.com/article.aspx?articleid=1203523">modern epidemic</a>” of overdiagnosis, which happens when someone is <a href="https://theconversation.com/preventing-over-diagnosis-how-to-stop-harming-the-healthy-8569">diagnosed with a disease that won’t actually harm them</a>. Being overdiagnosed means you’re likely to be over-treated, and potentially suffer the harms of that treatment without getting any of its benefits.</p>
<p>It can occur as a result of healthy people undergoing certain cancer screening programs, for instance, and being diagnosed and treated for a cancer that would never progress to cause symptoms or early death.</p>
<h2>Wanting to know</h2>
<p>While there’s ongoing scientific debate about how often this happens, a large <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61611-0/abstract">independent UK inquiry</a> estimated that, along with saving lives of those diagnosed with harmful cancers, perhaps one in five of the cancers detected via breast cancer screening are overdiagnosed. </p>
<p>Overdiagnosed cancers were defined in the inquiry’s <a href="http://www.cancerresearchuk.org/prod_consump/groups/cr_common/@nre/@pol/documents/generalcontent/breast-screening-report.pdf">full report</a> as those “diagnosed by screening that would not otherwise have come to attention in the woman‘s lifetime”.</p>
<p>For prostate cancer screening, evidence suggests as many as one in two cancers may be overdiagnosed – causing some <a href="http://annals.org/article.aspx?articleid=1216568">public health authorities</a> to recommend against screening for it at all.</p>
<p>Run with colleagues at Bond and Sydney universities, our national survey of 500 Australians – <a href="http://dx.plos.org/10thehh.1371/journal.pone.0125165">published today in global open-access journal PLOS ONE</a> – specifically asked people if they’d been screened for breast or prostate cancer. And if so, whether or not they’d been informed about the risk of overdiagnosis associated with the screening.</p>
<p>Of the men reporting being screened for prostate cancer, 80% said they had not been told of the risk of overdiagnosis. Of women who’d been screened for breast cancer, 87% said they had not been told. Overall, only one in ten said they’d ever been informed by a doctor about overdiagnosis.</p>
<p>Asked whether they thought that, along with the benefits of being screened, people should also be informed about the risk of being overdiagnosed, 93% agreed.</p>
<p>Remarkably, at the end of the anonymous telephone survey, 80% of people agreed to share their personal details so they could participate in follow-up qualitative research on overdiagnosis. Their agreement highlights a public hunger for more information about the issue.</p>
<h2>Expanding definitions</h2>
<p>Another reason overdiagnosis happens is because diagnostic thresholds for some diseases are lowered so much that people with mild symptoms, or at very low risk of illness, are labelled as “diseased” – even though many will never actually be harmed by the disease. </p>
<p>Consider “<a href="http://www.bmj.com/content/341/bmj.c4442">pre-hypertension</a>” which is said to affect a whopping one in three adults, or the continually expanding definitions of attention deficit hyperactivity disorder (<a href="https://theconversation.com/moving-the-diagnostic-goalposts-medicalising-adhd-8675">ADHD</a>).</p>
<p>These changes to disease definitions, which often expand the numbers of people classified as sick, are commonly made by panels of experts that include doctors who are paid to speak for or consult to drug companies. In a <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001500">previous study</a> published in PLOS Medicine, <a href="https://theconversation.com/how-diseases-get-defined-and-what-that-means-for-you-16965">our team found</a> around 75% of these experts have multiple relationships with a median of seven drug or device companies.</p>
<p>In our current survey, we asked the public what they thought about doctors who define disease also having relationships with pharmaceutical companies. This is likely the first time anywhere in the world the public has been asked about the experts who draw the line between health and illness. </p>
<p>Almost 80% of the survey participants thought these relationships with drug companies were inappropriate, and 90% thought the panels should have a minority of members with these conflicts of interest, or be totally free of them.</p>
<p>Public thinking, it seems, is very much in tune with recommendations from august bodies including the United States Institute of Medicine, which have <a href="http://www.iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx">concluded there is a need</a> for much greater independence between influential medical panels and the pharmaceutical industry.</p>
<h2>Better care</h2>
<p>Like all research, our survey has limitations and we’ve spelt them out in our published article. One of them is that out of all the people contacted and eligible for the survey, just under half agreed to take part, raising the possibility of differences between our sample and the wider population.</p>
<p>Notwithstanding limitations, our survey adds weight to calls to better inform people about the risk of overdiagnosis, particularly those who take part in cancer screening programs. This has <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2815%2960123-4/abstract">started to happen around the world</a>, and is on the cards in Australia. </p>
<p>On the question of conflicted experts, our results suggest there might be strong public sympathy for any professional group or policymaker brave enough to try and bring more independence to the influential panels that decide who is sick and how they should be treated.</p>
<p>Despite the counter-intuitive and complex nature of the problem, preventing overdiagnosis is increasingly on the radar of those working for a more rational and sustainable health-care system. It may help shift resources wasted on unnecessary care to those in genuine need.</p><img src="https://counter.theconversation.com/content/41889/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Ray Moynihan is a member of the committees planning the Preventing Overdiagnosis and Overuse meeting in Australia in August, and the Preventing Overdiagnosis conference in the US in September this year.</span></em></p>Researchers have been talking about the dangers of overdiagnosis for some time. But now a national survey shows most people aren’t told about the risk it poses to their health – and they want to know.Ray Moynihan, Senior Research Fellow, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/400362015-04-20T05:04:49Z2015-04-20T05:04:49ZThe mystery of breast cancer<p>For most of the common cancers, a major cause has been identified: smoking causes <a href="http://med.stanford.edu/biostatistics/abstract/RobertProctor_paper1.pdf">90% of lung cancer worldwide</a>, hepatitis viruses cause most liver cancer, <em>H pylori</em> bacteria <a href="http://www.ncbi.nlm.nih.gov/pubmed/24889903">causes stomach cancer</a>, Human papillomavirus causes almost all cases of <a href="http://www.cdc.gov/cancer/hpv/statistics/cases.htm">cervical cancer</a>, colon cancer is <a href="http://www.ncbi.nlm.nih.gov/pubmed/22158327">largely explained</a> by physical activity, diet and family history. </p>
<p>But for breast cancer, there is no smoking gun. It is almost unique among the common cancers of the world in that there is not a known major cause; there is no consensus among experts that proof of a major cause has been identified. </p>
<p>Yet, breast cancer is the most common form of cancer in <a href="http://www.who.int/mediacentre/factsheets/fs297/en/">women worldwide</a>. The risk <a href="http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx">is not equally distributed</a> around the globe, though. Women in North America and Northern Europe have long had five times the risk of women in Africa and Asia, though recently risk has been increasing fast in Africa and Asia for unknown reasons. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/78092/original/image-20150415-31691-dptqsl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/78092/original/image-20150415-31691-dptqsl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/78092/original/image-20150415-31691-dptqsl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/78092/original/image-20150415-31691-dptqsl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/78092/original/image-20150415-31691-dptqsl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/78092/original/image-20150415-31691-dptqsl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/78092/original/image-20150415-31691-dptqsl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Was it something I ate?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-2024202/stock-photo-supermarket.html?src=uWWE4rUoHUIzS65Kzhlheg-3-12">Supermarket aisle via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>Is diet to blame?</h2>
<p>Up until about 20 years ago, we thought it was all about diet. As people abandon their local food sources and begin to eat highly processed foods with lots of fats, the hypothesis went, breast cancer was thought to be more likely to develop. </p>
<p>This hypothesis was logical because when researchers analyzed countries’ per capita fat consumption and breast cancer mortality rates, they found a <a href="http://cancerres.aacrjournals.org/content/35/11_Part_2/3374">strong correlation</a>. In addition, rats fed a high-fat diet are more prone to breast tumors. </p>
<p>By studying Japanese migrants to California, researchers found that the first generation had low risk like their parents in Japan, but then by the second and third generation, <a href="http://www.ncbi.nlm.nih.gov/pubmed/7742407">risk was as high</a> as white American women. So, the genetics of race did not account for the stark differences in the breast cancer risk between Asia and America. This was also consistent with the idea that the change in food from the lean Asian diet to the high-fat American diet causes cancer. So it all made sense.</p>
<p>Until it didn’t. </p>
<h2>Diet studies find that fat is not the answer</h2>
<p>Starting in the mid-1980s, large, well-done prospective studies of diet and breast cancer began to be reported, and they were uniformly negative. Fat in the diet of adult women <a href="http://www.ncbi.nlm.nih.gov/pubmed/3785347">had no impact</a> on breast cancer risk at all. </p>
<p>This was very surprising – and very disappointing. The evidence for other aspects of diet, like fruits and vegetables, has been <a href="http://www.ncbi.nlm.nih.gov/pubmed/24330083">mixed</a>, though alcohol consumption does increase risk modestly. It is also clear that heavier women are at higher risk after menopause which might implicate the total amount of calories consumed if not the composition of the diet. </p>
<p>There is a chance that early life dietary fat exposure, even in utero, <a href="http://www.ncbi.nlm.nih.gov/pubmed/9823005">may be important</a>, but it’s difficult to study in humans, so we don’t know much about how it might relate to breast cancer risk later in life. </p>
<p>If diet is not the major cause of breast cancer, then what else about modernization might be the culprit? </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/78094/original/image-20150415-31660-xtlhen.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/78094/original/image-20150415-31660-xtlhen.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/78094/original/image-20150415-31660-xtlhen.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/78094/original/image-20150415-31660-xtlhen.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/78094/original/image-20150415-31660-xtlhen.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/78094/original/image-20150415-31660-xtlhen.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/78094/original/image-20150415-31660-xtlhen.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some risk factors, like exercise, can be modified.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-175183394/stock-photo-fit-sports-woman-jogging-at-park.html?src=h_0DMjDoxgREWJUukUoIEQ-1-0">Runner via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>Two kinds of risk factors: what we can modify, and what we can’t</h2>
<p>The factors shown to affect a woman’s risk for developing breast cancer fall into <a href="http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-risk-factors">two categories</a>. First, those that cannot be easily modified: age at menarche, age at birth of first child, family history, genes like BRCA1. And second, those that are modifiable: exercise, body weight, alcohol intake, night-work jobs. </p>
<p>The role of environmental pollution is controversial and also <a href="http://www.ncbi.nlm.nih.gov/pubmed/24818537">difficult to study</a>. The concern about chemicals, particularly endocrine disruptors, started after the realization that such chemicals could affect cancer risk in <a href="http://www.niehs.nih.gov/health/topics/agents/endocrine/">rodent models</a>. But in human studies the evidence is mixed.</p>
<p>Because child bearing at a young age and breast feeding reduce risk, the incidence throughout Africa, where birth rates tend to be higher, and where women start their families at younger ages, <a href="http://www.who.int/bulletin/volumes/91/9/13-020913/en/">has been lower</a>. </p>
<p>Death rates, however, from breast cancer in sub-Saharan Africa are now almost as high as in the developed world <a href="http://www.ncbi.nlm.nih.gov/pubmed/24604092">despite the incidence still being much lower</a>. This is because in Africa, women are diagnosed at a later stage of disease and also because there are far fewer treatment options.</p>
<p>The question is whether the known risk factors differ enough between the high-risk modern societies and the low-risk developing societies to account for the large differences in risk. The answer: probably not. Experts think that less than half the high risk in America is explained by the <a href="http://www.ncbi.nlm.nih.gov/pubmed/7473816">known risk factors</a>, and that these factors explain <a href="http://www.ncbi.nlm.nih.gov/pubmed/2228308">very little of the difference</a> in risk with Asia. </p>
<p>A related question is whether the high risk in America and Northern Europe is due to a combination of many known exposures, each of which affects risk a little bit, or mostly due to a major cause that has so far eluded detection. And maybe some of the known risk factors have a common cause which we don’t yet understand. </p>
<h2>Are we just finding more cancer?</h2>
<p>Since the 1980s, screening by mammography has accounted for some of the increase in incidence in the modern world compared to the developing world, but not nearly enough to explain the entire difference. About 20% of the cancers found by mammography are now believed to be of a type that would never have progressed beyond the very small early stage that mammography can detect. But the problem is that we can’t tell which are the benign <a href="http://jama.jamanetwork.com/article.aspx?articleid=1853165">ones and which are not</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/78095/original/image-20150415-19648-cw521g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/78095/original/image-20150415-19648-cw521g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/78095/original/image-20150415-19648-cw521g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/78095/original/image-20150415-19648-cw521g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/78095/original/image-20150415-19648-cw521g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/78095/original/image-20150415-19648-cw521g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/78095/original/image-20150415-19648-cw521g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Electric light and shift work may be factors.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-146043281/stock-photo-side-view-of-a-young-woman-working-on-computer-in-dark-office.html?src=R6VnowHB7Nqr7vQwuzgxsg-1-19">Office worker via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>What about electric light?</h2>
<p>Electric light is a hallmark of modern life. So, maybe the introduction and increasing use of electricity to light the night accounts for a portion of the worldwide breast cancer burden.</p>
<p>This might be because our circadian rhythm is disrupted, which affects hormones that <a href="http://onlinelibrary.wiley.com/doi/10.3322/caac.21218/abstract">influence breast cancer development</a>. For example, electric light at night can trick the body into daytime physiology in which the hormone melatonin is suppressed; and melatonin has been <a href="http://www.ncbi.nlm.nih.gov/pubmed/16322268">shown</a> to have a strong inhibitory effect on human breast tumors growing in rats.</p>
<p>The theory is easy to state but difficult to test in a rigorous manner. Studies have shown that night-working women are at <a href="http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045%2807%2970373-X/abstract">higher risk than day-working women</a>, which was the first prediction of the theory. </p>
<p>Other predictions are that blind women would be at lower risk, short sleepers would be at higher risk, and more highly lighted communities at night would have higher breast cancer incidence. Each of these has some modest support though <a href="http://www.ncbi.nlm.nih.gov/pubmed/19380369">none are conclusive</a>. What we do know is that electric light in the evening or at night can <a href="https://theconversation.com/a-dark-night-is-good-for-your-health-39161">disrupt our circadian rhythms</a>, and whether this harms our long term health, including risk of breast cancer, is not yet clear.</p>
<p>Whatever is going on, it’s important to find answers because breast cancer has become a scourge that now afflicts women all over the world in very large numbers, at almost two million new cases this year alone.</p><img src="https://counter.theconversation.com/content/40036/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Stevens has received funding from the National Institute for Environmental Health Sciences.</span></em></p>Major causes have been identified for most common cancers, like liver and lung. But we still haven’t identified one for breast cancer.Richard G. "Bugs" Stevens, Professor, School of Medicine, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/338452014-12-22T19:18:59Z2014-12-22T19:18:59ZGreat expectations: our naive optimism about medical care<figure><img src="https://images.theconversation.com/files/67327/original/image-20141216-24294-ifo3h9.jpg?ixlib=rb-1.1.0&rect=0%2C310%2C3510%2C2306&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most people overestimate the benefits and underestimate the harms of medical intervention. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/cannnela/4614340819">Barbara M./Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><blockquote>
<p>“It might do me some good and it won’t hurt to give it a go.”</p>
</blockquote>
<p>How often have you heard a phrase like this?</p>
<p>Most people have naïve optimism about medical care. That’s the finding of a systematic review of all available research on common medical treatments we <a href="http://archinte.jamanetwork.com/article.aspx?articleid=2038981&resultClick=1">published</a> today in the journal JAMA Internal Medicine.</p>
<p>We set out to synthesise all the research to date that asked people to quantify the benefits, and/or harms, of common medical treatments, tests and screens (where people are tested for a disease without any symptoms or signs). We also aimed to compare, where possible, people’s expectations with the actual benefits and harms that are derived from research. </p>
<p>Most screening studies were about cancer screening and conclusions were similar regardless of the cancer of focus (breast, cervical, prostate, bowel). </p>
<p>Expectations for various treatments had been studied and included surgery (such as hip and knee replacement, back surgery, cataract surgery), medications (such as those for inflammatory bowel disease, osteoporosis, statins for cardiovascular disease), and other things like cardiopulmonary resuscitation (CPR). </p>
<p>This was a big search: we screened over 15,000 papers to find the 35 studies which met our inclusion criteria. Together these had studied over 27,000 people. </p>
<p>In the majority of studies, most people overestimated benefits and underestimated the harms. There was only one study where the majority of participants underestimated the benefit and one where the majority overestimated the harm. Across most studies, the proportion of people who correctly estimated intervention benefits and harms was generally low.</p>
<p>In other words, people appear to have set a halo around medical care, expecting it to deliver better outcomes than is reality. In marketing terms, we clinicians have a dream sell: our “product” is thought to be far better than it really is. </p>
<p>For the most part, this finding was echoed across various interventions, settings (primary care and hospitals), and countries. </p>
<p>The first question, of course, is why do people have such great expectations about medical management? The answers can only be speculative. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/67329/original/image-20141216-24313-tnoceh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/67329/original/image-20141216-24313-tnoceh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/67329/original/image-20141216-24313-tnoceh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=805&fit=crop&dpr=1 600w, https://images.theconversation.com/files/67329/original/image-20141216-24313-tnoceh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=805&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/67329/original/image-20141216-24313-tnoceh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=805&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/67329/original/image-20141216-24313-tnoceh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1011&fit=crop&dpr=1 754w, https://images.theconversation.com/files/67329/original/image-20141216-24313-tnoceh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1011&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/67329/original/image-20141216-24313-tnoceh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1011&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Why are we so optimistic about medical care? The answers may be patient-related, or clinician-related.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/soozed/9877628084">soozed/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>There may be patient-related factors, such as: assumptions that more health care is better; optimistic bias (when individuals perceive that are at less risk than their peers); and unrealistic expectations may allow psychological needs such as hope and reassurance to be met. </p>
<p>Over-selling is something we come to expect in everyday marketing transactions and we are used to wearing a protective shield of scepticism, if not downright cynicism. But we seem to be generally less sceptical of medical care.</p>
<p>There are also probably clinician-related reasons, such as: clinicians wanting to convey hope and encouragement; the <a href="http://www.bmj.com/content/328/7438/474">strong drive</a> to do something rather than nothing, and the related fear of litigation; and clinicians themselves sometimes being unaware of the true effectiveness or benefit-harm trade-offs of interventions. </p>
<p>But there may also be more subtle factors such as the regression-to-the-mean-effect. This means that as even when an intervention is ineffective, clinicians often see patients improve anyway and this can lead to the false belief that the intervention provided was responsible for the improvement.</p>
<p>Greed on the part of some clinicians who are less scrupulous is probably involved too, especially in largely fee-for-service environments. </p>
<p>But clinicians’ enthusiasm for their speciality is also likely to be a larger contributor. To the man with a hammer in his hand, the world looks like nails. Surgeons are more likely to recommend surgery, radiotherapists radiation oncology, physiotherapists to suggest physiotherapy, and so on. </p>
<p>The next question is does this matter? </p>
<p>Very much so. Overly optimistic expectations undoubtedly contribute to the ever increasing use of health services and the growing problem of over-diagnosis, where disease labels are given even though the latent disease might not have ever caused symptoms, and over-treatment, where unnecessary treatments given. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/67331/original/image-20141216-24294-ifkj6s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/67331/original/image-20141216-24294-ifkj6s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/67331/original/image-20141216-24294-ifkj6s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/67331/original/image-20141216-24294-ifkj6s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/67331/original/image-20141216-24294-ifkj6s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/67331/original/image-20141216-24294-ifkj6s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/67331/original/image-20141216-24294-ifkj6s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/67331/original/image-20141216-24294-ifkj6s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Every intervention has benefits and harms and both should be acknowledged and communicated.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/tojosan/4308897037">Tojosan/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<p>There seems to be a <a href="http://www.ncbi.nlm.nih.gov/pubmed/17353491">vicious cycle</a> in which people have overly optimistic expectations about interventions and request them from their clinicians, who then provide them because it was requested, even if doing so causes the clinician discomfort. Receiving the intervention subsequently reinforces people’s belief that the intervention is beneficial and necessary and so the cycle continues. </p>
<p>Many payment systems favour providing an intervention rather than “just” talking with patients and there is the efficiency appeal of ordering a test or writing a prescription rather than taking the time and effort to explain to a patient why it may not be needed.</p>
<p>A third question is what can be done to counteract these unrealistic expectations? </p>
<p>Many groups have a role to play. Every intervention has benefits and harms and both should be acknowledged and communicated. This applies to: </p>
<ul>
<li><strong>researchers</strong> – harms are <a href="http://www.bmj.com/content/348/bmj.f7668">notoriously under-reported</a>, and even in our review, many more studies assessed expectations of benefit than harm, or benefit and harm</li>
<li><strong>journalists</strong> – media stories <a href="http://www.nejm.org/doi/full/10.1056/NEJM200006013422206">often portray</a> interventions in a misleading way</li>
<li><strong>health services and the pharmaceutical industry</strong> – for example, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1388137/">screening invitations</a> and <a href="http://www.vaoutcomes.org/wp-content/uploads/2012/11/drug_ads.pdf">drug advertisements</a> often present information tilted towards or only about the benefits</li>
<li><strong>clinicians</strong> – conversations between patients and clinicians tend to focus on the benefits of interventions and may not address, or downplay, the harms. </li>
</ul>
<p>Patients, and indeed any individual who is considering a screen, test, or treatment, can also be involved in the solution. Beyond being aware of this tendency to assume that interventions help a lot and harm little, asking their clinician three questions before consenting to any intervention is a good habit to acquire. They are: </p>
<ul>
<li>what are my options?</li>
<li>what are the possible benefits and harms of each option?</li>
<li><a href="http://www.askshareknow.com.au">how likely</a> is it that each of those benefits and harms will happen to me?</li>
</ul>
<p>Asking these questions can trigger a conversation between clinician and patient that hopefully enables an informed decision to be made. </p>
<p>Similarly, the <a href="http://www.choosingwisely.org">Choosing Wisely campaign</a> underway in many countries (and on its way to Australia) provides evidence-based information for the public about interventions that are commonly used, yet may be unnecessary, and encourages a conversation between clinicians and patients. </p>
<p>Modern medicine is slowly moving towards a commitment to true partnerships between clinicians and their patients. Realising that people often come to consultations with preconceptions and expectations is a step closer to achieving this. </p>
<p>In the process of negotiating the best clinical option, clinicians should elicit the patient’s expectations and preconceptions about what they are expecting from the intervention, discuss any misperceptions, and provide accurate information about the benefits and harms of each management option. </p>
<p>Only then can any genuine “<a href="https://www.mja.com.au/journal/2014/201/1/shared-decision-making-what-do-clinicians-need-know-and-why-should-they-bother">shared decision making</a>” start to occur and perhaps the impact of these great expectations lessened.</p><img src="https://counter.theconversation.com/content/33845/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tammy Hoffmann receives research funding from the NHMRC and book royalties for evidence-based practice books. </span></em></p><p class="fine-print"><em><span>Chris Del Mar receives research funding from the NHMRC, and book royalties.</span></em></p>“It might do me some good and it won’t hurt to give it a go.” How often have you heard a phrase like this? Most people have naïve optimism about medical care. That’s the finding of a systematic review…Tammy Hoffmann, A/Prof Clinical Epidemiology, Bond University; NHMRC Research Fellow, The University of QueenslandChris Del Mar, Professor of Public Health, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/347002014-12-09T07:23:45Z2014-12-09T07:23:45ZHow does breast density impact on cancer screening?<figure><img src="https://images.theconversation.com/files/66693/original/image-20141209-6712-1evm4b1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We're yet to find an alternative way to better detect breast cancer in women with dense breasts.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-231227074/stock-photo-mammography-examination-hospital-background-with-technology-health-machine.html?src=I7c8Kyu33z1Lv4w5zQVYOA-1-55">CristinaMuraca/Shutterstock</a></span></figcaption></figure><p>We’ve known for some time that women with dense breasts are at higher risk of breast cancers that are difficult to detect by mammography. To address this problem, 19 US states have <a href="http://breastscreeningaustralia.com/2014/07/17/breast-density-inform-inconsistency-delivers-confusion/">introduced laws</a> requiring health providers to notify women whose mammograms show they have “dense breasts”.</p>
<p>These women are encouraged to discuss this finding with their doctor and, if necessary, have follow-up ultrasounds or magnetic resonance imaging scans to look for possible breast cancers. </p>
<p>But <a href="http://www.nzherald.co.nz/world/news/article.cfm?c_id=2&objectid=11371312">new US modelling</a> testing the impact of routine follow-up ultrasounds for women with dense breasts found the process would be costly, lead to unnecessary anxiety and deliver little benefit. </p>
<p>While we’re yet to find a better way to detect breast cancers in women with dense breasts, directing all women with dense breasts to have follow-up imaging might be an unwarranted and costly public health strategy.</p>
<h2>Why does density matter?</h2>
<p>“Breast density” does not refer to how hard a woman’s breasts feel. It refers to the white or bright areas of a mammogram and is more appropriately referred to as “mammographic density”.</p>
<p>Mammographic density is important for two reasons. First, and in the context of the US laws, the brighter areas on the mammogram can cover up existing breast tumours. This is referred to as “masking”. </p>
<p>Australian researchers have been studying the masking phenomenon for many years and <a href="http://www.abc.net.au/science/articles/2001/01/12/232048.htm?site=science/Askanexpert&topic=latest">have found</a> the use of hormone therapy could increase the problem for some women. Therefore an “all clear” from a mammogram can be a “false negative”. </p>
<p>Second, for women of the same age and body mass index, those with higher mammographic density are at greater risk of a future breast cancer. The one-quarter of women in the highest-density category are almost three times <a href="http://www.ncbi.nlm.nih.gov/pubmed/12239257">more likely</a> to develop breast cancer than the one-quarter of women in the lowest-density category.</p>
<p>The predictive power is not dramatic on a personal level, as it is for having a mutation in a breast cancer susceptibility gene such as BRCA1 or BRCA2. But because women vary so much in their mammographic density, on a population basis it is among the strongest risk factors for breast cancer. </p>
<h2>Genetic link</h2>
<p>In collaboration with BreastScreen services across Australia and colleagues in Canada, my research team undertook a large twin study and <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa013390">found</a> genetic factors play an important role in breast density variation. </p>
<p>From this, we predicted that mammographic density explains about 10% of why breast cancer runs in families. New genetic studies are confirming this prediction.</p>
<p>We also <a href="https://minerva-access.unimelb.edu.au/handle/11343/35311">identified</a> the first gene that influences both mammographic density and breast cancer, called LSP1. A large international collaboration led by Associate Professor Jennifer Stone at the University of Western Australia has found at least ten more such genes. This research will soon be published.</p>
<p>We have also found that mammographic density measures that predict breast cancer risk “track” through life. This means mammographic density in early adulthood predicts mammographic density in mid-life, and hence breast cancer risk.</p>
<h2>Towards better detection</h2>
<p>We’re yet to find an alternative way to better detect breast cancer in women with dense breasts. But international researchers are working to:</p>
<ul>
<li><p>develop automated measures using digital mammograms that best predict breast cancer risk</p></li>
<li><p>develop optimal screening protocols (ages and times between mammograms) for women, depending on their mammographic density</p></li>
<li><p>determine the most cost-effective alternative screening strategies for women with mammographically dense breasts</p></li>
<li><p>implement these strategies in breast screening services, including those in developing countries in which breast cancer is becoming an increasingly important disease. </p></li>
</ul>
<p>While we’re making substantial progress in the first two areas, there is a long way to go for the last two.</p>
<p>Another area of research is to find out what can be done to lower a woman’s mammographic density and hence, it is hoped, her risk of breast cancer. </p>
<p>We know, for instance, that child birth gives a small but long-term reduction in breast cancer risk. During pregnancy, the breasts becomes mammographically dense, but after lactation the <a href="http://cebp.aacrjournals.org/content/early/2013/10/15/1055-9965.EPI-13-0481.full.pdf+html">density reduces</a> by an average of 7% when compared with the pre-pregnancy density. </p>
<p>There is also <a href="http://www.ncbi.nlm.nih.gov/pubmed/21483019">some evidence</a> that tamoxifen, a drug given to reduce breast cancer risk, especially for women who have had a breast cancer, might also reduce mammographic density. </p>
<p>Mammographic density also appears to explain why having a high body mass index in late adolescence is associated with being at lower risk of breast cancer.</p>
<p>So dense breasts are not a new phenomenon. Australian researchers and BreastScreen have been working hard for nearly two decades to understand and, most importantly, work out how to use this concept to reduce deaths from breast cancer. </p>
<p>With the increasing availability of digital mammography, breast density is more easily measured, and researchers continue to search for better ways to detect breast cancer in women with dense breasts. </p>
<p>The challenge now is to use mammographic density to help make breast screening more effective in preventing deaths from breast cancer, at lower financial cost and with fewer of the negative impacts inherent in all population-wide screening programs.</p><img src="https://counter.theconversation.com/content/34700/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Hopper receives funding from the National Breast Cancer Foundation, Cancer Council Australia, Cancer Australia, National Institutes of Health in the US, VicHealth.</span></em></p>We’ve known for some time that women with dense breasts are at higher risk of breast cancers that are difficult to detect by mammography. To address this problem, 19 US states have introduced laws requiring…John Hopper, NHMRC Australia Fellow, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/205302013-12-10T19:43:14Z2013-12-10T19:43:14ZCelebrity breast screening: all that glitters is not gold<figure><img src="https://images.theconversation.com/files/36737/original/wph76rxr-1386033089.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Today Show host, Lisa Wilkinson, undergoing a mammogram live on the Channel 9's Today Show. </span> <span class="attribution"><span class="source">PR IMAGE /AAP</span></span></figcaption></figure><p>Celebrities have taken to “live” mammograms on television, undergoing this usually very private procedure in a rather public way. This includes <a href="http://news.ninemsn.com.au/health/2013/11/19/08/07/lisa-wilkinson-undergoes-mammogram-on-live-tv">Today show co-host Lisa Wilkinson, and news presenter, Georgie Gardner</a>. </p>
<p>In the United States, Good Morning America host, Amy Robach, had a <a href="http://www.nytimes.com/2013/11/12/business/media/abc-anchor-says-test-on-show-found-breast-cancer.html?_r=0">television mammogram</a>, which led to a diagnosis of breast cancer and a double mastectomy.</p>
<p>These women have a simple message that’s easy to embrace – mammography screening saves lives. Sadly, it’s not that simple.</p>
<h2>Saving lives</h2>
<p>Imagine 1,000 average-risk women aged 50, with no breast symptoms, who choose to have a mammogram every two years until age 69. Approximately eight of these women will die from breast cancer. </p>
<p>Now imagine another 1,000 identical women who don’t get screened. Approximately 12 of these women will die due to breast cancer.</p>
<p>This means if 1,000 average-risk women are screened every two years from the age of 50 to 69, four of them will avoid a breast cancer death. Put another way, screening every two years for 20 years reduces the average woman’s risk of dying from breast cancer by a third, from 1.2% to 0.8%.</p>
<p>Saving four women in every 1,000 from breast cancer death is of enormous value, but what happens to the other 996 who don’t receive any benefit from screening?</p>
<p>The vast majority of women might feel incredibly relieved if they receive a negative test result after a mammogram. But we know that women <a href="http://www.ncbi.nlm.nih.gov/pubmed/10424829">often overestimate their risk</a> of getting breast cancer, a perception that <a href="http://www.ncbi.nlm.nih.gov/pubmed/14700240">may be enhanced by</a> screening program promotions and the publicity generated by celebrities.</p>
<p>If they were made aware of the figures above, they could rest assured that the threat of death is relatively small – 1.2% of women aged 50 will die from breast cancer over the next 20 years even without screening, and 0.8% with screening.</p>
<p>Most women don’t realise they’re more likely to die from lung cancer or heart disease because breast screening promotions have been very good at highlighting the benefits of early detection while <a href="http://www.bmj.com/content/338/bmj.b86">inadequately addressing the risks</a>.</p>
<p>It’s also the case that the figures above might be <a href="http://summaries.cochrane.org/CD001877/screening-for-breast-cancer-with-mammography">an optimistic interpretation</a> of 20- to 50-year-old data from the other side of the world. It’s possible that now, with much better treatment available and much more breast cancer awareness, screening <a href="http://link.springer.com/article/10.1007/s10549-011-1794-6">saves far fewer lives</a> than this estimate suggests.</p>
<h2>And the harms?</h2>
<p>In general, people are <a href="http://jama.jamanetwork.com/article.aspx?articleid=197942">enthusiastic about cancer screening</a> because they’re unprepared for what happens <a href="http://www.bmj.com/content/346/bmj.f158">if an abnormality is detected</a>. The paradox of screening is this: an abnormal result could save us, but also harm us.</p>
<p>The most common problem experienced by screened women is a false positive result; when a test raises suspicion of cancer but no cancer is found with further testing. Lisa Wilkinson <a href="http://news.ninemsn.com.au/health/2013/11/19/19/02/lisa-wilkinsons-breast-scare-after-mammogram">experienced this</a> after her on-air mammogram.</p>
<p>If a woman has a mammogram every two years for 20 years, there’s a 41% chance she will experience at least one false positive result. That’s almost one in two women. These healthy women then undergo further investigations to determine that they do not, in fact, have cancer.</p>
<p>They can suffer from psychological harm long after the initial scare of the false positive result. <a href="http://annfammed.org/content/11/2/106.full">This harm includes</a> anxiety and a state of mind somewhere between women with a normal mammogram and those with a breast cancer diagnosis.</p>
<h2>The danger of overdiagnosis</h2>
<p>The most challenging issue for anyone grappling with breast screening is overdiagnosis. </p>
<p>Women who are diagnosed with breast cancer through screening (such as Amy Robach) believe the mammogram saved their life. Sometimes this is true. Unfortunately, it’s more likely to be untrue and these women may have actually been overdiagnosed.</p>
<p>Overdiagnosis is when mammography detects small cancers that, if left alone, would not cause any symptoms or death. Women who undergo screening every two years for 20 years are three times <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61611-0/abstract">more likely to be overdiagnosed</a> than have their life saved. </p>
<p>This concept is counterintuitive because it’s at odds with our general understanding of cancer as a dread disease. That is, we’re used to thinking of breast cancer as <a href="http://sds.hss.cmu.edu/risk/articles/Women'sViewsonBreastCancer.pdf">uniformly lethal if left untreated</a>.</p>
<p>But studies increasingly show that finding tiny cancers <a href="http://jama.jamanetwork.com/article.aspx?articleID=1722196">doesn’t necessarily translate</a> into saving lives.</p>
<p>While the estimate of overdiagnosis is uncertain, the pattern is clear. Research from <a href="http://www.ncbi.nlm.nih.gov/pubmed/22025097">the United States</a>, <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61611-0/abstract">the United Kingdom</a>, and <a href="http://link.springer.com/article/10.1007/s10552-009-9459-z">Australia</a> shows it’s more common for women to be overdiagnosed than have their life saved by screening.</p>
<p>This wouldn’t be such a problem if breast cancer treatment was easy, say a tablet or injection with few side effects. But the treatment is complex and difficult; surgery, radiotherapy, chemotherapy, and cancer drugs are physically and psychologically damaging.</p>
<p>So these overdiagnosed women are harmed due to over-treatment – they receive treatment for cancers that don’t need to be fixed.</p>
<h2>With great power…</h2>
<p>This information usually <a href="http://www.bmj.com/content/346/bmj.f158">comes as a surprise</a> to most people. Indeed, some women mistakenly believe that mammograms <a href="http://www.mindbodygreen.com/0-11131/12-tips-to-help-you-prevent-breast-cancer.html">actually prevent breast cancer</a>; Georgie Gardner, for instance, said screening is a vital tool for preventing breast cancer on television during her on-air mammogram.</p>
<p>Mammograms and their benefits have been heavily promoted by screening programs, charities and celebrities while the science behind the harms has been largely ignored.</p>
<p>Efforts may go beyond persuasion and make <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1209407">women feel irresponsible and guilty</a> to convince them to have a mammogram.</p>
<p>In a <a href="http://www.heraldsun.com.au/news/opinion/ignoring-your-own-health-isnt-putting-others-first-its-downright-selfish/story-fnh4jt62-1226759560095">recent article about Wilkinson’s on-air mammogram</a> in the Herald Sun, journalist Tory Maguire said refusing a free mammogram was “stupid” and “selfish”. She quotes National Breast Cancer Foundation CEO Carole Renouf suggesting that women who decline the offer “endanger” their life.</p>
<p>But <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61611-0/abstract">independent recommendations</a> about breast screening acknowledge the harms and support the need for better, more balanced information so women know what they are signing up for.</p>
<p>When celebrities have a mammogram on television, the world watches. We have no doubt that Lisa Wilkinson, Georgie Gardner and Amy Robach had the very best intentions. But rather than using their fame and influence to persuade, they could start a healthy discussion about screening.</p>
<p>This would help women understand that there are harms, as well as benefits, from breast screening. And the trade-offs for both.</p><img src="https://counter.theconversation.com/content/20530/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alexandra Barratt receives funding from NHMRC and ARC.</span></em></p><p class="fine-print"><em><span>Gemma Jacklyn does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Celebrities have taken to “live” mammograms on television, undergoing this usually very private procedure in a rather public way. This includes Today show co-host Lisa Wilkinson, and news presenter, Georgie…Gemma Jacklyn, PhD candidate in Public Health, University of SydneyAlexandra Barratt, Professor of Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.