A “special communication” released by the Journal of the American Medical Association (JAMA) yesterday, urges the medical community to drastically alter the way it approaches screening for breast cancer.
The article points out that in spite of 20 years of mammograms, with 70% of women now getting them regularly, the risk of being diagnosed with an advanced and more dangerous breast cancer remains about the same. The overall risk of being diagnosed with breast cancer has decreased slightly in the past few years, but this is attributed to the millions of women who stopped using HRT, rather than to mammography screening.
The authors estimate that, “…for every breast cancer death averted… 838 women must undergo screening for 6 years, generating thousands of screens, hundreds of biopsies, and many cancers treated as if they were life threatening when they are not.”
One of the assumptions of routine breast cancer screening with mammography was that tumors would be detected earlier and treated earlier, and this would reduce the risk of dying from breast cancer. But what Dr. Laura Esserman and her team found instead is that while many more early stage breast cancers are being diagnosed, the more aggressive and dangerous breast cancers often are still not caught until they are advanced.
Esserman is the principal investigator for the ATHENA Breast Health Network, a University of California statewide collaboration created to revolutionize the way breast cancer is screened, diagnosed, tested and treated. Initially 150,000 women will participate in the study, and be followed for 20 years, generating data comparable to the famous Framingham Heart study that changed medicine’s approach to preventing and treating heart disease.
The JAMA article advocates key changes to the way breast cancer is diagnosed and treated, starting with distinguishing between low risk or precancers, and the more aggressive cancers, and treating them accordingly.
Changes would benefit women with breast cancer
For example, some 60,000 women a year who have low grade precancerous lesions such as ductal carcinoma in situ (DCIS), are diagnosed as having cancer and treated aggressively. This would be comparable to treating a woman with a Grade 1 pap smear with a hysterectomy. It is suggested that low grade precancerous lesions not be called cancer or treated as cancer. In the future, treatments can be tailored to specific types of tumors.
Another proposed key change is to supply both doctors and patients with the tools to make more informed decisions about prevention, screening, biopsy and treatment. It’s currently often the case that doctors and patients will opt for the most aggressive treatments available, even though the treatments may be more dangerous than the disease. Better-informed decision-making will reduce illness and death unnecessarily caused by overly aggressive treatment.
For example, the estrogen-blocking drug tamoxifen is commonly used to treat breast cancer, but researchers recently found that tamoxifen increases the risk of more aggressive breast cancers. Women with a low risk lesion or tumor that is likely never to advance to a life-threatening cancer may decide not to take tamoxifen.
In an Oct 21 article in the New York Times, (Benefits and Risks of Cancer Screening Are Not Always Clear, Experts Say) Esserman stated, “If you get screened, there’s a chance you’re going to find a cancer that might not be dangerous, and you want to make sure you understand that so you don’t get overtreated.”
Although the ATHENA project is not currently enrolling patients, women who have breast cancer, who wish to participate in a clinical trial, can go to BreastCancerTrials.org, which is a clinical trial matching service for women with breast cancer. The website is for patients, and is dedicated to providing accurate information about breast cancer clinical trials.
Photo: Laura J. Esserman, M.D., principal investigator of UC's ATHENA Breast Health Network/UCSF
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