Breast cancer screening not associated with a reduction in the incidence of advanced cancer

Mammograms tied to overdiagnosis of breast cancer

The current study offers fresh evidence linking routine screening to over-diagnosis of non-aggressive tumors because it compares outcomes over a single time period in two regions of Denmark – one that offered biennial mammography for women aged 50 to 69 and one that didn’t.

January 2017 Study Abstract

Background
Effective breast cancer screening should detect early-stage cancer and prevent advanced disease.

Objective
To assess the association between screening and the size of detected tumors and to estimate overdiagnosis (detection of tumors that would not become clinically relevant).

Design
Cohort study.

Breast Cancer Screening in Denmark: A Cohort Study of Tumor Size and Overdiagnosis, Annals of Internal Medicine, DOI: 10.7326/M16-0270, 10 JANUARY 2017.

Philips Mammography Truck, Brazil via philips_newscenter.

Setting
Denmark from 1980 to 2010.

Participants
Women aged 35 to 84 years.

Intervention
Screening programs offering biennial mammography for women aged 50 to 69 years beginning in different regions at different times.

Measurements
Trends in the incidence of advanced (>20 mm) and nonadvanced (≤20 mm) breast cancer tumors in screened and nonscreened women were measured. Two approaches were used to estimate the amount of overdiagnosis: comparing the incidence of advance and nonadvanced tumors among women aged 50 to 84 years in screening and nonscreening areas; and comparing the incidence for nonadvanced tumors among women aged 35 to 49, 50 to 69, and 70 to 84 years in screening and nonscreening areas.

Results
Screening was not associated with lower incidence of advanced tumors. The incidence of nonadvanced tumors increased in the screening versus prescreening periods (incidence rate ratio, 1.49 [95% CI, 1.43 to 1.54]). The first estimation approach found that 271 invasive breast cancer tumors and 179 ductal carcinoma in situ (DCIS) lesions were overdiagnosed in 2010 (overdiagnosis rate of 24.4% [including DCIS] and 14.7% [excluding DCIS]). The second approach, which accounted for regional differences in women younger than the screening age, found that 711 invasive tumors and 180 cases of DCIS were overdiagnosed in 2010 (overdiagnosis rate of 48.3% [including DCIS] and 38.6% [excluding DCIS]).

Limitation
Regional differences complicate interpretation.

Conclusion
Breast cancer screening was not associated with a reduction in the incidence of advanced cancer. It is likely that 1 in every 3 invasive tumors and cases of DCIS diagnosed in women offered screening represent overdiagnosis (incidence increase of 48.3%).

Cancer Risk after Fat Transfer: A Multicenter Case-Cohort Study

Fat Transfer After Mastectomy, is it Safe?

2017 Study Abstract

Background
Fat transfer is an increasingly popular method for refining postmastectomy breast reconstructions. However, concern persists that fat transfer may promote disease recurrence. Adipocytes are derived from adipose-derived stem cells and express adipocytokines that can facilitate active breast cancer cells in laboratory models. The authors sought to evaluate the association between fat transfer to the reconstructed breast and cancer recurrence in patients diagnosed with local or regional invasive breast cancers.

Methods
A multicenter, case-cohort study was performed. Eligible patients from four centers (Memorial Sloan Kettering, M. D. Anderson Cancer Center, Alvin J. Siteman Cancer Center, and the University of Chicago) were identified by each site’s institutional tumor registry or cancer data warehouse. Eligibility criteria were as follows: mastectomy with immediate breast reconstruction between 2006 and 2011, age older than 21 years, female sex, and incident diagnosis of invasive ductal carcinoma (stage I, II, or III). Cases consisted of all recurrences during the study period, and controls consisted of a 30 percent random sample of the study population. Cox proportional hazards regression was used to evaluate for association between fat transfer and time to recurrence in bivariate and multivariate models.

Cancer Risk after Fat Transfer: A Multicenter Case-Cohort Study, AMERICAN SOCIETY OF PLASTIC SURGEONS, Plastic & Reconstructive Surgery, January 2017 – Volume 139 – Issue 1 – p 11–18, doi: 10.1097/PRS.0000000000002838.

Results
The time to disease recurrence unadjusted hazard ratio for fat transfer was 0.99 (95 percent CI, 0.56 to 1.7). After adjustment for age, body mass index, stage, HER2/Neu receptor status, and estrogen receptor status, the hazard ratio was 0.97 (95 percent CI, 0.54 to 1.8).

Conclusion
In this population of breast cancer patients who had mastectomy with immediate reconstruction, fat transfer was not associated with a higher risk of cancer recurrence.

In this video published on 29 Dec 2016 bu the PRSJournal channel, Rod J. Rohrich, MD, Editor-in-Chief of “Plastic and Reconstructive Surgery” discusses the safety of Fat Transfer after Mastectomy vs. traditional reconstruction surgery.

Pink Anti-Cancer Food that is Good for You

Pinkwashing and Breast Cancer Awareness Month

Many of the ‘pink’ labelled food sold in October actually can cause cancer!

Many of the ‘pink’ products sold in October actually can cause cancer!

As prevention, these pink anti-cancer foods are a great start.

More Information

Does Pink October Month Causes Breast Cancer?

Straight Facts about PinkWashing

image of pinkwashing-breast-cancer
Many of the ‘pink’ products sold in October actually can cause cancer!

What have all these pink ribbon products and promotions done for men and women living with and at risk of breast cancer?

Actually, many of the ‘pink’ products you purchase actually can cause cancer!

More Information

The Connection Between Breast Cancer and the Environment

Breast Cancer Fund, State of the Evidence, Sixth Edition 2010

image of state-of-the-evidence
The Connection Between Breast Cancer and the Environment

From 2002 to 2010, the Breast Cancer Fund produced six editions of the landmark report, State of the Evidence: The Connection between Breast Cancer and the Environment.

Each edition presented a comprehensive summary of the scientific evidence to date linking exposures to chemicals and radiation in our everyday environments to increased breast cancer risk.

Abstract (pages 39 > 40)

The clearest evidence that a synthetic estrogen can increase risk for cancer decades later comes from the tragic experience with diethylstilbestrol (DES). Between 1938 and 1971, doctors prescribed DES for millions of pregnant women to prevent miscarriages. The drug was contraindicated in pregnancy use when daughters of women who took the drug were found to have higher rates of an extremely rare vaginal cancer compared to those who were not exposed to DES in the womb (Bibbo, 1977; Herbst, 1971). Research indicates that DES exposure is also associated with an increased risk of breast cancer in the women who took it during the 1950s (Colton, 1993; TitusErnstoff, 2001).

In a follow-up study of daughters who were exposed prenatally to DES, a nearly twofold increase in breast cancer risk was observed in women older than age 40. An even greater effect was found for women over the age of 50, although relatively few of the daughters had yet reached that age at the time of the study (Palmer, 2006; Troisi, 2007).

Recent studies examining the mechanisms by which DES might be exerting its carcinogenic effects indicate that the compound activates the same subcellular pathways that estradiol does, both by altering cellular metabolism and interaction with DNA (Saeed, 2009) and by increasing the rate of breast cell proliferation (Larson, 2006).

Transgender Men Can Face Fighting Breast Cancer Too

The medical world has blind spots in its understanding of how to take care of trans men and women

A transgender man, is somebody who is born female, and then takes male hormones to change gender. Many transgender people switch gender without having surgery to change their body.

… ” Zil Goldstein, a nurse practitioner and program director at Mount Sinai’s transgender center, said that while she had concerns about the long-term safety of transgender hormones, she worried more about the possible harm from not prescribing them – researchers report that 41 percent of transgender people attempt suicide.” …

…  “trans men with breast cancer were often urged to stop taking testosterone. One reason is that the body converts some testosterone to estrogen, which can speed the growth of many breast tumors. And some breast cancers may also be stimulated by testosterone, … “

Regular Mammograms Risk-Benefit Characterization Theater

Breast-Cancer and Mammography : Consider the Pros and Cons

How Tiny Are Benefits From Many Tests And Pills? Researchers Paint A Picture

Mammograms are said to cut the risk of dying from breast cancer by as much as 20 percent ; some researchers want people to question that kind of thinking.

More Information

France: how to end breast cancer screening

The French national breast screening program is to be “radically revised”

In view of controversies surrounding the effectiveness and consequences of breast screening, the French Minister for Health asked the French National Cancer Institute (INCa) to organize a broad public and scientific consultation on breast cancer screening. During one year, all stakeholders on breast screening ranging from citizens, patient’s organisations and charities to health professionals, screening experts, and governmental institutions had an opportunity to express their opinion on the benefits and on the harms of breast screening as well as on the way this screening is organised in France. The consultation report was publicly available on September 30th, 2016.

Reduction in breast cancer deaths is due to treatment not screening, finds study, The BMJ, 355/bmj.i5544/rr-1, 13 October 2016.

The consultation report concludes that there is no scientific consensus about the benefits and risks of mammographic screening. It regrets the absence of sound epidemiological studies on the impact of breast screening in France. It expresses deep concerns about the

“malfunctions anomalies in the current organization of screening and the consequences it engenders: unequal access; lack of understanding of key concepts underpinning screening by most stakeholders; confusion between primary prevention, screening and early diagnosis; lack of information [of women] on risks and uncertainties of screening (…); lack of involvement of general practitioners (…); misleading and outrageous pink October marketing (…); doubts on the efficiency of some therapeutic strategies, etc.”

The report recommends that the information to women and the information and training of health professionals include a complete, clear and neutral information on the benefit and harm balance of participation to screening, with a depiction of reasons underlying the on-going scientific controversy.

It recommends discontinuing the reimbursement of mammographic screening in women less than 50 years of age at average risk of breast cancer. For healthy women over 50 years of age, the report recommends to take steps towards stratification of screening according to personal risk factors. Screening should be individualised, with the implication that women with low risk profile should not be offered mammographic screening. It also recommends that GPs should be integral part of the screening approach.

The options being considered for the future of screening are as follows:

  • Scenario 1: the end of organized screening, with the relevance of mammograms being evaluated in the context of an individual doctor patient relationship.
  • Scenario 2: the end of organized screening as now practiced, and the establishment of a new, radically altered form of organized screening. [i.e., much reduced]

The report is confident that

“the implementation of these recommendations should significantly improve the current situation, which currently does not meet the minimum requirements in terms of scientific validity and of information allowing women at average risk of breast cancer to take decisions”

The consultation report implicitly raises the question of whether the INCa would be the best placed for implementing recommendations and bring the radical changes in the breast screening programme. As a matter of fact, the INCa efforts have largely concentrated on maximizing participation to screening, the consequence of which has been the broadcasting of oversimplified messages insisting on the health benefits of screening while downplaying the undesirable effects like the overdiagnosis. In this regard, the INCa has backed the policy of financial incentives to GPs linked to their ability to convince women to participate to screening. Our opinion is that a neutral body should shape the breast screening programme, determine its main working procedures, and formulate the information to women and to health professionals. The members of this neutral body should have no academic or financial conflict of interest in relation to breast screening, and should not be involved in its implementation. We believe that such a move would be respectful of the consultation report conclusions and contribute to empowering women to decide on their participation to breast screening.

Jean Doubovetzky
Emilie Franzin
Marc Gourmelin
Philippe Nicot

On behalf of The Cancer-rose group.

Breast-Cancer Tumor Size, Overdiagnosis, and Mammography Screening Effectiveness

NEJM Screening Mammograms, Analysis by Dr. H. Gilbert Welch

Dr. H. Gilbert Welch gives us a brief explanation of the findings of the New England Journal of Medicine article “Breast Cancer Tumor Size, Overdiagnosis, and Mammography Screening Effectiveness“, October 13, 2016.

Study Abstract

BACKGROUND
The goal of screening mammography is to detect small malignant tumors before they grow large enough to cause symptoms. Effective screening should therefore lead to the detection of a greater number of small tumors, followed by fewer large tumors over time.

METHODS
We used data from the Surveillance, Epidemiology, and End Results (SEER) program, 1975 through 2012, to calculate the tumor-size distribution and size-specific incidence of breast cancer among women 40 years of age or older. We then calculated the size-specific cancer case fatality rate for two time periods: a baseline period before the implementation of widespread screening mammography (1975 through 1979) and a period encompassing the most recent years for which 10 years of follow-up data were available (2000 through 2002).

RESULTS
After the advent of screening mammography, the proportion of detected breast tumors that were small (invasive tumors measuring

CONCLUSIONS
Although the rate of detection of large tumors fell after the introduction of screening mammography, the more favorable size distribution was primarily the result of the additional detection of small tumors. Women were more likely to have breast cancer that was overdiagnosed than to have earlier detection of a tumor that was destined to become large. The reduction in breast cancer mortality after the implementation of screening mammography was predominantly the result of improved systemic therapy.

If screening had been a drug, it would have been withdrawn from the market

Which country will be first to stop mammography screening?

Key points

  • Screening with mammography does not reduce the occurrence of advanced cancers.
  • Rigorous observational studies in Europe have failed to find an effect of mammography screening.
  • Mammography screening produces patients with breast cancer from among healthy women and increases the number of mastectomies performed.
  • The most effective method we have to reduce the occurrence of breast cancer is to stop screening.

Time to stop mammography screening?

The Canadian Task Force on Preventive Health Care should be congratulated for its new recommendations on screening for breast cancer in women at average risk aged 40–74 years. These guidelines are more balanced and more in accordance with the evidence than any previous recommendations.

The recommendations against routine clinical breast examinations, breast self-examinations and magnetic resonance imaging to screen for breast cancer in this age and risk group are all straightforward.

The recommendations on mammography screening are even more conservative than the change in policy suggested by the US Preventive Services Task Force in 2009, which created an uproar in the United States from people interested in maintaining the status quo. The new Canadian guidelines are appropriately cautious, advising against routinely screening women aged 40–49 years. The task force recommends screening women aged 50–69 years every two to three years, although it admits that this is a weak recommendation based on moderate-quality evidence, and screening women aged 70–74 years on the same schedule based on low-quality evidence. The task force also suggests that women who do not place a high value on a small reduction in breast cancer mortality, and who are concerned with false-positive results on mammography and overdiagnosis, may decline screening.

These guidelines are an important step in the right direction, away from the prevailing attitude that a woman who does not undergo screening is irresponsible. Recent research even suggests that it may be most wise to avoid screening altogether, at any age, as outlined below.

The Canadian Task Force on Preventive Health Care decided not to include observational studies in its systematic review unless they were needed to elucidate the harms of screening or the values and preferences of patients. However, important observational studies have been published in recent years, without which a systematic review would be incomplete. These observational studies have been discussed elsewhere and have also been included in an update (currently submitted for publication) of our 2009 Cochrane review of mammography screening.

Doubtful effect of screening

Time to stop mammography screening?; National Institutes of Health PMC3225414 183(17): 1957–1958, Nov 22 2011.

Programming a latest-gen mammography station, nicoyogui.

If screening does not reduce the occurrence of advanced cancers, it does not work. A systematic review of studies from seven countries showed that, on average, the rate of malignant tumours larger than 20 millimetres was not affected by screening. Because the size of a tumour is linearly correlated to the risk of metastasis, this result is evidence against an effect of screening.

Denmark has a unique control group within its population — only 20% of its population was screened during a 17-year period. The annual decrease in breast cancer mortality in the relevant age group (55–74 years) and period was 1% in the areas with screening and 2% in the non-screened areas.Among women who were too young to benefit from screening, the decreases were larger (5% for screened areas, 6% for unscreened areas). Similar results have been reported from the United Kingdom, Sweden and Norway.

A study involving women from 30 European countries showed that the mean decrease in breast cancer mortality between 1989 and 2005 among women less than 50 years of age was 37%; the corresponding decrease was 21% among women aged 50–69 years. The declines began before the start of organized screening programs in many countries and are more likely explained by the introduction of tamoxifen. The introduction of tamoxifen could explain the larger decline seen among young women who often have estrogen-sensitive tumours.

Another study compared three pairs of similar neighbouring countries that had introduced screening 10–15 years apart. The pairs were Northern Ireland and the Republic of Ireland, the Netherlands and Belgium, and Sweden and Norway. There was no relation between start of screening and the reduction in breast cancer mortality.The fall in breast cancer mortality was about the same in all countries. Furthermore, the decline was also about the same as that seen in the United States, where screening started as early as in Sweden.

Screening seems to be ineffective in today’s world for two reasons. First, adjuvant therapy, such as tamoxifen and chemotherapy, is highly effective (even when the cancer has metastasized) but was not often used at the time of the old trials. Second, public awareness of breast cancer has increased, and women tend to see a doctor much earlier today when they have noticed something unusual in their breast. In Denmark, the average size of a tumour decreased by nine millimetres from 1979 to 1989, a reduction that occurred before screening started. In addition, this decrease was larger than the average difference in tumour size seen between screened and control groups in trials (5 mm), despite the tendency for small, overdiagnosed tumours to spuriously exaggerate the difference.

It has often been claimed that mammography screening reduces breast cancer mortality by 30%. However, thorough systematic reviews have estimated only a 15% reduction, and data on tumour size from the trials are compatible with only a 12% effect.This effect is similar to the results seen in the most reliable studies, which showed a 10% effect after 13 years.

Overdiagnosis

Any possible effect of screening on breast cancer mortality must be marginal and could be counteracted by the life-shortening effect that radio-therapy and chemotherapy have when used in healthy women in whom breast cancer has been overdiagnosed (i.e., a diagnosis of breast cancer that would not have been made in the woman’s remaining life had she not undergone screening). The main effect of screening is to produce patients with breast cancer from among healthy women who would have remained free of breast disease for the rest of their lives had they not undergone screening. Compelling data from the US, Norway and Sweden show that most overdiagnosed tumours would have regressed spontaneously without treatment.  In addition, screening substantially increases the number of mastectomies performed, despite routine claims to the contrary by advocates of screening.

The best method we have to reduce the risk of breast cancer is to stop the screening program. This could reduce the risk by one-third in the screened age group, as the level of overdiagnosis in countries with organized screening programs is about 50%.

If screening had been a drug, it would have been withdrawn from the market. Thus, which country will be first to stop mammography screening?

Peter Gøtzsche, MD, 2011.