woman getting a mammogram, overdiagnosis, breast cancer survivors, hormone replacement therapy

Millions of women undergo regular mammograms because they have been repeatedly told that early cancer detection means a much better outcome. The implied promise: “if you get your annual mammogram we can catch cancer at its earliest stage and reduce your likelihood of dying from breast cancer.”
A new study in the New England Journal of Medicine, however, concludes that this promise has been unfulfilled. In a nutshell the article suggests that catching cancer early has not had a dramatic impact on the development of late-stage cancer or substantially improved long-term outcomes. According to the research, as many as 70,000 women in the U.S. each year (one in three) end up being treated for cancer that would not develop into something dangerous or deadly.
Not surprisingly, this heretical report has stirred up a hornet’s nest of controversy with radiologists and oncologists as well as with women who believe that getting a mammogram is the single most important thing they can do to protect their long-term health.
Everyone assumes that cancer must always be treated. Physicians have known for a long time, though, that a significant number of abnormal (yes, even cancerous) growths will disappear on their own or never become life threatening. This is not a message that has been communicated effectively to the public. Because it runs counter to what people have been told for decades, it drives them crazy. Further complicating the issue, doctors are not good at determining which cancers are “benign” and which are destined to kill. For the most part, however, they have kept this a secret. As a result, they treat just about everyone who shows up with a diagnosis of cancer and most patients are grateful, despite the toll such therapy takes.
The researchers tracked data for more than three decades, ever since widespread screening mammography was introduced in the U.S. in the 1970s. Not surprisingly, the number of early-stage breast cancer cases increased dramatically as a result of mammography. They went from 112 cases per 100,000 women per year to more than double that or 234 cases per 100,000 women. That means that as a result of screening mammography there were 122 more cases of early breast cancer identified for every 100,000 women thanks to mammography.
In theory, this ability to detect cancer at its earliest stages should have led to a dramatic drop in late-stage, serious cancers, and it should have saved a lot of lives. Ideally, one might have expected half as many life-threatening cancers. In fact, the absolute decrease was only 8%. The number of late-stage cancers decreased from 102 cases per 100,000 women to 94 cases per 100,000 women. In other words, only 8 women out of the 122 who were diagnosed early were likely to develop what the researchers called “advanced disease.”
Of course if you were among the 8, you might count yourself lucky. But what about the other 114 women who probably would not have gone on to develop life-threatening breast cancer? The authors of the article suggest that many, if not most, of these women were overdiagnosed. One of the authors, Gilbert Welch, MD, MPH, wrote in the New York Times that more than a million women were told that they had early stage cancer. They were probably not told it wouldn’t have threatened their lives. Almost assuredly most were treated anyway, either with surgery, radiation or chemotherapy or some combination of the three. Dr. Welch maintains that this treatment was for a cancer “that was never going to make them sick.” The treatment is not benign, however. All three therapies–surgery, chemo, radiation–carry their own risks. Both chemo and radiation may increase the risk for other cancers later in life.
When a doctor tells a woman that she has breast cancer, the world starts spinning. In that instant everything changes. Because cancer is such a scary diagnosis, the idea of watching, waiting and doing nothing is virtually impossible for most people. Most women are grateful if the doctor says the cancer has been “caught” early and that treatment will produce a long-lasting remission, if not a cure. The notion that early detection does not actually reduce the number of women who develop life-threatening breast cancer is hard to comprehend.
The most recent research in the New England Journal of Medicine is not the only study to suggest that screening mammography may promise more than it can deliver. Dr. Welch notes in the New York Times that European studies have concluded, “mammography has either a limited impact on breast cancer mortality (reducing it by less than 10 percent) or none at all.”
It is almost impossible for doctors or patients to conceive of overdiagnosis of breast cancer or unnecessary treatment. The bottom line, according to Dr. Welch, is that his medical colleagues need to be more honest. As he points out in the Times, “The truth is, a few breast cancers are destined to kill no matter what we do…While no one can dismiss the possibility that screening may help a tiny number of women, there’s no doubt that it leads many, many more to be treated for breast cancer unnecessarily.”
Just as with prostate cancer, researchers need to learn how to distinguish between the cancers that are “inconsequential” and those that will become aggressive and kill us. Women who are at high risk for life-threatening cancer because of genetics or personal history may indeed benefit from screening mammography, just as men who are at high risk for dangerous prostate cancer may benefit from a PSA test. For many others, though, the idea that they could actually live a normal life with untreated cancer comes as a total shock.
To learn more about this heretical notion, you may wish to listen to a free one-hour interview we conducted with Otis Brawley, MD, chief medical and scientific officer of the American Cancer Society. You cannot find a more established and respected cancer doctor than Dr. Brawley. You will be amazed at what you hear when it comes to the screening and diagnosis of cancer. Please keep an open mind and heart when you listen to this extraordinarily honest interview with one of the country’s leading physicians.
For a more in-depth discussion of mammograms you may wish to read our section on breast cancer and conversation with breast cancer expert Dr. Susan Love in our book, Top Screwups Doctors Make and How to Avoid Them.
We would love to get your comments on this article and Dr. Brawley’s interview below.

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  1. AW

    With 1 in 8 women being diagnosed with breast cancer, each woman needs to be aware of this percentage. I am so thankful I had the new 3 D mammography machine. Since the 3 D can see much deeper tissue than the usual 2 D, they were able to see the tiny breast cancer. I had a lumpectomy, followed by 36 rounds of radiation. They told me that this tiny breast cancer was too small to be felt. I am so thankful for this new 3 D mammography machine. Since it is new, insurance didn’t pay for the extra $50. Was one of the best $50 investments I ever made!

  2. DS

    That happened to me last year. Mammogram, then call-back for two more of them and ultrasound the same day and then “it was nothing.” I’d rather have JUST the ultrasound exam, but I don’t think they are done unless you first have the mammogram, which I think is just too much radiation. I think I may just quit getting them altogether.

  3. Barb

    I guess everyone has had her own experience with mammograms. Personally, I think they are a joke, especially when they detect “something”, then you have to go back twice for ultrasounds and, then, “Oh, it was nothing.” No more mammograms for me and don’t know how doctors feel when I say, “No!”

  4. Mary D.

    I agree—this is one reason our medical system is so out of wack. If you wouldn’t pay for it on your own if you had the money–why make the rest of us pay for it?

  5. Sue T

    My breast cancer was early stage also, but it was not DCIS or LCIS (ductal or lobular carcinoma in situ), so it was already spreading. I had a mastectomy since there were two lesions, but because of the type-information and because it was caught early (stage 1) I was able to skip both chemotherapy and radiation treatment. I did take an aromatase inhibitor for five years and was lucky enough not to have significant side effects.
    I think some of the problem here is that “early” can mean DCIS or LCIS but it can also mean stage 1 or 2 cancer. They are not the same, and not even the authors of the most recent study would suggest not treating stage 1 or 2 cancer. I’m pretty sure they would not suggest I didn’t benefit from mammograms. My breasts have always been lumpy so I couldn’t detect any difference, only the mammogram plus followup up ultrasound, biopsies, and eventually an MRI which verified there were two lesions, were sufficient to inform both me and my doctors about the best options for me given my family history (mother had breast cancer at nearly same age as mine).

  6. DIK V

    How can you ever convince a woman that a breast mammogram is not necessary?

  7. abigail

    Profit may be the motive for some testing , but many tests are done to avoid the possibility of a time consuming and costly lawsuit. If testing was not done and the patient was later found to have a condition that could have been treated and wasn’t, patients and/or their families will sue to be compensated.
    Patients did not used to sue their doctors for malpractice with the ease and frequency they do now.

  8. Janis

    I respect science and will read the study. I had stage one breast cancer a yr. ago, surgery and radiation. I saw my mother and her sister die of metastatic breast cancer. They NEVER had exams or mammograms, but died horrible deaths.
    I have taken my chances and made my choices to have regular mammograms, to do self-exams, and to have the procedures last year. I do not want to live out the rest of my life ignoring my diagnosis and family history.
    Who is determining WHAT TYPE of breast cancer is harmless and what types are harmful? Until we KNOW this, how CAN we choose to ignore checkups and mammograms? I know that mammograms cannot find all breast cancers, but it did find mine. I am grateful.

  9. Mammograms are not free...

    I noticed that someone mentioned that she gets mammograms because they are free. They may be free to her, but someone is paying for them… They are NOT free. We pay the people who work in the office, we pay medical docs to read them, we pay the receptionist in the offices to make the appointments and to just sit there. We pay for the huge equipment and then we pay for the new upgraded equipment when the old equipment is replaced, always paying the wages of the people who work there…
    I only hope that most people realized that someone pays for this stuff. If you use it and your medical insurance pays for it, then your company charges customers higher prices so they can give you insurance or your co-payment is higher. Someone pays for it and like with most things we should be aware of our impact on others, no matter how small.
    If everyone is doing it, a lot of us are paying for it.

  10. mitajoann

    After finding a lump, I was diagnosed with BC almost 19 years ago, had a lumpectomy and 7 weeks of radiation treatment. In retrospect, I believe the early stage cancer was probably a result of HRT following a hysterectomy. During my followup treatments, my HMO had a new diagnostic machine, which showed questionable spots several times. After having painful and disfiguring biopsies twice, I refused to have them after that. I have gone for biannual mammograms, but now, age 71, I wonder about the wisdom of them. My observation is that the younger one is at time of diagnosis, the more likely the cancer is to be virulent.

  11. CLM48

    I decided several years ago that annual mammograms made no sense based on the amount of radiation the body must absorb during the process; plus having to endure three false alarms in the time prior to discontinuing the tests. You can make self-exams work for you if you do them regularly. Regardless of how bumpy, dense, lumpy, whatever, your breasts are, you will become familiar with what is the “normal” you and then can determine what is suspicious as time goes on. I would encourage “LG” to reread the article. It is always difficult to head advice that runs counter to a decision one has made in the past. Thoughtfully considering all the facts presented in the article may help to avoid an unwise future procedure.

  12. Carol

    I am a breast cancer survivor of 19 years. Double mastectomy with implants now. I do not believe in mammograms for the following reason:
    20 years ago I like many females in this country, was told to get an annual mammogram or one every six months if breast cancer runs in the family I had a clean bill of health. Two months later I had my annual check up with my gynecologist. She found two lumps in my right breast that turned out to be positive. I had a radical mastectomy. Later on I has the same on my left breast. However, I was very lucky as all of the lymph nodes were negative. I did not have to go through any other treatments. I have been clean and so grateful for that gynecologist examination years ago. So my experience proved to me that mammograms are not the last word.

  13. Mary D.

    My life and marriage was ruined by the breast cancer industry. I had a radiology report that predicted that in my late 40s that a fibrocystic skeleton would drop over a calcium deposit. These self-serving clowns told my husband that the family would lose it’s insurance and even military retirement benefits. The stupid DOD lied and said that we’d lose everything. I had nerve damage from that biopsy-RSD- and my fingers turned black-began to flap helplessly. I was going to commit suicide because of the unrelenting pain– You guessed it-even with the biopsy report of a mineral deposit and fibrocystic skeleton, they still wanted to do chemo.
    I had nerve blocks that worked- the insurance that wanted to pay for a chemo wouldn’t cover it. I rebuilt my arm and fine motor control on my own. My breast always has a nugget or more of pain. getting bumped hard, like a kid running around a corner- I cannot swim and drive.
    A doctor talked me into getting a mammogram on the other breast. When I was leaving-staff and patients came out and laughed, pointed to me, and said things like-“She had a mammogram on only one breast-how stupid.”
    Now I have an aggressive atypical basal cell carcinoma on my face. I had 2 MOHS, and before the rescission could be done-new cancers popped up. I spent 30 years trying to get this cancer off-I just knew something was wrong, just as I knew nothing was wrong with my breast. HOW’S THAT 4 IRONY? TRYING TO TREAT U FOR A NON-EXISTENT CANCER, WHILE IGNORING A CANCER ON YOUR FACE- next week I’ll be in the cancer clinic, I’m terrified of them insisting on a mammogram and that setting the RSD off again.
    If decent medicine had been practiced and we didn’t have this hysteria about breast cancer-I wouldn’t be worried and fearing a mammogram. I tried to get the military to take off this cancer, aggressive atypical Basal Cell Carcinoma, I tried to get it off by civilian doctors as self-pay. After my marriage broke up, I became a student-I tried to get the university doctors to take it off. I tried to get it done with independent doctors, St. Joseph doctors, Lovelace-where the first astronauts were tested, Presbyterian, and the state hospital. They just touched the end and lightly wiggled it- This summer was the first time a doctor felt around and realized that it was very deep.
    If whatever doesn’t work-they’ll attach their selves to my facial bones and eat through the bones until my brains fall out. Since the last MOHS-3 weeks ago-more have popped up–Aggressive breast cancer would have been a mercy. I hate American medicine–And don’t tell me that I need a shrink-I also have statin toxicity because I let a doctor talk me into taking simivastatin- I peed blood for 3 months.

  14. D. S. Most

    This position re mammography’s value in dealing with breast cancer (BrCa) is analogous to the recent anti-prostate screening recommendations issued by the USPSTF (United States Preventive Services Task Force). It studied prostate cancer screening with PSA blood tests and concluded that more harm than good was being done to men who had been trained for years to believe early detection meant better chances for cure.
    The USPSTF relegated the idea that PSA screening was useful to the dustbin of medical history.
    The argument in CaP and in BrCa is that mammography and PSA screening aren’t able to discriminate between the “Tigers and the Pussycats”! Essentially, the medical community is admitting that it has been foisting onto the American (and worldwide) populations a pair of less-than-as-advertised procedures for early cancer detection.
    Over-treatment, with the attendant negative side effects has been far too common in both kinds of cancers that combined kill some 70,000 men and women each year.
    Sadly, what has emerged from both anti-screening positions is the tacit admission that we’re still unable to tell a patient the relative aggressiveness of his/her cancer!
    Think of all the $$ millions that have been contributed to all the world-wide cancer-fighting organizations that have produced such a result! We still cannot examine biopsy cell specimens and tell a patient that he/she can relax: IT’S ONLY A PUSSYCAT!!

  15. Penny H.

    I’ve had breast cancer twice. Both DCIS and both in the exact same place. The first time in 1997 it showed up on a mammogram, the second time in 2004 my doctor noticed a small dimple about two weeks after I had a “clean” mammogram. After the second discovery, I decided to have a bi-lateral mastectomy.
    My opinion is that, although there are some false positives and as in my second cancer, some false negatives the mammogram is still a useful tool. However, the patient’s age should be factored in. I was in my late 50’s/early 60’s and have a lot longer to live. I know of a woman who was 95 and was subjected to a lumpectomy and radiation. She also lived a distance from the health care facility and was the sole caretaker of her husband who had advanced Alzheimer’s. I was asked for my opinion and said that I didn’t think she should go through the surgery and radiation at her age. Her doctors and family insisted that she have the surgery, the radiation made her very ill, and she died a short time later not from the cancer, but from the treatment.

  16. CK

    My mother and sister both were treated for early stage BC. I went for annual mammograms and had several biopsies for hyperplasia. The last biopsy showed DCIS, ductal cancer in situ, and I underwent a lumpectomy, radiation and hormonal chemotherapy.
    Perhaps my BC might not have progressed and the treament would have been unnecessary. I was not told of this possibility. However, for my own peace of mind, had I been informed of that, I would have chosen to undergo the full treatment anyway.
    It’s a crap shoot, but given the odds, I would make the same decision again.
    Dear CK,
    Thank you for sharing your story. We believe that each decision must be made with full awareness of the pros and cons of the diagnostic procedure and the resulting treatment. We applaud you for taking a proactive position. Given your particular situation we are sure you made the exact right decision for you. Your peace of mind is extremely important.
    As long as physicians are honest about the benefits and risks of their recommendations and procedures, we think patients are capable of making informed decisions about what to do.

  17. carla

    Thank you, thank you, thank you!
    I have read so much information about mammos–pro and con. This is the final piece of evidence that I needed to say NO MORE radiation to my dense breasts:
    Low probability of finding an early cancer, high probability of finding a non-harmful lesion, and dosing myself with radiation.
    I’m arming myself with these printed materials to take to my MD appointment so I can stand up for myself.
    Dear Carla,
    We like the idea that you will be discussing this with your physician. We encourage you to have your doctor read the entire article in the New England Journal of Medicine:
    Once your doctor reviews this research you will both be in a better position to discuss the evidence and how it applies to your specific situation.

  18. KFH

    I had a mammogram at age 40 and have not had another since, despite constant attempts by my gynecologist, endocrinologist and primary care physician. Several even refused to treat my awful menopause symptoms without one!!!
    I finally persuaded my gynecologist to perform BRCA testing (negative) who then agreed to treat my menopause with HRT.
    I am trying to make what should be a personal health decision, but have been subjected to constant lecturing despite all the reports which indicate the limited usefulness of annual testing! Even my 78 year old mother is scolded for her refusals of annual mammograms…..There is NOT one case of breast cancer in my family history – this should be taken into consideration, but it never is!
    And we wonder why our health care costs are SKYROCKETING. Sadly, many doctors order tests to avoid potential lawsuits rather than based on data.

  19. DS

    I wonder if all the radiation from twenty years of x-rays caused the tiny blip they found last year. I had to go back a week after my routine yearly x-ray for still more x-rays before they did a sonogram which showed some abnormality in one duct. They told me not to worry about it.
    LC, where did you learn that most survivors find the lump themselves? My breasts are soft now, but at one time they were rather grainy or lumpy and I felt safer having an x-ray. Now, I am wondering if I should trust my own occasional self-exam.

  20. O.G.

    My sister was diagnosed over a year ago with a breast lump that was “so small that if we’d checked last year we wouldn’t have found it.”
    On the recommendation of her doctors, she underwent intensive radiation therapy. Less than a year later, she was diagnosed with Stage 4 lung cancer. Since she had stopped smoking many years ago, was it–directly–the radiation treatment for the breast cancer that caused it, and–indirectly–the mammogram which detected and led to treatment for, a very tiny breast lump, that started it all?
    This research certainly gives women more food for thought before having a mammogram in the first place. And do I detect distress on the part of the medical profession in general, and radiologists in particular, over possible lost profits?

  21. Karen

    +1 on the “not new” phenomenon. I get mammograms because they’re free, but it’s pretty clear from the numbers that they don’t make much difference. Funny how biology so often fails to conform to strict Aristotelian logic.
    I recommend The Emperor of All Maladies for a better understanding of the history of cancer and how we have attempted to treat it over the years.
    Early detection works completely well for cervical cancer and colon cancer, for certain. It probably works for testicular cancer. Don’t know about the rest.

  22. FP

    When I was 45 the doctor decided I needed a needle biopsy — which was negative. When I was 60 they saw “something” on the mammogram which, after checking old film, had been there forever(?).
    Those were scary days. Now I am almost 82 and reconsidering these annual checks.

  23. LG

    I was diagnosed with breast cancer twice and both were detected by mammograms. It angers me to read an article like this. We don’t know which cancers are not life threatening and which are. Waiting and doing nothing can lead to advanced cancer. I would rather be treated for breast cancer and be cancer free than take a chance like this.
    Hard to understand why any doctor would discourage mammography. As far as “prevention” I don’t know that there is such a thing. I exercise, eat a low fat diet, don’t smoke…. I thought I was doing all the right things and twice I was diagnosed (13 years apart). If you do not want mammograms that’s a personal choice but I resent being told they are unnecessary.

  24. CT

    I asked a physician friend how often she got mammograms. She said never, she didn’t believe in them. That was eight years ago and I’ve never had another one. I do a monthly self exam and have an exam by a gyn once a year. I was very concerned about radiation exposure in addition to over treatment.

  25. SP

    This is not new information. Years ago, after reading similar articles about the poor reliability mammograms, I decided to no longer get mammograms. I also have a very wise female physician who respects and supports my decision. A mammogram has little to do with “prevention”. Organizations, such as Breast Cancer Fund, are on the forefront of prevention education and empowering women with vital information to protect their own health.

  26. LC

    I gave up mammograms four years ago and wish it would’ve been alot sooner!
    I find that the majority of breast cancer survivors and/or patients have found the “lump” themselves….and usually shortly after having had a mammogram that found nothing!!!
    I put 2-and-2 together….plus the fact that mammograms generate millions of dollars in profits!!! I’m done!

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