Tuesday, November 3, 2009

factual versus over-promised when it comes to screening. The advantages to screening have been exaggerated"

Discord on Mammography Roils the ACS, Part Two
Sunday, 01 November 2009

Last week I began a discussion of the discord at the American Cancer Society (ACS) over its recommendations for screening mammography. I conclude, with references, this week.

The American organization that has been most firmly associated with screening mammography is the ACS. Apparently, the JAMA article momentarily tipped the scale in the debate against mammography. Although the ACS gives lip service to evidence-based medicine, in this case the evidence tilts away from mammography and towards skepticism. The new ACS chief medical officer, Otis W. Brawley, MD, told the Times, he was ready to embrace the factual approach. "I'm admitting that American medicine has over-promised when it comes to screening. The advantages to screening have been exaggerated" (Kolata 2009).

Dr. Brawley is a well-regarded medical oncologist who took over the top administrative position at the ACS two years ago. It took a lot of courage for him to try to adjust ACS's positions to the facts on the ground. Before coming to ACS, Dr. Brawley had expressed personal reservations about cancer screening, especially the use of the PSA test for prostate cancer. In 2000, he told a patients' Web site:

"I have never had a PSA and do not desire one. I have had relatives with the disease. I just do not believe it saves that many lives.... I am aware of 23 different organizations of experts in screening around the world who have considered the question and all have chosen not to make the blanket statement that screening saves lives and men should be screened. Most actually recommend men not get the test because it is not proven effective" (www.psa-rising.com).

So, if anything, Dr. Brawley could be considered a skeptic regarding cancer screening. But he also told the Times, "We don't want people to panic" over the new mammography position. But apparently the idea of scaling back mammography did lead to panic within ACS. Less than a day after publication of the Times article, the ACS put out a press release: "American Cancer Society Stands By Its Screening Guidelines."

Stands by its guidelines? How was that possible, when just hours before its medical director had directly contradicted those guidelines? Were they attempting to deny the accuracy of the Times report? One day it is revising its guidelines, and the next day standing by them? Here is an excerpt from the press release. Read it carefully:

"Today's New York Times...indicates that the American Cancer Society is changing its guidance on cancer screening to emphasize the risk of over-treatment from screening for breast, prostate, and other cancers. While the advantages of screening for some cancers have been overstated, there are advantages, especially in the case of breast, colon and cervical cancers. Mammography is effective - mammograms work and women should continue get them."

Notice that the press release does not say that the Times article was wrong or that Dr. Brawley had been misquoted. It simply falls back on the time worn argument that "mammograms work." It claims that breast is like colon and cervical cancer, not like discredited prostate cancer screening. It thus totally ignores the powerful arguments of Welch, Esserman and many others. It cites some studies of its own "proving" that mammography is effective, but just ignores the more recent and (in my opinion) more powerful arguments in JAMA and elsewhere.

Notice too how the ACS release associates mammography with colon and cervical cancer screening, rather than with prostate cancer screening. That is convenient, because there is little debate over the efficacy of colonoscopies for colon cancer or Pap smear (and HPV virus) screening for cervical cancer. The whole point of the recent JAMA article, however, was that mammography more closely resembles the faulty PSA screening program in its failure to significantly increase actual survival.

Although the ACS has now backtracked, I suspect that this reversal is only temporary. Dr. Brawley's previous skepticism about screening is well known. As long as he remains medical officer, he will probably push for clarity on this question. The mammography recommendations are now looking like the fringe position, while the position of the erstwhile skeptics has become mainstream. ACS cannot hold back this trend and sooner or later, it will have to modify its outdated position. That will be a victory for evidence-based medicine.

I hope, however, that ACS will make this revision in the context of a sweeping public review of its method of debating scientific issues, including its high-handed tendency to crush opponents, rather than engage in reasonable dialogue. For instance, we have seen in the past how ACS abandoned its notorious 'quackbuster' position regarding complementary and alternative medicine without making a clean sweep of its disgraceful history in that regard. ACS should admit that it (and not "American medicine" in general) was mainly responsible for the mammography recommendation and for various reasons got that wrong, long after many others had pointed out its errors. This may hurt in the short run, but it would be incredibly salutary for the long-term health of the organization. Or would such honesty be asking too much from a multi-billion organization?


We have a special 36-page report on "Mammography, Biopsy and the Detection of Breast Cancer." Here is what one reviewer, Samuel Epstein, MD, professor emeritus of Environmental and Occupational Medicine at the University of Illinois School of Public Health, said about this report:

"A characteristically thoughtful and incisive work that not only exposes the very real dangers of breast cancer screening...but also lays bare the astonishing lack of scientific evidence underpinning current screening recommendations. This is an outstanding and important work by an outstanding and important author."

To order our report, please click here or go to:
(Listed under "Current Topics")

--Ralph W. Moss, Ph.D.

also try www.cacare.com

1 comment:

Jo Firth, Safe Breast Imaging said...

Thank you for the history lesson on the reasoning behind the statements.
Fear is a very big driver of women to mammography screening. Even though women dont like the thought of a mammogram, the fear of missing a cancer is higher, and out of proportion to their actual risk.
There needs to be a lot of un-educating and reassurance to women that their risk is low, and there are many things they can do to reduce their risk.
In Australia, women now have the option of monitoring their breast health through measuring the electrical properties of their breast tissue. This has strong correlation to mammogram and ultrasound when comparing benign lumps. More importantly, there is strong correlation to symptoms and feelings that may precede a lump showing up. Given that a tumour takes on average 8 years to show up on a screening mammogram, we need to find other solutions if we are going to change outcomes.
Jo Firth
Safe Breast Imaging