BOSTON — Some years ago, I was inducted into a special club. I hadn’t applied for membership. I didn’t want to join. I won admission the old-fashioned way: I inherited it.
After both my mother and my aunt were diagnosed with breast cancer, I automatically became a member of The High Risk Group. Today, I am happy to say that both these eightysomething women are alive and well, thank you very much. But my family membership entitles me to more than a casual interest in the disease that will afflict one in eight American women.
Every year, with a slight sense of foreboding and a bit of black humor, I go for what my friend and fellow club member calls "the breast sandwich." I leave — so far — feeling as if I’ve won a reprieve, a stay of execution.
I’ve made this pilgrimage religiously because like many in my peer group and my club, I’ve believed that early detection is the key to a cure. We’ve been told that picking up cancer on a mammogram, before it’s big enough to feel, improves the odds of survival by 30 percent.
Of course, I can do the math. Those same figures mean that mammograms make no difference in 70 percent of the cases. Some cancers grow so slowly that the women would never die from them. Others grow so aggressively that the women don’t have a chance. Still, 30 percent is nothing to sneeze at.
Now I find myself sitting in the clubhouse staring at a study that says mammograms don’t save lives. More than a year ago, two Danish researchers reviewed seven huge studies on mammography and cast doubt on their value. This fall, they returned in full force to the British journal Lancet, saying again that "there is no reliable evidence that it reduces mortality."
Theirs is by no means the final answer. Different scientists looking over the same data respond like the legendary blind men studying the elephant. Some researchers strongly disagree with the Danish conclusions. There are enough other factors — from the age of the patient to the effectiveness of new treatments — to make any study of mammograms subject to, well, more study.
But it’s safe to say that the Danes have shaken the common wisdom and common confidence in the connection between mammograms and cures. Or maybe, on the other hand, they’ve just shaken a false sense of security.
Fran Visco, the tough-minded president of the National Breast Cancer Coalition, says, "We are finally beginning to question long-held assumptions about how to detect cancer earlier and what happens when we do. In this country, cancer has been reduced to a pink ribbon and a mammogram. Is mammogram the key to saving lives? It’s not un-American to ask that question."
The mammogram is the most popular, the most promoted form of "early detection." Yet by the time cancer can be seen, it has been growing for seven to 10 years. Maybe, as breast doctor Susan Love suggests, our focus on screening has "made it sound like you just do your mammograms, your self-exams, and everything will be OK."
In fact, we learned a couple of years ago that monthly self-exams do not save lives. Now we are wondering if we’ve overestimated the value of mammograms.
What we really need, Love says, is the equivalent of the Pap smear for cervical cancer, a test that "gets to the cells that are just thinking about becoming cancer."
For now, the take-home message for a woman over 50 or a woman in the high-risk society is not likely to change. As Love says, "I have doubts about mammography, but I get my mammogram because it’s the best tool we have for diagnosis and screening. It probably changes the outcome for some women, but not all. I think this woman should get a mammogram but fight like hell for something better."
As for women under 50? Screening this age group has been controversial for years. Statistically, we would have to screen 2,000 40-year-old women for 10 years and do 600 biopsies to prevent one death. Is that good public policy? If not, explain it to the woman who feels her life was saved. Or to the politician who votes against insurance coverage.
Each year 233,000 women are diagnosed with breast cancer. Progress comes with dueling studies and evolving treatments. We read research done on thousands and make hard decisions one-by-one.
Kay Dickersin, a Brown medical school professor and breast cancer survivor, says, "We have to become more comfortable with uncertainty. There aren’t just yes or no answers. It’s not a failure of medicine. It’s where we are."
As for those who wish for more cure and less confusion, all I can say is … join the club.
Ellen Goodman can be reached at The Washington Post Writers Group, 1150 15th St. NW, Washington, DC 20071-9200 or send e-mail to EllenGoodman@Globe.com.
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