I regard this information on breast cancer screening as amongst the most important I have written about over the years. Please take time to read it carefully.
The National Cancer Institute (NCI) commission last year concluded that ‘early stage cancers’ such as ductal carcinoma in situ (DCIS) should not be regarded as cancers, but benign or indolent growths and that millions of women were wrongly diagnosed with ‘breast cancer’. In an attempt to quantify the benefits and harms of screening mammography Welch et al. came to the following conclusions: Among 1 000 US women age 50 years who are screened annually for a decade, 0.3 to 3.2 will avoid a breast cancer death, 490 to 670 will have at least one false alarm, and three to 14 will be over diagnosed and treated needlessly. They conclude by saying that they hoped that these facts would help women to make a decision ‘either to feel comfortable about their decision to pursue screening or to feel equally comfortable about their decision not to pursue screening’.¹
DUCTAL CELL CANCER OF THE BREAST: IS IT A CANCER AND DOES IT MATTER?
The controversy rages on with a lot of rhetoric from both sides of the line. Many professionals believe that it is cancer and therefore should be treated as a cancer. Others believe that it is a precancerous lesion, and calling it a cancer just raises the fears of women and pushes them to agree with doctors who want to move onto aggressive treatment. All breast cancer associations run on this theme. Here I relook at the debate and hopefully help doctors make sense of the argument. There are a number of issues in this controversy:
- Are these cancer cells or precancerous cells? This is crucial and can change the way everyone deals with the problem. Professionals and associations can fall by this very decision, and one can understand the rhetoric around the issue. If you have just spent millions of dollars investing in machines to do mammograms, then you will want to at least recuperate your investment before becoming an advocate of no mammograms. There is a similar argument around prostate cancer and whether the early stages are ‘real’ cancers or just precancerous cells that may or may not become ‘real’ cancers. Now even thyroid cancer and cervical cancer diagnosis is being reviewed. The majority of so-called prostate cancers present in 80% of men over the age of 80 never spread, and should perhaps never be called cancerous as they tend not to behave like a cancer. This may also apply to much younger men.
- The NCI commission panel published online in JAMA (July 2015) confirmed that the public and professionals alike should stop calling low-risk lesions like DCIS and high-grade prostatic intraepithelial neoplasia ‘cancer’. The report continued: ‘The practice of oncology in the US is in need of a host of reforms and initiatives to mitigate the problem of over-diagnosis and over-treatment of cancer.’
- Are the early lesions picked up by histology cancer cells, pre-cancer cells or just aberrant cells which come and go constantly in the body?
- If these are all precancerous cells, then what potential is there of these cells becoming cancerous, and what conditions are required for this to occur?
- Should doctors manage these lesions aggressively, do watchful waiting or treat them in an integrative way? The latter is definitely NOT just watchful waiting, but is deeply embedded in the idea of supporting health and moving anyone with the diagnosis of a precancerous condition towards more health so that the health can heal. This is a real option, especially because precancerous cells can go either way, i.e. towards cancer or return to normal cells, as indeed seems to happen.
- Does cancer screening make any difference to outcomes? Until the most recent study² it was thought that the cancer-related deaths outcome was the most important outcome to consider. Then along came the problem of false alarms and over-diagnosis. Now even breast cancer deaths have been overshadowed by the fact that the overall mortality does not change with screening. That is a shocking outcome and changes everything we thought was true.
This study² indicates that while breast cancer screening might reduce cancer-specific mortality, it has not conclusively been shown to have an effect on overall mortality. One can conclude from the results of a study³ done in Norway, that breast screening is not reducing the overall incidence of advanced breast cancer diagnosis while it is picking up increasing amounts of ductal cell cancers, the majority which never become problematic.
Recent estimates of ‘over-diagnosis’ rates in common cancers include the following: prostate 60%; breast 30%; thyroid 90%; skin 90%; lung 18%.
SO IS SCREENING SAVING LIVES, OR INCREASING THE BURDEN OF ILL HEALTH?
The answer to this question has become a serious debate and can no longer be taken for granted. In other words, enrolment in Norway’s breast screening programme increased the chance of being diagnosed with an early-stage breast ‘cancer’ diagnosis by 221%, and more disturbingly, increased the chance of being diagnosed with an advanced (lethal) breast cancer by 35% – exactly opposite of what would be expected if the mammograms were actually catching malignant tumours early, which would imply the incidence of the more lethal, late stage cancers would be lower and not higher.
According to Dr Prasad, author of a BMJ article, the screening may seem to save some women from dying of breast cancer but if ‘overall’ mortality is looked at, then the screening has not benefited women and may even contribute to them dying from some other cause.² This of course points to the danger of screening, false diagnosis, further investigations, stress induced by false positives and the possibility that all the radiation contributes to activation of other cancers.
Dr Prasad said in an interview: ‘Proponents of cancer screening say that screening tests have been shown to save lives. What we’re trying to show is that, strictly speaking, that’s … an overstatement.’4
Not just an overstatement, but a serious indictment of conventional medicine practices and the enormous harm that may again be done by governments, cancer institutes and medical specialists pushing early screening. This burden is in addition to poor education of doctors around diet management and other lifestyle management skills essential to preventive medicine rather than seeing screening as the way to go to prevent morbidity and mortality.
The rationale for cancer screening is that this will reduce the burden of deaths from cancer and that lowering cancer-specific deaths will decrease overall mortality. These assumptions no longer seem to be supported by the facts.
This will require a major turnaround for medical doctors and cancer organisations. The evidence suggests that screening for breast cancer should no longer be routine but taken on an individual basis, taking into account the many risk factors for that person.
The study by Harding and colleagues found a positive correlation between the extent of screening and breast cancer incidence but not with breast cancer mortality. So while there was an absolute increase of 10 percentage points in the extent of screening, this was accompanied by a 16% higher cancer diagnosis but no significant change in breast cancer deaths. They suggested that their findings point to a widespread overdiagnosis.5
It seems that breast-cancer screening and even prostate screening has been over-promoted, with a whole industry involved as doctors, hospitals and governments get into the practice of providing a service for detecting early cancers. As I have often pointed out, once an industry gets started it grows exponentially and common sense often gets thrown out of the window, especially when money is involved. We now have the situation where cancer screening is so sensitive that it is picking up premalignant and very early cancers that may never cause a problem and may even regress. Instead of saving lives, research is now suggesting that regular screening may do the opposite, causing more harm and suffering, and that the overall mortality does not decrease. Women continue to die and screening may even contribute to the increasing death rate. There is some evidence that the radiation involved in screening or treatment may activate cancer stem cells. According to the authors of the study, when tumours are challenged by certain stressors, such as radiation, this may generate cancer stem cells, along with surviving cancer stem cells, to produce more tumours.6
Any indication of a ductal-cell cancer can be approached by supporting health and seeing what the body can do with this extra support. The innate intelligence of the body knows what to do. Integrative doctors can provide natural products and suggest lifestyle changes necessary for potential cancer to reverse itself back to happy cells.
Overall, 22% of screen-detected invasive breast cancers are overdiagnosed.7
A multidisciplinary group of French health professionals and patients, independent of all organisations or administrations, and without any conflict of interest, has voluntarily developed an information leaflet intended for women in an attempt to give them back the power of a really informed decision.8, 9, 10 This fully referenced leaflet is freely downloadable: http:// cancer-rose.fr/wp-content/uploads/2015/10/Cancer-Rose_16pUK2-2-copie.pdf
- Welch H et al. Quantifying the benefits and harms of screening mammography. JAMA Intern Med; 2014;174(3):448-454.
- Prasad V, Lenzer J, Newman D. Why cancer screening has never been shown to ‘save lives’—and what we can do about it. BMJ; 2016;352:h6080.
- Louadal ML et al Trends in breast cancer stage distribution before, during, and after introduction of screening programme in Norway. Eur J Public Health. 2014;24(6):1017-22.
- Harding C, et al. Breast cancer screening, incidence, and mortality across US counties. JAMA Intern Med 2015; 175(9):1483 1489.
- Lagadec C, Vlashi E et al. Radiation-induced reprogramming of breast cancer cells. Stem Cells. 2012;(30):833-844.
- Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA. Twenty-five year follow-up for breast cancer incidence and mortality of the Canadian National Breast screening Study: randomised screening trial. BMJ. 2014 Feb 11; 348:g366.
- 8. Hersch J, et al. How do we achieve informed choice for women considering breast screening? Prev Med. 2011 Sep; 53(3):144-6.
- Domenighetti G, et al. Women’s perception of the benefits of mammography screening: population-based survey in four countries. International Journal of Epidemiology. 2003; 32:816–821.
- Braillon A, Nicot P. Cancer screening and informed consent. A new French exception? Prev Med. 2011 Dec; 53(6):437; author reply 438.