Routine mammograms: evil, necessary, or both?

By Anne Kingston - Friday, November 25, 2011 at 7:12 PM - 0 Comments

Last week, the Canadian Task Force on Preventive Health Care issued new breast cancer-screening guidelines that have raised questions and stoked debate. The task force recommended women under 50 who are not at high risk of breast cancer forego routine mammograms. It also recommended that the interval time between mammograms for women aged 50 to 69 be extended from every one to two years to every two to three years—unless their doctors suggest otherwise. And, contrary to what women have been told for decades, it concluded women should no longer conduct regular breast self-examinations.

To sort through the confusion, Anne Kingston spoke with Eileen Rakovitch, a radiation oncologist and chair of the breast cancer program at Toronto’s Sunnybrook hospital.

Q: It seems this debate never ends. Let’s start with mammograms. Radiologists in the U.S. and Canada have disagreed on this in the past: in the U.S., the recommendation is that women over age 40 should have regular mammograms; in Canada, the thinking has been that women at average risk should begin screening at age 50. Continue…

FDA revokes approval on blockbuster breast cancer drug

By macleans.ca - Friday, November 18, 2011 at 2:23 PM - 0 Comments

The U.S. Food and Drug Administration announced on Friday it will revoke its approval of blockbuster drug Avastin for use in breast cancer patients, saying it found no evidence that it prolongs their lives, while it has serious side effects. The FDA had initially approved Avastin to treat metastatic breast cancer in 2008 under an expedited approval program that grants patients early access to promising drugs even as additional clinical trials are carried out. “Unfortunately the additional studies failed to confirm Avastin’s initial promise,” FDA Commissioner Dr. Margaret Hamburg told ABC News. The additional evidence showed that Avastin patients lived no longer than those taking standard chemotherapy. The drug, however, can cause serious conditions such as severe high blood pressure, as well as bleeding and perforations in the nose, stomach and intestines.

ABC News

How do you know when to get screened for breast cancer?

By Julia Belluz - Monday, July 18, 2011 at 2:22 PM - 14 Comments

The Statement: “The benefits of mammography are going to depend a lot on what your underlying risk is, and the current guidelines look only at age… I think that, other things being equal, it’s reasonable for a patient and their doctor at that point to say, ‘we’re going to put off the next mammogram until age 50.’” (Dr. John Schousboe, 07/06/2011)

Dr. John Schousboe, of the Park Nicollet Clinic in Minnesota, is speaking here about a new health- and cost-effectiveness analysis of mammography (breast x-rays) he co-authored, which was published in the Annals of Internal Medicine. The study suggests that risk factors other than age—breast density, family history, and history of breast biopsy—should also be taken into account when determining who should be screened regularly. Continue…

A nice rack of slogans

By Anne Kingston - Monday, October 18, 2010 at 9:00 AM - 0 Comments

Gary Kazanjian/Fresno Bee/Getty Images

Last week, when people logged into their Facebook feed, they found themselves confronted by titillating and occasionally creepy disclosures on female friends’ status updates: “I like it on the floor” was popular. And many children got to read mom admitting: “I like it hanging from the bedpost.” It soon emerged that the “it” in the innuendo-laden meme referred to where the women liked to put their purses, and that the whole thing was an incongruous stealth campaign to raise breast cancer awareness. Last year’s version was a “What colour is your bra?” campaign—which also made headlines, though it was nominally more connected to the cause.

Proponents of the viral crusade argue that a breast cancer awareness campaign that gets attention without mentioning the disease is ingenious. Perhaps, but it highlights the provocative sexualized pulse of the new breast cancer awareness campaigns targeted at women under 40—and more than a few men. The cheeky tone is evident in Feel Your Boobies, a U.S. foundation started by Leigh Hurst, who had a breast cancer diagnosis at age 33, and the “boob lube” soap sold on savethe­tatas.com. “I (heart) boobies” rubber bracelets sold by San Diego-based Keep a Breast are considered so risqué many U.S. school boards banned them. Michelle Murray, a member of the organization’s board who lives in Sudbury, Ont., can’t keep the five-dollar items in stock: “Even my dad wears one.”

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Cancer answer?

By Kate Lunau - Thursday, October 7, 2010 at 10:00 AM - 0 Comments

Photograph by Tsar Fedorsky/Getty ImagesLeif Ellisen says 'smart drugs' will one day change the way cancer is treated

This summer, Vancouver cancer researchers announced a medical first. Presented with an extremely rare case of tongue cancer—it was so unusual there were no standard treatments to use—they sequenced the DNA of the patient’s tumour, and discovered similarities with another cancer (renal cell carcinoma, a type of kidney cancer) for which there’s a known therapy. The patient received drugs tailored to these results, and the cancer stopped growing for several months. Steven Jones, a molecular biologist with the B.C. Cancer Agency Genome Sciences Centre and one of two lead researchers on the study, calls it a breakthrough. It isn’t standard in hospitals to genetically sequence a patient’s tumour, but “the goal would be, maybe in 10 years, this would be routine,” he says.

Dr. Leif Ellisen, an associate professor of medicine at Harvard Medical School, is working to bring tumour genotyping from the lab into the clinic. He and a team have designed a system that can screen relatively large numbers of patients for a variety of mutations across different cancer genes. These genetic mutations are a tumour’s “Achilles’ heel,” noted a recent editorial in the journal EMBO Molecular Medicine. “Every tumour has a flaw,” says Ellisen, who’ll be discussing his work as part of the Scienta Health Series in Toronto on Oct. 7, and his goal is to find it.

It’s the mantra of a growing number of researchers, who tout personalized medicine—treatments tailored to each individual—as the future of cancer care. Traditionally, cancer treatment “has been one-size-fits all,” Ellisen says. “If it’s breast cancer, you treat it one way; if it’s lung cancer, you treat it another.” The downside is that costly drugs are administered to patients, sometimes with harmful side effects and no real promise they’ll work. “The treatment needs to be tailored to the individual characteristics of the patient and, we’re learning now, the characteristics of the tumour,” he says. Cancers are typically classified by the organs where they arise, but it’s possible that a breast cancer and a lung cancer, for example, might share a genetic abnormality. As a result, they might even respond to the same treatment.

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Masters wrap: Left behind by Phil

By Colby Cosh - Monday, April 12, 2010 at 4:29 PM - 14 Comments

The gods of golf decided to go for cheap melodrama on Sunday, letting Phil Mickelson walk away from the field and take a third Masters as his cancer-fighting wife Amy looked on. Well, maybe we shouldn’t credit it to the gods, but to Mickelson’s all-around game, which only Tiger Woods can match at times when his morale and concentration aren’t shot to hell.

Insofar as fate or divine intervention had anything to do with Lefty’s win, they seemed to be against it. He had an extremely makeable birdie putt on the 2nd hole, but on his backswing a stamen from a pine tree plopped directly in the path of his ball. This was creepy, as Bill Simmons would say, on a Blair Witch level. As Jim Nantz and Verne Lundquist summoned their formidable intellectual powers to the task of figuring out what the hell happened, CBS cut to a wide shot of the hole. The day was sunny, without enough wind to stir a puff of pipesmoke; there were, and are, no trees within 70 or 80 yards of the hole. The offending vegetation appeared to have dropped vertically out of a clear sky. 81-year-old Dan Jenkins, the Twitterizing dean of the world’s golf writers, quipped “I’ve never seen that before, but this is only my 60th Masters.”

If Mickelson had lost by one shot, everyone would be making a big deal of the incident today; since it betokened nothing and is already being forgotten, let it serve an instructive lesson in how superstitions come about. But let’s also note that a stamen is the male reproductive organ of a plant. Apparently Phil has less trouble getting distracted by such things than some other golfers [rimshot].

I never liked the old Phil Mickelson much. Somehow, and I’m not at all sure this was ever a fair perception, he seemed to combine smugness, haphazard stewardship of his talent, and weak nerve; that he was liked by American galleries from the beginning only made matters worse. It was a source of wholly non-patriotic delight to me when fellow “lefty” Mike Weir beat him to a major-championship victory. (Weir, Mickelson, and New Zealander Sir Bob Charles, the only lefty swingers to win majors, are all right-handed in everyday life; the world is still waiting for a truly lefty Lefty.)

But in the face of the Tiger era, Mickelson buckled down, worked hard, and found another gear, without sacrificing his family, his cheerfulness, or his relationship with the fans. With each passing year he looks more impressive, more like someone who stands as a living rebuke to Woods—to say nothing of the Sergio Garcias, the David Duvals, and the Notah Begays, the players who had the innate gifts to match Mickelson’s tournament record but haven’t closed the deal. It’s doubly endearing that Lefty has been quietly trying to minimize the bathos of his wife’s and mother’s cancer diagnoses, subtly discouraging reporters from whispering at him as though they were huddled in the rear pews of a funeral Mass. (Journalists don’t equate cancer with death; they think it’s much worse.)

Before the fourth-round tee time, I heard some mike-wielding goofball actually approach Mickelson and attempt a lurid thumbnail sketch of a tumour-ravaged, vomit-flecked Amy feebly rising from her sickbed to watch Sunday’s golf from home. Mickelson, forgiving and full of pep, pointed out that the Mrs. had joined him in Augusta and would be in the gallery that very day. And so she was. She looked great.

Location, location, location

By Kate Lunau - Thursday, January 21, 2010 at 10:30 AM - 2 Comments

YAKABUSKI had an unofficial 'screening program'

Concerned about an aunt who’d been diagnosed with breast cancer, Vicky Yakabuski—then in her thirties—got a referral from her doctor for a mammogram, a habit she got into keeping each year. At age 46, Yakabuski learned she had breast cancer. “It was a treacherous time,” says the homemaker, now 48, who lives in Stouffville, Ont., and it was hard on her husband and two daughters. After a mastectomy and chemotherapy, she’s doing better; she and supporters (dubbed “Team Victorious”) raised $15,200 in October’s Canadian Breast Cancer Foundation CIBC Run for the Cure. As for the mammogram, she says, “it saved my life.”

Breast cancer is the most commonly diagnosed cancer among Canadian women, yet for those under 50, the benefits of regular mammograms remain controversial. Because it’s less common in younger women—the annual risk of developing it at 40 is half what it is at 50—experts warn that regular testing can actually do more harm than good. (Women in their forties, who have denser breast tissue, are more likely to get false positive results.) Others insist it saves lives: one B.C. study showed that providing women in their forties with regular mammograms reduced deaths from breast cancer by 25 per cent. Even so, medical bodies offer conflicting advice, and screening programs vary between provinces. This “creates confusion,” says Beth Easton of the Canadian Breast Cancer Foundation (CBCF), and can put women at risk.

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A game-changer on abortion & breast cancer? You make the call

By Colby Cosh - Tuesday, January 12, 2010 at 2:24 PM - 105 Comments

The long-standing controversy over the link between therapeutic abortion and breast cancer found its way onto unexpected territory—the Globe and Mail website—on Friday. The pro-life movement has long been quarrying the epidemiological literature for the smoking gun of what it calls “ABC“. This is what pro-lifers ask Santa for Christmas, or wish for when they see a falling star: that abortion will turn out to carry previously unsuspected harms which might become the pretext for outlawing it completely, for imposing severe restrictions on it, or, at the very least, for stigmatizing it like tobacco and allowing clients to receive a scary mandatory lecture on cancer risk in the name of informed consent.

Thus far, science hasn’t been much help to them. ABC is a tricky topic because there are confounders in the picture: in general, spending less time pregnant (and more time menstruating) gives women a slightly greater lifetime risk of breast cancer. Abortion probably does increase breast cancer risk insofar as it eliminates one pregnancy—just as being able to drive increases one’s risk of ending up with shards of windshield glass under one’s eyelids.

Whether abortion imposes a distinct burden of cancer risk is another question, one much harder to answer. Occasionally a study will turn up that suggests it might. And that’s what has happened now. Gloria Galloway writes:

Three years ago, [Saskatchewan MP Maurice Vellacott] helped to bring an American doctor and activist to Parliament Hill to tell Canadian women that abortion increases the risk of breast cancer. It turned out that the doctor, Angela Lanfranchi, was speaking from a defined religious point of view that had little apparent basis in science.

And, at the time, the link between the procedure and the disease had been discounted by the National Cancer Institute in the United States, the Society of Obstetricians and Gynaecologists of Canada (and their U.S. counterparts), as well as the Canadian Cancer Society and the Canadian Breast Cancer Network.

But a study released last fall (available here but only for a fee) by the respected Fred Hutchinson Cancer Research Institute in Seattle by a number of distinguished cancer experts including Louise Brinton, the chief of the Hormonal and Reproductive Epidemiology Branch of the National Cancer Institute, lists induced abortion as being “associated with an increased risk for breast cancer.” Background documents further suggest that it increases the risk of the disease by 40 per cent.

An e-mail to Dr. Brinton on Friday was returned by an Institute spokesman named Michael Miller who said: “NCI has no comment on this study. Our statement and other information on this issue can be found at http://www.cancer.gov/cancertopics/ere.” …Requests for an explanation of the apparent discrepancy between that position and the information contained in the study released last spring went unanswered by NCI.

I visited the library to double-check whether Galloway had characterized the study’s findings correctly. The data behind the study come from a breast-cancer surveillance project in the Seattle area that included interviews with 897 women who had suffered invasive breast cancers before the age of 45. Here’s the part that’s the cause of all the excitement—a line in a table of odds ratios for “known and suspected risk factors among women 45 years of age and younger”:

The odds ratios were derived by adjusting for age, family history of breast cancer, lactation history, and duration of oral contraceptive use: the double dagger indicates that only women who had been pregnant at least once were included in the “never” row under the “Abortion” heading, so the statistically significant 40% apparent increase in background risk actually leaves never-pregnant women out of the background completely. This is notable, especially given that the study is population-based (the authors boast that it is the “largest of its kind”; their goal was not just to measure breast-cancer risk but to differentiate between etiologic subtypes of breast cancer).

On the other hand, it’s not that notable. If you look at the raw numbers, you’ll see that the randomized control group of 1,569 Seattle-area women with no history of breast cancer broke down between “Never [had an abortion] and “Ever” pretty much the same way that the breast-cancer victims did. Most of the “40%” extra risk, in other words, is the product of statistical adjustments, and may, in part, be attributable to confounding variables that weren’t controlled for. Income wasn’t controlled for, and as you can see in the table itself, it might make a difference; neither was obesity. And 40% is not a big number in epidemiology. In general researchers don’t get worked up about an odds ratio until it is at least 2.0, and it is seen over and over again in multiple studies.

Galloway is, frankly, not being careful enough when she describes the study as implying that abortion “increases the risk of the disease by 40 per cent.” This study is strictly about breast cancer in women under 45—a small fraction of all breast-cancer cases (though, to be sure, it is a fraction that is of special concern). In no way can it provide justification for any statement about overall lifetime breast-cancer risk.

Moreover, there is really no “discrepancy” between the NCI’s stated position on ABC and this particular study. Here’s what the NCI says officially:

The relationship between induced and spontaneous abortion and breast cancer risk has been the subject of extensive research beginning in the late 1950s. Until the mid-1990s, the evidence was inconsistent. Findings from some studies suggested there was no increase in risk of breast cancer among women who had had an abortion, while findings from other studies suggested there was an increased risk. Most of these studies, however, were flawed in a number of ways that can lead to unreliable results. Only a small number of women were included in many of these studies, and for most, the data were collected only after breast cancer had been diagnosed, and women’s histories of miscarriage and abortion were based on their “self-report” rather than on their medical records. Since then, better-designed studies have been conducted. These newer studies examined large numbers of women, collected data before breast cancer was found, and gathered medical history information from medical records rather than simply from self-reports, thereby generating more reliable findings.

Although the new Seattle study is large and features randomized controls, it too is a retrospective, questionnaire-based study, reliant on self-reporting; it does not meet the gold standard for epidemiological evidence. The NCI has no reason I can see to change, or apologize for, its position.

Revolt of the booboisie

By Colby Cosh - Friday, November 20, 2009 at 6:00 AM - 40 Comments

Speaking of health care reform in the USA… if you need a demonstration of what it’s up against, study the apoplectic response to new guidelines for breast cancer screening issued by the U.S. Preventive Services Task Force, an independent agency of the Department of Health and Human Services. The USPSTF has decided to recommend that women aged 40-49 should no longer bother obtaining mammograms as a matter of course; that women 50 and up need them only once every two years; and that breast self-examination is largely useless. The result has been the creation of an instant coalition of rage between conservatives paranoid about “death panels”—behold, an example of the real thing, already doing its genocidal work!—and conspiracist women paranoid about a male-dominated medical profession and its apparent desire to do away with them. (Some people, of course, manage to be both at the same time.)

Confronted with such a tag team, HHS secretary Kathleen Sebelius couldn’t throw her task force under the proverbial bus fast enough. She promised that the new guidelines “won’t set US policy”. In practice, she has thus established frequent breast cancer screening as a sacred taboo. The evidence on the costs and benefits of intensive screening is still evolving, but the debate is over. Even if other clinical agencies come to agree with the USPSTF, as they might, neither Medicare nor future Obamacare will be politically able to budge from the orthodoxy of routine annual screening for every woman over 40.

The key word here is “routine”. The coalition of excitables is behaving as if the USPSTF recommended that no woman under 50 should ever get a mammogram. What the USPSTF said was that the decision to start early regular mammography is, given present evidence, too complicated to be the subject of a simple fiat covering the entire populace. “The decision to start regular, biennial screening mammography before the age of 50 years,” they said, “should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.”

Every woman has a different risk profile, not only for breast cancer itself, but for the legitimate harms that can arise from overdetection, ranging from excess radiation exposure to complications from needless biopsies and surgeries. It is NOT, contrary to what some of the excitables would have you believe, a simple matter of avoiding the pain of mammograms and the psychological stress from false positives. (But, at that, it might be worth asking some of the more affluent critics: if more mammograms are inherently better for you, why stop at one a year? Why not one every two weeks? What price peace of mind?)

As Steven Pearlstein observes in a brilliant column for the Washington Post, the whole spectacle is about as unedifying as could be imagined. Of course, if you’re an American against nationalized health care, or just a Canadian who appreciates the benefit of having a radically different health system just a few hours’ drive away, you can take comfort in the overpowering evidence that the American public is still not ready to relinquish the benefits of personal control over the consumption of medical services. (Even if regulation of insurance programs has rendered those benefits largely theoretical.)

But one still doesn’t like to see what one might regard as the “right” side of the debate win for the wrong reasons—namely, that Americans and their media are no longer capable of exercising rudimentary logic or understanding the most basic nuances of science. Such a passion-wracked polity cannot survive as a liberal-democratic republic for too long, with or without socialized medicine. I mourn a little when I read a passage like this in the comment section of the San Jose Mercury News:

Ironically, mammograms do save lives. The U.S. Preventive Services Task Force acknowledged as much in its report. For example, since 1990 the breast cancer mortality rate among women age 40-49 decreased 3.3 percent a year, largely due to mammograms. But breast cancer is relatively rare in that age group, so the task force decided the risks of mammograms, including false positives that lead to anxiety and unneeded treatment, outweigh the benefits.
Tell that to any woman who was diagnosed in her 40s. I know several. I bet you do, too.

An important point underlying the USPSTF’s new guideline is that breast cancer is dramatically overdiagnosed in women under 50. Incredibly, the author of this op-ed, Patty Fisher, thinks the fact she knows a lot of women under 50 who were diagnosed with breast cancer is a refutation of this! (She has also told a flat-out lie, of course, about what the task force actually said; it acknowledged that for many women, the benefits of aggressive early screening may in fact outweigh the risks.) The relevant number, for the purposes of discussing the guideline, is not simply the number of women between the ages of 40 and 49 who have been diagnosed with breast cancer because of mammograms. The relevant number is the number of women between 40-49 who would forgo mammography until the age of 50 because of their risk profile, and then die of breast cancer specifically because the lack of early detection failed to catch a truly dangerous, fast-growing tumour. And the evidence suggests that there really aren’t that many of those women.

The San Francisco Chronicle went further in the quest to put a “human face” on the debate, hunting for individual women who have had breast cancers detected in their forties. Again, without access to extensive case histories, the reader cannot judge whether application of the USPSTF guideline would have actually harmed these women. But they are personally convinced, whatever mere statistics or even the details of their own cases might say. “I can’t believe [early mammography is] not saving a lot of women,” fumes cancer survivor Laura Scanlan. “It saved me.”

Well, there you have it. The great American syllogism for the 21st century. X benefited me, therefore X must be good for everybody, and not bad for anybody. I’m every woman: it’s all in me.

The angry breast cancer survivors

By Anne Kingston - Thursday, November 20, 2008 at 8:00 AM - 32 Comments

Breast cancer awareness month, also known as October, came and went with scant attention paid to a new, groundbreaking book: After the Cure: The Untold Stories of Breast Cancer Survivors by Emily Abel and Saskia Subramanian. Then again, stories of women coping with life-altering, post-treatment maladies have remained “untold” for a reason. As Abel, a professor of health services and women’s studies at the University of California, and Subramanian, a sociologist at the UCLA Centre for Culture and Health, point out, the topic runs counter to the “celebratory breast cancer culture,” one filled with inspiring narratives of good health and spiritual rejuvenation.

That wasn’t Abel’s experience after radiation and chemo for breast cancer in 1993. Her doctor told her recovery would take a year; to this day she still suffers from fatigue. She began noticing a “cone of silence” around the subject of health when talking with other survivors: “Everybody was supposed to say ‘I’m fine, I’m great’ and of course we were fine—those of us who survived were really very lucky and we did consider ourselves fine. But we began to realize we also had other problems that no one was paying much attention to.” Continue…

Prescription: Turn that frown upside-down

By Lianne George - Friday, August 22, 2008 at 4:19 PM - 0 Comments

Researchers are now saying that some of women’s greatest health challenges can be remedied with one thing: happiness. Simple enough, right?

A team of researchers at Ben-Gurion University of the Negev, Israel, questioned 255 women with breast cancer about their well-being and their levels of happiness, optimism, anxiety and depression before they were diagnosed. They studied them against 367 healthy control subjects. The study, published in the journal BMC Cancer, concluded that those with a positive outlook on life were better protected against the disease. Continue…