Why You Might Not Need a Mammo
Anita KunzFrom Health magazineLaura Esserman is running behind. A conference call for the grant proposal shes working on lasted longer than expected, then her 15-year-old son burst unexpectedly into her office to use her computer and bum 75 cents for bus fare. Now she has lost her reading glasses. Again. “This is the sixth pair that has disappeared. I have no idea where they go,” she says, looking under a book on the broad, paper-strewn desk in her sixth-floor office at the University of California, San Francisco (UCSF) Medical Center, where she is a nationally known breast surgeon. Despite the flurry of distractions, interruptions, and mysteriously vanishing eyewear, Dr. Esserman seems calm. Maybe its her years of intensive surgical training, or the discipline she honed earning an MBA from the Stanford Graduate School of Business while working as a practicing surgeon. In any case, that equanimity has served her well of late.
Last October, she and a urology colleague published an article in the Journal of the American Medical Association (JAMA) that sounded an alarm about what she calls “the elephant in the room”the rarely-talked-about downsides of routine breast and prostate cancer screening. Routine mammograms, their article said, find too many unusual-looking clusters of cells that turn out to be benign, leading to unnecessary biopsies (and, they argued in a later editorial, needless anxiety). Whats more, all of our intensive screening efforts result in many women being treated for tumors that might never have become life-threatening.
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Getty ImagesThe article reignited a controversy about when women should begin getting routine mammogramsa subject that breast cancer experts have been debating for the past 15 to 20 years. This professional dispute burst into a public firestorm shortly after Dr. Essermans article was published, when the U.S. Preventive Services Task Force (USPSTF)which Dr. Esserman isnt part ofsuggested that, despite experts telling women for years that they should start screening in their 40s, average-risk women could wait until theyre 50.
“After the JAMA article, I got a lot of support from colleagues, but I also received my share of angry e-mails and letters,” Dr. Esserman says. Doctors as well as breast cancer survivors wrote impassioned letters telling her stories about cancer that was found in women in their 40s thanks to screening. One colleague even confronted her in the middle of a national meeting. “Some people said that I was making things too confusing. They accused me of being a numbers cruncher who doesnt care about individual women,” Dr. Esserman says. “Thats the criticism that bothered me the most, because nothing could be further from the truth. I treat women with breast cancer every day. I care deeply about all my patients and spend hours thinking about how to best help them.”
She understands why physicians are wary of embracing the new guidelines. “No doctor wants to make a mistake,” she says. “But the fear of not finding cancer drives us to do too much.”
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Mass mammo confusionTo understand just how unpopular this notion is, its important to note that many prestigious medical and advocacy groups, including the American Cancer Society (ACS), the American Congress of Obstetricians and Gynecologists, Susan G. Komen for the Cure, and the American College of Radiology, vigorously oppose the new USPSTF guidelines and continue to recommend that all women in their 40s have regular mammograms. “We have a public-health recommendation that we believe has saved lives, and we dont believe the evidence is sufficient to change that position,” says J. Leonard Lichtenfeld, MD, deputy chief medical officer for the national office of the ACS. “Its true that were finding breast cancers today that may never have caused a woman difficulty in her life. But at this time were not able to distinguish between the ones which will be less aggressive and the ones that are likely to cause a problem, and our position is, were not willing to risk missing something just so we can reduce overdiagnosis and treatment.”
Getty ImagesBesides the risk of missing a potentially fatal cancer, experts are concerned that the new guidelines have raised doubts in womens minds about the benefits of mammography. “Women are questioning whether mammography is valuable,” says Carol Lee, MD, chairwoman of the Breast Imaging Commission of the American College of Radiology. “I find that frustrating, because we have tried so hard to encourage women for years to get screening mammograms, and Im worried that this will set back the cause and result in a decreased utilization of a tool that we know can save lives.”
Despite all the disagreement, Dr. Esserman stands by her views. “Mammography can be a valuable tool, and anyone whos at high risk should absolutely be screened in her 40s,” she says. “But we need to be honest about the risks and benefits of mammography. Low-risk women in their 40s should know that premenopausal breast tissue is often dense, so mammography is not as sensitive at finding cancers. Younger women are also more likely to be called back for what we call calcifications, which radiologists may flag as abnormal or suspicious. But the majority of these suspicious findings turn out, after a stressful biopsy, to be nothing.”
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Anne HamerskyDr. Esserman, 53, herself chose not to get mammograms in her 40s; she waited because she “knew the data”the fact that mammograms find something suspicious in 7 to 10 out of every 100 young women, but just a small percentage of those actually have invasive cancer. So its a little hard for her to understand what everyones so upset about. “No one wants to miss a lethal cancer, but bad things can happen whether you screen or not,” she says. “For instance, young women are more likely to have the kind of cancer that is aggressive and fast-growing and crops up between screenings.” (In other words, these tumors often grow so quickly that a woman would be able to notice one on her own before her next mammo rolled around.) “So its extremely important not only to know your risk factors but to know your own breasts,” Dr. Esserman says, pointing out that 50 percent of all cancers are found by women themselves.
Thats why, even though she and other experts (including the ACS) say that you dont need to perform lengthy breast self-exams, Dr. Esserman does advocate regular quickie self-exams, in which you raise your arm above your head and feel carefully but quickly along the length and breadth of each breast. “Its important to be familiar with what your breast tissue feels like so youll recognize a change and to see a doctor if you feel something different,” she says. “I do themI just feel myself up all the time.” (The ACS also recommends developing “breast awareness.”)
The truth is, little of what she has said about mammograms or screening is news to her colleagues in the breast cancer community. “I work with 60 people who know everything that Laura Esserman knows,” says Steven Come, MD, director of the breast medical oncology program at Beth Israel Deaconess Medical Center in Boston. But, he says, Dr. Esserman is gifted at taking the next step: “Theres a difference between knowing the issues and going out and doing something about them.”
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Doing less, not moreFour floors below Dr. Essermans office, several women are sitting in the waiting room of the UCSFs Carol Franc Buck Breast Care Center. A young woman with a bandana covering her bald head has a quiet conversation with the receptionist, then takes a seat with an older woman who can only be her mother, the two look so similar. Above their heads hangs a red hand-stitched quilt with squares that feature single words: hope, faith, laughter. The mood is calm, hopeful, friendlya first impression that extends beyond the waiting area. Dr. Esserman, who is director of the center, encourages the sharing of information among the specialists who work in different treatment realms, from diagnosis to reconstructionan approach she believes improves outcomes and makes the grueling ordeal of surgery, chemotherapy, and radiation a little less stressful for patients.
Getty ImagesMost importantly, she believes in being straight with her patients. Betsy Imholz, 60, an attorney in San Francisco and a patient at the UCSF, says Dr. Essermans approach was markedly different from that of her former doctor. “When my annual mammogram found a cluster of irregular cells, the radiologist told me I needed a biopsy,” she says. “But when I started asking her questions like ‘Why do you think I need a biopsy? and ‘What do you really think this is? she seemed impatient.” A friend referred her to Dr. Esserman, who talked to her for half an hour. (Dr. Esserman often spends an hour-and-a-half or more with someone who has just received a diagnosis.)
“She was very frank with me,” Imholz recalls. “She looked me in the eye and listened carefully. She told me, ‘We dont know everything about these types of findings, so theres no one right answer. You have choices. You can get a biopsy or you can come back in six months and well do another mammogram.” Imholz didnt want a biopsy, which comes with its own set of issuesanxiety, potential scarring, time, expense. So she chose to wait. That was two years ago, and the cluster has actually shrunk since it was discovereda positive outcome that would happen more often, Dr. Esserman believes, if doctors were willing to simply monitor certain spots instead of immediately doing a biopsy.
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Anita Kunz“I want to help more doctors feel comfortable with doing less intervention,” she says. “If patients are very risk-averse and waiting six months to find out if a suspicious spot is dangerous would make them crazy, then you do the biopsy. But if we take a watch-and-wait approach to more patients who have low-risk findings on their mammograms, we can probably do a third fewer biopsies.” Some things found on mammograms arent cancers at all, like calcifications that at the worst might be low-grade DCIS (ductal carcinoma in situ, an abnormal growth in the milk ducts), Dr. Esserman says. “We shouldnt even call DCIS cancer, because that word is so scary, and its really not an accurate description of whats going on,” she says. Screening can also turn up relatively nonthreatening cancers that she calls “IDLE tumors” (for Indolent Lesions of Epithelial Origin)low-risk lesions that arent likely to progress into anything serious. “The goal is to be able to personalize choices, explain the options, and let women decide how much intervention theyre comfortable with,” she says.
The idea of doing less runs counter to the time-honored approach to cancer care in the United States, which has long been characterized by one word: more. More mammograms, more MRIs, more biopsies. But Dr. Esserman and the USPSTF arent the only ones saying its time to acknowledge that more isnt always better. In fact, Hope S. Rugo, MD, an oncologist who works closely with Dr. Esserman and is director of Breast Oncology and Clinical Trials Education at the UCSF Helen Diller Family Comprehensive Cancer Center, points out that countries in which mammography screening starts later dont have an appreciable increase in mortality in women in their 40s.
The difficulty is getting doctors to act on this knowledge. “The new mammogram guidelines are reasonable given the data on which they are based, and most doctors agree that overtreatment is an issue,” Dr. Come says. But, he adds, “very few women or their physicians are willing to take a watch-and-wait approach to a suspicious mammogram finding until we have bomb-proof criteria to tell us whats harmless and what isntand were not there yet.”
The kind of thinking Dr. Come describes rankles Dr. Esserman. She says, “If doctors had been too afraid to try to ratchet back treatment wed still be doing radical mastectomies”brutal surgeries involving the removal of not only the breasts, but the underlying chest muscles and all the lymph nodes in the armpit, which were standard treatment for breast cancer until the mid-1970s. “Sometimes you need to be bold enough to try something new. If other people arent, thats fine. Our group is.”
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Getty ImagesLooking aheadDr. Esserman says that the key is to better personalize all aspects of breast cancer care, including screening. “I think well find that its a good thing to screen fewer women in their 40s,” she notes. “What keeps me up at night is not that were going to miss cancers by doing fewer mammograms. Its trying to figure out how I can make our whole approach to breast cancer, from screening to treatment, safer and more effective.” Indeed, even as she was opening herself up to criticism over the mammography issue“knowingly and willingly, because I felt it was important to finally talk about it,” she points outshe had projects underway that she hopes will help improve the way we screen for, treat, and prevent this disease.
One is a large-scale research collaboration among the five University of California medical centers, called the ATHENA Breast Health Network. The universities are recruiting more than 150,000 women across the state who will be screened for breast cancer and followed for decades. Dr. Esserman and her colleagues will collect detailed medical and lifestyle data on participants, with the hope that the trove of information will help provide insights into who gets breast cancer and whyin the same way the long-term Framingham Heart Study has led to the identification of major risk factors for heart disease and strokeand in turn help make screening guidelines more specific by identifying additional risk factors. The collaborators hope the information will also help doctors tailor prevention and treatment strategies for women at risk of different types of breast cancer.
Another trial, I-SPY 2, launched in March, will involve about 800 women with high-risk, fast-growing breast cancersthose that crop up between screenings and can be deadly even if theyre detected early by mammograms. “These are womenoften in their 30s and 40swho can be difficult to treat because their cancers are so aggressive,” Dr. Esserman says. The trial will match promising new drugs in the development pipeline with patients who have tumors with specific molecular biomarkers. Why is this a big deal? Current drug development is a slow, expensive process. It can cost up to $1 billion and take 15 to 20 years to bring a new breast cancer drug to the market. “With this trial, were going to be much more nimble,” Dr. Esserman says. “Well learn within months instead of years which drugs show promise for which types of tumors. My patients dont have years to wait for new treatments. They need them now.”
Anna D. Barker, PhD, who recently retired as deputy director of the National Cancer Institute, worked closely with Dr. Esserman in setting up the study and says she has just the right set of scientific, social, and business skills to bring together the disparate groups that are involvedcancer-research centers, the U.S. Food and Drug Administration, the National Cancer Institute, and pharmaceutical companiesand convince them that theyll all benefit by working together. But, she adds, “Laura is opinionated and an advocate of change, which is good news for some people and not for others.”
Thats the nature of anyone whos willing to be controversial, Dr. Rugo says. “Not everyone will like you and support what youre doing. Part of the challenge of being successful is facing opposition and forging ahead.”
Yet Dr. Esserman has earned respect even from those who disagree with her opinions. “She is a highly respected physician who has been forthright in her opinions,” says the ACSs Dr. Lichtenfeld. “Ive worked with her before, and Id be honored to work with her again.”
For her part, Dr. Esserman mostly takes both praise and criticism in stride. “We cant lose courage. If we get intimidated or rest on our laurels and say this is the best we can do, then we will always have women dying of breast cancer. The only way were going to make progress with this disease is to keep moving forward, regardless of whether everyone agrees or not. ”
For more on the changes in breast cancer screening guidelines, go to Health.com/mammo-mess and Health.com/breast-questions. And check out our complete breast cancer coverage at Health.com/breast-cancer.