Worried Sick: How Vulnerable Are You Really to Heart Attack, Stroke or Breast Cancer?

By Maggie Mahar, Health Beat. Posted November 27, 2008.

"This is the best-case scenario for screening postmenopausal women," Hadler explains. One out of 250 will be saved, and two out of 250 will be exposed to the risk and worry of treatment without deriving any benefit. Hadler sums up the findings: "Early detection [via a mammogram] makes less sense the older the woman, or the more morbidities [potentially fatal diseases] that she suffers. In such a circumstance, breast cancer is but one of the processes vying for the proximate cause of death and not the most likely to win." 

Moreover, there is no "best-case scenario" for screening younger woman, unless they have a family history of early death from breast cancer. This, Hadler notes,  is why "the American College of Physicians  believes that the risks of unnecessary biopsies far outweighs the likelihood of saving a life, and therefore does not recommend mammography before age 50 and suggests that women do not need to be screened after age 74. Similarly, the U.S. Preventive Services Task Force recommends mammography screening only every one to two years for women age 50-69.

Precancers

Too often, Hadler warns, mammograms discover ductal carcinoma in situ (DCIS); "in situ" suggests that there is no discernible evidence that the cancer is spreading. By the 1970s, physicians were finding more and more cases of DCIS.

"It's about this time that the notion of a ‘precancer' really took hold," Hadler observes. "Powerful surgeons writing in powerful journals were advocating mastectomy to expunge the risk, whatever its magnitude."  DCIS can become invasive, he acknowledges, "but low-grade, tiny DCIS lesions take their time to become invasive, even more time to become metastatic." 

"It is defensible to excise DCIS if it is discovered in a younger patient," he says. "That's not the issue. The issues are what are the yield and iatrogenicity [danger of inadvertently harming the patient] when trying [so] hard to discover DCIS in the first place?"

Today, "we are witnessing an epidemic of DCIS," says Hadler. "In 1980, DCIS accounted for only 2 percent of breast cancers. Between 1973 and 1992, the age-adjusted incidence rate of DCIS increased nearly sixfold. Meanwhile, the age-adjusted rise in the incidence of invasive ductal cancer was only 34 percent. Women are not getting more cancers. Rather, U.S. women are getting more breast biopsies thanks to mammography."  And once diagnosed, "local excision is always recommended, often with some radiation therapy, chemotherapy or surgical exploration of the nodules." And local excision can be extensive, to assure "clean margins." Often, women then opt for painful, expensive breast reconstruction.

How many of these women would have been better off if they had never known about the lesion? As Hadler points out, older women in particular, are likely to die of something else before this type of  cancer becomes invasive.

Nevertheless,  Americans have been sold on the idea that early detection is always best. Hadler says:  "the public-awareness program for cancer has been far more successful in promoting enthusiasm than reason." Research shows that "Americans are willing to undergo screening without regard to the efficacy of the tests or the likelihood that they will lead to unnecessary treatment."

Hadler and Popper

Who is Nortin Hadler, and why he is saying these terrible things about screening and early detection? Hadler is a scientist and a physician. He started his career as a geneticist, moved on to study immunochemistry, and spent his first decade on faculty as a physical biochemistry professor.  Today, he is  a professor of medicine and an attending rheumatologist at UNC hospitals.  He has closed his laboratory, but he retains "a keen appreciation for the scientific method at its most rigorous."

See more stories tagged with: health, risk, breast cancer, stroke, heart attack

Maggie Mahar is a fellow at the Century Foundation and the author of Money-Driven Medicine: The Real Reason Health Care Costs So Much (Harper/Collins 2006).

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