Thursday, November 19, 2009

New mammogram testing recommendations: an opportunity to cure precancer

In Yesterday's blog, I began a discussion of the new recommendation for mammographic breast cancer screening, announced by the United States Preventive Services Task Force (November 16).

The task force recommended that routine mammography screening begin at age 40, not age 50 (the previous recommendation).

The reason for the new recommendation relates to the low number of positive (malignant) cases in the 40-50 year age group and the high number of false-positives (nodules that are not invasive cancer) in the same age group.

I've been listening to a lot of discussion on TV and radio, and was surprised by the overwhelming (and strong) rejection of the new recommendation. Basically, it was just like any political issue: opponents rallying to reject the offered report, finding nothing of value and much to be reviled.

It seems to me that we stand to learn a lot from the task force's work, even if we don't follow their recommendation to the letter.

The problem with mammographic testing in young persons is that the test picks up small lesions that may be early invasive cancers, or they may be precancers (lesions that are not yet invasive cancers and that pose no immediate medical threat), or they may be lesions that mimic cancers but are actually benign disorders that have no medical consequence. When you look at younger and younger age groups (age groups not likely to have many invasive cancers), you pick up a disproportionate number of precancers and non-cancerous nodules.

The problem has been that these non-invasive lesions have been worked up by oncologists and surgeons with an array of surgical, diagnostic, and treatment interventions that have wasted money and caused great emotional distress in women who have not greatly benefited from the process.

Rather than drop testing, there are a number of options we could take, as a society, that might be better than the current way of doing things.

Radiologists could get together and develop diagnostic criteria for nodules that don't quite meet the criteria for malignancy. Radiologists and clinicians could then come up with recommendations for these nodules (e.g., repeat mammographic examination in 6 months, or 1 year, or whatever). Basically, the diagnosis and the recommended action would spare women from the mental, physical and economic consequences of an immediate cancer work-up.

Alternatively, the diagnosis of a "questionable" lesion could be used to qualify patients for inclusion in clinical trials for the treatment of precancers. Precancers are the non-invasive lesions that precede the development of invasive cancers. Precancers can be treated much more easily than cancers (this is the message developed in my recently published book, Precancer: The Beginning and the End of Cancer)Women with mammographic lesions consistent with precancer could be treated with experimental precancer treatments. If these treatments were found to be effective, we could greatly reduce, maybe eliminate, the breast cancer death rate.

The task force has made some important conclusions, based on their evaluation of the data. It would be a shame if we missed this opportunity to advance breast cancer treatment, simply because we don't like their final recommendation.

- © 2009 Jules J. Berman, Ph.D., M.D.

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About my book, Precancer: The Beginning and the End of Cancer. Nearly every type of cancer passes through a precancer phase, during which it cannot metastasize or invade other tissues. While medicine is not always successful in treating or curing advanced stages of cancers, recent advances in our understanding of carcinogenesis have helped us to develop strategies to prevent, diagnose, and treat many cancers at the precancer stage. Research in this field is escalating rapidly as the evidence increasingly shows that the number of annual cancer deaths could be drastically reduced through the effective treatment and cure of precancer lesions. This book begins by explaining why it has been so difficult to cure cancers, followed by a review of precancer biology, with descriptions of the most common precancer lesions. The final chapters provide practical socio-political and medical goals for precancer treatment, including discussions of the economics and politics of treating precancers.

I urge you to read more about this important topic. Google Books has provided a generous preview of this book.