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Cancer Survivor or Victim of Overdiagnosis?
ByH. GILBERT WELCHPublished: November 21, 2012
Hanover, N.H.FOR decades women have been toldthat one of the most important thingsthey can do to protect their health is tohave regularmammograms. But overthe past few years, it’s becomeincreasingly clear that thesescreenings are not all they’re crackedup to be. The latest piece of evidenceappears in a study in Wednesday’sNew England Journal of Medicine,conducted by the oncologist Archie Bleyer and me.The study looks at the big picture, the effect of three decades of mammography screening in the United States. After correcting forunderlying trends and the use of hormone replacement therapy, we found that theintroduction of screening has been associated with about 1.5 million additional womenreceiving a diagnosis of early stage breast cancer.That would be a good thing if it meant that 1.5 million
women had gotten adiagnosis of late-stage breast cancer. Then we could say that screening had advancedthetime of diagnosis and provided the opportunity of reduced mortality for 1.5 million women.But instead, we found that there were only around 0.1 million fewer women with adiagnosis of late-stage breast cancer. This discrepancy means there was a lot of overdiagnosis: more than a million women who were told they had early stagecancer—most of whom underwent surgery,chemotherapy or radiation — for a “cancer” that wasnever going to make them sick. Although it’s impossible to know which women these are,that’s some pretty serious harm.But even more damaging is what these data suggest about the benefit of screening. Ifitdoes not advance the time of diagnosis of late-stage cancer, it won’t reduce mortality. Infact, we found no change in the number of women with life-threatening metastatic breastcancer.The harm of overdiagnosis shouldn’t come as a surprise. Six years ago, a long-termfollow-up of a randomized trial showed that about one-quarter of cancers detected by screening were overdiagnosed. And this study reflected mammograms as used in the1980s. Newer digital mammograms detect a lot more abnormalities, and the estimates of overdiagnosis have risen commensurately: now somewhere between a third and half of screen-detected cancers.The news on the benefits of screening isn’t any better. Some of the original trials from back in the ’80s suggested that mammography reduced breast cancer mortality by as much as25 percent. This figure became the conventional wisdom. In the last two years, however,three investigations in Europe came to a radically different conclusion: mammographyhaseither a limited impact on breast cancer mortality (reducing it by less than 10 percent) ornone at all.
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Cancer Survivor or Victim of Overdiagnosis? - NYTimes.comhttp://www.nytimes.com/2012/11/22/opinion/cancer-survivor-or-victim...1 of 328/05/2013 8:04 p.m.