In my 20 plus years of practice I have never seen such bewildering recommendations released as Canadian guidelines for breast cancer screening. It’s a serious watershed. Curbing costs have trumped saving lives.
We have come to a crossroad. The cost of healthcare has been running away and the payer has created faceless ‘committees’ who just might be deciding who lives and who dies with brutal guidelines on what gets ‘covered’ – aka – paid.
The guidelines, released Monday by the Canadian Task Force on Preventive Health Care, recommend against routine mammography screening for most women age 40 to 49, arguing the “harms and costs of false-positive results, over diagnosis and overtreatment” outweigh any “significant reductions in the relative risk of death from breast cancer”.
The Task Force recommends women 50 to 74 with an average risk of breast cancer should get a mammogram every two to three years. They point to evidence showing that 2100 women need to be screened over 11 years to prevent one death, but one in three of them get false-positives.
How they compiled these results is highly questionable. Dr. Nancy Wadden is chair of the Canadian Association of Radiologist’s Mammography Accreditation Program and medical director of the breast screening program for Newfoundland and Labrador. She says the task force looked at studies that were over 25 years old [involving] equipment that is outdated and not even available anymore. “There’s been enormous changes in breast imaging since that time, [and] in addition, radiologists’ interpretation skills have improved tremendously,” says Dr. Wadden.
So there’s good reason for concern, and Canadians need to think critically about what these new guidelines mean for them. The new guidelines suggest most women in their 40s should not have routine mammograms because they may cause more harm than good because of false positive results (follow up testing proves negative for cancer); results that might lead to unnecessary testing such as the need for follow up ultrasound, MRI or biopsy.
Does the risk of false positive results outweigh the benefit of preventing a small number of deaths from breast cancer?
I can say to you, I don’t want to be the one who died from not getting screened. I’m prepared to do testing which turns out to determine I don’t have cancer. Frankly, I’ll take the fear of false positives over the fear of ignorantly not knowing I have cancer anytime. Early detection can save lives. I’ve always said to my patients: dying some time is a 100% certainty but I’m not going down passively, and I want to do all I can for my patients, too.
Here’s what I advise:
1. Screening should be based on risk factors that can begin even earlier than 40 years of age. It can range for genetic risk, obesity, and drug use e.g. HRT use, to poor lifestyle habits – smoking, high alcohol consumption, and bad dietary habits leading to nutrient deficiencies, e.g. Vitamin D.
2. Do self breast examinations (SBE) – otherwise how else would you know there is a lump of concern between annual check ups? (The Task Force also recommended no SBE).
3. Mammograms may be one imaging modality for breast cancer screening but there are other diagnostic tests that can be done, including ultrasound and MRI breast. Getting more information from various methods reduces the inaccuracy of just one modality. Women with dense or cystic breasts should consider this approach. Depending on what is found will depend if you do screening every 6 months, 1, 2, or 3 years.
4. Consider genetic testing especially if there is a strong family history. This will provide better insight of how to approach the type and frequency of screening.
5. Live a clean lifestyle and be of healthy weight
An estimated 51-hundred Canadian women will die of breast cancer this year. I certainly don’t want to be one of those women.
What you will need to decide in the years to come is if you will be willing to pay for your screening if you fall outside of the guidelines for screening. My answer is yes. It’s already happening. Women who feel they are at risk but don’t ‘qualify’ for OHIP coverage are now paying for their breast MRI for $1000-1500.
The time is now here. The public health system cannot pay for all screening. I understand this reality. It can no longer afford being all things to everyone anymore. It’s now up to you – the health ‘consumer’ to decide what you want to ‘buy’.
Be proactive. Take personal control. It isn’t about money. It is about life – your life – your contributions to society, friends and being there for as long as you can for your loved ones.
GOOD NEWS: Keep your eyes and ears peeled for news on an ALTERNATE and affordable screening method for breast and ovarian cancer – an exclusive first for our health centre. Stay tuned….
Elaine Chin, M.D.
Breast Cancer Screening – who benefits from it -CB online Nov 29-2011
