I got a call from Kaiser Permanente several days ago informing me that I was due for my yearly mammogram. That call came the day before I saw the headline in the NY Times telling me that having a test every other year is now the recommendation from the U.S. Preventive Services Task Force for a woman my age. Besides, they say, nevermind the breast self-exam, or even the exam by my primary care physician. None of this is going to save my life. Statistically, anyway. And besides, more frequent exams may lead me to extreme anxiety when a lump is found that turns out to be benign (which has happened 2 or 3 times already), and I may be subjected to unnecessary treatment for an early-stage cancer which might have gone away on its own--unnecessary treatment being more tests, and perhaps radiation and/or chemotherapy, and even surgery. Whoa! What should a woman do?
Robert Aronowitz gives a fascinating history of the treatment of breast cancer in his article "Addicted to Mammograms" (NY Times, 11/20/09). Aronowitz tells us that in the 19th century, doctors had cottoned onto the germ theory, conquering diseases like cholera, but were frustrated in their attempts to cure cancer. Cancer had been considered a systemic illness, running throughout the body, and so why operate on a specific tumor.
In the 1870's doctors began to believe that cancer begins locally and remains local for some time before spreading (what we now call metastasis). Concurrently, anesthesia was being developed, and so doctors were encouraged to operate--in the case of breast cancer, to remove the breast of the patient. By the turn of the century, William Halsted of Johns Hopkins was promoting an approach that included the removal of the breast as well as the lymph nodes in the armpit and the muscles attached to the breast and chest wall. This approach soon became medical dogma--even though Halsted's own clinical observations indicated that the operation did not save lives: he became aware that patients died of metastatic cancer.
Early in the second decade of the 20th century, doctors began advising women to see their doctors "without delay" if they discovered a breast lump. The message was that if you discovered the cancer in time, surgery could provide a cure. This claim was, unfortunately, based on wishful thinking and not hard scientific evidence--and resulted in the creation of what Aronowitz calls "a culture of fear" around breast cancer, as women understandably tried to gain more and more control over cancer, believing that surveillance and early detection and treatment would save lives. During the 1930's and '40's more and more cancer was being diagnosed and treated, much of it in the early stages, and cancer survival rates seemed to support the early detection theory.
However, by the 1950's some researchers were pointing out that despite the seeming progress, mortality rates for breast cancer had hardly improved. And they continued in the same vein from 1950 to 1990, with about 28 cancer deaths per 100,000 people. In 1971, evidence showed that mammograms were of little value to women under 50--but this news collided with the prevailing practice, and so it was ignored.
As with all medical decisions, there are trade-offs--some are clearer than others. To prevent one death from breast cancer, you have to screen 1,900 women in their 40's for 10 years. During the screening you will find more than 1,000 false-positives, and these women will have to endure all the resulting overtreatment.
Not to mention the financial piece--and to be sure, cost will be considered by the government and by insurers. Medical diagnosis and treatment is limited in every country and every culture--because resources are finite. Every society has to decide where to best place those resources. Some citizens are afraid that medical care will be "rationed" under the new health care plan Congress is now considering. It is being rationed already, in favor of those who have money. It should be rationed on a more logical and scientific and just basis.
But this begs the question: so should I have my mammogram? I'll probably discuss this with my doctor, who is a wise man. My mother died of breast cancer, and her sister died of cancer, too. In fact, all my 6 aunts and uncles on my father's side died of cancer, too. Does this make me "high risk"? Like all women, I've been socialized to be frightened of my body--it's too fat, it's not the right shape, it's sure to become "diseased" if I don't worry about it every moment. What's the balance between prudence and pathological concern? Like many women, I just don't know.
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