The Wisdom of Menopause
Page 65
The argument isn’t just over whether or not annual mammograms are cost efficient or even whether they save lives. The debate is also bringing to light the fact that routine annual screening may actually cause harm. First of all, the procedure itself isn’t always benign. A 1994 study in the Lancet showed that the breast compression required by mammograms may cause small, in-situ tumors to rupture, spreading cancer cells into surrounding tissues and possibly resulting in more invasive cancers and metastases.70
But the most frequent harm done by routine screening involves the incidence of false positives (saying that there’s something abnormal when there isn’t), which occur in about 10 percent of mammograms. And this risk increases over time. In 2000, the Journal of the National Cancer Institute pointed out that the cumulative risk of having false positive mammograms is quite significant in many women. By the ninth mammogram, the study reported, the false positive risk can be as high as 100 percent in women with multiple high-risk factors.71 Another study estimated that after ten mammograms, about half all women (49 percent) will have had a false positive result, which will have led to a needle biopsy or an open biopsy in 19 percent.72
In two reviews published in the Lancet, Danish researchers Ole Olsen and Peter Gotzsche examined seven randomized, controlled mammography studies and found that the screening tool not only didn’t save lives but also often led to needless treatments and were linked to a 20 percent increase in mastectomies—many of them unnecessary.73
A 2000 study from the Journal of the National Cancer Institute followed nearly 40,000 Canadian women between the ages of fifty and fifty-nine, concluding that annual mammograms were no more effective than standard breast exams in reducing breast cancer mortality. (We now know that routine breast exams don’t save lives, either.) Mammography didn’t increase the survival rate of those who were diagnosed with breast cancer.74 And still another study published in the Journal of the American Medical Association found that women age seventy and older benefited very little from mammography.75 The cancers detected at this age would never have killed them.
MRIS AND BREAST CANCER DETECTION
Magnetic resonance imaging (MRIs) are becoming increasingly popular methods of breast cancer detection, and at least 27 percent of women diagnosed with breast cancer opt for pretreatment MRIs to gather information for deciding what treatment they want to pursue. But research suggests that these MRIs may do more harm than good. A 2009 study from the prestigious Fox Chase Cancer Research Center in Philadelphia found women diagnosed with breast cancer who got MRIs delayed their treatment by an average of three weeks and increased their rate of mastectomy by 80 percent (thanks to the high rate of false positives with MRIs), although the pathology reports done after the mastectomies indicated that many of these women would have been good candidates for lumpectomy.76
THE PROMISE OF THERMOGRAPHY
Thermography (infrared imaging) is a noninvasive, safe technology that records the amount of heat emanating from breast (or other) tissue, thus detecting inflammation long before the appearance of a tumor. This technology certainly isn’t new. It dates back to World War II, when U.S. planes used it to identify active enemy missile silos. Its first medical application was in the 1950s, more than a decade before the introduction of mammography.
According to thermography expert Philip Getson, D.O., when used as part of a comprehensive multifaceted approach, thermography can lead to early detection of 95 percent of early-stage cancers, which increases the long-term survival rate by as much as 60 percent. He adds that when it’s done properly, thermography has an average sensitivity and specificity of 90 percent, meaning that 90 percent of the time, scans do not indicate problems that don’t really exist nor do they fail to indicate a problem when one really does exist. Some studies show an even better track record. For example, a 2003 study of 769 women who had suspicious mammograms followed by thermograms showed that the thermograms were 97 percent correct in detecting breast cancer.77
Dr. Getson, an associate professor of medicine at Drexel University College of Medicine in Philadelphia, has been a medical thermographer since 1982, the year the FDA approved thermography as an adjunctive breast-cancer screening test. Certified by four thermographic boards, he lectures extensively on thermography and has interpreted more than 10,000 images. I asked him to share his thoughts on the benefits of thermography, and here is what he had to say:
Thermography detects the physiologic changes in the breast tissue that have been shown to correlate with cancerous or precancerous states. It is widely acknowledged that cancers, even in their earliest stages, need nutrients to maintain or accelerate their growth. In order to facilitate this process, blood vessels remain open, inactive blood vessels are activated, and new blood vessels are formed (a process known as neoangiogenesis). This vascular process causes an increase in surface temperature in the affected regions, which can be viewed with infrared imaging cameras. Additionally, the newly formed or activated blood vessels have a distinct appearance that thermography can detect.
Since thermal imaging detects changes at the cellular level, studies suggest that this test can detect activity eight to ten years before any other test.78 This makes it unique in that it affords us the opportunity to view changes before the actual formation of the tumor. Studies have shown that by the time a tumor has grown to sufficient size to be detectable by physical examination or mammography, it has in fact been growing for about seven years, achieving more than twenty-five doublings of the malignant cell colony. (At ninety days, there are two cells; at one year, there are 16 cells; at five years, there are 1,048,576 cells, which is still undetectable by a mammogram; at eight years, almost 4 billion cells.)
Thermography is unaffected by breast density, implants, or scars from surgery. It allows for the avoidance of potentially harmful radiation, a known carcinogen. Radiation from routine mammograms poses significant cumulative risk of initiating and promoting breast cancer. In fact, a mammogram results in a thousandfold greater radiation exposure than a chest X-ray. Additionally, each rad (radiation absorbed dose) of exposure increases breast cancer risk by 1 percent annually, an extremely worrisome statistic for premenopausal women whose breasts are more sensitive to radiation. Premenopausal women who get annual mammograms for ten years are exposed to a total of ten rads for each breast. Over a thirty-year time frame (from ages forty to seventy, for example), that amounts to a cumulative dosage of 30 rads of radiation per breast. By comparison, Nagasaki atomic bomb survivors absorbed an average of 32 rads of radiation.
Breast thermography is a noncontact test. Conversely, mammography involves placing the breast between two plates and subjecting the breast to painful compression. The recommended force to be used for the compression of breast tissue in a mammogram is three hundred newtons, the equivalent of placing a fifty-pound weight on the breast.
All of this information became even more important on November 16, 2009, when the U.S. Preventive Services Task Force Breast Cancer Screening Recommendations for the General Population was released, changing a long-standing position regarding mammography. Prior to that, in April of 2007, the American College of Physicians issued new guidelines that urged women in their forties to consult with their doctors about whether to have a mammogram. These guidelines were then quickly endorsed by the U.S. Preventive Services Task Force, which issues the federal government’s official recommendations on preventive medicine.
According to the 1998 Merck Manual, for every case of breast cancer diagnosed each year, five to ten women will needlessly undergo a painful breast biopsy. Therefore, statistically, each woman who undergoes annual screening mammograms for ten years has at least a 50 percent chance of undergoing a breast biopsy.
Compare that to breast thermography, which has been researched for more than forty years with a database of more than a quarter of a million women. There are more than 800 peerreviewed thermographic studies. This research has concluded that a persistently abnormal thermogram is consistent with a twen
ty-two-fold increase in the risk of developing breast cancer. An abnormal thermogram is ten times more significant as a future risk indicator for breast cancer than a first-order family history of the disease. An abnormal infrared image is the single most important marker of high risk for developing breast cancer.79 Because of the safety inherent in the test, thermography can be performed on an individual of any age, including those who are pregnant or breast-feeding.
It is true that not all thermographic equipment is the same, nor is every center backed by qualified, board-certified physicians who are specifically trained in the interpretation of these images. Women (and men) seeking to have infrared imaging should ask the following questions:
1. What is the “drift factor” in the apparatus? Anything over 0.2 degrees Centigrade leads to poor reproducibility.
2. What are the credentials of the interpreting physician?
3. Is the room in which the study is performed free of outside light and the temperature always kept at 68–72° F with a proper cooling system in place?
4. Are the images marked up for future comparison?
5. Are the studies read on site or sent by email to a distant interpreter?
6. Is the physician available to explain and discuss all findings?
In my opinion thermography is the best screening method currently available. Although it is not a diagnostic procedure, one of its great strengths is that it allows a woman and her health care practitioner to be proactive about breast health. Because thermograms show subtle changes that occur long before the formation of a tumor, a woman whose scan indicates inflammation can take several steps to decrease the inflammation before returning for a follow-up thermogram to determine if she has been successful. Only when the thermographer deems a scan to be highly abnormal and suspects cancer would a patient need to follow up with a mammogram to confirm the diagnosis. Further, a woman diagnosed with DCIS can use a thermogram (in conjunction with advice from her health care providers) to help decide if her treatment should be aggressive or conservative. Thermograms are also better than mammograms for telling the difference between harmless fibrocystic masses and more suspicious lumps.80
Thermography can be used on any area of the body—not just the breasts—to identify and track inflammation and to improve overall health. While it is not usually covered by insurance (and can cost anywhere from $90 to $250 for a scan), this has more to do with politics and economics than science. (To find a practitioner in your area who does thermography, visit www.breastthermography.com; www.breastthermography.org; or the websites for the International Academy of Clinical Thermology, www.iact-org.org, or for the American College of Clinical Thermology, www.thermologyonline.org.)
My Breast-Screening Suggestions
~ TRANSFORM THE REGULAR BREAST SELF-EXAM (BSE). For decades, women have been encouraged to examine their breasts regularly as a way to find breast cancer at the earliest possible stage, get it treated early, and thus save their lives. This has led to a “search-and-destroy” approach to breast exams that encourages you to make your hands into mine sweepers in search of something that may kill you. No wonder so many women skip this routine but end up feeling guilty as a result. As the late Francis Moore, M.D., of Harvard Medical School wrote, “What man would enjoy lowering his trousers in front of a mirror once a month and examining his testicles carefully, by rigorous palpation, looking for testicular tumors?”81 Still, no one seriously questioned the advisability of doing regular BSEs until 2002, when the results of a large randomized trial of BSE were released, showing that the practice didn’t change breast cancer mortality.
The study involved over 260,000 women in Shanghai, who were divided into two groups and followed for five years. Half the group was trained in BSE and had that training reinforced at the workplace, while the other half, the control group, had no training in BSE nor were they encouraged to perform BSE of any kind. At the end of five years, the study found that those women in the BSE group found more benign breast lumps than the control group, but their breast cancer mortality was not reduced at all. The death rate from breast cancer was the same in both groups. The study authors concluded that “women who choose to practice BSE should be informed that its efficacy is unproven and that it may increase their chances of having a benign breast biopsy.”82 A smaller but still substantial 1999 study done in Russia followed 57,712 women who did BSE and another 64,749 in a control group, reporting similar results.83
In November 2009, the tide turned for good when new breast cancer screening guidelines from the United States Preventive Services Task Force (an influential government-appointed group giving guidance to doctors, insurance companies, and policy makers) recommended that doctors no longer teach this practice.84 The American Cancer Society, the Canadian Cancer Society, the Canadian Task Force on Preventive Health Care, the World Health Organization, the U.S. Preventive Services Task Force, and the U.K. National Health Services all no longer recommend routine BSE. The one holdout is the American College of Obstetricians and Gynecologists, which continues to recommend BSE in its breast cancer screening guidelines.
But even if you don’t perform monthly BSEs (and I, for one, don’t recommend them), that doesn’t mean that you shouldn’t get to know your breasts. It simply means that a paradigm shift is called for. When a woman attends to her breasts with loving care and a loving consciousness on a regular basis, it is entirely possible that she will be influencing her breast cells in a positive, health-enhancing way. That’s why I recommend a monthly breast self-massage as a healthy and viable alternative to the outmoded BSE. (Do not do this if you have been recently diagnosed with breast cancer, because it may increase tumor spread; it’s fine once treatment is finished.) Many women never touch their breasts with love or tenderness, having been led to believe that their breasts are the property of their mates and not really part of their own bodies. Invite your breasts into your life by getting to know them and touching them regularly. Then your regular breast self-exam becomes an opportunity for healing. Breast massage activates lymph drainage, increases blood flow, and oxygenates tissue—all good ways to help create breast health. After all, for millions of years of human evolution, women nursed babies for most of their reproductive years, a process that provides a great deal of breast stimulation. This massage can also be done by your partner in a nonsexual, supportive way.
FIGURE 18: THE LYMPH SYSTEM
Here’s a technique developed by Dana Wyrick, who practices lymphedema therapy at Mesa Physical Therapy/San Diego Virtual Lymphedema Clinic in San Diego, California.85
Self-Massage of Chest and Breast
I recommend doing this massage in the most pleasurable environment possible—for example, in a rosewater-scented bath with your favorite music playing. Do each side of your chest independently. Instructions below are for the left side; simply reverse “hand” instruction to do your right side. Use a light touch. Your object is to move the skin, not to massage the muscles. The following routine, when done properly, will assist the lymphatic capillaries in removing toxins and impurities from the body tissue. The stroking will also accelerate transport of impurities to the lymph nodes, where they will be processed and rendered harmless. Finally, cleansed lymph will be returned to the bloodstream, where the now-harmless impurities may be carried to the lungs, kidneys, and colon for elimination.
1. With the first three fingers of your right hand, locate the hollow above your left collarbone. Stroking from your shoulders toward your neck, lightly stretch the skin in the hollow. Repeat this movement five to ten times.
2. Now cover the hairy part of your left armpit with the fingers of your right hand held very flat. Stretch the skin of your armpit upward five to ten times.
3. Next, again using a flat right hand, lightly stroke (“pet”) the skin from the breastbone to the armpit. Do this above the breast, over the breast, and below the breast, repeating each path five to ten times.
4. Finally, using a flat right hand, lightly stroke from your wai
st up to your armpit on your left side, repeating five to ten times.
Now change hands and massage the right side of your chest.
~ MAMMOGRAMS FOR WOMEN FIFTY TO SEVENTY-FOUR. The new United States Preventive Services Task Force guidelines released in 2009 recommend that most women start regular mammograms at age fifty instead of forty, as previously recommended.86 The guidelines further suggest that women between ages fifty and seventy-four have mammograms only every other year. Ideally, mammograms should be done at a multidisciplinary breast center, where your film can be read immediately and where you can also get additional diagnostic procedures or treatment if necessary. Most major medical centers now have these centers. However, I continue to be concerned about the cumulative effect of yearly radiation on breast tissue health. (By the way, the guidelines do not recommend routine screening for women older than seventy-four because the risks and benefits remain unknown.)
The task force cited evidence that women in their forties are less likely to have breast cancer but nonetheless have a 60 percent greater chance of getting a false-positive result from a mammogram because of denser breast tissue, making the risks of routine monograms for this group outweigh the benefits (a 15 percent reduction in breast cancer mortality).87 The denser breast tissue is perfectly normal, although it often makes mammograms difficult to read and interpret because the X-rays can’t penetrate it. About fifty out of a thousand women with dense breasts will require further diagnostic procedures, such as additional mammograms, sonograms, and even biopsies, to determine whether or not they have breast cancer. Of these, it is estimated that only two will have breast cancer.88 The others will often go through a great deal of anxiety, which could be avoided if we were to use functional technologies such as thermography. Breast surgeon Dixie Mills, M.D., says, “I often recommend a woman get a baseline mammogram and see how dense her tissue is (a factor that cannot be determined by feel) and add this information into her choice of manner of screening. Women should not be made to feel that they are to blame for their breasts being dense; it is a factor of mammogram pictures being limited to shades of black and gray and white on a flat photo.” (In older women this dense tissue is often replaced with fat, making mammograms more accurate.)