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Cancer screening debate points to the political power of the breast

Don't mess with the breast. That's the clear message that has emerged from the uproar over a medical panel's recommendation last week that American women don't need as many mammograms as they're getting.

The new mammogram advice has divided doctors, outraged breast cancer survivors and sparked calls for congressional hearings. But the reaction may say less about scientific evidence than about the potent politics of breast cancer awareness.

Breast cancer isn't the biggest killer of American women (that's heart disease), nor is it even their biggest cancer killer (that's lung cancer). Yet breast cancer research received more funding from the National Cancer Institute last year than lung and prostate cancers combined, despite the fact that those two account for more new cancer diagnoses.

But other cancers don't have the pink ribbon campaigns, the fundraising runs and three-day walks, the T-shirts with clever slogans like "save the ta-tas." They don't have a large and vocal lobby of survivors, friends and family who see screening as lifesaving and essential to women's health in general.

Above all, other cancers don't involve a body part that symbolizes beauty, femininity, sexuality and motherhood.

"We want to save the breasts because they can be beautiful and because they nurse the child — and that makes the stakes so much higher," said Dr. Barron Lerner, a professor at Columbia University's medical center who wrote The Breast Cancer Wars: Hope, Fear and the Pursuit of a Cure in Twentieth Century America.

"Everybody would like to have their whole colon, I suppose, and men would like to have their prostate," he said.

"But if you're losing your breast it's highly symbolic. And because the tests have been marketed for so long as saving breasts and saving lives, it's just very jarring to hear that they don't do it."

• • •

The U.S. Preventive Services Task Force is an independent panel of doctors and nurses, appointed by the head of the Agency for Healthcare Research and Quality. Their recommendations are guided by science, not cost. Health and Human Services Secretary Kathleen Sebelius last week tried to distance panelists from the Obama administration by noting the panel was appointed under President George W. Bush.

The group hardly shattered scientific precedent with its recommendation that most women don't need mammograms until they are 50, and can be screened only every other year.

Other prestigious groups, such as the World Health Organization, have similar recommendations. But when another federal panel issued similar guidance a decade ago, the findings were condemned by a unanimous vote of the U.S. Senate.

The St. Petersburg Times asked readers what they thought and heard mostly from women like Janice Henry, who was diagnosed with breast cancer at age 47 through a mammogram. Since the release of the new guidelines, the 14-year survivor has been in contact with many others.

"We have decided that we should be members of the 'I Would Be Dead Club,' " the South Tampa woman said in an e-mail. "We want other women to realize, if you wait until age 50, it might be too late!"

Maggie Neal feels just as strongly. She was 41 when a routine mammogram last year picked up something suspicious. The Tampa woman had a bilateral mastectomy and gets her last round of the cancer drug Herceptin on Christmas Eve.

"I can't shout it off a mountain louder," Neal said. "Mammograms save lives."

Particularly distressing to Barbara Lambert, 68, was the panel's finding that breast self-exams have little value. For it wasn't her annual mammograms that detected her cancer.

The St. Petersburg woman found it July 5 while showering. Diagnosis: Stage 2 invasive ductal carcinoma that had spread to a lymph node. She had a bilateral mastectomy plus chemo.

"I firmly, firmly believe self-exam is almost as good as mammography,'' said Lambert, who thinks a more advanced digital mammogram would have found her cancer.

"Women should understand and know their own breasts. At the first sign of something different, talk to your doctor.''

• • •

Researchers know that some cancers grow so slowly they never cause problems. Others are so aggressive, it's too late to stop them by the time they show up on mammograms.

Still, doctors often can't determine which cancers are the lethal ones, so they must treat the breast cancers they find. Surgery, radiation and chemotherapy come with their own risks, although many women will gladly trade them for the relief of hearing the cancer is out.

The panel responsible for the new mammogram advice looked at numerous studies weighing the risks and benefits of the screening. They found that to save one life, 1,900 women in their 40s must be screened. Among women in their 50s, about 1,300 must be screened to save a life.

To which a woman whose cancer was found might say: so what?

But the medical concern with so much screening is that many more experience false alarms, resulting in untold anxiety, further testing and surgical biopsies, with their attendant risks.

The risks of mammography worry Elizabeth Ponzetti, 75, who has had regular mammograms for almost three decades.

The Safety Harbor woman has no history of breast cancer among her grandmother, mother or sisters, and thinks she'll hold off on more screening.

"I don't think it's good. Not before you're 50," said Ponzetti, who has five daughters. "The yearly is too much. The radiation accumulating is too much."

• • •

The American Cancer Society continues to recommend annual mammograms for women beginning at 40. Key doctors' groups like the American College of Obstetricians and Gynecologist haven't changed their similar guidelines, and it's likely their members haven't, either.

"Personally, I have seen so many breast cancers in women in their late 30s or early 40s, that I still feel very strongly about yearly screening from 40 on,'' said Dr. Jennifer Gilby, a St. Petersburg ob-gyn, in a chat on the Times' health blog this week.

The sentiment is similar among some doctors in training. "I believe that waiting an extra 10 years to start screening is going to cause a lot of anxiety in patients," said Dr. Sarah Eisen, a 27-year-old surgical resident at the University of South Florida, who has worked with patients facing mastectomies.

"That's always the first question, 'Am I going to have to have my breasts cut off,' " said Eisen, who says she'll start mammograms in her 40s.

Lerner, the author of Breast Cancer Wars, is among doctors who think the current controversy is another step in a slow shift in views on mammography.

"Each of these times that the issue comes to the surface more and more people at least have pause and think in their minds, 'Maybe there's a reason that we keep reading these stories every few years and maybe the test isn't that good," he said.

Times staff writer Charlotte Sutton and researcher Shirl Kennedy contributed. Letitia Stein can be reached at lstein@sptimes.com or (813) 226-3322.

On the web

To read a transcript of Dr. Jennifer Gilby's live chat about the new cancer screening guidelines, go to our Personal Best blog at www.blogs.tampabay.com/health



On the Web

To read a transcript of Dr. Jennifer Gilby's live chat about the new cancer screening guidelines, go to our Personal Best blog at blogs.tampabay.com/health.

Cancer screening debate points to the political power of the breast 11/24/09 [Last modified: Tuesday, November 24, 2009 11:19pm]

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