Stephanie Hall believes the mammogram that found a pea-sized lump in her right breast may have saved her life. She had a lumpectomy, followed by three months of radiation therapy. Eleven years later, the Palm Harbor woman is a staunch advocate of the screening test.
But what would have happened if she never found out about the lump?
Maybe nothing at all, says a growing chorus of medical experts.
More attention than ever is being paid to the limits of mammography and other cancer screening technology. As the national health care debate rages, researchers and cancer advocates are hotly contesting whether women are told about the downside of testing to find early-stage breast cancer.
To be clear, leading authorities still urge women to get mammograms, which are shown to decrease the risk of death from breast cancer.
But at a cost: To prolong the life of one woman, more than 1,000 are screened, some researchers say. Some will be treated for tumors that, while cancerous, would never have become life-threatening. Other women will suffer the trauma of a false alarm.
The trouble is that while mammograms can find lumps, they cannot predict which early cancers will become killers.
Even the American Cancer Society, which stands by its recommendation that women get mammograms every year after age 40, acknowledges the limits.
"It's not a perfect test. It does have imperfections and it does have some problems associated with them, but when you look at the total picture of evidence for mammograms, it is our opinion that those benefits outweigh the risks," said Dr. Len Lichtenfeld, its deputy chief medical officer.
Then why does the American Cancer Society promote a simplified public message on mammography?
"The science behind the message is always much more complex than the message itself,'' he said.
But understanding that complexity, researchers say, can help women be informed medical consumers, better equipped to make the screening decision and to face their options when a mammogram finds a lump.
Screening carries risks
Because mammograms can find tumors so early, they can prompt doctors to treat tumors that would never cause symptoms or death. Often unable to differentiate between the lethal and the harmless breast tumors, doctors are compelled to treat them all.
Although screening has caught more early cancers, it hasn't made as much of a dent in late-stage cancers. Some of the most aggressive cancers grow so quickly, routine mammograms wouldn't catch them in time.
"There are a whole cascade of harms that come from diagnosing cancers that didn't need to be diagnosed," said Dr. Barnett Kramer, associate director for disease prevention at the National Institutes of Health.
Chemotherapy can harm the heart. Radiation is a known carcinogen. A cancer diagnosis can be prohibitively expensive, even for those with insurance. Women may lose their jobs (and if they lose their insurance, have serious trouble finding new coverage) and suffer serious depression.
An international review found that mammography screening leads to a 15 percent reduction in breast cancer deaths. But in raw numbers, this means that if 2,000 women are screened regularly for 10 years, one will avoid dying from breast cancer.
Another 10 women, who would never have been diagnosed without the screening, will be treated unnecessarily for a cancer that, if science had better ways of evaluating early cancerous changes, could be left alone. These women will have at least part of their breast removed and may also receive radiation or chemotherapy. Another 200 women in the group will have a false alarm — and potentially a surgical biopsy, with its attendant risks.
Those figures, based on a review of seven clinical trials on mammography involving 600,000 women, come from the highly regarded Cochrane Collaboration. Experts still are debating the numbers, but the Denmark-based author of the review believes they should be part of the discussion.
"Women have been denied the truth for so long," Dr. Peter Gotzsche said in an e-mail.
Death rates reduced
Particularly controversial is the value of mammograms for women ages 40 to 50, when the probability of breast cancer is low and false positives are more likely.
Robert Kaplan, a professor of public health and medicine at the University of California, Los Angeles, believes women should know it's reasonable to seek screening — and also not to get screened. "What I promote is shared medical decisionmaking. We lay out the information as clearly as we can."
He advises women to educate themselves and talk to their doctors. The American Cancer Society also encourages women to ask questions, but worries about the long-term effects of fewer mammograms.
"With all the shortcomings, mammography has been successful in reducing death rates from breast cancer," Lichtenfeld said. "To say that it's ineffective, I think, does a disservice."
Since her treatment, Hall, 68, has had a mammogram every year. No one ever talked to her about the risks associated with screening, but she feels lucky her cancer was found early.
"If I thought that I had cancer growing inside of me, I would want to have it excised," Hall said. "I would not want to have it hanging over my head and potentially flaring up one day."
Letitia Stein can be reached at firstname.lastname@example.org or (813) 226-3322. For more health news, visit www.tampabay.com/health.