Once again, we’re seeing the confusion and controversy surrounding breast cancer screening being used as a political tool by those who know little–or care little–about the evidence. Earlier this week, an NPR Morning Edition report ran with the misleading headline, “Congress May Be Forced To Intervene Again On Mammogram Recommendations.” And the headline was only the beginning of an imbalanced story filled with misconceptions, gaps in context, and misunderstanding of the science.
The story, which was from a political reporter (and not a science or healthcare reporter), Juana Summers, discussed the most recent developments this year following the U. S. Preventive Services Task Force (USPSTF)’s 2009 recommendation that routine screening mammograms for average-risk women should begin at age 50, rather than 40 years. As outlined in the recommendations, for those ages 40 to 49, screening mammography has not been shown to decrease mortality due to breast cancer, yet the evidence does show that such screening is associated with a significantly higher number of false positives, with resulting unnecessary biopsies and worry. In addition, what is often lost or not sufficiently stressed in media coverage is that these recommendations do not apply to women with increased risk for breast cancer (e.g., family history, known BRCA1 or BRCA2 mutation, chest radiation). The Task Force’s recommendations were aimed at reducing the very real harms for women at average risk, including unnecessary further tests as described above, as well as preventing overdiagnosis and overtreatment–e.g., the detection of ductal carcinoma in situ (DCIS), sometimes called “stage 0,” which in most cases will never go on to become invasive, resulting in unnecessary aggressive treatment interventions. However, due to no or poor reporting of the science behind these recommendations, the resulting public outcry, and political jockeying, legislation was passed by Congress overriding the Task Force’s recommendations.
As the USPSTF now moves ahead with an update of these guidelines–where a draft released earlier this week shows that the Task Force “essentially repeated its earlier recommendation”–Summers reported that another political firestorm appeared to be on the horizon. And the online article’s headline, “Congress May Be Forced to Intervene Again …” certainly suggests that Congress has “no choice” but to step in again.
Summers’ story began with comments from Debbie Wasserman Schultz, Florida Congresswoman and Chair of the Democratic National Committee (DNC). Though she was diagnosed with breast cancer herself, and although she describes herself as a breast cancer advocate, I would argue that Schultz has a tendency to focus on the emotional, the sensational, and the politically expedient, rather than the evidence when she discusses these issues. Witness the following:
In Summers’ report, Schultz says, “Forty-one – I was – I had just had my first mammogram a few months before I found the lump.” Summers states, “That is Debbie Wasserman Schultz … Diagnosed at 41 years old, she says that if the recommendation had been in place, she may not have gotten a mammogram and her own cancer wouldn’t have been caught early. What’s more, she says the task force is essentially handing women a death sentence.” Schultz then says, “We know that there are women that [sic] will die if this recommendation goes through.”
But didn’t Schultz say that she had had her first mammogram a few months before she found a lump herself? In looking into this further: in a 2013 Glamour Magazine interview with Schultz, she noted: “My diagnosis was a couple of months after a clean mammogram. I had aggressive breast cancer, and it grew fast from the time I had my mammogram, or it was there and the mammogram missed it. Nothing is foolproof. You can’t make yourself crazy, but you have to be vigilant.”
So apparently screening mammography did not detect her breast cancer. Though one anecdote, her own story does not support the case she is trying to make so vociferously.
But I was pleased to see that a subsequent article in NPR Ombudsman by Elizabeth Jensen, entitled “Political Story on Breast Cancer Screenings was Missing Some Science” (though the word “some” is perhaps a bit generous). Jensen explains that Summers’ report drew strong criticism, including from physicians who had serious concerns about the lack of context and no explanation of the evidence behind the Task Force’s recommendations. They felt that a more nuanced discussion of this complex issue is required, where the reasoning behind the recommendations is explained and a careful balance is suggested in weighing potential benefits against possible harms in the context of individual patient needs.
And back to the politics. In writing about the original NPR piece, Gary Schwitzer of HealthNewsReview.org noted that several politicians were quoted, with all showing their opposition to the Task Force recommendations. In contrast, however, he stressed that “the 4-minute piece had no interview with anyone with the Task Force. Not a quote. Not a word. That’s imbalance. You can talk about bipartisan opposition all you want. But on a scientific controversy, citing bipartisan opposition doesn’t equate to balanced or sound journalism.”
Though the angle of the story was chosen to be a political one, there is no getting beyond the fact that it’s about an important, complex medical issue. Many of us would submit that much of politics is about obfuscation, and that is frustrating to say the least–but that can become downright dangerous when scientific questions are pulled into the mix and being on the “right side” of the issue becomes more important to many than the evidence. NPR did a disservice to its listeners and readers by not providing a clear explanation of the Task Force’s recommendations, not interviewing anyone on the Task Force, interviewing solely politicians who voiced disagreement with the recommendations and were uninformed about the science and/or had other concerns, and perpetuating the controversy, confusion, and misunderstanding about this important issue.
As Schwitzer so rightfully concluded, “If we once again allow news coverage of this issue to be dominated by politics–and by coverage that delivers a superficial thumbnail sketch of a scientific controversy –we will have done more harm to women and to all news consumers than anything we can do with mammograms or without them.”
The breast cancer death rate per 100,000 US women has changed very little….2011 v 1970… despite mammograms, estrogen staging, a plethora of new promising chemotherapy agents, et cetra. Fact is, many modern breast cancer protocols have recently eliminated adjuvant chemotherapy for many stages of breast cancer. . Search the net Ms Wasserman!…..chemotherapy works for lymphomas and childhood leukemias but not for breast, lung, pancreas, liver, gonads and a bunch of stuff that we are about to learn about!
There is so much money in cancer chemotherapy that public figures such as you, should leave the cure rate analysis to unbiased professionals. Rather than rock stars like yourself.
Statistics don’t lie….but staticians sure can lie
George Meredith MD
Thank you so much for your comment, Dr. Meredith. Very well said!
Ten years ago, I went to my doctor seeking answers about the skin thickening of my right breast. Two mammograms over two years failed to detect my DCIS. Clearly there was something different about my right breast, but the results of my mammograms and my doctor’s lack of interest to further investigate resulted in significant spread of my stage 0 disease. My doctor only sprang into action after I discovered a discharge from that right breast. (Looking back now, I should have gone for a second opinion and started researching right away instead of later.)
Why aren’t all doctors educating their patients more about this disease and the diagnostic tools used to find it?—lack of time? Not one doctor ever took the time to explain to me the inadequacies of a mammogram. They ordered the test, called me to say all is well and off I went into the world to meet them again in a year.
Are doctors also part of the politics associated with mammograms? If so, how? What benefit do they receive relying on these x-rays since the test is so inadequate? Do tests—accurate or not—keep people believing their doctor is in control of their health? Are doctors ignoring the evidence to make their patients happy? Or, do doctors also experience a false sense of security as I did when my mammograms came back with negative results? Are they afraid to do biopsies because someone may complain of unnecessary pain if no disease is found? Maybe my experience is not the norm.
There is no way to tell yet which DCIS (pre)-cancers will become invasive. Until research provides those answers, aggressive treatments and painful biopsies (plus mammograms not used as the only diagnostic tool when a biopsy could occur) are a much better approach then too little, too late—at least in my opinion since my DCIS became invasive and finally metastasized. Not sure if earlier treatment of my disease would have saved my life, but it might have.
Hi, Lisa. Thank you for your thoughtful, insightful comments concerning the politics that seems to infiltrate every aspect of the debate itself–and the response to the debate–over screening mammography. The questions you’re posing here are such important ones, including whether some doctors are also unwittingly or consciously part of the politics surrounding screening mammography. I would love to conduct a truly meaningful investigation of these crucial questions through honest discussions with physicians and/or perhaps through a robust anonymous survey, where they would be willing to candidly answer the critical questions you’ve noted here. This could offer a new perspective and lend important new insights to this ongoing discussion, which could perhaps shed a stronger light on the very real repercussions that can result from NOT following the evidence and the importance of clearly emphasizing the also very real limitations of screening mammography.
What the general public really needs to know urgently is that both the news coverage and the official medical “science” of mammography is predominantly about politics.
NPR is a loud voice of the mainstream media, mainly serving big corporate interests and politically correct ideologies. Just like Schultz’ experience of her missed aggressive breast cancer is typical, rather than the exception, if you know the real science of mammography instead of the glorified misleading propaganda messages (eg mammograms save lives) put out by the medical industry and the allied mainstream media (sources: Rolf Hefti’s ‘The Mammogram Myth’ (TheMammogramMyth dot com) and Peter Gotzsche’s ‘Mammography Screening: Truth, Lies and Controversy’).
Thank you so much for your comments, Danny. IMHO, you’re absolutely right on all counts. One of the most dangerous and misleading “public service announcements” we’ve ever been slammed with (over and over again) has been the message that “mammograms save lives.” It hurts me to even type that, since it’s so mired in politics, lack of understanding regarding–or refusal to acknowledge–the science, and fund-raising efforts in the guise of “raising awareness” that further mires this important issue by lowering the health literacy of the general public.
Even minus politics, this story, like all health coverage, will be sensationalized and the facts and context will go missing, and there will never be enough nuance. I’ve struggled with writing on this issue for the very reason you illustrate here: it makes no sense for me to advocate for mammograms, since it failed to find my stage 3 cancer, which I found a few weeks later myself. Nonetheless, this issue makes me angry and confused. Sigh–as usual there are no answers or solutions, and the discussion simply makes me weary.
Completely agreed. “Weary” is the perfect word to describe how so many of us feel about this apparently never-ending issue. I’m just so sick of the willful obfuscation, the agendas, the ignorance, the deliberate choice of some to ignore the evidence and the facts because it’s inconvenient and doesn’t jive with what they’d prefer to believe. Sometimes–like now–I can’t help but feel like I’m banging my head against the wall.