Screening

A couple of weeks ago I received a letter from California Pacific Medical Center reminding me that as my 40^th birthday was approaching, I should schedule a routine mammogram. Sometimes irony is so exquisite, isn’t it? At least, I could remind myself that one of the sole benefits of having had a double mastectomy is never having to have a mammogram again.

Before I had ever actually had one, I sat squeamishly through the opening montage of the film Please Give (2010)—a sequence of mammograms being given to an array of breasts, large and small. The effect was comedic, but also discomfiting, and even my husband had to exclaim, as many women have said over time, “That test must have been invented by a man!”

In fact, it was. By a German-Jewish doctor and researcher named Albert Salomon. In 1913! Salomon pioneered mammography by using X-rays to image several thousand cancerous breasts that had been removed by mastectomy; this way he came to recognize and classify the signs and stigmata of tumors and differentiate them in these images from normal tissue. Salomon was never able to apply his technique clinically as a screening tool, for his career in Berlin was cut off when the Nazis came to power in 1933. Salomon survived the war in hiding in Holland, but his daughter, the artist Charlotte Salomon (whose work was featured in an exhibition at the Contemporary Jewish Museum just last year) died in Auschwitz.

The use of mammography languished for almost half a century, until another doctor, Jacob Gershon-Cohen, began using it clinically to identify breast cancer; he inaugurated the first U.S. clinical trial of mammograms as a diagnostic device in 1956, completed in 1961. Gershon-Cohen was a brilliant radiologist and a fervent proselytizer for this kind of screening. As a result of his trial and others completed in the early ‘70s, routine mammograms became the fact of life they are for women everywhere.

Unfortunately, enshrined as they are in the annual check-up, mammograms are much less effective than one might think. In The Emperor of all Maladies, an incredible book on the history of cancer research that reads like a page-turner even for the science-illiterate among us, author Siddhartha Mukherjee details the many decades of trials that have followed, which have turned up a more ambiguous view of the potency of this technology. Essentially, mammograms are quite effective at reducing mortality in women over 55 by catching cancers early (a reduction of 20-30%), but there is almost no detectable benefit to women between the ages of 40-55. “In women between 40 and 50,” he writes, “the mammogram begins to squint at an uncomfortable threshold—exceeding its inherent capacity to become a discriminating test. No matter how intensively we test mammography in this group of women, it will always be a poor screening tool.”

This was true in my case. In my first and last dance with that behemoth machine, it was barely able to discern the lump that I had found, and it missed entirely the several others that were lurking scattershot near and far from it. For others, the problem is overdetection—the images will pick up something that looks unusual but will turn out to be either benign or possibly small carcinomas that will never develop into invasive ones. Screening in these cases may be leading to painful procedures that may not be necessary at all.

To put this into another context: I was returning this weekend from a celebration of the aforementioned 40^th birthday in New York City. My travel buddy had valiantly volunteered to schlep home an iced bag full of bagels, babka, cream cheese, and whitefish to her equally valiant husband. Our return was delayed, cancelled, rebooked, rerouted —and every time we went through security, they had to stop and flag the darn whitefish. (Actually, I think the cream cheese was the culprit.) As we know, airport screening machines are exquisitely sensitive and they lean entirely in the direction of overdetection. Every deodorant and snack bar is suspect. But we prioritize absolute security, and the costs are in time and inconvenience. But if we had to get a biopsy every time the scanner at the airport picked up an oversized toothpaste tube, we’d think differently. Especially if some of those biopsies led to further treatments that have major side effects and risks.

There was controversy a couple of years ago when a national health panel suggested that women under 50 who were not in a high-risk category forgo having a yearly mammogram. Because we don’t have a lot of other early detection options, we cling to it, but it is a blunt instrument. The question is not whether it detects things, but whether in so doing it saves lives, and for women under 50 that is far from established. Barbara Ehrenreich, in a trenchant article for Harper’s on the Breast Cancer Industry, quotes two experts on the topic:

“David Plotkin, director of the Memorial Cancer Research Foundation of Southern California, concludes that the benefits of routine mammography ‘are not well established; if they do exist, they are not as great as many women hope.’ Alan Spievack, a surgeon recently retired from the Harvard Medical School, goes further, concluding from his analysis of dozens of studies that routine screening mammography is, in the words of famous British surgeon Dr. Michael Baum, ‘one of the greatest deceptions perpetrated on the women of the Western world.’”

Anecdotally, I can say that everyone I’ve talked to that has undergone this experience found a lump on their own, but this may well be skewed by age, since many of us were not yet receiving regular mammograms. A new program being piloted by the UC system, across five of their campuses, is the Athena Breast Health Network, which is trying to define a way to assess each individual’s risk for breast cancer, including using family history, genetic testing, and other screening techniques. Women can go to any of the five campuses and get a personalized assessment, which will include methods for not only early detection but risk reduction before anything has developed. In essence, they are acting on the realization that screening has to be more individualized and prevention needs to start much sooner.

With all due respect to Drs. Salomon and Gershon-Cohen for their genius and persistence, we still need a more precise way to distinguish between growths that are indolent and those that are aggressive and prone to spread. A picture may not be worth a thousand words, if those words are false positives.

P.S. For worried gastronomes, you’ll be relieved to know that the whitefish made it home safely after all.