Breast cancer screening: stirring the pot

After listening to Laura Esserman's talk on the opening day of AACR's annual meeting on why we should rethink breast cancer screening and treatment for low-grade cancers, I can understand why her opinions cause quite a stir. I also think she made some very valid points that have been missed by the mainstream media and the public.Esserman, a nationally known breast surgeon and director of the UCSF Carol Franc Buck Breast Care Center, made waves when she and another well-known oncologist, published an article in JAMA,"Rethinking Screening for Breast and Prostate Cancer," in which they write: After 20 years of screening for breast and prostate cancer, several observations can be made. First, the incidence of these cancers increased after the introduction of screening but has never returned to prescreening levels. Second, the increase in the relative fraction of early stage cancers has increased. Third, the incidence of regional cancers has not decreased at a commensurate rate. One possible explanation is that screening may be increasing the burden of low-risk cancers without significantly reducing the burden of more aggressively growing cancers and therefore not resulting in the anticipated reduction in cancer mortality. To reduce morbidity and mortality from prostate cancer and breast cancer, new approaches for screening, early detection, and prevention for both diseases should be considered.Although I can't remember her figures exactly, Esserman gave an example of the thousands of women who will be screened for breast cancer over 10 years, many will get call backs about suspicious lesions and many will have biopsies. Many will have false-positives. Many will have surgery and undergo treatment for cancers that may grow so slowly or disappear on their own. And of those thousands of women, one life will be saved. Now, when we hear this example given on why breast cancer screening recommendations should be revised, we only hear "one life was saved." Was it worth it? Of course. But Esserman points out what we're not hearing: Why did thousands of women have to undergo worry, biopsies, surgery, treatment--all when it may not even be necessary?The argument shouldn't be screening is good or bad, she says, but is it more or less beneficial? Instead, she calls for better screening methods and better strategies on who should be screened. Even with annual screenings, some women may end up finding their own cancers, aggressive tumors that can grow to a noticeable size in a matter of months. On the other hand, some women may have cancers found by screening that may not become invasive cancers; they may grow so slowly or disappear on their own. Esserman says we should be putting more effort into finding ways to distinguish between the two. If we can do that, women wouldn't be subjected to needless surgery and treatment for a cancer that might never have caused a problem, a type she calls an "idle" cancer.The screening controversy is far from resolved, but talking about it and demanding answers helps everyone. As Esserman said during her presentation, we should be demanding better screening. And questioning the status quo on such an important issue is a step forward, not a step back.