Women's Bodies, Women's Wisdom (74 page)

One helpful way to assess your risk for breast cancer—which in turn can help you decide how often you want to have mammograms—is to use the National Cancer Institute’s Breast Cancer Risk Assessment Tool, available online at
www.cancer.gov/bcrisktool.
After you answer seven simple questions, it calculates both your risk of getting invasive breast cancer in the next five years as well as your lifetime risk, and it compares each to the risk for the average U.S. woman of the same age and race or ethnicity.

A number of other negative studies on mammography have appeared in the medical literature over the years—and these are finally getting the press they deserve. In 2000, the
Journal of the National Cancer Institute
pointed out that the cumulative risk of having false positive mammograms is quite significant in many women. And in 2002, a National Cancer Institute advisory panel con cluded that the benefits of mammography are uncertain, in part because of the substantial chance of receiving a false positive result. While this is possible in any age group, it is most common in women in their forties because they tend to have denser and more fibrous breasts that get read as false positives on mammograms and then require biopsy. Andrew Wolf, M.D., an associate professor at the University of Virginia School of Medicine, supports these findings. In an August 2003 review article on breast cancer screening in
Consultant,
Dr. Wolf states, “If a woman begins getting regular mammograms at age 40, there is virtually a 100 percent chance that some kind of abnormality will show up that will warrant at least a follow-up mammogram, an ultrasound scan, or a call from the physician recommending a six-month follow-up examination. It is also likely that over the course of a lifetime, she will undergo an unnecessary breast biopsy.”
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For me, the biggest concern about mammography is that it doesn’t appear to reduce mortality from breast cancer any better than simple breast exam (which also doesn’t decrease mortality). According to a 2000 study from the
Journal of the National Cancer Institute,
after following nearly forty thousand women between the ages of fifty and fifty-nine, researchers found that annual mammograms were no more effective than standard breast exams in reducing breast cancer mortality.
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Another study published in the
Journal of the American Medical Association
found that women age seventy and older benefited very little from mammography.
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The can cers detected at this age never would have killed them. Then there are those researchers who doubt the safety of mammography because of radiation exposure. A 1994 study published in the
Lancet
addressed another concern that many women have brought up with me—that the breast compression that occurs during a mammogram may cause small, in-situ tumors to rupture, thereby spreading cancer cells into surrounding tissues and potentially leading to more invasive cancers and metastases.
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Cornelia Baines, M.D., professor emerita at the University of Toronto and former deputy director of the Canadian National Breast Screening Study, put it succinctly when she said, “I remain convinced that the current enthusiasm for screening is based more on fear, false hope and greed than on evidence.”
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I agree with Dr. Baines completely.

The bottom line is this: When it comes to mammograms, things are not as cut-and-dried as they seem. There’s a lot we simply don’t know. After discussing their options with a knowledgeable health care practitioner, all women will need to follow their own inner guidance on this issue, taking full responsibility for their choices. Intelligent, informed women can be trusted to do what’s right for them, including forgoing mammograms—and I support them wholeheartedly.

The Limits of Conventional Early Detection

Doing breast self-exams and getting mammograms (or sonograms) regularly is not the same as
prevention
. In other words, it is not the same as brushing and flossing the teeth, which actually prevents cavities and periodontal disease. As one of my colleagues said of breast cancer, “We identify the risks, but we don’t know what to do until they manifest as disease.” Our culture uses mammograms as a fix but doesn’t encourage women to change their diets, exercise, stop smok ing, and learn how to be in relationships that nurture them. These are preventive changes that favor healthy breasts. But as one researcher has said, it’s difficult to put together a constituency for prevention. It is treatment that gets our attention. If your sister or mother dies of breast cancer, you usually give money to programs that do research to produce better treatments; you don’t start a whole-food restaurant in your neighborhood or advocate teaching eighth-grade girls how to appreciate their breasts and make sure they have optimal levels of vitamin D. Our culture is crisis-oriented, acting only once the horse is out of the barn.

There is a third option, however. You can use thermography, mammography, and other disease screening as an external guidance system. And if any abnormality appears, you then have the opportunity to ask the abnormal cells what they need that they’re not getting. The earlier in the disease process you make adjustments to your diet, beliefs, and lifestyle, the easier it is to transform your cells. (See my Program to Promote Healthy Breast Tissue, page 352.)

Breast Ultrasound: An Adjunct (and Sometime
Alternative) to Mammography

In many women, particularly those with dense breasts, ultrasound screening of breast tissue (reading breast tissue by sending sound waves through it and reading the echoes on a screen) is more appropriate and helpful than mammography. With the advent of high-resolution ultrasound, some authorities feel that this modality may become the method of choice for detecting an invasive breast carcinoma, with mammography reserved for localizing intraductal carcinoma marked by calcifications. One advantage of ultrasound is that it doesn’t involve radiation and is also far more comfortable. Routine ultrasound screening of breast tissue with expert interpretation of the scans is not nearly as widely available as mammography, and most women aren’t offered this choice.

In the diagnosis of a nonpalpable mass (one that you can’t feel but that is discovered on mammography), ultrasound can also be invaluable for guiding fine-needle or core-needle aspiration. High-resolution breast ul trasound has also made it much easier to delineate palpable breast lumps. An ultrasound can easily tell the difference between a cyst and a lump. And if a breast mass is solid, the ultrasound has a 98 percent specificity in terms of being able to distinguish a benign lesion from a malignant one. In fact, some studies have shown that ultrasound is the single most accurate diagnostic test for those women with palpable breast masses, yielding a 99.7 percent positive predictive value if it’s used by those who are skilled in this technique.
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If there’s any question about the findings, a needle biopsy can now be done in the office set ting to determine whether or not a breast mass is malignant. This has spared many women from disfiguring breast biopsies and the anxiety that comes from not knowing what she’s dealing with.

There is another reason why ultrasound is important. Mammography is often not helpful in women who are younger, have dense breasts, have postoperative scarring, suffer from acute or chronic radiation effects, are on hormone replacement, or are less than forty-five to fifty years of age. Sonograms are also more accurate than mam mograms for diagnosing breast problems accurately in women who’ve had breast implants. The highest-risk women are those who’ve already had radiation to their breasts. Sonography is often a good alternative for these women. Mammography is still the most common screening modality for most asymptomatic women, but ultrasound is also helpful. Many centers will not do screening ultrasounds because it is very time-consuming and it is difficult to compare pictures from year to year. However, some centers offer screening ultrasounds for high-risk women.

Magnetic resonance imaging is the latest tool in the breast cancer detection department. But MRI will most likely never be used as a screening test— it is too expensive (at least $2,000), it’s too hard to do (women have to lie still for up to an hour, often medicated), and there are too many false positives. MRI may play a role in high-risk women with dense breasts or suspicious mammograms, though I’d certainly make the decision judiciously. I would recommend having it done only at a breast center whose per sonnel are highly experienced in their use. (By the way, at least 27 percent of women recently diagnosed with breast cancer have what is called pretreatment MRI in an attempt to gather information for treatment decisions. Yet a 2009 study from a leading U.S. cancer research and treatment center found this practice did more harm than good. The MRI delayed treatment by an average of three weeks and increased mastectomy rates by 80 percent—because of the high rate of false positives—in women who would have been good candidates for lumpectomy.)
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True Prevention: Thermography

Thermography—a noninvasive, safe technology that simply records the amount of heat emanating from breast (or other) tissue—is the screening modality of choice. The FDA approved it as an adjunctive breast cancer screening test in 1982, and in my view it could replace the vast number of mammograms women are subjected to. When you get a thermogram, the thermographer uses an infrared thermal-imaging camera to capture the amount of heat on the body’s surface. Abnormal heat patterns in breast tissue indicate increased blood circulation to a given area secondary to cellular inflammation, a well-documented precursor for cancer. Thermogram images are scored according to how much inflammation is present. If the image is highly abnormal and there is a high suspicion of cancer, then a mammogram can be ordered to confirm the diagnosis. Standard treatment would follow. In the vast majority of cases, however, a thermogram will indicate a tendency toward breast abnormalities long before these would develop into palpable lumps or mammographic abnormalities.
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This is good news because it means a thermogram allows a woman and her health care practitioner to be proactive. If her scan shows inflammation, she can then go on a program (such as the one on page 352 of this chapter) to improve her breast health. Decreased cellular inflammation can easily be documented on a follow-up thermogram. This approach is far more empowering than that of routine mammography, in which a woman simply waits for an abnormality to show up without being given the tools to be proactive about her breast health. And a thermogram can help a woman diagnosed with ductal carcinoma in situ (and her health care providers) decide whether or not she requires aggressive or conservative treatment. (See “The DCIS Dilemma,” below.) Another valuable bonus is that thermograms don’t confuse harmless fibrocystic masses with worrisome lumps as often as mammography.
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Routine thermograms could save thousands of women from undergoing unnecessary biopsies and disfigurement. And because breast inflammation is a marker of inflammation in other areas of the body, using thermograms would also help improve overall health at the same time. Unfortunately, ther-mography is often not covered by insurance (scans cost anywhere from $90 to $250), a fact that has more to do with politics and economics than science. (To find a practitioner in your area who does thermography, visit
www.breastthermography.com
,
www.breastthermography.org
, or the websites for the International Academy of Clinical Thermology,
www.iact-org.org
, or for the American College of Clinical Thermology,
www.thermologyonline.org
.)

A B
RIEF
H
ISTORY OF
T
HERMOGRAPHY

Back in the 1970s and ’80s, a great deal of research showed that thermography was highly effective in screening for abnormalities that included breast cancer.
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Researchers observed that thermographic scans were highly specific for each woman, providing a unique thermal “signature” that remained remarkably constant from year to year. Like other breast screening modalities, thermography didn’t diagnose anything, it simply pointed out the presence of an abnormality. Here are some study highlights:

A 1980 study of 1,245 women by Michel Gautherie, Ph.D., and Charles Gros, M.D., at the Louis Pasteur University School of Medicine in Strasbourg, France, concluded that an abnormal thermogram was the
single most important marker
of high risk for developing breast cancer.
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