It remains to be seen whether Robach's mammogram really will make a life-saving difference, whether her cancer was truly found early, and if so, whether it is the type of cancer that, when treated properly and successfully, will result in a normal life expectancy.
An ideal screening intervention focuses on detection of disease that will "ultimately cause harm, is more likely to be cured if detected early, and for which curative treatments are more effective in early-stage disease." Unfortunately, this is not always the case. The main issue is that breast cancer is not one disease. There are at least ten molecular types each with different prognoses. Breast cancer’s biological complexity coupled with the limitations of x-rays and computer-aided technologies to see cancers clearly and the differences in expertise among radiologists and diagnostic centers to make sense of them, make it hard to say with any degree of certainty that a mammogram saved anyone’s particular life.
There is a growing consensus that universal screening saves far fewer lives than people think. Dr. Otis Brawley, chief medical officer of the American Cancer Society has said on numerous occasions that, "American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated." Nonetheless 40-year-old Robach, who immediately scheduled a bilateral mastectomy (an aggressive intervention found to be unnecessary in most cases), counts her life among those saved.
The Rise of the On-Air Health Screening
Amy Robach's agreement to have the “first ever live television mammogram” follows a relatively recent trend of TV personalities getting on-air health checkups. Katie Couric's live colonoscopy on NBC's Today show in March 2000 was the first. A study published in the Journal of the American Medical Association found that Couric's televised colon cancer awareness campaign was temporally associated with an increase in colonoscopy use in 2 different data sets. The demonstrated "Couric-effect" encouraged other shows to use celebrity spokespersons to encourage public participation in select health based initiatives.
NBC Today show anchors Matt Lauer and Al Roker recently had digital rectal exams, behind closed doors, on live TV as part of the show's initiative "to raise awareness for men’s health issues.” Health News Review pointed out several problems with the segment, including conflicts of interest, misleading health information, and the overzealous promise of the lives to be saved along with the omission of associated risks and complications. The trend toward infotainment rather than balanced and accurate discussion of the potential benefits and potential harms of mass screening repeats in Good Morning America's focus on the unequivocal belief that Robach's on-air mammogram will save lives. And now, using the erroneous conclusion that a single data point represents a trend, Robach's resultant treatment for breast cancer seems to support the idea that she's one of them. Robach may indeed be one of them. She won't know for sure for many years. But beyond the dramatic story of the single data point, there is an entire body of evidence that suggests otherwise.
Following hundreds of thousands of women over long periods of time, randomized clinical trials have found that very few women, only about 15 percent, have their lives saved by routine mammogram screenings. Some studies put the screening-associated reduction as low as two percent. The problem is that some breast cancers don’t show up well on mammograms, or at all; some cancers, even though they may be small, have already spread throughout the body; and some of the most aggressive types of breast cancer show up between mammograms.
Although increased screening has led to an emphasis on early detection as the way to reduce cancer deaths, universal screening has not translated into a reduction in the number of invasive cancers (i.e., the types that have the capacity to spread and cause death). With rates of recurrence at 20 to 30 percent even 15 years or longer after diagnosis, an average prognosis of only one to three years for people whose cancer has spread to distant organs, and approximately 40 thousand deaths from the disease year after year, "early detection" does not accurately describe the scenario for most breast cancers. Yet, the seemingly unequivocal and unwavering support of some doctors, celebrities, radiology centers, and professional mouthpieces still promote a one-size-fits-all approach to breast cancer screening even when they fail to support diagnostic mammograms (i.e., those used to help make a diagnosis once signs or symptoms have already appeared).
Breast Cancer's False Narrative
Stories about Amy Robach's on-air mammogram and public reveal mirror breast cancer's false narrative that "Every cancer is curable as long as you catch it in time." Epitomized by the phrase, "That mammogram just saved your life,” the idea that early detection via screening is the key to survival is a misleading overstatement, one that reverberates in an awareness inspired echo chamber especially during the month of October. Professors Steven Woloshin, MD, and Lisa M. Schwartz, MD, of the Department of Veterans Affairs Medical Center and the Dartmouth Institute for Health Policy and Clinical Practice, published an essay in British Medical Journal criticizing advertisements (notably those from the wealthiest breast cancer charity in the world, Susan G. Komen [for the cure]) that play into the false narrative by exaggerating and distorting medical information to sell wholesale mammography screening. Yet, the mammogram "get screened now" mantra resounds even though Komen's chief scientific advisor Dr. Eric Winer admitted that "We have oversold mammography to the American public."
The body of evidence does not support universal screening; it supports individualized informed decision making based on specific benefits and harms. The 2009 recommendation from the United States Preventive Services Task Force against universal screening mammography for women aged 40 to 49 recognized the limitations of this popular diagnostic tool in reducing deaths from breast cancer. The updated systematic review of randomized, controlled trials with 10 or more years of follow-up also found evidence of harm from universal screening, as it leads to overdiagnosis and overtreatment. This admission and change in recommendations continually sets off a flurry of disagreements among doctors and professional associations alike. Yet the evidence continues to mount that universal mammography screening overpromises and underdelivers.
In particular, screening has increased the number of cases of “indolent/precancerous” tumors which, according to a working group of the National Cancer Institute, tend to be potentially clinically insignificant. Instead of finding the aggressive cancers that are the most life threatening, one in five breast cancer diagnoses fall into the stage zero/precancer category. Treating these conditions has not led to a decrease in late stage disease as would be expected if they were all early indicators of invasive cancer. The working group sees this flaw in screening as an opportunity for improvement.
“Going forward, the ability to design better screening programs will depend on the ability to better characterize the biology of the disease detected and to use disease dynamics (behavior over time) and molecular diagnostics that determine whether cancer will be aggressive or indolent to avoid overtreatment. . . . Physicians, patients, and the general public must recognize that overdiagnosis is common and occurs more frequently with screening."
The group also implores the media to "better understand and communicate the message so that as a community the approach to screening can be improved.”
Will Amy Robach's oft-tweeted personal story on morning television open the public discussion about the need for better screening programs? Will it foster a deeper understanding of which breast conditions will benefit from treatment, thereby reducing deaths, and which will not? Will it help individual women weigh the potential benefits and the potential harms of universal screening in terms of overdiagnosis and overtreatment? Or will Robach's story, as a "walking example" of how "having a mammogram saved my life,” give greater social force to breast cancer's false narrative? Will it end up, in the long run, confusing the public even more about the complexities and limitations of universal mammography screening?
Amos Zeeberg, digital editor of Nautilus, put it this way: "The surprising inefficiency of mammograms doesn’t mean they need to end, but that they should be reasonably evaluated, not treated as our divine shield against cancer, administered to everyone with breasts, and paired unquestioningly with the most aggressive treatments available." I hope the producers of Good Morning America are listening, Amos.
Dr. Gayle Sulik is the author of Pink Ribbon Blues: How Breast Cancer Culture Undermines Women's Health. More information is available on the book's website.
© 2013 Gayle Sulik, PhD ♦ Pink Ribbon Blues on Psychology Today