by Sean Philpott, Director of the Center for Bioethics and Clinical Leadership
Like most married couples, my husband and I have a morning routine. I tend to get up first, shower, get dressed, get a cup of coffee, and make lunch. Dan is a little slower to get started, and likes to listen to a program like Good Morning America or the Today Show while ironing our shirts.
Normally the television is just background noise to me, but last week I actually stopped and listened in disbelief as ABC News correspondent Amy Robach revealed publicly that she’d been diagnosed with breast cancer. She underwent a double mastectomy later that week.
Ms. Robach’s diagnosis came after an on-air mammogram conducted in early October as part of Good Morning America’s cancer screening promotion, timed to coincide with National Breast Cancer Awareness month. The 40-year-old journalist had not undergone a screening exam before, but was pushed to do so by her producers and by fellow correspondent and friend Robin Roberts, herself a cancer survivor. According to Ms. Robach, by pressuring her to get a mammogram (the first ever to be nationally televised no less), Robin Roberts “saved my life”.
This is all well and good, and I wish Ms. Robach a swift recovery. At the risk of sounding cold-hearted, however, let me explain exactly what is wrong with this story.
The benefits of hindsight aside, Amy Robach should have never received a mammogram in the first place. According to guidelines issued by the US Preventative Services Task Force, an independent and non-partisan group of healthcare experts, most women should not undergo regular mammography until they are at least 50 years old. That Ms. Robach was pressured to do for the sake of television ratings is problematic to begin with, despite the apparently positive outcome. Worse yet is the false narrative about the benefits of routine cancer screening that the story creates.
For women with no family history of breast cancer, the likelihood of developing it is 1 in 70 for those in their 40’s. That rises to 1 in 35 for those in their 50s, and to 1 in 25 for women in their 60’s. Those seem like pretty high odds, so why shouldn’t every woman be screened annually? They shouldn’t because routine mammograms for women like Ms. Robach actually yield little benefit. But they come with considerable expense and risk.
Despite the possibility of developing cancer at a young age, conducting annual mammograms for all women in their 40’s will not significantly reduce the number of cancer-related deaths. In fact, only a single death will be prevented for every 2000 women so screened. The cost of routing testing aside, many of these women may also be harmed. Consider, for example, the physical and psychological toll of false test results.
Although mammography is the best screening tool we currently have, it is also notoriously inaccurate. On average, it misses 20-30 percent of all cases of cancer (so called false negative results).
Mammography also has a high rate of false positives: findings that look like cancer but are later determined to be benign. The chance that a woman will have a false positive result increases with every mammogram. According to the Susan G. Komen Breast Cancer Foundation, after just 10 yearly mammograms more than half of women will receive a false positive test result. They will only be determined to be cancer free after additional testing, including invasive biopsies.
Moreover, the psychological effects of a false positive can be profound. One recent Danish study found that women who received such false results suffered from anxiety and depression. These symptoms continued for years, even after cancer had been definitively ruled out. Inconvenient facts like these do not make for good television. Heartwarming stories of survival do.
By coming forward with her own tale of diagnosis and treatment, Amy Robach hopes to “inspire every woman who hears it to get a mammogram, to take a self exam. No excuses. It is the difference between life and death.” It probably will inspire more than a few women to get mammograms. Just as Katie Couric’s live colonoscopy led to an uptick in the number of people being screened for colon cancer, so to will Ms. Robach’s on-air mammography lead to more women undergoing that procedure. A few lives may even be saved.
Despite this, Amy Robach’s story is likely to do more harm than good. It will perpetuate the myth that more screening, starting at an earlier age, is a winning strategy in the on-going war on cancer. It will continue to confuse patients and clinicians alike about the potential benefits and limitations of routine testing, and contribute to the problem of overdiagnosis and overtreatment.
Universal screening programs, as promoted by Ms. Robach and her producers at Good Morning America, are not the answer. Such programs save few lives and come at great cost, despite what media reports might suggest.
[This blog entry was originally presented as an oral commentary on Northeast Public Radio on November 21, 2013. It is also available on the WAMC website. Its contents are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]