Breast Cancer Screening

Making Sense of Complex and Evolving Evidence

Nehmat Houssami, Diana Miglioretti

• Publisher: Academic Press
• Year: 2016
• Print ISBN: 9780128022092
• eBook ISBN: 9780128024942
• Topic: Medicine
• Subtopic: Oncology

Breast Cancer Screening: Making Sense of Complex and Evolving Evidence covers broad aspects of breast cancer screening specifically focusing on current evidence, emerging evidence, and issues that will be critical for future breast screening practice such as tailored screening and shared decision-making in breast screening. The scope of the book is relevant to a global audience. This book provides balanced perspectives on this increasingly controversial topic, using scientific evidence to explain the evolution of knowledge relating to breast cancer screening. Breast Cancer Screening covers the key points related to this debate including the context of increasingly complex and conflicting evidence, divergent opinions on the benefits and harms of breast screening, and variability in screening practice and outcomes across settings around the world. - Explains complex and evolving evidence on breast screening with a balanced approach - Provides balanced information and up-to-date evidence in an increasingly complex area - Addresses emerging topical issues such as screening trials of digital breast tomosynthesis, tailored breast screening, and shared decision-making in breast screening - Assists academics and researchers in identifying areas needing further research

Chapter 1

Breast Cancer Screening

Balancing Evidence With Culture, Politics, Money, and Media

Joann G. Elmore, Professor of Medicine School of Medicine and Adjunct Professor of Epidemiology School of Public Health, University of Washington, Harborview Medical Center, Seattle, WA, United States

Abstract

Culture, politics, money, and media intersect to influence the interpretation of scientific evidence with direct effects on the lives of women. Before venturing into detailed chapters reviewing the scientific evidence on breast cancer screening, we begin this textbook with an overview of the history of the breast, of breast cancer screening, and the perfect storm of politics and science surrounding this topic. We examine the complex forces that determine the lens through which many well-intentioned individuals view the same scientific evidence, yet arrive at different interpretations.

Keywords

Breast; history; breast cancer screening; benefits and harms; guidelines; informed decision making; advocacy

Chapter Outline

Plain Language Summary 2

History 2

History of the Breast 2

History of Medical Screening 4

History of Screening With Breast Self-Exam and Clinical Breast Exam 5

History of Mammography Screening 6

History of the Media and Marketing Related to Breast Cancer Screening 7

History of Science on Breast Cancer Screening 8

The Accumulation of Evidence on the Benefits 8

The Accumulation of Scientific Evidence on Potential Harms 10

History of Variability in Guideline Recommendations and Quality 13

History of Informed Medical Decision Making 15

History of Patient Activism, Politics, and Law in Screening 16

Methods to Identify High-Risk Women for Screening 18

Studying Rapidly Evolving New Technologies and Our General Technophilia 21

Thoughts on the Future 22

Conclusion 22

Glossary 23

List of Acronyms and Abbreviations 24

References 24

Plain Language Summary

Culture, politics, money, and media intersect to influence the interpretation of scientific evidence, directly affecting the lives of women. Before venturing into detailed chapters reviewing the scientific evidence on breast cancer screening, we begin this textbook with an overview of the history of the breast, of breast cancer screening, and of the perfect storm of politics and science surrounding this topic. We examine the complex forces that shape the way many well-intentioned individuals view the same scientific evidence, yet arrive at vastly different interpretations.

This chapter provides a brief overview on the history of the breast, breast cancer screening, scientific evidence for and against different screening strategies, and important influences on the development of screening strategies.

History

History of the Breast

Over the years, well-intentioned individuals have reviewed the scientific evidence on breast cancer screening, yet come to surprisingly different conclusions. While many chapters in this textbook describe the scientific evidence surrounding breast cancer screening dating back decades, the interpretation of this evidence is influenced by complex factors. Individual interpretation of scientific medical information is colored by a heightened fear of breast cancer, mass media campaigns promoting screening, political involvement, and financial incentives all colliding with the complicated culture that surrounds women’s health in general, and breast health in particular. While a financial conflict of interest might be concrete and obvious, an emotional conflict of interest is subtle and can be deeply rooted. Just as a Rorschach ink blot might be interpreted quite differently by individuals, the interpretation of scientific evidence remains challenging in the area of breast cancer screening with multiple and variable interpretations.

To understand the complex nature of breast cancer screening scientific data, a reflection on the history of the breast is a helpful starting point. While thousands of pages have been written on this topic,^1–5 a summary of key themes is briefly covered here.

The breast was depicted in ancient art as a symbol of motherhood, comfort, and nourishment. For example, this ancient Greek sculpture (Fig. 1.1) depicts a mother feeding her twins, with the mother’s right hand gently playing with the foot of one of the infants. The mother seems relaxed in this nurturing context. Sculptor Jean-Jacques Caffieri’s marble statue titled Hope Nourishes Love shows a young woman who represents Hope nursing a winged Cupid, personifying love (Fig. 1.2). Fig. 1.3 depicts Artemis, goddess of the hunt and wild animals, in her temple at Ephesus (in present-day Turkey) with striking rows of pendant objects on her torso. Most scholars have identified these pendant objects as breasts. The nourishing breast is tied to power and strength in this hunter-goddess’s statue. Just as scientists variably interpret medical data, the interpretation of art has varied over the years. While most assume that the repeated paired objects on this statue are breasts, a scientist in 1978 claimed that, as no nipples were depicted, the round objects represent bulls’ testicles,⁶ adding an example of variability in interpretation of visual data based on the viewer’s perspective.

Figure 1.1 Kourotrophos statue from Paolo Orsi Museum (Siracusa, Sicily). © “Museo archeologico regionale paolo orsi, dea madre che allatta due gemelli in calcare, da megara hyblaea necropoli ovest, 550 ac.” (https://commons.wikimedia.org/wiki/File:Museo_archeologico_regionale_paolo_orsi,_dea_madre_che_allatta_due_gemelli_in_calcare,_da_megara_hyblaea_necropoli_ovest,_550_ac..webp#/media/File:Museo_archeologico_regionale_paolo_orsi,_dea_madre_che_allatta_due_gemelli_in_calcare,_da_megara_hyblaea_necropoli_ovest,_550_ac..webp.) by I. Sailko. Licensed under CC BY 2.5 via Commons—http://creativecommons.org/licenses/by/2.5/.

Figure 1.2 Hope Nourishes Love sculpture by Jean-Jacques Caffieri (1769). Digital image courtesy of the Getty’s Open Content Program.

Figure 1.3 Artemis at Ephesos (Turkey, 2nd century). Artemis of Ephesus by QuartierLatin1968/Wikimedia Commons/CC BY-SA 2.0.

While historic depictions have also sexualized the breast, over the centuries, artistic depictions of the breast became increasingly sensual. Representations of the breast moved from scenes of nourishment between Madonna and Child to increasingly sexualized images. In the last century, the slender flapper image of a woman was replaced with full-bodied women and the breast came to represent a key feature of a woman’s sexuality. Push-up bras and breast augmentation became commonplace and were openly discussed in conversations.

Breast cancer is one of the most feared afflictions in modern society because of its potential devastation of both the woman and her family, given the nurturing, comforting, and sexual attributes of breasts, in addition to the risk of death from the disease. Descriptions of breast cancer treatments date back thousands of years and include the cauterization of breast tumors and ulcers as described in Egyptian textbooks. In describing breast cancer, authors of the past bluntly stated: “There is no treatment.”⁷ Thankfully, this is no longer the case. However, early treatments included extensive surgical resections. As the surgical treatments for breast cancer were developed, images of mastectomy scars came to represent mutilation of the body and death. This new symbolism was evident in artist and former fashion model Matuschka’s stunning self-portrait, featured on the cover of The New York Times Magazine in 1993, in which she boldly exposed the remnants of her postmastectomy breast. The juxtaposition of the model’s lithe body and the taboo scar forced readers to confront breast cancer and its raw physical impact.

History of Medical Screening

Given the historical value society has placed on women and the breast, it is no surprise that breast cancer screening remains in the forefront of societal focus. With the development of successful treatment for early-stage breast cancer, early detection screening programs became a possible approach to consider.

Effective medical screening includes conside...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• List of Contributors
• Foreword
• Chapter 1. Breast Cancer Screening: Balancing Evidence With Culture, Politics, Money, and Media
• Chapter 2. Estimates of Screening Benefit: The Randomized Trials of Breast Cancer Screening
• Chapter 3. Weighing the Benefits and Harms: Screening Mammography in the Balance
• Chapter 4. The Importance of Observational Evidence to Estimate and Monitor Mortality Reduction From Current Breast Cancer Screening
• Chapter 5. The Role of Microsimulation Modeling in Evaluating the Outcomes and Effect of Screening
• Chapter 6. Challenges in Understanding and Quantifying Overdiagnosis and Overtreatment
• Chapter 7. Challenges and Opportunities in the Implementation of Risk-Based Screening for Breast Cancer
• Chapter 8. Breast Cancer Screening in the Older Woman
• Chapter 9. Screening Women in Their 40s
• Chapter 10. Screening for Breast Cancer in Women With Dense Breasts
• Chapter 11. Screening Women With Known or Suspected Cancer Gene Mutations
• Chapter 12. Imaging Surveillance of Women With a Personal History of Breast Cancer
• Chapter 13. Evolution of Mammography Screening: From Film Screen to Digital Breast Tomosynthesis
• Chapter 14. Ethical and Societal Considerations in Breast Cancer Screening
• Chapter 15. Treatment of Screen-Detected Breast Cancer: Can We Avoid or Minimize Overtreatment?
• Chapter 16. Informed and Shared Decision Making in Breast Screening
• Index
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