Sandra Lee, the celebrity chef and author, announced Tuesday that she has breast cancer. She did so during a tearful, emotionally powerful interview on “Good Morning America” -- to talk about her diagnosis and her treatment, and to offer advice. She wants all women to get breast cancer screening, even at young ages.
"Girls in 20s and their 30s just have to know,” Lee, 48, said. “And I don't want women to wait. And that's why I'm talking. … If it saves one person, and makes one more person go get a mammogram, and if they're sitting down right now watching this, don't watch this TV. Go pick your phone up, and call your doctor and get your rear end in there and get a mammogram right now.”
Watching the interview, it would be difficult not to feel sympathy and inspiration -- particularly since Lee was speaking with Robin Roberts, the GMA host who also had (and survived) a high-profile fight with breast cancer. Lee’s prognosis seems good, based on what she described on camera. While she spoke of the physical and emotional challenges of cancer treatment, which in her case will include a double mastectomy, she also talked about her expectations of recovery and her plans for afterward, which include talking to her young nieces about mammography.
But the question of who should get breast cancer screening -- and, more important, when people should get it -- is actually among the most controversial topics in medicine today.
Mammography first gained acceptance as a screening tool in the 1960s and 1970s. Widespread use followed in the 1980s and '90s -- thanks to activism, public education, government outreach and recommendations from independent scientific authorities. Today, screening rates in the U.S. are among the highest in the world, with about eight in 10 women getting the test, although poor, uninsured women are far less likely to get regular mammograms and progress on improving screening rates has stalled recently, according to newly released data from the U.S. Centers for Disease Control and Prevention.
Most experts agree that the development and refinement of screening technology has saved many lives overall, because it has given physicians the tools to diagnose tumors much earlier -- in many cases, early enough to remove a lethal cancer before it spreads and kills. But screening for breast cancer, like any medical intervention, has downsides as well as upsides.
Mammograms have gotten better at detecting tumors in the earliest stages -- so much so that, in some cases, they are detecting tumors that might not be dangerous. (This is also true for testing to detect other cancers, particularly prostate cancer.) The scans also can yield false positives. Either result will typically lead to a biopsy and, in many cases, some kind of treatment, whether it's surgery, radiation, chemotherapy, hormonal therapy, or some combination of the four. Each of these carry risks. Invasive procedures are not just painful, but can potentially cause infections. Medications, particularly the powerful drugs that fight cancer, can have difficult, toxic side effects.
Recognition of these harms has caused many experts to question the wisdom of universal screening at younger ages. In 2009, the U.S. Preventative Services Task Force, a government-funded panel of independent experts, formally changed its guidelines, suggesting that most women get screening every two years, rather than every year, and starting at age 50, rather than 40. The task force continued to recommend testing at younger ages for women at high risk of the disease, because of family histories or positive tests for the genes scientists have linked to breast cancer. But women between ages 40 and 49 should weigh the benefits and costs and make their own decisions, the task force said. (A draft version of newly updated guidelines from the task force makes basically the same recommendations.)
The guidelines became instantly controversial, dividing advocacy groups and the medical profession. Alarmed members of Congress ended up adding a provision to the Affordable Care Act guaranteeing full mammogram coverage at age 40, regardless of the task force recommendations. Today, groups like the American Cancer Society continue to recommend screening at age 40. Many and possibly most physicians continue to follow that standard, while people who were diagnosed before the age of 50 -- a group that now includes Sandra Lee -- plausibly say that early detection may have saved or dramatically altered their lives.
The experts who questioned the wisdom of such early testing a few years ago haven't changed their minds -- and can point to new research to back up their argument.
One major study on the issue came out last year, in the British Medical Journal. Its basis was a study of 90,000 people in Canada, and it used a truly randomized model, which is the most scientific method available for judging the effectiveness of a medical treatment. Some participants got mammograms starting at 40, others at 50. The mortality rates for both groups -- in other words, the proportion who ultimately died from breast cancer -- was basically the same. To put it another way, screening people at 40 didn’t save lives relative to screening people at 50.
"We found absolutely no benefit in terms of reduction of deaths from the use of mammography," Anthony Miller, an epidemiologist at the University of Toronto and lead author on that study, told the Los Angeles Times.
Still, some researchers question what that study -- or others undermining the case for routine screening at 40 -- really shows. Among other things, these skeptics say, the data may not fully account for the performance of the most recent screening or treatment innovations, since it’s inevitably based on medical care administered many years ago.
Therese Bevers, medical director of the MD Anderson Cancer Prevention Center in Houston, was among those skeptical of the most recent research findings. "There were limitations in the study that skewed the results," Bevers said at the time. "The reality is that early detection of breast cancer improves the odds of successful treatment."
On Tuesday, Bevers told The Huffington Post that the guidelines at MD Anderson, as well as those from the National Comprehensive Cancer Network, still call for annual mammography starting at age 40.
This debate over the proper timing of breast cancer screening has been raging for a while and probably won't be settled anytime soon -- although some researchers are working on methods to estimate breast cancer risk that combine age with other factors, potentially making the choices a bit more clear. One such project, from the government-sponsored Breast Cancer Surveillance Consortium, even has an online "risk calculator" for women who want guidance on their breast cancer risk when weighing the benefits and harms of mammography.
In the meantime, nearly all leading physicians, whatever their views on the latest research, emphasize something called “shared decision-making” -- which basically means giving patients as much information as possible, and allowing them to make decisions after consulting with experts and loved ones.
It's a recognition that not everybody will make the same judgments about how to weigh the potential upsides and downsides -- as well as a formula for more conversations, perhaps along the lines of the ones Lee says she plans to have with her family.