Breast Cancer Screening

Living Well in Myanmar

Making informed decisions on the benefits of breast cancer screening

It’s tricky work for a primary care doctor to help patients decide when and how to get screened for a particular disease. A good example is breast cancer. Most women assume that getting regular mammograms is protection enough. They have been taught by advocacy organisations and medical professionals that screening prevents death.

However, the truth is that in nations where treatment is available to the majority of the population, most women diagnosed with breast cancer don’t die from the disease. Also, mammograms fail to detect many cases of breast cancer. So, unfortunately, some women with breast cancer blame themselves for not having received regular mammograms. At the same time, women who adhere to annual mammogram guidelines aren’t getting the level of protection they might think.

While it’s generally correct that mammograms reduce the risk of dying from breast cancer, they in fact have both beneficial and harmful effects. This is illustrated in a new report published in the April 2 issue of the Journal of the American Medical Association. The authors reviewed all available data from the last fifty years and found that women in their 40s benefit from a 15 percent decline in death from breast cancer when they undergo regular screenings.

They also found that 19pc of cancers detected are actually over-diagnoses, meaning that the screenings found cancers that will never actually harm the woman. Unfortunately these harmless cancers are then unnecessarily evaluated and treated with biopsies, surgeries, medications and radiation. The implication is that, for women in their 40s, mammography may be doing more harm than good.

In the evolving discussion on mammography, it’s safe to say that benefits have been overstated and harms have been understated. It’s also apparent that we can no longer assume that discovering a possible breast cancer is always beneficial. These are frustrating conclusions, particularly since breast cancer is such a common disease.The average woman has a 1-in-8 chance of developing breast cancer over the course of her life.

For these reasons it’s no surprise that recommendations on age limits and frequency of screening differ amongst the various medical committees and associations that write guidelines. They suggest “talking with your physician” to make a personal decision.

Some women are happy to accept the possibility of unnecessary treatment if it means they have a mildly reduced risk of dying from breast cancer. Others look at the numbers and feel more comfortable waiting until their 50s or 60s to begin receiving mammograms. Regardless, it is important for women to know that breast cancer screening is not perfect, that it misses some cancers and that some women die of breast cancer even when they have mammograms.

For Myanmar, attempting to establish a responsibly functioning health system, it’s difficult to decide the priority of mammography within the broad range of health-care challenges. If screening for breast cancer with currently available methods is not as effective as we had hoped, how much of an extremely limited bucket of resources should it receive?

Furthermore, as the middle class grows in Myanmar over the coming years and drives demand for mammograms, how do we prepare general practitioners for these difficult conversations? Post-medical school training for primary care doctors in Myanmar is extremely limited at the moment. Implementing a countrywide guideline on breast cancer screening that relies on strong patient-doctor relationships will demand that multiple aspects of the health system be improved.  © Christoph Gelsdorf 2013