SEEKING REASSURANCE EARLY DETECTION OF BREAST CANCER MEANS A BETTER PROGNOSIS ... BUT WHERE DOES MAMMOGRAPHY REALLY FIT IN?

Byline: Mariko Thompson Staff Writer

Ramona Kurasz never was able to feel the lump in her left breast, but it was there. Nearly three years ago, Kurasz, the daughter of a breast cancer survivor, went to Glendale Memorial Hospital Marcia Ray Breast Center for her annual mammogram, where a suspicious calcified deposit on the X-ray caught the radiologist's eye.

A diagnostic mammogram and a surgical biopsy confirmed what the radiologist suspected. Kurasz, then 48, had an early-stage tumor measuring 1.1 centimeters. She underwent a lumpectomy, chemotherapy and radiation treatment. Today, she is among the growing numbers of women who are surviving breast cancer.

``All you saw on the mammogram was a small calcium deposit,'' said Kurasz, a property manager in Glendale. ``The radiologist thought it looked suspicious. God bless him and his family, because he sure saved mine.''

Mammography is championed by many doctors as the gold standard for early detection of breast cancer, an invasive and elusive disease that kills more than 40,000 American women each year. Dr. Lawrence Bassett, director of the Iris Cantor Center for Breast Imaging at UCLA's Jonsson Cancer Center, credits mammography with playing a pivotal role in the mortality rate's continued decline and the detection of tumors at earlier and earlier stages.

``We've gone from a place where every cancer that came in was large and palpable to where most are found at an early stage,'' Bassett said. ``While we have a long way to go, we've come a darn long way.''

Reconsidering the guidelines

A year ago, a systematic review published by two Danish scientists that analyzed the quality of the seven large-scale mammography trials to date called into question whether mammography screening does indeed save lives. A number of organizations reassessed their mammography guidelines following the review.

In February, the National Cancer Institute upheld its recommendation that women in their 40s and older receive mammograms every one to two years. The American Cancer Society continues to advocate annual mammograms starting at age 40.

But the National Breast Cancer Coalition, an advocacy group whose founders include the renowned Dr. Susan Love who also teaches at UCLA, issued a more cautionary note. While mammography has been a useful tool in detecting cancers in women over 50, the coalition does not recommend blanket mammography screenings based on age. Instead, the coalition calls for mammography tests based on individual factors.

``Politically and emotionally, we all want to have an easy answer to something that's random and confusing,'' said Sara Collina, senior policy analyst for the coalition. ``As an advocate for breast cancer patients, a comforting message is only comforting if it's absolutely correct. There are real downsides to providing mammograms when there's no evidence that it prolongs life.''

The current policy of blanket screenings spends resources that might otherwise go toward health care for women who have been diagnosed with breast cancer, Collina said. An annual screening that targets younger women in good health may cause undue emotional stress. The coalition also is concerned about women enduring aggressive and toxic medical treatment for certain types of early breast cancers, ones science can't predict will ever become invasive tumors.

``When we do not know, Americans in general tend to say let's do more rather than less,'' Collina said.

Doctors who advocate screenings say early detection allows for less invasive procedures.

``Our goal with early detection is to improve the quality of life,'' said Dr. Mary Yamashita, medical director of the Marcia Ray Breast Center. ``You want to find it when it's small so that women can have minimal treatments and still have life expectancy greater than 10 years.''

In the early-detection trinity of mammography, clinical breast exam and breast self-exams, mammography isn't the only practice that's come under scrutiny. A large-scale study published earlier this month found no benefit to breast self-exams. Not only did self-exams have no impact on the death rate, it did not lead to earlier detection and was more likely to lead to biopsies of benign breast lesions.

Bassett, who was not involved in the study, said in his experience most women discover tumors in their breasts accidentally rather than through regular self-exams. He places more emphasis on women getting annual clinical breast exams.

``If you can do a self breast exam and you're comfortable with it, then do it,'' he said. ``If you're only creating anxiety, it's probably better not to do it. Many women tell me that they don't and they feel guilty. I don't want women to feel guilty.''

Pros and cons 

Though considered more accurate and cost effective than other breast imaging technologies, mammography is not perfect. According to the National Cancer Institute, about 20 percent of mammograms that come up negative have missed cancers. On the flip side, the National Breast Cancer Coalition estimates that half of all women who do annual screenings over 10 years will receive at least one false positive. About 80 percent of women with false positives will not have breast cancer.

Denise Hayes of Burbank, who has a family history of breast cancer, knows the agony that follows a suspicious finding on a mammogram. A year ago in October, she got called back for more tests. Doctors determined that Hayes most likely has a cyst.

``It puts the fear of God into you,'' Hayes said. ``My mom came with me and held my hand when they did the ultrasound. She was a great support, having gone through it herself.''

Reading a mammogram requires great interpretive skill. Breast tissue, particularly in younger women, can be dense. Benign cysts and fibrous tissues are common. Though new technology is being harnessed, doctors are split on whether digital mammography or computer-aided detection will have much impact.

The Iris Cantor Center for Breast Imaging at UCLA's Jonsson Cancer Center will participate in a national study on digital mammography, which allows the image to be manipulated on a computer monitor. In computer-aided detection, the computer serves as a second set of eyes, marking areas of concern for the radiologist.

``For a radiologist whose only job is to read mammograms, computer-aided detection probably doesn't increase their accuracy,'' said Dr. Christy Russell of USC-Norris Comprehensive Cancer Center. ``For the radiologist who does other things, there's a little bit of an increase in detections.''

The statistics

Over a lifetime, women have a 1-in-8 chance of developing breast cancer, a statistic that frightens more than informs. From 1994 to 1998, 77 percent of new cases were diagnosed in women age 50 and older. According to the American Cancer Society, the probability of a 30-year-old woman developing breast cancer over the next decade is 1 in 249, while a 70-year-old woman sees her risk increase to 1 in 24.

Besides age, known risk factors include family history, not having children, having one's first child after the age of 30, drinking alcohol, early menstruation, late menopause, post-menopausal hormone replacement therapy and obesity after menopause. The role of other environmental factors - from pesticides to electromagnetic fields to diet - remains to be seen.

Starting in 1989, the death rate began to fall by 1.6 percent a year, accelerating to 3.4 percent between 1995 and 1998. That statistic is tempered by the incidence rates.

``The incidence continues to climb,'' Russell said. ``But the good news is that the only area in which they're climbing is early-stage breast cancer, and that's from mammography.''

In 2001, 192,200 women were diagnosed with invasive breast cancer. Another 47,100 were diagnosed with tumors confined to the ducts, the majority of which will not become invasive.

Except for skin cancer, breast cancer is the second-most-common cancer in women. Only lung cancer accounts for more cancer-related deaths.

``If you take the attitude that you can fight it, that really does help,'' Kurasz said.

For Kurasz, the ordeal is not over. Besides the threat of recurrence, she suffers from lymphedema, a common problem among breast cancer survivors in which the lymph nodes have trouble draining and cause swelling.

More than anything, Kurasz is scared by what the family history of breast cancer could mean for her 29-year-old daughter. Her daughter will undergo her first mammogram next year.

CAPTION(S):

3 photos, box

Photo:

(1 -- cover -- color) A life saving mammogram

Glendale resident Ramona Kurasz believes in early screening helpred her, but some experts dispute its value

Charlotte Schmid-Maybach/Staff Photographer

(2) ``Our goal with early detection is to improve the quality of life. You want to find it when it's small so that women can have minimal treatments and still have life expectancy greater than 10 years.'' says Dr. Mary Yamashita, medical director of Glendale's Marcia Ray Breast Center.

Hans Gutknecht/Staff Photographer

(3) Ramona Kurasz, left

Charlotte Schmid-Maybach/Staff Photographer

Box:

CANCER SCREENING: WHEN TO GET TESTED

American Cancer Society

Gregg Miller/Staff Artist