The stormy landscape of the breast, as seen on ultrasound. At top center (dark circle) is a small cyst. Source: Wikimedia Commons. Credit: Nevit Dilmen.
By Laura Newman, contributor
In a unanimous decision, FDA has approved the first breast ultrasound imaging system for dense breast tissue “for use in combination with a standard mammography in women with dense breast tissue who have a negative mammogram and no symptoms of breast cancer.” Patients should not interpret FDA’s approval of the somo-v Automated Breast Ultrasound System as an endorsement of the device as necessarily beneficial for this indication and this will be a thorny concept for many patients to appreciate.
If the approval did not take place in the setting of intense pressure to both inform women that they have dense breasts and lobbying to roll out all sorts of imaging studies quickly, no matter how well they have been studied, it would not be worth posting.
Dense breasts are worrisome to women, especially young women (in their 40s particularly) because they have proved a risk factor for developing breast cancer. Doing ultrasound on every woman with dense breasts, though, who has no symptoms, and a normal mammogram potentially encompasses as many as 40% of women undergoing screening mammography who also have dense breasts, according to the FDA’s press release. Dense breast tissue is most common in young women, specifically women in their forties, and breast density declines with age.
The limitations of mammography in seeing through dense breast tissue have been well known for decades and the search has been on for better imaging studies. Government appointed panels have reviewed the issue and mammography for women in their forties has been controversial. What’s new is the “Are You Dense?” patient movement and legislation to inform women that they have dense breasts.
Merits and pitfalls of device approval
The approval of breast ultrasound hinges on a study of 200 women with dense breast evaluated retrospectively at 13 sites across the United States with mammography and ultrasound. The study showed a statistically significant increase in breast cancer detection when ultrasound was used with mammography.
Approval of a device of this nature (noninvasive, already approved in general, but not for this indication) does not require the company to demonstrate that use of the device reduces morbidity or mortality, or that health benefits outweigh risks.
Eitan Amir, MD, PhD, medical oncologist at Princess Margaret Hospital, Toronto, Canada, said: “It’s really not a policy decision. All this is, is notice that if you want to buy the technology, you can.”
That’s clearly an important point, but not one that patients in the US understand. Patients hear “FDA approval” and assume that means a technology most certainly is for them and a necessary add-on. This disconnect in the FDA medical device approval process and in what patients think it means warrants an overhaul or at the minimum, a clarification for the public.
Materials for FDA submission are available on the FDA website, including the study filed with FDA and a PowerPoint presentation, but lots of luck, finding them quickly. “In the submission by Sunnyvale CA uSystems to FDA, the company stated that screening reduces lymph node positive breast cancer,” noted Amir. “There are few data to support this comment.”
Is cancer detection a sufficient goal?
In the FDA study, more cancers were identified with ultrasound. However, one has to question whether breast cancer detection alone is meaningful in driving use of a technology. In the past year, prostate cancer detection through PSA screening has been attacked because several studies and epidemiologists have found that screening is a poor predictor of who will die from prostate cancer or be bothered by it during their lifetime. We seem to be picking up findings that don’t lead to much to worry about, according to some researchers. Could new imaging studies for breast cancer suffer the same limitation? It is possible.
Another question is whether or not the detected cancers on ultrasound in the FDA study would have been identified shortly thereafter on a routine mammogram. It’s a question that is unclear from the FDA submission, according to Amir.
One of the problems that arises from excess screening is overdiagnosis, overtreatment, and high-cost, unaffordable care. An outcomes analysis of 9,232 women in the US Breast Cancer Surveillance Consortium led by Gretchen L. Gierach, PhD, MPH, at the National Institutes of Health MD, and published online in the August 21 Journal of the National Cancer Institute, revealed: “High mammographic breast density was not associated with risk of death from breast cancer or death from any cause after accounting for other patient and tumor characteristics.” –Gierach et al., 2012
Proposed breast cancer screening tests
Meanwhile, numerous imaging modalities have been proposed as an adjunct to mammography and as potential replacements for mammography. In 2002, proponents of positron emission tomography (PET) asked Medicare to approve pet scans for imaging dense breast tissue, especially in Asian women. The Medicare Coverage Advisory Commission heard testimony, but in the end, Medicare did not approve it for the dense-breast indication.
PET scans are far less popular today, while magnetic resonance imaging (AKA MR, MRI) and imaging have emerged as as adjuncts to mammography for women with certain risk factors. Like ultrasound, the outcomes data is not in the bag for screening with it.
In an interview with Monica Morrow, MD, Chief of Breast Surgery at Memorial Sloan-Kettering Cancer Center, New York, several months ago concerning the rise in legislation to inform women about dense breasts, which frequently leads to additional imaging studies, she said: “There is no good data that women with dense breasts benefit from additional MR screening.” She is not the only investigator to question potentially deleterious use of MR ahead of data collection and analysis. Many breast researchers have expressed fear that women will opt for double mastectomies, based on MR, that in the end, may have been absolutely unnecessary.
“There is one clear indication for MR screening,” stressed Morrow, explaining that women with BRCA mutations should be screened with MRI. “Outside of that group, there was no evidence that screening women with MR was beneficial.”
At just about every breast cancer meeting in the past two years, the benefits and harms of MR and other proposed screening modalities come up, and there is no consensus in the field. It should be noted, though, that plenty of breast physicians are skeptical about broad use of MR– not just generalists outside of the field. In other words, it is not breast and radiology specialists versus the US Preventive Services Task Force – a very important message for patients to understand.
One thing is clear: as these new technologies gain FDA approval, it will be a windfall for industry. If industry is successful and doctors are biased to promoting these tests, many may offer them on the estimated 40% of women with dense breasts who undergo routine mammograms, as well as other women evaluated as having a high lifetime risk. The tests will be offered in a setting of unclear value and uncertain harms. Even though FDA has not approved breast MRI for screening dense breasts, breast MR is being used off label and it is far more costly than mammography.
When patients raise concerns about the unaffordability of medical care, they should be counseled about the uncertain benefit and potential harms of such a test. That may be a tall bill for most Americans to consider: it’s clear that the more is better philosophy is alive and well. Early detection of something, anything, even something dormant, going nowhere, is preferable to skipping a test, and risking who-knows-what, and that is something, most of us cannot imagine at the outset.
[Today's post is from Patient POV, the blog of Laura Newman, a science writer who has worked in health care for most of her adult life, first as a health policy analyst, and as a medical journalist for the last two decades. She was a proud member of the women’s health movement. She has a longstanding interest in what matters to patients and thinks that patients should play a major role in planning and operational discussions about healthcare. Laura’s news stories have appeared in Scientific American blogs, WebMD Medical News, Medscape, Drug Topics, Applied Neurology, Neurology Today, the Journal of the National Cancer Institute, The Lancet, and BMJ, and numerous other outlets. You can find her on Twitter @lauranewmanny.] Ed note: The original version of this post contains a posted correction that is incorporated into the version you’ve read here.
The opinions in this article do not necessarily conflict with or reflect those of the DXS editorial team.
It’s tempting to cast the role of women in STEM (Science, Technology, Engineering, and Math) as one of struggles and battles because of their sex, rather than as one of contributions because of their minds. But for Women’s History Month and this Diversity in Science Carnival #14, our focus is the role of women in the enterprise of STEM. There’s more to a woman than her sex and her struggles in science–there is, after all, the enormous body of work women have contributed to science.
Our history is ongoing, but we can start with a look back. Thanks to the efforts of the Smithsonian Institution Archives, we can put faces to the names of some of the female STEMmers of history. In a presentation of photographs in an 8 by 9 space, we can see the images of 72 women who contributed to the enterprise of STEM, many of them involved with the Smithsonian in some capacity. As their clothes and the dates on the photos tell us, these women were doing their work in a time when most women didn’t even wear pants.
Some are Big Names–you’ve probably heard of Marie Curie. But others are like many of us, women working in the trenches of science, contributing to the enterprise of STEM in ways big and small. Women like Arlene Frances Fung, whose bio tells us she was born in Trinidad, went to medical school in Ireland, and by 1968 was engaged in chromosome research at a cancer institute in Philadelphia. From Trinidad to cancer research, her story is one of the millions we could tell about women’s historical contributions to science, if only we could find them all. But here there are 72, and we encourage you to click on each image, look at their direct gazes, ponder how their interest in science and knowledge trumped the heavy pressures of social mores, and discover the contributions these 72 women made, each on her own “little two inches wide of ivory.”
For more on historical and current women in science, you can also see Double X Science’s “Notable Women in Science” series, curated by Adrienne Roehrich.
And then there are the women STEMmers of today, who likely are, according to blogger Emma Leedham writing at her blog Pipettes and Paintbrushes, still underpaid. Leedham also mulls here what constitutes a role model for women–does it require being both a woman and a scientist, or one or the other?
Laurel L. James
Laurel L. James, writing at the University of Washington blog for the school’s SACNAS student chapter, answers with her post, “To identify my role as a woman in science: I must first honor my mother, my family and my past.” Her mother was the first “Miss Indian America,” and Laurel is a self-described non-traditional student at the school, where she is a graduate student in forest resources. She traces her journey to science, one that involved role models who were not scientists but who, as she writes, showed her “how to hang onto the things that are important with the expectation of getting something in return all the while, persevering and knowing who you are; while walking with grace and dignity.” I’d hazard that these words describe many a woman who has moved against the currents of her society to contribute something to the sciences.
A great site, Steminist.com, which features the “voices of women in science, tech, engineering, and math,” runs a series of interviews with modern-day STEMmers, including Double X Science’s own Jeanne Garbarino, and Naadiya Moosajee, an engineer and cofounder of South African Women in Engineering. You can follow Naadiya on Twitter here. Steminist is also running their version of March Madness, except that in honor of Women’s History Month, we can choose “Which historical women in STEM rock (our) world.” The 64 historical STEMinists in the tourney are listed here and include Emily Warren Robling (left), who took over completion of the Brooklyn Bridge when her husband’s health prevented his doing so; she is known as the first woman field engineer. Double X Science also has a series about today’s women in science, Double Xpression, which you can find here.
Today, you can find a woman–or many women–in STEM just about anywhere you look, whether it is as a government scientist at NOAA like Melanie Harrison, PhD, or at NASA. It hasn’t always been that way, and it can still be better. But women have always been a presence in STEM. In the 18thand 19th centuries, astronomer Caroline Herschellabored away through the dark hours of just about every night of her adult life, tracking the night sky. Today, women continue these labors, and STEM wouldn’t be what it is today without women like Herschel willing to stay up all night with the skies or spend days on end in the field or lean over a microscope for hours just to add a tiny bit more to what we know about our world and our universe.
For women in science, we’re there–at night, in the lab, in the field–because we love science. But as the non-science role models seem to tell us, we stick to it–and can stick with it–because we had role models in and out of science who showed us that regardless of our goals, our attitudes and willingness to move forward in spite of obstacles are really what drive us to success in STEM careers. Among the links I received for this carnival was one to Science Club for Girls, which is sponsoring a “Letter to My Young Self” roundup for Women’s History Month. The letters I’ve read invariably have that “stick with it” message, but one stood out for me, and I close with a quote from it.
It’s a letter by Chitra Thakur-Mahadik, who earned her PhD in biochemistry and hemoglobinopathy from the University of Mumbai and served as staff scientist a Mumbai children’s hospital for 25 years. She wrote to her younger, “partially sighted” self that, “The future is ahead and it is not bad!” She goes on to say, “Be fearless but be compassionate to yourself and others… be brave, keep your eyes and ears open and face the world happily. What if there are limitations? Work through them with awareness. –Yours, Chitra”
Links and resources for women in STEM, courtesy of D.N. Lee
Stay tuned for the April Diversity in Science Carnival #15: Confronting the Imposter Syndrome. This topic promises to resonate for many groups in science. I’m pretty sure we’ve all felt at least of twinge of imposter syndrome at some point in our education and careers. Your editor for this carnival will be the inimitable Scicurious, who blogs at Scientific American and Scientopia.
UPDATE: Carnival #15 is now available! Go read about imposter syndrome, why it happens, who has it, and what you can do about it.
Are some of these possible signs of breast cancer present in a famous work of art? Image: public domain, US gov
by Liza Gross, contributor
[Ed. note: This article was originally posted on KQED QUEST on October 3, 2012. It is reposted here with kind permission.]
Just a generation ago, October belonged to the colors of fall, when “every green thing loves to die in bright colors,” as Henry Ward Beecher said. (Growing up back East, you read a lot of odes to fall foliage in school.) For years after moving to the Bay Area from Pennsylvania, I felt a twinge of melancholy when October rolled around, knowing the once-demure woodlands would let loose in a fleeting blaze of brash reds and orange-tinged yellows without me.
Now, of course, October belongs to all things pink, as high-profile outfits from the NFL to Ace Hardware set aside 31 days to raise awareness and money for Breast Cancer Awareness Month. (National Breast Cancer Awareness Month was launched in 1985 by CancerCare, a nonprofit cancer support group, and cancer-drug maker AstraZeneca.)
But as women’s health advocate Dr. Susan Love says, awareness of the disease isn’t the issue. “When the NFL is wearing pink gloves, I think you can say we’re aware,” she said last year. “But the awareness isn’t enough.”
It’s a message that gets lost in an ocean of pink-ribbon products (from bagels and teddy bears to vodka and wine glasses), even though critics like the San Francisco-based nonprofit Breast Cancer Action have warned about “pinkwashing” for years, urging people to look behind the feel-good messages to see who’s really benefiting from the commercialization of cancer.
Breast Cancer Action’s Think Before You Pink—Raise a Stink! campaign encourages consumers to think critically about pink products and ask four simple questions to find out what proportion of proceeds go to breast cancer programs and whether the products sold are safe. The group has especially targeted cosmetics companies for marketing pink merchandise even as they sell products with toxic ingredients. (For more information, download the group’s 30-page “toolkit”.)
The group also urges companies to be more transparent and has long called out those it believes use a good cause to increase their bottom line.
Like Eureka, which donated a dollar for every vacuum cleaner sold in its “Clean for the Cure” campaign. Or American Express, which donated a penny per transaction in its “Charge for the Cure.” Both companies bowed out of the pink sweepstakes after Breast Cancer Action asked just how breast cancer patients were benefiting from the campaigns in a 2002 ad in the New York Times.
In October 2000, the San Francisco-based advocacy group
Breast Cancer Action ran a full page ad in the New York Times
West Coast Edition with text (not shown) inviting readers to
participate in its ”Stop Cancer Where It Starts” Campaign.
The campaign criticized breast cancer awareness campaigns
for pushing early detection and mammograms
(without acknowledging their limitations) while ignoring prevention.
(Image: Courtesy Breast Cancer Action)
Others, like KFC with its 2010 “Buckets for the Cure” campaign, climb on the pink bandwagon to peddle decidedly unhealthy products. Stephen Colbert’s take on the “pink bucket dilemma” shows just how ludicrous cause marketing has become. (Forward to 1:13.)
But even when money goes to breast cancer programs and not corporate coffers, is it going to the right place? Love (and several advocacy groups) has said for years that we need to shift our focus from cures to causes—and prevention.
If we can develop a vaccine for cervical cancer, says Love, why not for breast cancer? Early results of a clinical trial show promising results for a vaccine designed to prevent recurrence of one form of breast cancer. (The data were presented at a meeting and have not yet gone through peer review.)
As I wrote in May, Love’s Research Foundation is looking for volunteers in her online Army of Women to identify potential causes in order to eradicate the disease. (Anyone can sign up.)
In the late 1990s, The Breast Cancer Fund, the American Cancer Society,
and the Susan G. Komen Breast Cancer Foundation invited American
artists and writers to submit work about their breast cancer experiences.
The resulting exhibit (and book)—Art.Rage.Us.—opened in 1998
at San Francisco’s Main Library. At the time, project coordinator and
Breast Cancer Action Co-founder Susan Claymon said,
“Art.Rage.Us. presents deeply moving and beautiful expressions
from women with breast cancer, along with intensely personal
statements that provide a window into their hearts and minds.”
Claymon died of breast cancer in 2000. She was 61.
Prevention is also a primary concern for the Athena Breast Health Network, a partnership of the five University of California medical centers that collects personalized data on breast cancer patients to optimize treatment and ultimately figure out how to stop cancer before it starts. The site also includes a comprehensive list of breast cancer risk factors.
Recent research suggests that the biology behind one of the listed risk factors, dense breast tissue, may be more complicated than previously thought. Earlier studies found that women with dense breasts had a higher risk of developing breast cancer. (And this finding led to the“right to know” legislation that Gov. Brown recently signed, requiring doctors to tell women if their mammograms show they have dense breasts.) But a recent study in the Journal of the National Cancer Institute suggests that women with denser breasts are not more likely to die of breast cancer. The greatest risk was found for women who had the fattiest breast tissue, a condition linked to obesity. This suggests that if you have dense breast tissue, you may be more likely to get cancer—but not die of it. Love’s blog explained the significance of the findings:
The recent study on breast density showed us, yet again, that women who are obese when they are diagnosed with breast cancer are more likely to die of breast cancer than women who are not obese. Doctors need to do more than tell women about their breast density or remind them to get a mammogram. They need to be teaching women the importance of exercising, losing weight (if necessary) and eating a well-balanced diet—both before and after a breast cancer diagnosis.Continue reading →
My workaday business is scientific editing. I just completed a behemoth job of hundreds of pages, all focused on reporting the findings of clinical trials (meaning trials involving humans instead of other animals) of a drug that keeps people alive. Among those trials was one in which healthy people participated, which is one way that companies who develop therapies test their treatments. It’s important to know what outcomes are in healthy people as well as those who are targets of the therapy. I read in these papers how the healthy people responded to the therapy–how they underwent needle sticks for blood draws so that researchers could analyze seemingly every last chemical in their blood, how they dealt with side effects minor and greater, including headaches, vomiting, and other distress, and how their participation helped researchers determine the need for a lower dose. As I read about them and the details of their participation, I though, “Wow.” Here are these healthy people entering clinical trials–yes, they do get paid–and their participation helps guide the application of these therapies for people who would die without them. That is some citizen science. If you’ve ever taken an FDA-approved drug for anything, you’ve benefited from these people–paid or unpaid–who have entered into clinical trials. We’re all beneficiaries of their contributions, their blood draws, urine samples, headaches, gastrointestinal distress, and time away from their families. And when it comes to women, we can contribute to these trials in many, many ways. Becoming a part of clinical research means being a part of the practice of science. When I think of the importance of women in clinical research, I think about women like Elizabeth Glaser, who established the Elizabeth Glaser Pediatric AIDS foundation before she–and one of her two children–died of AIDS. Part of the foundation’s focus is funding research into AIDS prevention and cure in children. Elizabeth contracted HIV while receiving a blood transfusion during the birth of her daughter, Ariel, and she passed the virus to both her daughter and her son, Jake, who followed. Ariel died in 1988, but Jake is now a healthy adult, still alive in part thanks to his mother’s work to fund research and to people who participate in clinical trials for therapies against HIV/AIDS. Today, December 1, is World AIDS Day. The theme for this year’s day is, “Leading with science, uniting for action.” Since the advent of the first-reported cases of HIV in 1981, more than 25 million people have died of AIDS worldwide. In 2008, 2 million people died, in spite of therapies that now save lives. Almost everyone who now lives with HIV lives in low- and middle-income countries and has no access to these effective therapies. There still is no cure for HIV. In the United States, about 1 million people have an HIV infection. Of these, women represent about 27% of new infections each year and 25% of those infected. Clinical trials are one critical way that these women–and their children–can have medical interventions they need to remain healthy. It is one way to lead with science, to unite for action. Not every day is World AIDS Day, but every day, someone, somewhere–a woman, mother, sister, daughter–needs medical interventions. Historically, women have been underrepresented in clinical studies. Mother, scientist, and four-time breast cancer survivor Susan Niebur, now in deep pain from metastatic breast cancer, has called–repeatedly–for more research into fighting metastatic breast cancer. As she notes, no woman survives this cancer. Thirty percent of cases of breast cancer progress to metastatic (spreading) breast cancer, yet only 3% of funding goes to researching it, even as most women diagnosed with it die within three years. Niebur observes that wearing a ribbon does not cure cancer. She writes, “I just want more time.” Part of giving women with breast cancer more time is participating in clinical research studies–studies that need both women who have cancer and women who do not–so that research can advance, drugs in the pipeline can move forward in testing. As Niebur has written, we need an Army of Women willing to get into the trenches of research, get needle sticks, give up urine, and possibly vomit occasionally, so that other women–all women–can benefit from clinical research. If that need on behalf of other XXers isn’t sufficient, keep in mind that participation in trials can also include other benefits. More and more women are finding that participation pays, literally, sometimes in the thousands of dollars. But it’s not just the money–some women have even reported that their participation has led them to better health, given them more time to spend with their children as they make this money in a few days at a time throughout the year. These are not trivial benefits, and the contributions women make when they participate in trials are not trivial either. Would you like to learn more about clinical trials, how they work, and where you might find one in which you could participate? A place to start is ClinicalTrials.gov, a database of ongoing and past trials in the United States and around the world. After all, in spite of all of those personal benefits for a participant, the most important part for those who suffer and die is that you participate. In this case, you do not ask science what it can do for you. You ask, on behalf of girls and women and everyone everywhere, What can you do for science? Emily Willingham