After digesting the news that the frequency of mammograms should be cut back, that clinical breast examinations are no longer recommended and that routine self-exams that were so long promoted as lifesavers aren't useful either, women and health professionals are divided into two major camps: the angry doubters of the science vowing business as usual and those resigned (grudgingly or not) to accept the evidence and change their ways.
But in the wake of the controversial new breast cancer screening guidelines, there is one response that is common to almost all women: "What the hell do I do now?"
For the past generation, as breast cancer survivors and their loved ones built a powerful social movement, a couple of key messages have been hammered home: 1) Breast cancer is a major killer of women; and 2) Spotting cancer early with screening is your best defence.
But in the enthusiastic push to inform and empower – most of it well meaning, but some of it commercially driven – those messages have been perverted.
It is fine to embrace pink ribbons, walks for the cure and the like, but not at the expense of science and context.
So, first and foremost, women need a bit of a reality check.
Yes, breast cancer is a major killer. An estimated 5,100 Canadian women (and 55 men) will die of breast cancer this year.
But these cases occur overwhelmingly in women in their 70s and 80s. That is not to suggest they are unimportant, but we will all die of something.
Three in four Canadians die of cancer or cardiovascular disease – which are, above all, diseases of aging (and, to a lesser extent, of lifestyle and socioeconomic status).
Many scary statistics are trotted out but the bottom line is this: The average woman has a 3-per-cent lifetime risk of dying of breast cancer.
Your breasts are not ticking time bombs. Young women – with few exceptions – are not dying of breast cancer.
Still, if we can prevent women (and men) from developing breast cancer, if we can minimize their suffering by delaying the onset of symptoms, if we can extend survival in cancer sufferers with better treatments, we should.
But how do we do so?
In recent years, the philosophy we embraced was this: Spot a cancerous tumour early, eliminate it (with surgery, radiation or chemotherapy), and cancer will be beaten and mortality reduced.
We invested heavily in screening: Mass mammography screening programs were developed; women were urged to do routine breast self-examination at the same time every month; and physicians and nurses were trained in clinical breast examination.
We also invested in research, and the research told us that the basic theory – screening saves lives – was sound but our methods needed refining. The research underscored that screening could also result in harm, in the form of overtreatment.
The new breast cancer screening guidelines, drafted by the Canadian Task Force on Preventive Health Care, reflect the science. But given the firestorm of controversy that erupted since their publication, it's worth repeating what the guidelines actually say, not what critics – and to a lesser extent supporters – say they say:
1) The task force said women aged 50 to 74 should have screening mammograms every two to three years. (In many provinces, screening is offered annually beginning at age 40.) The task force did not reject screening mammography. Rather, it said screening works best in postmenopausal women with the caveats that more is not better and earlier is not better.
2) Routine clinical breast examinations and breast self-examination are no longer recommended because they do more harm than good.
The task force did not say women should not be aware of changes in their breasts; on the contrary, it noted that more than half of cancers are detected in this manner. What it said is that doing systematic checks – examining your breasts each month at the same point in your menstrual period, as used to be counselled – confers no real benefit.
These recommendations, of course, do not apply to high-risk women, for example, those with a personal or family history of breast cancer, or who have tested positive for the breast cancer genes BRCA1 or BRCA2.
But we have to dispense too with the attitude that everyone is at high risk; going for a mammogram every two to three years is just fine for the vast majority of women.
Finally, let's not forget that screening is not prevention. It's a way of accelerating treatment (and too often unnecessarily). We're not going to screen our way to reductions in breast cancer incidence and mortality.
Rather, we need to invest in better treatments for women who do have cancerous tumours.
But, above all, we need to invest in real prevention – in understanding and promoting interventions that prevent cancer.
Here's what we know works: Being physically active, eating well, maintaining a healthy weight, not smoking, moderate consumption of alcohol, limiting exposure to estrogen (which is highly complex given the hormone's role in the reproductive cycle) and radiation (including mammograms). We know too that being poor, lacking an education and living in an unsound environment all hike your risk of breast cancer.
There is no magic prevention tool. But neither is breast cancer a sword of Damocles hanging over the head of every woman.
Hopefully, the changes in the guidelines have helped raise awareness – about the real level of risk, about the importance of evidence, about the limitations of technology, about the need to be more in touch with our bodies and ourselves.
So, in answer to the burning question from those concerned about their risk of breast cancer: "What the hell do I do now?"
Well, live well. Get screened – but not excessively. Be in tune with your body.
Don't be frightened. Be aware. And alive.