A lesion detected in a routine mammogam was the start of a nightmare for Alison Cantle.
While breast screening plays a vital part in cancer treatment, a false alarm can be disastrous
When Alison Cantle was recalled after her first mammogram two years ago, she was deeply upset. Her family history was ominous: her mother had fought breast cancer twice, and an aunt had died of the disease. "I felt sick," she says. "I was so worried, I read the letter five times."
Her second appointment was not reassuring. Alison, 54, a client services director from Fleet, Hampshire, and her husband Stephen, a businessman, found the atmosphere at the special breast cancer clinic distressing. "It was awful; the waiting room was full of frightened, crying women.’
When she entered the radiology room for her mammography, she saw an X-ray on the light box. "I remember looking at it and thinking, ‘Oh poor woman’, as it was obvious there was a large lesion on one of the breasts. Then I noticed my name on the bottom of the X-ray. I felt cold."
Around 1.5 million women, aged between 50 and 70, are screened routinely every year under the NHS National Breast Screening programme; five per cent of them will be recalled. For most, a second screen will clear them of cancer. But for just under one per cent, the process will lead to further investigations, the majority of which will confirm breast cancer.
Alison’s case was unusual, though. Her mammogram revealed a complex sclerosing (a thickening/hardening of tissue) lesion, also known as a radial breast scar – a star-shaped density that shows up on X-rays and which may, in a handful of cases, be hiding a cancer. Radial scars are rare: consultant radiologist David Grieve, of Spire Thames Valley Hospital, and the Heatherwood and Wexham Park NHS Trust, says that one in 2,500 women attending his unit are diagnosed with one – approximately six a year. Prior to the advent of screening, they were only discovered by chance, post-operatively.
"Radial scars are a benign abnormality probably due to inflammation or hormonal changes," says Dr Grieve. "They appear on a mammogram as lines radiating out from a centre, just like a malignant tumour. But they are a very definite type of tissue, and a diagnosis can be confirmed by pathologists after a biopsy.
"Unfortunately, this still doesn’t rule out the possibility that somewhere in the rays of the scar there are cancerous cells which may have been missed by the biopsy. In which case, policy – decided by a multi-disciplinary team including radiologists, oncologists, pathologists and other health care professionals – has traditionally been to remove the area of tissue to be on the safe side."
Alison’s radial breast scar brought her into the category of women who are exposed to the fear of cancer, without necessarily the risk – a group that some experts are concerned is becoming too large.
Screening has had a major impact on the fight against breast cancer: the World Health Organisation’s International Agency for Research on Cancer found a 35 per cent reduction in mortality from breast cancer among screened women aged between 50 and 69, and concludes that out of every 500 women screened, one life will be saved. Yet a report from the Nordic Cochrane Centre (the Scandinavian arm of the independent healthcare review organisation known as the Cochrane Collaboration) on breast cancer and screening published in the British Medical Journal in February suggests that for every woman whose life is saved, 10 other women will undergo unnecessary treatment. They may have surgery to remove a lump or even all of their breast, followed by chemotherapy or radiotherapy. Another 200 women will endure the worry and distress of a false alarm.
Dr. Karsten Juhl Jørgensen, a researcher at the institute, said: "Our main concern was that women are not being informed about the dangers of over-diagnosis. The invitation for screening is focused on the benefits, but doesn’t mention the potential harm; the psychological consequences are underestimated. We’ve recognised for a long time that over screening in prostate cancer is dangerous but we have neglected breast cancer."
The study was welcomed by leading British specialists, including Professor Michael Baum, a key figure in the establishment of the NHS breast screening programme who has subsequently questioned its value. He has warned that some cancers detected through screening "might never appear in a woman’s natural lifespan", that women are being over-diagnosed and over-treated, and there is a failure to provide them with the full facts.
Alison Cantle fell into the last group. After three mammograms, she was told that the results were inconclusive, and she would need a biopsy. "By this time I was numb," she says. The specialists took 13 "core" samples of tissue from the area. "The instrument they use is like a hole punch," says Alison now, with a shiver. She waited three weeks for the results.
The news was good – and bad. The surgeon told her that she didn’t have cancer but she still needed a "wee operation" as the radial scar could be "hiding" a cancer. Alison says: "Neither Stephen nor I could understand it. My husband is a former medical journalist and used to interviewing doctors, so he pressed for more answers, statistics, information. But still we felt rather brushed off. They were insisting that I needed to be operated on."
Alison decided to research the issue herself, and discovered that radial scars were largely unknown before mass screening programmes were introduced. She also learnt that about seven per cent of radial scars hide a cancer. This has led to a decision in some areas – including Surrey and Hampshire where Alison was being treated – that the area of breast tissue behind a radial scar must be cut out.
Alison was not happy about having a lumpectomy. She was convinced by her own research that cancer was unlikely, but felt under too much pressure not to agree to the operation. "The surgeon just told me there was a risk; and with my family history, I felt I had to accept that."
But when she returned to hospital some weeks later for the procedure – "with a heavy heart" – another surprise was in store. "The radiologist took a mammogram to pinpoint the area of excision but she couldn’t find any scar at all. It had simply vanished." The operation was cancelled.
The Daily Telegraph