Probably the most important breakthrough in breast cancer in the last thirty-five years has been the realization that earlier detection can result in lowered mortality from the disease—that finding the cancer earlier can save lives. This hopeful premise was developed as a result of three known but apparently unrelated facts.
1. Over 90 percent of breast cancer is detected by the woman herself. She finds her lump or “tumor,” becomes uneasy, rushes to her physician after more or less delay while she hopes the abnormal mass will disappear, and tells him that last week or the night before she found this little lump and “Of course, it does not bother me and so it’s nothing. Right?” Her physician is faced with a very apprehensive woman whom he would like to reassure. He is often under considerable pressure to follow a “wait and see” attitude with what may be a questionable lump. Eventually, if the mass is a definite and persistent one, it will be brought to the hands of a surgeon who will remove it and make a definite diagnosis.
It is, however, the woman herself who starts the train of events as the result of a lump or pain or nipple discharge. These days, when women realize more and more the value of a regular, complete physical examination with a Pap smear (named after its developer, Dr. Papanicolaou) to evaluate the neck of the womb, it is common for the gynecologist or other clinician to examine the breast routinely, and significant trouble is sometimes discovered in this way. Occasionally an abnormality is detected in the course of a screening examination offered with the specific purpose of finding a breast cancer earlier.
2. It has been known for many years that, regardless of how extensive a surgical procedure has been performed or whether X-ray or cobalt therapy has been used in conjunction with surgery, if there has been no involvement of glands in the armpit (known as axillary lymph nodes) at time of surgery, over 85 percent of the women will be alive and well five years after surgery. If, however, such glands have been involved with cancer, only about 50 percent will remain well. The obvious conclusion must be that the overwhelming factor determining the outcome is the extent of the disease at the time of operation. If the cancer is localized to the breast, the outcome is far more favorable. If the process has extended beyond the breast, the chances of complete recovery are far fewer. The lesson to be learned is: “Find the cancer when it is still only in the breast, the earlier the better.”
This concept, however, needed proof. Perhaps, it could be argued, those cancers which turned out to have no glandular involvement were actually milder cases. Perhaps, it was said, the overall death rate would be the same. Indeed, there had been mass screening examinations at cancer-detection centers using clinical examination only with very little effect on the mortality rate. Something else was needed.
3. That something was the procedure known as mammography. This examination, which is merely a simple X-ray study of the breast without injection of any material and with only minimal handling of the breast, has a history extending back practically to the discovery of X rays at the very end of the last century. The first authenticated use of the procedure was in 1913. Over the years it had been advocated as a useful examination in France, Germany, Italy, the United States, and particularly Uruguay, where Dr. Raoul Leborgne emphasized its value in making breast-cancer diagnosis more accurate. He also clearly described X-ray findings of cancers before they could be felt. Although there was a flurry of activity in the 1930s and 1940s in the United States, the technique was discarded by most physicians for its uncertain results. Its praises continued to be sung, however, by Dr. Jacob Gershon-Cohen in Philadelphia, by Dr. Charles Gros in Strasbourg, and Dr. Leborgne in Montevideo, in addition to others in different parts of the world. As a matter of fact, mammography continued to be used increasingly, particularly in France, Germany, Italy, and Holland.
About 1960, Dr. Robert Egan in Houston presented his variation in technique of X-ray examination of the breast, which aroused the keen interest on the part of the Cancer Control Program of the National Institutes of Health. His technique proved to be reproducible by others, who found that they also could achieve an acceptable accuracy of interpretation quickly. A dozen centers were soon established for indoctrination of radiologists, and mammography was launched on its career as a useful method in the diagnosis of breast diseases.
If we think about these facts a bit, an obvious remedy suggests itself. Why not have women examined when they are apparently well, before they find lumps, examine them with palpation and the X ray, and ferret out the cancers at an earlier stage? Then we might ask: If we did find cancers in an earlier stage, would it make a real difference in how long a woman would live? Could she really be cured if the cancer were found earlier? And if this were so, how much would mammography contribute to the final results?
The author, a radiologist, early saw the potential of this “old-new” technique, and was in charge of one of the training centers located in New York City. The first mammogram, or X ray of the breast, seen by the author in Dr. Egan’s laboratory at the University of Texas M. D. Anderson Hospital and Tumor Institute in Houston, was of a breast cancer which could not be felt at the time of operation but which had been discovered at the X-ray examination. The concept that herein lay a method for detection of breast cancer in a prepalpable stage took root and blossomed into the next phase of the story—a screening program in which women at random would be examined for breast cancer with the hope that earlier diagnosis might lead to a reduction in the mortality rate from this disease.
But first let’s consider what is meant by “screening.” By way of illustration, suppose you have a plastic bag filled with sand. Interspersed with the sand are pebbles of sizes and shapes varying from very tiny to very large, some round and some irregular. If you feel the bag quickly, you can probably pick out the fairly large pebbles. If you are more careful, you can probably detect some of the smaller ones. But you will probably miss the real small ones. If you now pour the sand through sieves with smaller and smaller holes, you will catch more and more of the smaller pebbles. If you vary the type of hole in the sieve, you may pick up irregular stones as well as smooth round ones.
Screening is really like using sieves to detect abnormalities. In the breast, most abnormal lumps can be found by palpation. Some lumps can be found only by the shadow they produce on an X ray. Some are detected by the increased heat they register on a thermogram. Some are too small to be detected by any of our present techniques. These may show up a few months later when they have grown large enough for our finest sieves. The screening process also presupposes that we are examining women who have not detected anything wrong with their own breasts and are coming in for just a checkup. Of course, it is at such times that the screening process—by adding the different techniques in tandem—will be more likely to find abnormalities in their earliest stages when they are most amenable to treatment and cure.
In 1963 a carefully conducted statistical study was begun by the Health Insurance Plan of Greater New York under contract with the National Institutes of Health. The study, initiated by the author, was supervised by Sam Shapiro, vice-president of the Health Insurance Plan and in charge of research and statistics, and by Dr. Michael B. Shimkin, then associate director of the National Cancer Institute.
The Health Insurance Plan is a prepaid subscriber plan that offers comprehensive medical care through thirty-one medical groups located in Greater New York. For the study, 62,000 women were chosen from twenty-three of the groups to participate in the program. These women, aged 40 to 64, were chosen at random as 31,000 carefully matched pairs. In this way 31,000 women were then designated as the control group, while their counterparts constituted the study group.
Women in the control group received their usual medical care when they applied for it. Over the years, many of them developed breast symptoms and visited their group physicians for care. Some required breast operations, and occasional cancers were found and treated. The 31,000 women of the study group, on the other hand, were invited to come in for an extensive interview for data that might be helpful in future studies, a clinical examination, usually by a surgeon of the group, and mammography or X-ray study of the breasts. The examination was repeated three additional times on an annual basis. After the third annual examination, no further studies were made. Enough time has now elapsed for statistical comparison of the two groups of women.
The results of a six-year follow-up of all women showed a remarkable reduction in the number of deaths from breast cancer in the study group as compared with those in the control. The one-third reduction in mortality persisted into the seventh year of follow-up. After six years of follow-up, one-third fewer women died of breast cancer in the study group than in the control group. Treatment in both groups was the same. The characteristics of the women—age, number of children, family history, etc.—were the same. The only difference was the periodic breast examination, which included mammography. This difference accounted for a remarkable saving of lives. One could say that if the control-group women had been exposed to the same examination, perhaps one third of those who have died would still be alive today. These are striking statistics.
Furthermore, when we evaluated the specific role of mammography, there were some startling conclusions. The clinical and the X-ray examinations were done independently so that neither clinician nor radiologist knew of the findings of the other. In this way, one could know which method led to the cancer diagnosis.
It is a known fact that in regular medical practice, when a breast cancer is suspected on clinical examination and the patient is referred to a radiologist for an opinion on mammography, both physicians will agree on the diagnosis in over 80 percent of proven cases. Only occasionally is a cancer suspected on the basis of X-ray findings without some abnormality on palpation. It is also unusual for a cancer to be obvious to the clinician and not apparent to the radiologist.
Much to the surprise of everyone, one third of the cancers found in the Health Insurance Plan study were not felt by the clinician. At the same time, two fifths of the cancers were noted by the surgeon, but not detected by the radiologist. In only one fifth of the cases were the cancers found by both physicians. More important, in the control group, fewer than one half of the cancers were localized to the breast and showed no evidence of spread to the armpit glands at operation, while in the study group, three quarters of the cancers were localized to the breast.
The most striking fact to come out of the study is that out of forty-four cancers found only by mammography and not felt by the clinician, only one woman died in a five-year period of follow-up.
The study, therefore, has proved that persuading women to undergo examination, which includes palpation and mammography, can save a substantial proportion of those with breast cancer. It also has told us that an examination must include not only the usual clinical examination (palpation), but also the X-ray study, if absence of even one of these methods would result in the missing of too many cancers in the earlier stages when treatment is so successful.
The author, however, was not satisfied. The techniques used in the H. I. P. study were too time-consuming, too expensive, and too tiring to the patient and technician alike. He also felt that since well women were being examined repeatedly, the radiation dosage used should be reduced to very minimal, altogether safe levels. The new technique of thermography, also, had come to the fore and appeared to be sufficiently promising as a detection method to warrant inclusion in the screening examination.
This information led to the creation of the Stella and Charles Guttman Breast Diagnostic Institute in New York City in 1968. Initiated with funds from Charles Guttman, a New York City philanthropist with a life-long interest in helping his fellowman, especially in the medical field, the organization has operated in close association with the American Cancer Society, New York City division. The author is medical director of the Institute, and has collaborated closely with Mr. Salvatore Cicetti, executive director of the American Cancer Society, New York City division, to devise an efficient, accurate, economical, and safe method to include all important procedures for a thorough breast examination. Also, steps have been taken to train paramedical personnel to assist physicians in the screening process. Various avenues have been explored to stimulate women at risk of breast cancer to accept and even seek breast examinations when they have no symptoms. Such measures are especially necessary in low-income groups.
The Institute has received financial support from the American Cancer Society, the National Cancer Institute, several foundations including the Stella and Charles Guttman Foundation, the Bruner Foundation, the William G. Connell Foundation, and the Damon Runyon Memorial Fund, as well as the United Order of True Sisters, the Cancer 18 Group, and many private individuals. No charge is made for its screening services, which are available to all women living in New York City. An examination is given, which includes a medical history, a clinical examination, mammography, and thermography.
Particularly gratifying is the success of the Guttman Institute in developing a practical method for earlier breast-cancer detection, and the impact this has had on the national scene. The American Cancer Society, which initiated the idea of multiple screening centers in the United States, has been joined by the National Cancer Institute in developing and funding a network of twenty-seven demonstration projects involving twenty-nine institutions throughout the United States, to determine whether mass screening for breast cancer is practical. Each project has agreed to screen at least 5,000 women a year, for two years, using the methods of clinical examination, mammography, and thermography. Successful projects will continue for at least five years. Emphasis will be placed on the use of volunteers and staff of divisions and units of the American Cancer Society to encourage all women in the community to have this thorough examination.
In this way, a mechanism has been developed to tell all women that methods for saving lives from breast cancer are available and that women owe it to themselves and their families to take advantage of this new hope.