Breast Cancer Screening: Paternalistic, Sexist, Say Critics

Not Just Semantics

Nick Mulcahy

April 25, 2012

April 25, 2012 — A retired American academic turned healthcare blogger has charged that breast cancer screening in the United States is "sexist."

Carole Schroeder, PhD, RN, emeritus associate professor at the University of Washington School of Nursing in Seattle, writes in her CancerRealityCheck blog that mammography screening is recommended to women "sans discussion." This is in contrast to prostate cancer screening guidance for men, which "professional organizations, advocacy groups, and the media" all now say should be an "informed choice," she states. This means that physician–patient discussion about screening harms and benefits is recommended.

A bit of paternalism or what?

"A bit of paternalism or what?" writes Dr. Schroeder about this difference in screenings in her post, entitled Sexism in Cancer Screening: PSA and Mammography.

She was inspired to write her blog post after a recent essay in the Journal of the National Cancer Institute (2011;103:1821-1826), which called for "shared decision making" in cancer screening.

In that essay, a research officer at a major university said that the medical community has "unintentionally adopted a very paternalistic stance" toward women with regard to breast cancer screening.

Breast and prostate cancer screening suffer from a "similar ambiguity of evidence," wrote Michael Edward Stefanek, PhD, associate vice president of collaborative research in the office of the vice president at Indiana University in Bloomington.

Despite this similarity, said Dr. Stefanek, guidelines "have typically recommended that men make informed decisions about prostate cancer screening," whereas women have been "summoned" to breast cancer screening.

Dr. Schroeder was encouraged to see Dr. Stefanek's call for shared decision making in cancer screening.

But in an interview with Medscape Medical News, Dr. Schroeder said that sexism is a more accurate term than paternalism to describe what is happening in cancer screening.

Sexism More Than Paternalism

Paternalism is sometimes needed in medicine, but sexism is wholly inappropriate, said Dr. Schroeder. "Paternalism is expected in medicine in really complicated cases," she said, adding that at times healthcare professionals have to make judgment calls with patients. However, "sexism reflects institutionalized discrimination against women," she said.

This is not merely a matter of semantics, noted Dr. Schroeder. "Sexism maintains power differentials. It's all about power. It's not happening by chance," she told Medscape Medical News.

There is a great deal of money at stake in cancer screening, she pointed out.

If that is true, then why wouldn't the medical community also summon men to prostate cancer screening?

We reflect in our screening what goes on in our society.

"It's more socially acceptable for a woman to be told what to do by a man than it is for a man to be told what to do by another man," Dr. Schroeder explained. "We reflect in our screening what goes on in our society."

In the United States, medicine is based on a "male model" of healthcare and is dominated by men, she argued. Evidence of this can be found in many arenas, including income. Female radiologists, for example, make less than their male counterparts, she said, citing the Medscape Physician Compensation Report: 2012 Results.

American guidelines for breast and cancer screening reflect broad stereotypes about women and men, Dr. Schroeder said. For instance, "women aren't good at math, women are 'less than' and need to be taken care of"— and are thus advised to be screened for breast cancer. However, stereotypes indicate that men are good at math and can take care of themselves — and are thus advised to rationally review prostate cancer screening with their doctor, she explained.

Harms and Benefits and Timing

In his essay, Dr. Stefanek said that any "sex-based difference" between prostate and breast cancer screening is in need of scientific review.

"We must...question whether our practice of summoning women to have mammograms, while providing men informed choice for prostate cancer screening, is consistent with a scientific analysis of the relative harms and benefits," he wrote.

The harms and benefits of breast cancer screening, especially in healthy women, have been increasingly discussed and debated in the past few years.

In 2010, H. Gilbert Welch MD, MPH, from the Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, in Lebanon, New Hampshire, said that there is "a delicate balance between modest benefit and modest harm" with mammography screening in healthy women. Dr. Welch, who is one of the most prominent analysts and critics of cancer screening in the United States, and the author of Should I Be Tested for Cancer?, wrote this assessment in an editorial published in the New England Journal of Medicine (2010;363:1276-1278), which accompanied a Norwegian population-based study of the country's breast cancer screening program (2010;363:1203-1210).

In his editorial, Dr. Welch estimated that a 10-year course of screening mammography for 2500 women 50 years of age would save the life of 1 woman from breast cancer. At the same time, up to 1000 women would have had a "false alarm," and about half of those would undergo biopsy. Furthermore, breast cancer will have been overdiagnosed in 5 to 15 women, who would have been treated needlessly with surgery, radiation, or chemotherapy, alone or in combination.

Whatever the exact ratio of harms to benefits with breast cancer screening, critics such as Dr. Welch, Dr. Stefanek, and Dr. Schroeder all make the point that discussion of them is not routinely advised by organizations that issue guidelines.

Guidance about prostate cancer screening is now on its way to becoming a different story.

In October 2011, the US Preventive Services Task Force (USPSTF) issued draft recommendations against routine screening for prostate cancer using the prostate-specific antigen (PSA) test in healthy men. However, the PSA story did not erupt in the media like the furor that followed the release of the USPSTF breast cancer screening recommendations in 2009, and there were no press statements protesting the guidelines from prominent oncology organizations. In the end, urologists and the American Urological Association seemed to be alone in their fight against the recommendation. The final USPSTF recommendation is due this spring, and it will likely reopen the debate.

The recommendations of the American Cancer Society (ACS) for prostate and breast cancer screening of healthy adults provide a good example of just how different the guidance is for the 2 cancers.

In a review of the ACS Guidelines for the Early Detection of Cancer, published online, Medscape Medical News found that the ACS recommends annual mammography screening for healthy women older than 40 years, with no mention of either a patient–doctor discussion or harms related to screening, such as unnecessary biopsies.

The prostate cancer recommendation is very different.

"The American Cancer Society recommends that men make an informed decision with their doctor about whether to be tested for prostate cancer. Research has not yet proven that the potential benefits of testing outweigh the harms of testing and treatment."

Dr. Schroeder suggested that these different presentations about cancer screening could change in the years to come.

Studies casting doubt on the effectiveness of prostate cancer screening with the PSA test surfaced long before similarly doubtful studies on mammography, she emphasized. Because of this matter of "timing," there is a "vast difference" in terms of the "public understanding" of the harms and benefits of PSA testing and mammography, she said.

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