Date: Wed, 30 Jun 1999 23:51:41 -0700

One major program of X-ray diagnosis--mammography, aimed at tracking down breast cancer in women--has also resulted in disaster. Breast cancer is the leading cause of death among American women between the ages of forty-four and fifty-five. Apparently X rays have contributed to the problem rather than helping to solve it.[39]

An X ray of the breast can reveal tumors in their early stages, and thus can have beneficial results. But because the breast is highly radiation-sensitive, the mammogram itself can cause cancer. The danger can be heightened by the subject's genetic makeup, preexisting benign breast disease, artificial menopause, obesity, and hormonal imbalances. Ironically, because the breast tissue of younger women is denser than that of older women, detection of their cancer through mammography is more difficult, if not impossible, in many cases.

The idea of using X rays to detect breast cancer gained credence in the 1930s. By the 1960s mammography was in common use, and a study begun in 1963 by the Health Insurance Plan of New York (HIP) concluded that mammography could reduce mortality rates among women.[40] In 1973 the American Cancer Society and National Cancer Institute cosponsored the establishment of the Breast Cancer Detection Demonstration Projects (BCDDP). Twenty-seven projects were established with the goal of examining a quarter million women. The project program included instruction in breast self-examinations, an initial clinical history, and a physical examination which included a thermogram (which uses an infrared camera to study body temperatures) and a mammogram X ray. The entire program was repeated each year for five years, with a five-year observation period after screening. By 1976 about eighteen hundred cases of breast cancer had been detected.[41]

But the program took on the aura of a fad. In 1974, after Betty Ford and Happy Rockefeller suffered mastectomies, the interest in methods of preventing breast cancer soared. Rose Kushner, executive director of the Maryland-based Breast Cancer Advisory Center, found that "women all over the country were inundated with information about this life-saving machine, and waiting lists for mammograms were often months long. Omitted from this flood of media coverage, however, was the behind-the-scenes conflict among scientists about the potential danger of exposing healthy breasts to a known carcinogen: x ray."[42]

In January of 1975 Dr. John C. Bailar III published an article in the Annals of Internal Medicine warning that the Health Insurance Plan study, which had prompted so much faith in mammography, had not in fact demonstrated any increase in survival rates among the women under fifty who had been given the X rays.[43] Drs. Irwin Bross and Leslie Blumenson of Buffalo's Roswell Park Memorial Laboratory soon estimated that based on dosage levels, twice as many deaths as cures could result from mammographic screenings.[44] By early 1977 Bross had become an outspoken critic of the program, calling it a "disastrous mistake" that would "produce the worst . . . epidemic of cancer in medical history." At a meeting sponsored by the National Cancer Institute, Bross accused the American Cancer Society and the American College of Radiology of subjecting a quarter million American women to X-ray dosages equivalent "to death warrants with a 15-year delay in the execution."[45] Dr. Rosalie Bertell, a mathematician and an expert in radiation and the causes of cancer, later explained that a basic arithmetical error had been made in the design of the mammography program, which may well have resulted in serious health effects to early participants in the program.

Some changes were made after the error was pointed out, she said, but had the program continued as originally planned, it might have caused up to twelve breast cancers for every one it picked up. "A lot of this I blame on the nuclear establishment," she said, "which has gone out of its way to convince everybody that low level radiation is no hazard. The nuclear physicist gives cancer risk per year, whereas health professionals give reproductive lifetime (30 year) or lifetime (70 year) risk. A physician using a physicist's estimates and not noting the timeframe difference will underestimate the risk." The medical profession, she said, was also accepting the word of the weapons industry about the magnitude of the risk per year, even if corrected for longer time spans, letting nuclear physicists determine what doses of radiation were safe, and what were not. Thus, she charged, "the doctors have abdicated responsibility in this area."[46]

The medical establishment gradually responded to the criticism. In August of 1976 the National Cancer Institute set interim guidelines for X rays at the screening centers, warning that "we cannot recommend the routine use of mammography in screening [women without demonstrable symptoms] ages 35 to 50."[47] In 1977 the federal government recommended that women below the age of fifty be X-rayed only if they or a member of their immediate family had a history of breast cancer. The American Cancer Society has suggested that women under thirty-five be given mammographies only if there is clear evidence of a need for it.[48]

Nonetheless the controversy continued. Leonard Solon, director of New York City's Bureau of Radiation Control, worried in 1976 that inadequate training was leading to faulty administration of mammograms.[49] In 1977 the BRH found that roughly 35 percent of the mammograms being taken had technical problems affecting their usability.[50] Bross warned that "the irresponsible or incompetent use of x ray" could not be stopped if health agencies waited for the medical profession to give the word. "If one million women each receive 1,000 millirem of x rays, between 50 and 200 can be expected to develop breast cancer as a result," he said. "The risk for radiation-induced breast cancer is higher than for all other radiation-induced cancers, including thyroid, lung, leukemia, and bone tumors."[51]

39. J. D. Boice, "Risk of Breast Cancer Following Low-Dose Radiation Exposure," Radiology 131 (June 1979): 589-597; G. W. Beebe, et al., "Studies of the Mortality of A-bomb Survivors, Report 6, Mortality and Radiation Dose, 1950-1974," Radiation Research 75 (July 1978): 138-201; F. A. Mettler, "Breast Neoplasms in Women Treated with X-rays for Acute Postpartum Mastitis," Journal of the National Cancer Institute 43 (October 1969): 803-811.

40. S. Shapiro, et al., Changes in Five-year Breast Cancer Mortality in a Breast Cancer Screening Program, presented at the Seventh National Cancer Conference (Philadelphia: J. B. Lippincott, 1973), pp. 663-678.

41. Winifred F. Malone, "National Cancer Institute Guidelines for Mammography," presented at Ninth National Conference on Radiation Control, Seattle, Washington, June 19-23, 1977, p. 51.

42. 1979 X-ray Hearings, p. 115.

43. John C. Bailar, "Mammography, A Contrary View," Annals of Internal Medicine 84 (1976): 77-84.

44. I. D. Bross and Leslie Blumenson, "Screening Random Asymptomatic Women Under 50 by Annual Mammographies: Does it Make Sense?" Journal of Surgical Oncology 8, No. 5 (1976): 437-445.

45. I. D. Bross, "Written Statement Submitted for the NIH/NCI Consensus Development Meeting on Breast Cancer Screening, September 14-16, 1977, at the Invitation of Dr. Donald Frederickson," p. 1.

46. Citizens' Hearings, p. 85.

47. Diane Fink, "Letter of Screening Guidelines to Breast Cancer Center Directors," August 1976.

48. "Modification #1, Operational Memorandum #6," Breast Cancer DetectionDemonstration Project, National Cancer Institute, May 5, 1977.

During a 1977 lecture Dr. Richard G. Lester of the University of Texas Department of Radiology discussed the statistical limitations of the screening program. There is a sharp increase in the incidence of breast cancer among women between the ages of forty to forty-five. The BCDDP program established the screening program at age thirty-five because proponents "believed, despite the fact that it was more recognized that the HIP Study showed no improvement in survivorship under the age of 50, that techniques had improved enough so that such an improvement would be demonstrated."

In October 1975 the National Cancer Institute initiated three committees to review the use of X-ray mammography for women under age fifty. One group, headed by Dr. Lester Breslow of UCLA, was to estimate the benefits of adding mammography to history and physical examination in the HIP breast-cancer screening project. The Breslow report, presented in July 1976, recommended that routine mammographic screening in women less than fifty years of age be discontinued; the amount of radiation in mammography for women in all ages be standardized at the lowest level possible for diagnostic quality; and additional randomized clinical trials involving women under fifty be carried out to more clearly define the value of mammography in relation to other means of detecting breast cancer.

A second group, under the direction of Dr. Louis Thomas, a NCI pathologist, reviewed the pathology data from the HIP survey. The third group, under Dr. Arthur Upton, was asked to lead a group evaluating the relation between the benefit and risk of mammographic screening for the detection of breast cancer. The Upton report found that although the risk of a mammogram increasing an individual's risks of developing breast cancer was small, the total risk to a large population of healthy women was not justified.

49. Leonard Solon, "The Options: New York City Mammography Regulations," presented at the Eighth National Conference on Radiation Control, Springfield, Illinois, May 2-7, 1976, p. 241; M. J. Homer, "Mammography Training in Diagnostic Radiology Residency Programs," Radiology 135, No.2 (May 1980): 529-531.

In a letter to the American Journal of Roentgenology ("National Conference on Breast Cancer: Adequacy of Mammography Training," 133, No. 1 [July 1979]: 161) Dr. Marc J. Homer of the New England Medical Center Hospital stated: "Not too long ago I prepared for my oral boards in radiology. Though subjects as esoteric as congenital hypophosphatemia and the Mounier-Kuhn syndrome were covered . . . I was never required to learn mammography. Though last year I saw more breast cancers on my viewbox than all the colon, stomach, and kidney cancers combined, I never had to interpret a single mammogram as a resident . . . Anything less than a resident learning the technical and interpretative aspects of mammography is inadequate and will only serve to keep mammography as a `second class radiology examination.'"

50. Ronald G. Jans and Thomas R. Ohlhaber, "Breast Exposure: Nationwide Trends--Progress to Date," presented at Ninth Annual National Conference on Radiation Control, Seattle, WA, June 19-23, 1977, p. 222.

51. Bross, "Written Statement," p. 2.

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Doses for Typical X-Ray Examinations in Millirads Average no. Estimated of films perìeffectiveî exam (a) dose per exam (c) Mammography 2*/per breast 300-600

Upper GI 4.3 150-400

Thoracic Spine 3* 150-400

Lower Gl 2.9 90-250

Lumbosacral Spine 3.4 70-250

Lumbar Spine (LS) 2.9 50-180

Intravenous Pyelogram (IVP) 5.3 50-150

Cervical Spine 3.7 40-80

Cholecystography 3.3 25-60

Abdomen or KUB 1.6 10-60

Skull 4 20-50

Lumbo-pelvic 1.4 5-35

Chest (radiographic) 1.6 5-35

Dental (whole mouth) 16* 10-30*

Hip or Upper Femur (thigh) 3* 2-25*

Shoulder 2* 2-25*

Dental (bitewing) 3* 5*

Extremities 2.7 5*

(a) U.S., Department of Health, Education, and Welfare (FDA) Publication 73-8047, Population Exposure to X-rays U.S. 1970, (Rockville, MD.: Public Health Service, November 1973).

(c) Preliminary estimates based on work in progress: P.W. Laws and M. Ross, ìA Somatic Dose Index for Diagnostic Radiology,î to be presented at the second Annual Meeting of the Health Physics Society (Atlanta, GA.: 3/77).

*Estimated by author.

High Risk Contrast X-Ray Examinations