After her death on Feb. 10, 2014, people recalled Shirley Temple's charm and charming movies, and her famous songs "Good Ship Lollipop" and "Animal Crackers in My Soup." But often forgotten today is her courage in telling the world in 1972 that at age 44 she had developed breast cancer and had undergone a mastectomy. She was one of the first celebrities to acknowledge having cancer and the first to crusade for breast cancer awareness and early diagnosis. She must always be remembered as an important cancer crusader.
As she said at the time of her diagnosis, "The only reason I am telling you this is to convince other women to watch for any lump or unusual symptoms. There is almost certain cure for this cancer if it is caught early enough."
Had Shirley Temple been treated for breast cancer more recently, she might have been able to avoid mastectomy and have the cancer detected and treated when it was smaller. Mammography was only recommended as a screening test in 1976. And all women who later developed breast cancers have been considered for breast-conserving, limited surgery with only removal of the cancerous lump (lumpectomy) with follow up radiation therapy, rather than mastectomy. For example, this was the treatment that Sheryl Crow received after her breast cancer was found in 2006.
But at about the same time breast cancer survivor Shirley Temple Black died, a report from a Canadian study was published suggesting that screening mammography does not save lives. Should women continue to have mammograms, as encouraged by most physicians as well as many physician organizations, or should women stop having screening mammograms?
The national Canadian study reported on 90,000 women between ages 40 and 59 who either had mammograms annually for five years, or just routine care and/or breast exams. The study found no difference in overall breast cancer specific survival over 25 years.
Is that the whole story? No, because the discovery of cancers with mammography that were not felt by the doctor resulted in 86 percent survival compared to only 67 percent in patients who did not have mammograms! Discovery of a cancer by mammogram (which was not felt by the physician) had spread to lymph nodes in only 17 percent of patients, compared to more frequent 32 percent node involvement by cancer in patients without mammograms. Lymph node involvement would usually require follow up chemotherapy in addition to surgery. Also, the average size of cancer was 1.9 cm in patients diagnosed with mammography (Stage I, with 77 percent survival if cancers were under 2 cm) compared to 2.1 cm without mammography (Stage II, with only 55 percent survival if cancers were over 2 cm).
The Canadian study has been criticized heavily by the American College of Radiology, suggesting that program was flawed and had poor quality mammography, different from what is used in the United States. A prior study in Sweden in 133,000 women followed for 29 years found a reduction in cancer deaths from breast cancer of 31 percent.
Also, the guidelines from the American Cancer Society continue to recommend screening mammograms annually starting at age 40 and continuing annually as long as women remain healthy. Because smoking is associated with increased breast cancer (with 24 percent increased risk of breast cancers in smokers, 61 percent increased risk in women smoking before menstruation started, and 41 percent increased risk in women who had been smoking for 11 or more years before having their first child), avoiding smoking is also recommended. We should remember that Shirley Temple had already become a chain smoker by age 17, and perhaps that is why she developed her cancer at age 44.
So what should a cautious woman do, knowing the recommendations of Shirley Temple and in light of the recent mammography report. Here are my tips.
• Women with any breast symptom should tell their doctors about the symptom and ask if a mammogram might be needed.
• Women without any symptoms over age 40 should strongly consider having annual mammography and breast exam by their doctors. They should discuss use of mammograms, plus also ultrasound and/or breast MRI if they are at higher risk of cancer (family history of breast cancer, or dense breasts on prior mammogram).
• If the doctor does not have a strong recommendation about mammogram, consider a second opinion. See my book Surviving American Medicine about how and where to get second opinions.
• Women should avoid lifestyles at higher risk of breast cancer, such as smoking, excess drinking, and lack of exercise.
• If a mammogram is abnormal, discuss with your physician about having a needle biopsy to find out if the abnormality is cancer, or just a benign condition. If a biopsy shows cancer, ask for a second pathology opinion to be certain of the diagnosis before proceeding.
• If a cancer is confirmed, get advice from your doctor about breast conserving surgery versus mastectomy versus neoadjuvant chemotherapy (chemotherapy preceding the surgery to shrink the tumor and allow breast conserving surgery rather than mastectomy). Usually a second opinion from another oncologist helps to further understand what approach you would want to follow. Always remember the important advice of Shirley Temple who had a biopsy before deciding whether to have a mastectomy. The doctor can make the incision, I'll make the decision!
Mammograms still appear to save lives, and decrease the size of tumors found so fewer women need to have mastectomy or more toxic therapies such as chemotherapy and radiation. Women should have discussions with their physicians about screening mammograms and breast cancer prevention.