The good news here is that it might eventually be possible to screen breast cancers on a genetic level, using other kinds of tests – even blood tests – to look for the biological traces of those genes. This might also help with the chronic problem of overtreatment in breast cancer. If we can single out that small percentage of women whose tumors will metastasize, we can spare the rest the usual regimen of surgery, radiation, and chemotherapy. Gene-signature research is one of a number of reasons that many scientists are optimistic about the fight against breast cancer. But it is an advance that has nothing to do with taking more pictures, or taking better pictures. It has to do with going beyond the picture.
Under the circumstances, it is not hard to understand why mammography draws so much controversy. The picture promises certainty, and it cannot deliver on that promise. Even after forty years of research, there remains widespread disagreement over how much benefit women in the critical fifty-to-sixty-nine age bracket receive from breast X-rays, and further disagreement about whether there is enough evidence to justify regular mammography in women under fifty and over seventy. Is there any way to resolve the disagreement? Donald Berry says that there probably isn’t – that a clinical trial that could definitively answer the question of mammography’s precise benefits would have to be so large (involving more than five hundred thousand women) and so expensive (costing billions of dollars) as to be impractical. The resulting confusion has turned radiologists who do mammograms into one of the chief targets of malpractice litigation. “The problem is that mammographers – radiology groups – do hundreds of thousands of these mammograms, giving women the illusion that these things work and they are good, and if a lump is found and in most cases if it is found early, they tell women they have the probability of a higher survival rate,” says E. Clay Parker, a Florida plaintiff’s attorney, who recently won a $5.1 million judgment against an Orlando radiologist. “But then, when it comes to defending themselves, they tell you that the reality is that it doesn’t make a difference when you find it. So you scratch your head and say, ‘Well, why do you do mammography, then?’”
The answer is that mammograms do not have to be infallible to save lives. A modest estimate of mammography’s benefit is that it reduces the risk of dying from breast cancer by about 10 percent – which works out, for the average woman in her fifties, to be about three extra days of life, or, to put it another way, a health benefit on a par with wearing a helmet on a ten-hour bicycle trip. That is not a trivial benefit. Multiplied across the millions of adult women in the United States, it amounts to thousands of lives saved every year, and, in combination with a medical regimen that includes radiation, surgery, and new and promising drugs, it has helped brighten the prognosis for women with breast cancer. Mammography isn’t as good as we’d like it to be. But we are still better off than we would be without it.
“There is increasingly an understanding among those of us who do this a lot that our efforts to sell mammography may have been overvigorous,” Dershaw said, “and that although we didn’t intend to, the perception may have been that mammography accomplishes even more than it does.” He was looking, as he spoke, at the mammogram of the woman whose tumor would have been invisible had it been a few centimeters to the right. Did looking at an X-ray like that make him nervous? Dershaw shook his head. “You have to respect the limitations of the technology,” he said. “My job with the mammogram isn’t to find what I can’t find with a mammogram. It’s to find what I can find with a mammogram. If I’m not going to accept that, then I shouldn’t be reading mammograms.”
7.
In February of 2002, just before the start of the Iraq war, Secretary of State Colin Powell went before the United Nations to declare that Iraq was in defiance of international law. He presented transcripts of telephone conversations between senior Iraqi military officials, purportedly discussing attempts to conceal weapons of mass destruction. He told of eyewitness accounts of mobile biological-weapons facilities. And, most persuasive, he presented a series of images – carefully annotated, high-resolution satellite photographs of what he said was the Taji Iraqi chemical-munitions facility.
“Let me say a word about satellite images before I show a couple,” Powell began. “The photos that I am about to show you are sometimes hard for the average person to interpret, hard for me. The painstaking work of photo analysis takes experts with years and years of experience, poring for hours and hours over light tables. But as I show you these images, I will try to capture and explain what they mean, what they indicate, to our imagery specialists.” The first photograph was dated November 10, 2002, just three months earlier, and years after the Iraqis were supposed to have rid themselves of all weapons of mass destruction. “Let me give you a closer look,” Powell said as he flipped to a closeup of the first photograph. It showed a rectangular building, with a vehicle parked next to it. “Look at the image on the left. On the left is a closeup of one of the four chemical bunkers. The two arrows indicate the presence of sure signs that the bunkers are storing chemical munitions. The arrow at the top that says ‘Security’ points to a facility that is a signature item for this kind of bunker. Inside that facility are special guards and special equipment to monitor any leakage that might come out of the bunker.” Then he moved to the vehicle next to the building. It was, he said, another signature item. “It’s a decontamination vehicle in case something goes wrong… It is moving around those four and it moves as needed to move as people are working in the different bunkers.”
Powell’s analysis assumed, of course, that you could tell from the picture what kind of truck it was. But pictures of trucks, taken from above, are not always as clear as we would like; sometimes trucks hauling oil tanks look just like trucks hauling Scud launchers, and, while a picture is a good start, if you really want to know what you’re looking at, you probably need more than a picture. I looked at the photographs with Patrick Eddington, who for many years was an imagery analyst with the
Something Borrowed
1.
One day in the spring of 2004, a psychiatrist named Dorothy Lewis got a call from her friend Betty, who works in New York City. Betty had just seen a Broadway play called
Lewis has studied serial killers for the past twenty-five years. With her collaborator, the neurologist Jonathan Pincus, she has published a great many research papers, showing that serial killers tend to suffer from predictable patterns of psychological, physical, and neurological dysfunction: that they were almost all the victims of harrowing physical and sexual abuse as children, and that almost all of them have suffered some kind of brain injury
