My mother’s breast cancer was discovered on a routine screening mammogram in 2019, when she was 69. It was a small but high-grade invasive ductal carcinoma that led to a lumpectomy, radiation, and hormone therapy. It was a textbook case for the value of screening mammograms: cancer caught early, when it was easily treatable, with no need for a mastectomy or chemotherapy. With that, my mom joined the large and growing club of breast cancer survivors—more than 4 million in the United States in 2025, according to the American Cancer Society.
I was 38 at the time of her diagnosis, but my doctor argued that my mom’s cancer changed my risk profile enough to warrant getting started with screening early. For the next couple of years, I dutifully underwent the big squeeze once a year.
But in 2022, when the invitation to my next mammogram hit my inbox, I balked. I was performing at a major regional theater at the time, and the COVID-19 protocols were intense. Twice weekly, all the cast members had to undergo PCR testing, performed by a nurse who seemed to take pleasure in seeing how painfully she could plunge her swabs into our nasal cavities. There was no opting out. We were forced to mask whenever we weren’t onstage. (This was well after everyone had been vaccinated—a precondition of employment.) When a couple of actors inevitably tested positive for COVID-19, the whole company received stern emails lecturing us on being more stringent with our precautions.
It was all starting to feel like one big medical machine that grabbed healthy people with its tentacles, pinned us down, and probed us to see what invisible threats we might be harboring. Not because it was good for us, but because the findings somehow fed the machine itself—justifying its existence while sucking ever more agency from the humans being manhandled. Some of my castmates welcomed the medical theater and in fact lobbied for even more frequent testing. For me, the word safety started to trigger a gag response.
In the midst of this, my mammogram reminder arrived. Staring at the email in my theater dressing room, I thought, “Not a chance.”
Some people emerged from the COVID-19 years with their faith in public health officials intact, their ire directed solely at those who resisted the “experts.” Others swung the other way, their faith totally shattered, even in seemingly settled questions such as the safety of long-established vaccines. The epistemic landscape around matters of health is now a bombed-out ruin. The institutions smolder, opposing tribes have staked out their turf, and war profiteers abound.
This is the landscape I wander, looking for truth like a dowser in the desert. I still trust the medical establishment enough to stitch me back together if I’m ill or injured. But like a lot of people, I have a new skepticism of its ever-growing catalog of preventive guidelines that rarely seem to emphasize promoting health but skew toward turning healthy people into patients-in-waiting, overly focused on narrow dimensions of disease. At the same time, the alternative and “functional” world is full of its own pitfalls and fear merchants. It, too, can oversimplify and oversell; it, too, dangles the illusion of total control.
The battles play out all day, every day, in our feeds, where there’s an influencer for every temperament. Whatever your position on the trustworthiness of the medical establishment, there’s someone posting online or yammering on a podcast ready to support or refute you, armed with studies, stats, and anecdotes. Each can be compelling in isolation. Taken together, their contradictory messages—all delivered with evangelical certitude—can be dizzying.
Peptides. Ivermectin. Universal Hepatitis B vaccines for newborns. Raw milk. MRNA technology. All contested, all fraught.
Mammograms are no different. On one side there are people like Dr. Thais Aliabadi, a board-certified OB-GYN and doctor to the stars, telling millions of “Huberman Lab” podcast listeners her story of getting a routine mammogram that led to a biopsy deemed benign, followed by a risk calculation (based on factors like family history, age at first menses, and age at first childbirth) that pegged her lifetime chance of breast cancer at 37%. Convinced that wasn’t a number she could live with, she fought for a prophylactic double mastectomy. When the pathologists examined the removed tissue, they found a small, previously invisible cancer in one breast—proof, in her telling, that more aggressive screening and preventative surgery had saved her life.
On the other side is Dr. Jenn Simmons, a former breast surgeon turned functional-medicine entrepreneur who regularly tells her more than 100,000 followers that mammograms have never been shown to save lives, that many mastectomies performed in the wake of screening are unnecessary products of overdiagnosis and fear, and that the radiation from mammograms can cause the very cancers women are trying to detect. She urges women toward diet and lifestyle overhaul, “terrain” testing, and radiation-free QT ultrasounds at her centers instead.
Between these poles sits the U.S. Preventive Services Task Force, an independent panel of national experts in disease prevention and evidence-based medicine that issues recommendations about clinical preventive services. It doesn’t endorse risk calculators or supplemental screening. Its guidance is almost comically bland by comparison: biennial mammograms for women between 40 and 74, full stop.
Even the mainstream “Early detection saves lives” mantra now comes in optimization-age form: Longevity doctor Peter Attia argues that the only way to beat cancer is to “catch it early with aggressive screening” (ideally regular full-body MRIs), while the physicians behind the “Sensible Medicine” Substack write that in an era of vastly improved treatments, the better strategy may be to “live as healthy as you can, and then pay attention to symptoms,” rather than submit to a lifetime of screening and downstream cascades.
And the cascades do come. In 2014, when she was 53, my friend Cecily went in for a routine mammogram that turned up something suspicious. A biopsy showed it was cancer, but because of its location behind the nipple, the doctors said a full diagnosis wasn’t possible until her breast was removed. After her mastectomy was done, the diagnosis came: It was ductal carcinoma in situ, high-grade but noninvasive—stage-zero cancer, part of a category of lesions that some experts wonder whether we should call “cancer” at all. An oncologist later assured Cecily that its grade meant her lesion would likely have become invasive, though it’s impossible to know for sure.
Was this a good outcome? The maximally risk-averse would say yes. Cecily herself is at peace with it. But I can’t help but view it as a cautionary tale about what the medical machine sets in motion once it finds something it can’t unsee.
The data show that mammograms do reduce the chance of dying of breast cancer a little, for some women, at the cost of a lot of unnecessary medical drama for many others. A 2006 Cochrane review estimated that unnecessary diagnosis and treatment are roughly 10 times more common than a breast cancer death prevented by screening. And as Simmons likes to point out, no randomized controlled trial of mammogram screening has ever found a reduction in all-cause mortality.
There’s an oft-repeated statistic that 1 in 8 women will be diagnosed with breast cancer in her lifetime. It seems intuitive that every one of these diagnoses that doesn’t prove fatal represents a life saved by treatment. But this, according to Dr. Gilbert Welch, a senior investigator at the Center for Surgery and Public Health at Mass General Brigham and author of Overdiagnosed: Making People Sick in the Pursuit of Health, is one of the biggest misconceptions in modern medicine. It turns out that not every cancer you survive is one that was going to kill you. This is often news to the layperson who’s absorbed a lifetime of mainstream cancer messaging.
“We all develop cancer cells at different points in our life,” Welch tells me. “When you find really early forms, you don’t know if it’s a form that’s actually going to progress.” Some cancers outgrow their blood supply and starve. Some are successfully contained by the immune system. Some grow so slowly that something else is almost certain to kill you first.
These kinds of cancers may be more common than we think. A 2017 review that pooled 13 autopsy studies of women who died of other causes found that, on average, about 1 in 5 had tiny, undiagnosed breast cancers or precursor lesions hiding in their tissue. Meanwhile, the lifetime risk of dying of breast cancer is about 1 in 40, suggesting that many of these cancers are essentially biological background noise. If a cancer is never destined to cause disease, the value of finding it may be nil—or even negative.
Conversely, some cancers are so swift and wily that finding them may just mean undergoing brutal treatment for naught. It was always going to kill you, but now you’ve spent your final months or years consumed by worry and suffering the debilitating effects of surgery and toxic drugs.
The third scenario is the one that actually benefits from screening: the invasive cancer destined to be deadly but caught when surgery and drugs can still bend the curve. (Advances in treatment have broadened the boundaries of this category, pulling more women back from the brink regardless of how their cancer was found. A 2011 study comparing pairs of European countries with disparate screening programs but similar access to modern therapies found that breast cancer mortality declined in all pairs to a similar degree, suggesting better treatment deserves most of the credit for increasing survival rates.)
The problem is that when screenings detect cancer in asymptomatic women, we often don’t know which category it falls into. The natural dynamics of how cancers grow—or don’t—isn’t well studied in humans. Studying it on a mass scale seems too risky. Even on the individual level, as soon as something is labeled “cancer” by a pathologist, we tend to cut it out, blast it with radiation, or kill it with drugs.
When we find cancers that meet the pathological definition of disease but would never have caused symptoms or death, that’s known as overdiagnosis. According to the Susan G. Komen for the Cure foundation, studies suggest 5%-50% of ductal carcinoma in situ and small, invasive breast cancers found with screening mammography may be overdiagnosed. Overtreatment is everything that follows: the surgeries, radiation, hormone therapy, scans, and side effects imposed without benefit.
It’s hard to know exactly how many cancers are overdiagnosed. As Welch put it to me, “Overdiagnosis isn’t something we can directly observe. It’s like a black hole in astrophysics—you never see it directly; you infer it from what’s happening around it.”
A 2016 study coauthored by Welch and published in The New England Journal of Medicine tried to do exactly that, using four decades of U.S. cancer registry data. By its calculations, for every one woman in whom mammography finds a tumor that would have gone on to become life-threatening, roughly four women are diagnosed and treated for tumors that would never have harmed them. Similarly, a landmark 2012 review by the Independent UK Panel on Breast Cancer Screening, published in The Lancet, concluded that for every breast cancer death averted by mammography, roughly three women endure unnecessary treatment.
This infographic from a 2014 Journal of the American Medical Association article on breast cancer screening’s benefits and harms illustrates the reality:
Not even the seemingly intuitive argument that mammogram screening can prevent the need for more aggressive treatment seems to stand up under scrutiny. “It’s clear from randomized controlled trials that women in mammography groups get more surgery and more mastectomies,” Welch says. A 2009 Cochrane review of eight trials found that women in groups assigned to receive mammograms were 20% more likely to undergo mastectomy and 30% more likely to undergo surgery.
Some women don’t hesitate to make the trade-off of removing their breasts to reduce their cancer risk. But for many women, it can be a massive blow. “I went into a real phase of grief about my breasts,” Cecily tells me. “They were just sitting on my chest, but as my surgery neared, I began to really clue into how much sensation they have. I didn’t know what it was going to be like to be a woman without these breasts.” When it was time for reconstruction, she didn’t welcome the opportunity, as some do, to choose a whole new size and shape. All she wanted was what she’d had.
“If mammograms don’t save lives but do save breasts, that would still be a worthwhile endeavor,” Simmons tells me. “But if we’re not saving lives and we’re not saving breasts, what are we doing?”
This all seems to point to a self-evident conclusion: Mammograms aren’t worth it. And yet, the anecdotes. We all know someone who believes that a mammogram saved her life. The media is saturated with these stories, along with pink-ribbon campaigns and impassioned pleas for women to schedule their potentially life-saving mammogram. My own mother’s story seems to support the mainstream narrative; finding her invasive cancer early allowed doctors to treat it easily with a breast-preserving lumpectomy and radiation.
Personal stories are compelling, which is probably why promoters of regular screening deploy them so relentlessly. And because we can’t say for certain whether any one person was overdiagnosed, everyone naturally believes that they’re among the sliver of breast cancer survivors whose life really was saved by early detection. Some of them are correct. We just don’t know which ones. The surgeons and oncologists who see cancer all day, every day, may also understandably assume that each intervention was necessary and life-saving. What they don’t see is the invisible counterfactual piece—the women for whom restraint would have led to less harm.
The whole landscape is dominated by action bias. When faced with uncertainty, most of us would rather do something than nothing, even when “nothing” would be wiser. This is especially true once we’ve established the value of that thing in people’s minds with authoritative messaging and appeals to emotion. In his book The Emperor of All Maladies, Dr. Siddhartha Mukherjee writes, “Once a screening program is released at a population-wide level, it’s hard to ask the population to stop screening for cancer. Even if the benefits of the test were relatively minimal—as with mammography—the wave of anxiety and fury released if the test was withdrawn would not be containable.”
In medicine, action bias is also baked into doctors’ training and incentives. No surgeon wants to be the one who watched and waited while a cancer ran wild, but almost no one is ever blamed for exercising an “abundance of caution” by screening or treating too aggressively.
“There’s what I call the chagrin factor,” says Dr. Adam Cifu, a general internist, professor of medicine at the University of Chicago, and coauthor with Vinay Prasad of Ending Medical Reversal. “Even if you know that most women who get mammograms don’t benefit from them and that most women who don’t get mammograms don’t have complications because of that, having a [patient] who’s not up to date on her mammogram get diagnosed with breast cancer just feels terrible.”
There’s also the question of temperament: what kind of risk you can more easily live with. As we learned in the COVID-19 years, two camps can look at the same landscape and find very different things to fear: the virus or the authoritarian measures determined to control it. Likewise with the mammogram wars—people look at the same set of facts and zero in on different risks. It’s a question of how big a net you want to use to ensnare the dangerous element, and if you’re OK with the collateral damage to everything else that gets caught in it along the way. A question of how much unencumbered life you’re prepared to sacrifice to avert a single death.
At a forum in 2023, former National Institutes of Health director Francis Collins reflected on the U.S. COVID-19 response thus: “If you’re a public health person, and you’re trying to make a decision, you have this very narrow view of what the right decision is, and that is something that will save a life. Doesn’t matter what else happens, so you attach infinite value to stopping the disease and saving a life. You attach zero value to whether this actually totally disrupts people’s lives, ruins the economy, and has many kids kept out of school in a way that they never might quite recover from.”
When I spoke with Welch, he pulled up a slide on a deck he’d created, on which he’d rewritten the latter half of Collins’ quote to reflect the current public health perspective on mammograms: “You attach zero value to whether this actually spreads inordinate fear about breast cancer, interrupts women’s lives, causes a few to be treated needlessly, and makes [having] a breast cancer scare a rite of passage for American women.”
Technological innovation has given us increasingly precise ways of looking at what’s going on inside our bodies, without a commensurate increase in discernment for the value of what we find. There’s a belief that if we can see more, we’ll know more. But it’s just as likely that we lose the ability to see the forest for the trees. “Increase the resolution to infinity, and we all have something abnormal,” Welch says. “It doesn’t mean [removing it] can improve our lives.”
This dynamic shows up not only with tools that peer inside our bodies but also with those that interrogate our supposed risk on paper. Family history, prior biopsies, breast density, maybe a sprinkling of genetic variants all get plugged into a “risk calculator,” which then spits out a lifetime percentage. A mother’s cancer puts you on the more-intense screening track, which increases the odds you’ll have a biopsy, which in turn gets fed back into the next calculator as an additional risk factor. The more closely you’re watched, the more “abnormal” tissue gets found and sampled; the more that’s found and sampled, the higher your modeled risk appears; the higher your risk looks, the stronger the push for MRI, for chemoprevention drugs, for prophylactic surgery. The numbers seem objective, but they’re partly a record of the vigor of the hunt.
“This is what we call self-fulfilling risk factors,” Welch tells me. “Once someone identifies a risk factor, if people then react with more intensive screening, it will actually reinforce the risk factor and make it more powerful.” As with Macbeth’s witches, the foretelling drives the very outcome it foretold.
MRIs, 3D mammograms, genetic tests, and blood-based cancer screening tools are the physical analog. More sensitive tests pick up more “suspicious” findings; more findings lead to more biopsies and diagnoses; more diagnoses feed back into risk models and clinical intuition as proof that we’re right to be vigilant. “We’re adding a lot of testing without any clear improvement in clinical outcomes,” Cifu says. Meanwhile, evidence suggests that the biggest mover of the needle on the outcome that matters—cancer mortality—isn’t earlier and earlier detection, but the steady march of better therapies.
The effect of all this risk messaging is to expand the category of what Mukherjee refers to as “previvors,” people living in anxious wait for an illness that may or may not ever appear. “The borders of Cancerland … have become to feel all-encompassing,” he writes in The Emperor of All Maladies. “In the past, entry was reserved for those with the diagnosis of cancer. Today many more people, in one way or another, are slowly, and unwittingly, forced into becoming citizens.”
Some are counseled to act as if probability were fate. Dr. Cindy Teal, a breast surgeon and coauthor with Dr. Rachel Brem of No Longer Radical, writes, “I often tell my patients who are getting preventive mastectomies that they’re beating cancer before ever getting it.”
But even when cancer is definitively found, we still don’t know how to tell what any given malignancy is going to do. “We haven’t gotten to the point where we can type a tumor and say, ‘This tumor is not going to progress,’” Welch tells me. We’re very good at freezing one moment in time and labeling what we see; we’re much less good at using time itself as a diagnostic tool.
It’s different with lung cancer. When small, ambiguous nodules are found in the lungs, the default isn’t necessarily to rush in with a needle. Instead, people are rescanned in three or six months, and the tumor’s behavior over time becomes part of the test. A speck that sits unchanged may be dismissed, while one that doubles in size sparks urgency. “This is making use of the diagnostic value of time, which begins to combine a whole bunch of tumor- and host-related factors,” Welch tells me.
That almost never happens with breast imaging. A radiologist sees something that can’t be waved away as clearly benign, and the standard move is to biopsy now and sort out the meaning later. There are understandable reasons for this—legal fears, Cifu’s “chagrin factor,” the difficulty of asking women to wait for months with anxious uncertainty—but it leads to many unnecessary procedures. Simmons notes that 80% of breast biopsies turn out to be negative for cancer. “If they would just allow for time, at least half, if not more, of those biopsies would go away,” she says.
In her own practice, she tries to build that time in. For women who want screening but don’t have any breast symptoms, she eschews mammograms in favor of QT imaging, a kind of high-resolution 3D ultrasound that uses sound waves to generate detailed, volumetric images of breast tissue without radiation or compression. (It’s currently FDA-cleared only as a supplemental screening tool to be used in conjunction with mammography, especially for women with dense breasts.)
“If we find something in an asymptomatic woman, we’re going to see what its growth characteristics are,” Simmons says. “We’re going to observe her. We’re not labeling her, we’re not biopsying her, we’re not giving her a diagnosis, because she likely doesn’t need one. If it has a doubling time of less than 100 days, then this is someone who will actually benefit from treatment.”
The machinery of our health-care system, though, isn’t designed for watchful waiting; it’s designed for throughput. All of its incentives point in that direction, beginning with screening. The rate of cancer testing is one of the most common quality measures on health-care report cards, which drive hospital rankings, insurer bonuses, and internal performance reviews. Clinics get gold stars and better contracts for hitting screening targets, and doctors are nudged by automated reminders and dashboards that equate more testing with better care. Screening mammography is also a major revenue stream for hospitals and outpatient imaging centers; entire breast centers and some radiologists’ jobs exist because the machinery is kept running at full tilt.
The physical aftermath of Cecily’s mastectomy was complex: the loss of erotic sensation, the way sex and clothes felt different. But she also describes the experience as strangely generative: “When I woke up from surgery, I wanted to see if they were able to save my nipple. I pulled up my gown and looked, and I saw that they had. I also saw all the tubes, and that it was a flat wall. The voice that came to me then said, ‘You’re already whole.’”
Her story sits at the fault line of the mammogram wars. It’s a vivid example of possible overtreatment and also, for her, a way to experience and integrate something profoundly, universally human. “I choose not to view it as a tragedy, but as a path of vulnerability that we all will eventually come to know,” she tells me. “I think we run into trouble when we think that we’ve been victims.”
This, for me, is the ticket. No one wants to be a victim. In many women’s minds, cancer is the most likely victimizer, and anything they can do to detect it, beat it, or even preempt it is empowering. But I see a different threat. I do not want to be collateral damage in a too-wide net cast by a patronizing medical machine that thinks it knows what’s best for me better than I do. I want to go out with my boobs on.
If breast cancer comes for me, I’ll treat it. I’ll watch for signs myself, but I’m not going hunting for it. I’ll focus on prevention to a reasonable degree and let the chips fall where they may. I can give you the evidence supporting my choice all day long, but ultimately, it comes down to who I am. I value an unencumbered life over a tiny decrease in the risk of one particular kind of death.
Today, preventive mastectomies may no longer be considered radical, but a position like mine is. As with those who resisted public health’s overreach with COVID-19, women who decline mammograms are too often accused by friends, family, and doctors of being foolish, selfish, or lacking in empathy for those whose lives have been disrupted by cancer. Especially in progressive circles like mine, women are invited to shout not just our abortions, but also our screenings and shots. Declining recommended preventive care, on the other hand, carries the stain of the damned: being anti-science.
So be it.
Still, the costs are both social and epistemic. As you begin to unlatch yourself from the machine of mainstream consensus—or what’s presented as such by brushing dissent aside—what comes isn’t freedom but a free fall. The stakes of getting a mammogram may be much lower than we’ve been led to believe, but the stakes of understanding that, and its implications for the trustworthiness of the consensus pipeline, are much higher. It’s hard not to start interrogating everything else, medical or otherwise, that you’ve taken on faith. It’s no longer just about averting death, but about how you’re going to live.
How do I live, when most everyone around me is still downloading the machine’s ready-made consensus via overnight updates I’m no longer equipped or inclined to receive? How do I live, when so many others who’ve unplugged have sprinted off in deranged directions of their own? How do I live, when the lens through which I’d long seen the world shatters, and my vision goes fuzzy, full of static?
I keep returning to the diagnostic value of time. When the terrain is uncertain and the meaning unclear, the best thing to do may be to sit still. Do nothing. Seek others who are comfortable saying, “I don’t know.” See what grows and what self-corrects. We’re surrounded by evidence of the harms of overreacting. Underexplored is the value of restraint.
So maybe, for now, that’s how I’ll live: by making a home on the edge of what I can bear not to know.
