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News & ArtsFriday, November 20, 2009
Health / The Ladies The Panic Over Mammograms
Posted by Audrey Van Buskirk on Fri, Nov 20, 2009 at 11:24 AM
All the people who rail against Republicans in general and Sarah Palin specifically for ignoring the facts (about abstinence-only education, about global warming and industrial pollution) should take a deep breath and actually read the science about breast-cancer screening.
The articles from the United States Preventive Services Task Force, published in the Annals of Internal Medicine, calling for a reduction in breast-cancer screening are surprisingly calm given the maelstrom they've unleashed.
"I definitely think this is the beginning of rationed care and I am very upset that women are the first to get slammed with this," said Dr. Elizabeth Vliet, a women's health care specialist based in Tucson, Ariz., and an ardent opponent of health care reform. "I think that this change is designed to cut costs, not improve women's health."
From a Fox News piece:
"I absolutely believe this could be a form of rationing," said Rep. Phil Gingrey, R-Ga, a practicing obstetrician and gynecologist for 26 years. "It scares me."
Here's what the report says: There is no benefit to teaching women to do breast self-exams.
This is not some secret plot to let women die. It's the result of analysis that proves that women who are taught and harangued about doing monthly breast self-exams are no more likely to find anything cancerous than women who don't. Women who aren't doing regular breast self-exams find just as many lumps as women who are: If you have a tumor, you notice it. For example, no one told me to check my legs for tumors, but I discovered one in my thigh last year. Similarly, if a man gets a tumor in his scrotum, chances are he'll find it, and not because he's doing regular scrotum self-exams.
Regarding mammograms: the National Cancer Institute estimates woman have a 12 percent lifetime chance of developing breast cancer. According to the USPTF, mammography can detect early breast cancer and reduces breast cancer deaths by 15 percent. But the benefits don't come without harms, primarily from the numerous false positive results leading to unnecessary treatment and anxiety.
From the report:
The cumulative risk for false-positive mammography results has been reported as 21% to 49% after 10 mammography examinations for women in general (39—41), and up to 56% for women aged 40 to 49 years.
The harms outweigh the benefits for women—those without breast-cancer risk factors—between the ages of 40 and 49 (age is by far the largest risk factor for breast cancer). So the panel, which does not take cost into consideration when making its reports, no longer recommends regular breast screenings for this population. For women between 50 and 59, the evidence shows that a mammogram every two years preserves the benefits without increasing the harms. Though even for them, mammograms are far from a panacea. (The recommendations for prostate cancer screenings have similarly declined, as have tests for colon cancer.)
Mammograms are so unreliable—as many as one in 10 gives a false positive reading—a woman is nearly guaranteed of having a false positive test in her lifetime. These lead to biopises (not a painless procedure) and sometimes radiation and chemotherapy for tumors that were so slow growing they would never have killed you anyway.
Another point from the report:
New technologies, such as digital mammography and MRI, have become widely used in the United States without definitive studies of their effect on screening. Consumer expectations that new technology is better than old may obscure potential adverse effects, such as higher false-positive results and expense.
More, better preventive care sounds like a good idea. We want to believe that if we just get checked enough with the fanciest new equipment we won't get sick and die. But even if that were true, how far are we willing to go as a society to make it so? Think of it this way: if you knew you had a 95 percent chance of getting breast cancer would you have a preventive mastectomy? What if your chances were 50 percent? 10 percent? 2 percent?
While people are screaming that the new recommendations on mammograms are a way for the insurance industry to save money, no one seems concerned about the flip side: imaging centers, radiologists, pathologists, technicians, and whole lot of other people make millions every year performing tests that are costly, unnecessary, and painful.
In what may be another nail in the coffin for health care reform, today the American College of Obstetricians and Gynecologists came out with another reduction in screening recommendation, this time for pap smears.
“A review of the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs and avoids unnecessary interventions that could be harmful,” said Dr. Alan G. Waxman, a professor at the University of New Mexico who directed the process.
While Health and Human Services Secretary Kathleen Sebelius moved quickly to distance the administration from the new recommendations, they're being used as proof that the Obama administration wants to ration health care (though it already is rationed) and may further torpedo the chances of substantive health care reform (which will mean the millions of women who have no health insurance—let alone access to regular mammograms—must continue their hope-and-pray approach to health).
That isn't good science or common sense.
1
rationing = making decisions about use of resources that are not infinite.
inevitable.
why do we run away from this honest word?
inevitable.
why do we run away from this honest word?
2
i'm no doctor, but based on what i have come to understand about cancer, the worst possible thing you can to do a tumor is smash it and radiate it at the same time.
if there IS a tumor in the breast at the time of the mammogram, i think the patient is at a significantly higher risk of that tumor becoming problematic as a direct result of the procedure.
at this point in my life i don't intend to ever have a mammogram.
if there IS a tumor in the breast at the time of the mammogram, i think the patient is at a significantly higher risk of that tumor becoming problematic as a direct result of the procedure.
at this point in my life i don't intend to ever have a mammogram.
3
It is hard to be rational when looking at data like this.
On the one hand, I agree that based purely on statistics, routine mammograms for all women in their 40s is on balance not a good policy.
On the other hand, a good friend of mine got breast cancer in her mid-40s, had it discovered on her annual mammogram, and was treated and cured. If not for her annual mammograms, she would be dead right now. That is 100% certain.
So while the data supports their assertion, it flies in the face of anecdotal stories like my friend that many of us are familiar with. It is very hard to reconcile that rationally.
Plus, change is hard.
On the one hand, I agree that based purely on statistics, routine mammograms for all women in their 40s is on balance not a good policy.
On the other hand, a good friend of mine got breast cancer in her mid-40s, had it discovered on her annual mammogram, and was treated and cured. If not for her annual mammograms, she would be dead right now. That is 100% certain.
So while the data supports their assertion, it flies in the face of anecdotal stories like my friend that many of us are familiar with. It is very hard to reconcile that rationally.
Plus, change is hard.
4
wtf? So, let me get this straight, your theory is that breast cancer and mammograms are just an evil plot by doctors and medical imagine facilities to make billions off of women while making them suffer.
I did I just wake up in Palinland?
I did I just wake up in Palinland?
5
Look, there is a very very simple take home message.
Self-inspection for lumps - good.
Inspection of young breast tissue (30 or younger) - pretty much a waste of time unless you have breast cancer genes and are already known to be high risk - still doesn't work well.
Inspection from 30 to 50 - if high risk in your family, might be worth the risk of radiation; otherwise, not worth the risk and too many false positives that have no impact on survival. Keep doing self-inspection, though. If dense hard tissue not very useful - if soft tissue (e.g. you have very squishy floppy breasts) then might be worthwhile.
Inspection from 50 to 70 (some say 80, the literature is fuzzy on this) - highly recommended you get mammograms.
After 70 or 80 - mostly not worth it.
You can find boring complicated explanations at CDC and NIH which will basically say this, but in very unclear language.
Self-inspection for lumps - good.
Inspection of young breast tissue (30 or younger) - pretty much a waste of time unless you have breast cancer genes and are already known to be high risk - still doesn't work well.
Inspection from 30 to 50 - if high risk in your family, might be worth the risk of radiation; otherwise, not worth the risk and too many false positives that have no impact on survival. Keep doing self-inspection, though. If dense hard tissue not very useful - if soft tissue (e.g. you have very squishy floppy breasts) then might be worthwhile.
Inspection from 50 to 70 (some say 80, the literature is fuzzy on this) - highly recommended you get mammograms.
After 70 or 80 - mostly not worth it.
You can find boring complicated explanations at CDC and NIH which will basically say this, but in very unclear language.
6
But personally, since some women younger than 50 should get mammograms (family risk, etc) they should be COVERED by medical insurance plans ALWAYS.
9
Yeah, I think you've got it, Reverse Polarity. There's the anecdotal case plus our own personal logic: Would I be willing to have an unnecessary biopsy or x-rays if it ruled out the possibility of a problem? Of course. That doesn't mean that statistically speaking it's a good way to spend scarce resources. But most of us want more knowledge about our health rather than less, and it's hard to give that up.
10
Bu - but, if Republicans can't scare the unwashed masses with hysterical, off-the-rails, out-of-context, unfounded, non-factual, panic-inducing tirades against the evil gubbamint (the same gubbamint they want to be in charge of, mind you), then really what's the point of keeping them around?
11
Paps are vital, esp with the prevalence of HPV in today's society. No way should these be reduced. Every woman needs an annual, it's the right thing to do.
12
@11: But the data don't support that. Personally, I'd rather make my health care decisions based on data than superstition.
13
My doctor told me I didn't need an annual every year. If you aren't having new sex partners in that year, why would you?
14
@4: Your hysterical characterizaton of an opponents reasoned argument which doesn't consider its merits or offer a rational critique is the sort of rhetorical cancer which is metastasizing throughout our world.
Wake up people. Without the ability to weigh options and choose the best among then after consideration of the consequences, we are probably more than at any time in history at risk of losing much of what we have worked so hard to gain.
Wake up people. Without the ability to weigh options and choose the best among then after consideration of the consequences, we are probably more than at any time in history at risk of losing much of what we have worked so hard to gain.
15
I don't really understand the controversy here. If this is where the evidence is leading us, then doctors are going to implement the new screening procedures regardless of health care reform. Evidence Based Practice is the expectation now.
We just changed our standard practice guidelines in BC a few months ago, with more time between PAPs (for those with a certain number of consecutive normal results) and we no longer recommend self breast-exams.
We just changed our standard practice guidelines in BC a few months ago, with more time between PAPs (for those with a certain number of consecutive normal results) and we no longer recommend self breast-exams.
16
Good grief can't people compromise ? Depends on the risk, how about women between 40 and 50 have Mammograms every two or three years instead of every year ?
17
There is a risk related to the radiation from mammograms, as well as the additional procedures related to false positives. In the past we were told that the benefits outweigh the risks. Now, based on more thorough studies, they are telling us that the risks outweigh the benefits. That makes perfect sense to me.
One problem with anecdotal stories is that we don't have all of the facts: did that person saved by a mammogram have a have history of breast cancer, did she smoke two packs a day while on birth control pills, did she have any signs or symptoms? If so, she would have been slated to get the mammogram under the new guidelines as well.
Thanks, Audrey, for writing a sensible piece on this over-blown controversy.
One problem with anecdotal stories is that we don't have all of the facts: did that person saved by a mammogram have a have history of breast cancer, did she smoke two packs a day while on birth control pills, did she have any signs or symptoms? If so, she would have been slated to get the mammogram under the new guidelines as well.
Thanks, Audrey, for writing a sensible piece on this over-blown controversy.
18
As someone with a strong family history, I'm NOT looking forward to fighting with my insurance company over this in ten years' time.
19
Good LORD this is a long post. Now that I mention it there have been many unnecessarily long posts on SLOG lately. It would be great if more of the Stranger staff and guest sloggers followed Dan Savage's example and put most of the content for posts like this after the jump.
20
I understand all the research and rationale regarding this change.
I cannot reconcile one thing in my mind though.
I personally know 3 women who had potentially life threatening breast cancer diagnosed because of a mamogram they got while they were under age 45. Three women. Two of them had radical mastectomies, one is currently treating with chemo and radiation. All three were told by their physicians that their cancer, if gone undetected, could very possibly have progressed so far that it would have eventually killed them.
None of them felt a lump. Only one of them had any family history of cancer.
You only know if it was unnecessary after the fact.
I cannot reconcile one thing in my mind though.
I personally know 3 women who had potentially life threatening breast cancer diagnosed because of a mamogram they got while they were under age 45. Three women. Two of them had radical mastectomies, one is currently treating with chemo and radiation. All three were told by their physicians that their cancer, if gone undetected, could very possibly have progressed so far that it would have eventually killed them.
None of them felt a lump. Only one of them had any family history of cancer.
You only know if it was unnecessary after the fact.
21
That's why you should self-examine before 50.
UNLESS you have multiple direct family members who got breast cancer - in which case a simple breast cancer gene test might be worth it - if you have either of the two genes then the advice is different - otherwise it isn't.
Look, radiation has some dangers, it's a balance of risks.
Self-exam - always good. Radiation is only USEFUL in diagnosis when you don't have dense tissue and you're at risk - which is pretty much 50 to 70/80.
OK? Facts. Not anecdotes. Anecdotally, nobody has ever survived life.
UNLESS you have multiple direct family members who got breast cancer - in which case a simple breast cancer gene test might be worth it - if you have either of the two genes then the advice is different - otherwise it isn't.
Look, radiation has some dangers, it's a balance of risks.
Self-exam - always good. Radiation is only USEFUL in diagnosis when you don't have dense tissue and you're at risk - which is pretty much 50 to 70/80.
OK? Facts. Not anecdotes. Anecdotally, nobody has ever survived life.
22
Maybe I'm being incredibly naive here (it's highly possible), but we're talking about a change in recommendation, right? It doesn't mean you're no longer allowed to get a PAP every year or a mammogram if you feel you should. It just means studies have found it unnecessary to recommend undergoing those procedures so frequently. On the other hand, if this change in recommendation gives insurance companies a green light to restrict funding for PAPs and mammograms, that's another issue, and even more cause to institute a robust public option.
23
The new guide lines would have killed my wife.
40... No history of cancer... Went in for screening - stage 2A breast cancer.
You can't easily feel a tumor. They're not round... More like a spider web. She had three. One was +4cm. It was hard to detect even knowing it was there.
Fuck the new guide lines. They only say that it's okay for a certain percentage of women to die. Get fucking screened.
40... No history of cancer... Went in for screening - stage 2A breast cancer.
You can't easily feel a tumor. They're not round... More like a spider web. She had three. One was +4cm. It was hard to detect even knowing it was there.
Fuck the new guide lines. They only say that it's okay for a certain percentage of women to die. Get fucking screened.
24
It's a shame you had to use female pseudonym to relate the facts w/out being called sexist.
Understandable. But a shame nevertheless.
Understandable. But a shame nevertheless.
25
Hey, thanks for the post. On the other side of the issue of people knowing women who had cancer and were saved by early treatment-- I know a number of women (more than I know than who have had cancer), including myself, who had unnecessary biopsies and surgery because of false positives. And guess what? Painful. Scarring. Worrying. AND Even with insurance that can be expensive--re deductible and coinsurance. I know someone who had seven biopsies--all false positive.
Used to be the same backlash when recommendations changed from radical mastectomies to lumpectomies. We want to save women's lives, but it is also a legitimate issue that women don't want their bodies cut up for no reason either. My doctor admitted that though more women are surviving breast cancer these days, it is not because of early detection, it is because of better treatment.
I had someone in the field tell me that there are 8 false positives for every two legitimate cancers. If that is true, that means 80% of women with biopsies don't need them.
Used to be the same backlash when recommendations changed from radical mastectomies to lumpectomies. We want to save women's lives, but it is also a legitimate issue that women don't want their bodies cut up for no reason either. My doctor admitted that though more women are surviving breast cancer these days, it is not because of early detection, it is because of better treatment.
I had someone in the field tell me that there are 8 false positives for every two legitimate cancers. If that is true, that means 80% of women with biopsies don't need them.
26
@23: Actually, they're saying, on whole, it causes more harm than good. What's difficult to grasp there? Or do you like harming women?
27
Diagnosed at 43 by my doctor doing a manual exam. The lumps were in an area that is difficult to screen, and indeed the mammogram I had earlier that very same day, came back clear. I'm lucky she is a Nervous Nelly and didn't have me just wait a year for my next exam. As it is, I had 2 lumps removed and got to keep Li'l Lefty. If I were to have followed the suggested changes in guidelines, I would be lopsided at best, and quite possibly dead. The irony, (which is in no way lost on me) is that the meds I am currently on to prevent a recurrence of the breast cancer have left me at an increased risk for other reproductive cancers. So the day before Thanksgiving I'm going in for a biopsy to see if indeed that is the case, since I am exhibiting symptoms that may be uterine cancer.
I will now go and sing a rousing chorus of I Enjoy Being A Girl. Feel free to join in.
I will now go and sing a rousing chorus of I Enjoy Being A Girl. Feel free to join in.
28
Money is an issue of course. They used to X-ray the lungs of smokers because it might catch the cancer earlier. Somehow it didn't do just that, so they stopped recommending that procedure. Did it save a few lives here and there? Probably. but so would a lot of things. Cost v. benefit.
29
@27- With all respect for your story, I don't think the new guidelines eliminate doctor breast-exams, just self exams. Or did you find the lump yourself during a routine breast exam? I think the research shows that most of the lumps women find themselves are not during regular self-exams, but more often through normal touching, or their partners find them.
Good luck this thanksgiving, that's a real bummer.
Good luck this thanksgiving, that's a real bummer.
30
The panel's recommendations make sense. The panel was objective and used sound data. This is evidence-based medicine. It doesn't rely on anecdote, conjecture, feelings, or politics; it relies on data and science.
Interestingly, similar recommendations have been made regarding prostate cancer.
Interestingly, similar recommendations have been made regarding prostate cancer.
31
@29- The new guidelines recommend that women in their forties not have regular mammograms (unless they are considered high risk for breast cancer because of genetics or other factors). So, in some cases, the new guidelines do, in fact, call for women to choose not to have doctor breast exams.
32
"The new guide lines would have killed my wife."
My god! Seriously. How on earth can you possibly know this? Because the doctor said so? One of the points that researchers have made is that they've discovered that breast cancers that they previously thought needed to be treated actually were turning out to be nonfatal and so slow growing that the cancers wouldn't have seriously affected women in their lifetimes. The same conclusions have been accepted with respect to prostate cancer. This is just one possible explanation of how your comment might not be true.
Even if it is true, we don't have anyone here to make a comment about how they shouldn't have died in surgery that they didn't need for a cancer or false positive that shouldn't have been operated on. Because that person is dead.
My point: Can we stop arguing with individual stories? There's a reason we make public-health recommendations with evidence-based medicine and not based on feeling or anecdotes.
My god! Seriously. How on earth can you possibly know this? Because the doctor said so? One of the points that researchers have made is that they've discovered that breast cancers that they previously thought needed to be treated actually were turning out to be nonfatal and so slow growing that the cancers wouldn't have seriously affected women in their lifetimes. The same conclusions have been accepted with respect to prostate cancer. This is just one possible explanation of how your comment might not be true.
Even if it is true, we don't have anyone here to make a comment about how they shouldn't have died in surgery that they didn't need for a cancer or false positive that shouldn't have been operated on. Because that person is dead.
My point: Can we stop arguing with individual stories? There's a reason we make public-health recommendations with evidence-based medicine and not based on feeling or anecdotes.
33
@31- a mammogram is not the same as a breast exam in the doctor's office, where they just feel your boobs.
34
The post and several commenters overstate the "objetivity" of the mamogram recommendation.
There are a couple ways that such a recommendation could be truely objective. It could be that studies show no measurable difference in mortality between 40-50 year-olds who get mamograms and those who don't. Or it could even be that studies show increased mortality in 40-50 year-olds who get mamograms (because, e.g. of the dangers of treating false positives).
In fact, studies show neither. They show that mamograms yield about the same decrease in mortality in 40-50 year-olds as they do in 50-60 year-olds: around 15%. So why not recommend mamograms for 40-50 year-olds? Because the baseline mortality due to breast cancer in 40-50 year-olds is so low that the panel judged the small increased risk of death from this group not getting mamograms to be outweighed by the benefits of less stress and inconvenience due to the procedure, false positives, and unnecessary treatments.
But there is no scientifically objective rule about how much stress reduction is worth how much increased risk of death. By picking a different value for this "price," the panel could have concluded that 50-60 year-olds shouldn't get mamograms, or that 20-30 year-olds should.
I am not saying that the panel's pick was unreasonable, or influenced by political pressure to cuts costs. But it wasn't "scientifically objective" either, and it probably way influenced by the general feeling in the public health community that we over-treat and need to move in the other direction.
By the way, one of the things that "evidence-based medicine" can state objectively is that breast self-exams don't appear to be useful in the general population. There is no measurable difference in mortality between those who do self-exams and those who don't.
More...
There are a couple ways that such a recommendation could be truely objective. It could be that studies show no measurable difference in mortality between 40-50 year-olds who get mamograms and those who don't. Or it could even be that studies show increased mortality in 40-50 year-olds who get mamograms (because, e.g. of the dangers of treating false positives).
In fact, studies show neither. They show that mamograms yield about the same decrease in mortality in 40-50 year-olds as they do in 50-60 year-olds: around 15%. So why not recommend mamograms for 40-50 year-olds? Because the baseline mortality due to breast cancer in 40-50 year-olds is so low that the panel judged the small increased risk of death from this group not getting mamograms to be outweighed by the benefits of less stress and inconvenience due to the procedure, false positives, and unnecessary treatments.
But there is no scientifically objective rule about how much stress reduction is worth how much increased risk of death. By picking a different value for this "price," the panel could have concluded that 50-60 year-olds shouldn't get mamograms, or that 20-30 year-olds should.
I am not saying that the panel's pick was unreasonable, or influenced by political pressure to cuts costs. But it wasn't "scientifically objective" either, and it probably way influenced by the general feeling in the public health community that we over-treat and need to move in the other direction.
By the way, one of the things that "evidence-based medicine" can state objectively is that breast self-exams don't appear to be useful in the general population. There is no measurable difference in mortality between those who do self-exams and those who don't.
35
@34: Your post does not reflect the reality that mammography as a screening tool just does not work as well in younger women. The primary reason is that young women (particularly thin, nulliparous women) have denser breasts (these are precisely the women at higher a priori risk of breast cancer, BTW). This makes finding a calcification or other signs of potential cancer very difficult.
Also, it is a fact that radiation is more harmful to younger breast tissue, although most of these expert panels discount any risk from radiation (which, granted, would be small). Show me ANY study that has been published to examine whether nulliparous women (whose breast glandular tissue is undifferentiated) are more sensitive to the effects of radiation.
Hopefully we will keep searching for and eventually find a more accurate screening tool that does not potentially cause the disease it is trying to detect.
Also, it is a fact that radiation is more harmful to younger breast tissue, although most of these expert panels discount any risk from radiation (which, granted, would be small). Show me ANY study that has been published to examine whether nulliparous women (whose breast glandular tissue is undifferentiated) are more sensitive to the effects of radiation.
Hopefully we will keep searching for and eventually find a more accurate screening tool that does not potentially cause the disease it is trying to detect.
36
I have a pretty darn big vocab (plus Latin classes in my background) but I had to look up nulliparous. Never having given birth! I like learning new words. Thanks, emma's bee.
37
You guys are putting WAAAY too much trust in the ability of doctors and mammograms to figure out anything. Mammograms (and other cancer screening methods) are a really dumb technology It's not like you stick a boob in the machine and magically you find out if you have cancer. This isn't CSI. All it does is tell you if you have dense tissue in your breast. The answer is almost always yes. Then you have to chop up the breast into hamburger meat to get at and biopsy the cells in question. Too much reliance by doctors and patients on dumb tests like this are where the problem is.
If you want the problem to be fixed, start raising money or lobbying the government to support research into alternate screening methods. Or better, for basic research into topics relating to cancers. Who knows, maybe there are some blood markers for common breast cancer types. Research doesn't happen in a void and is rarely supported when there is no perceived need for it.
If you want the problem to be fixed, start raising money or lobbying the government to support research into alternate screening methods. Or better, for basic research into topics relating to cancers. Who knows, maybe there are some blood markers for common breast cancer types. Research doesn't happen in a void and is rarely supported when there is no perceived need for it.
38
If the radiology doses in mammograms were too small to be harmful, then why do technicians need to shield themselves while doing the procedure on the patients? Why would I want to increase my chance of getting breast cancer by zapping my breasts with x-rays? If I did have a tumor, why would I want to aggravate it and spread the malignant cells throughout my body by squeezing my breasts in an x-ray machine? I wonder how many so-called lives were honestly "saved" from the false positives and all the unnecessary procedures. Of course, doctors have to say they saved your life....they have to justify why you want through all that trouble. I've been told to get mammograms since I turned 40 and refuse to do it for the above reasons. I do not want to expose my body to harmful x-rays, especially since I'm in the lowest risk category possible. Maybe when I turn 50 I might consider a screening, but hopefully, they will use a better technique by then (ultrasound, maybe?).
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