Jesus Creed

Jesus Creed


Mammogram Testing Changes

posted by Scot McKnight

All is well, but Kris
recently went through her annual mammogram, the discovery of a change from last year with development of a cluster of microcalcifications, another mammogram and a consultation, and then a biopsy and a consultation with the radiologist to be given a
clean bill of health. Whew! As her husband, the days of praying and waiting and wondering
and worrying … some ups and downs … yes … a normal pattern for those who first learn of
potential cancer. And wonderful relief to learn that she’s fine.

But now we are told
… maybe it was all for nothing. In fact, when Kris first read these reports she was not too happy. Are these doctors putting women through too much needless anxiety? Or, is this just a rogue report and finding?

Some recent studies are suggesting major
shifting in the testing of women with mammograms. Some are saying no need for
tests before 50; others are poo-poohing the idea that self-testing does much
good … and this recalls a debate all the way to Congress about a decade ago.

Some say this is insurance companies
telling us that mammograms aren’t needed, and some pushback by saying insurance
companies don’t want to pay the fees. Others are saying science is showing more
today and … well, here’s stuff from The Washington Post...

What do you think about these changes? Any stories to tell?


One side, this is a
bad move
:

“We can’t allow
the insurance industry to continue to drive health-care decisions,”
said Rep. Debbie Wasserman Schultz (D-Fla.),
who said earlier this year that she had undergone treatment for breast cancer.

The recommendations
also garnered harsh criticism from powerful medical groups including the
American Cancer Society — which says it will continue to recommend regular
mammograms for women older than 40 — and the Access to Medical Imaging
Coalition, which warned that the findings would “turn back the clock on
the war on breast cancer.”

“The only
conclusion I can come to is it’s economically motivated,” said Carol H.
Lee, who chairs the American College of Radiology’s breast-imaging commission.
“In this climate, when we are all paying attention to how we can decrease
the cost of health care, in my opinion that’s the primary motivation.”

 On the other side,
this is good move:

But Ned Calonge, who
chairs the 16-member panel, defended the recommendations and denied that cost
or the debate over health-care reform played any role in the decision.
“Cost just isn’t a consideration when the task force deliberates,”
said Calonge, who is also the chief medical officer for the Colorado Department
of Public Health and Environment. Twelve of the task force members were seated
during the Bush administration, and the remaining four were chosen before
President George W. Bush left office, he said.

To conduct the
review, Heidi D. Nelson of the Oregon Health & Science University in
Portland led an analysis of data from more than 40 studies, including a new
British study involving more than 160,000 women and data collected from more
than 600,000 women in the United States.

In addition, the task
force commissioned an unusual study led by Jeanne S. Mandelblatt of the
Georgetown Lombardi Comprehensive Cancer Center and funded by the National
Cancer Institute that involved six separate teams of researchers analyzing the
risks and benefits of 20 screening strategies.

“I think anytime you use science
to kind of fundamentally change what people are used to, I think it’s a
difficult thing to grapple with,” Calonge said of the new guidelines.



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Comments read comments(32)
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Scot McKnight

posted November 18, 2009 at 3:43 pm

Carl Holmes

posted November 18, 2009 at 3:50 pm


Scot,
My Grandmother died of Breast cancer at age 47. My wifes friend got the dreaded diagnosis at 45. Both diagnosed via mamogram. So, I am a little biased.
I am not a government conspiracy theorist, but I find the timing interesting considering the government is about to jump into the insurance industry full hog.
I also find the H1N1 which has largely been pumped up timing rather interesting, and the fact that they are already predicting a avian flu next year.
Panic and get health insurance and call your senators to get it, just dont use it to much. Seems that is the message.
For the record I believe we need serious work in the health industry and having government support for it I am for… but all the hype is just driving me to not even watch the news… from any source fair and balanced or otherwise.



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Brad

posted November 18, 2009 at 4:01 pm


I agree with Carl. It’s very hard for me not to cynically suspect a government panel making a recommendation that seems to be in the government’s self-interest. Seems a way to ration health care without appearing to ration health care. Should we expect to see more of this kind of recommendation? It would not surprise me.



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RJS

posted November 18, 2009 at 4:04 pm


I had a false alarm with this back in my mid 30’s that resulted in a number of tests. It gave some level of concern and delayed our second child by about a year, because pregnancy during a time of uncertainty didn’t seem wise.
But because a true positive is so much more devastating I wouldn’t use such experiences as a reason to avoid tests. Early detection is critical.



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Your Name

posted November 18, 2009 at 4:07 pm


I clearly don’t know the science enough to evaluate these recommendations one way or the other.
I do believe that we test way too much “just to be on the safe side” and the mammogram issue may well be an example of that.
I have a harder time understanding decreasing the attention to self-tests which are free and do not involve exposure to radiation, etc.
I am struck by how many people I hear saying “bet they don’t do anything like this for PSA (prostate) tests!” when actually there have been roughly similar recommendations regarding PSA tests for about a decade now and it was met with much the same reaction.



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Kristen

posted November 18, 2009 at 4:16 pm


aack sorry that last “Your Name” is me.



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Allan R. Bevere

posted November 18, 2009 at 4:56 pm


I do not know enough about the research to answer competently, other than to say that in over twenty-five years as a pastor, I have ministered to several women under fifty whose breast cancer was caught early by mammogram, and who were cured or whose lives were lengthened by years.
The only other thing I would add is that three of the five most important people in my life are women. I want such screening to be available to them.



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Brian B.

posted November 18, 2009 at 5:31 pm


This is just about mammograms. Notice that the report also indicates that women should not be taught to do regular self exams.
My mother-in-law was diagnosed with breast cancer less than a month before my wedding. She had a mastectomy while we were on our honemoon. My wife’s grandmother recently had her own battle with breast cancer.
Considering the fact that the previous two generations have had the disease, my wife is an extremely high risk patient with regard to breast cancer. This new report gives me great concern. Regardless of the motivation behind the report, I hope that my wife’s physician disregards the general nature of this report and takes my wife’s own personal medical history into account.



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Brian B.

posted November 18, 2009 at 5:31 pm


The first line of my comment (#8) should say: This is NOT just about mammograms.



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Dana Ames

posted November 18, 2009 at 6:23 pm


I’ve transcribed medical records for oncology doctors for 19 years. I quit breast self-exams years ago; by the time a cancer is big enough to be easily palpated, the odds for beating it are pretty slim. Because of that, and because I do not know my family history, since I am adopted, I had a baseline mammogram at age 36, then every two years until age 40, then yearly since then. Early detection is indeed critical. Same for prostate cancer; if a cancer is located out of reach of the doctor’s finger, it can be missed for years. PSA testing, like mammograms, though not perfect, is more accurate (and less painful). Yes, include both at your yearly doctor visit; why not?
This is yet another reason why we must provide universal health care coverage, preferably through not-for-profit, regulated insurance companies: preserves competition, puts some checks on greed, lets doctors do medicine instead of paper work. We don’t need to make anything “socialized”. There is no excuse for the U.S. to be at 23rd or some such place, behind every other industrialized nation, in our health care outcomes.
see: http://www.amazon.com/Healing-America-Global-Better-Cheaper/dp/1594202346/ref=sr_1_1?ie=UTF8&s=books&qid=1258585959&sr=8-1
I heard this author on the radio the other day. Just makes sense.
Dana
That CNN ad is incredibly annoying.



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eric

posted November 18, 2009 at 8:26 pm


I hope some doctors respond to this. the fact is that the incidence of reduced cancer deaths via mammograms in the 40 year old range is very marginal and mainly based on some canadian studies done years ago. Also the fact is that the US Preventive Task Force originally published very similar guidelines 8 years ago, but retracted and revised them under intense political pressure from womens
and other groups.The real question is whether we should use tests of very marginal value.. Other areas of study you may recall included discontinuing PSA prostate tests in men over age 75, doing only one aortic ultrasound ever and only on men who smoke and are 65, and the lack of utility in screening carotid dopplers.. Now I will grant that this guideline is very conservative and they tend to make recommendations based on a convincing lack of positive evidence.This has nothing to do with Obama and I suggest the readers review past published guidelines as noted above. Another fact is that cancer can be copntrolled/cured in over 80% of cases.. One “in house” argument is whether death rates are dropping from earlier diagnosis or better therapeutics.I do really feel for those that personally have families strickenwith this disease, and I personally do endorse earlier mammograms esp with family history or fibrocystic disease, and remember, doctors know these are only one set of guidelines.. I hope this doesn’t confuse folks too much



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Mike M

posted November 18, 2009 at 8:45 pm


Good points Eric. I read the recommendations (http://www.annals.org/content/151/10/716.full) and they appear at first glance to be based on good research. Nothing prevents a woman from getting a mammogram. Nothing prevents a woman from doing her own breast exam either even though teaching it to women is not recommended. I still do, though: that’s how my sister found her cancerous lesion in the first place. However, she was over 50 at the time, too.



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Mike M

posted November 18, 2009 at 8:46 pm


I don’t like the CNN ads, BTW



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Scot McKnight

posted November 18, 2009 at 9:08 pm


Mike M, do you mean Beliefnet ads?



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Mike M

posted November 18, 2009 at 10:09 pm


Scot: yes. The CNN ads kept popping up INSTEAD of where I wanted to go on the Jesus Creed and I had to “skip this ad” to get there.



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Dianne P

posted November 18, 2009 at 10:37 pm


The irony is that this announcement was on the news Tuesday morning… the very day that I went for my routine screening mammogram.
Coincidence???



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Mike M

posted November 19, 2009 at 12:30 am


Dianne: Coincidence? I think not.
There is a big push for evidence-based medicine (EBM) and I’m not sure these new mammomgram recommendations are extreme. They may jolt are standard sensibilities but sometimes good medicine does that. For example, there is a set of conditions called “The Ottawa Ankle Rules” that describe how physicians can detect ankle sprains versus fractures without the use of x-rays. This procedure saves time as well as money and avoids unnecessary radiation exposure. In my experience, the OAR’s have been 100% predictive.
While fractures and cancers are not on the same plane, perhaps the new recommendations can redirect our efforts into getting the most bang for our bucks. If you don’t have a close family history of breast cancer and you are under 50, do you really need a mammogram? These recommedations say no. I say let’s look at the evidence first before deciding. Besides, recommedations don’t PREVENT anyone from getting a mammogram. That would be poor medicine.
As a side note: every single time I used the OAR’s to rule-in an ankle sprain, the patient has requested x-rays anyways. All of them have been negative for fractures.



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Kate

posted November 19, 2009 at 1:06 am


I can’t comment on the timing, but it’s good to hear this is finally being discussed in the US. As a physician, I’m with Mike M and believe that screening needs to be evidence based. I believe that the high rates of use of (innapropriate)screening tests in the US are due to it’s being part of a profitable industry.
Screening tests are not harmless. PSA testing may discover a cancer that results in major, disabling surgery when, if left alone the patient would have lived to a great age without ever discovering the diagnosis. Yes, prostate cancer sometinmes kills, but it is often relatively harmless and the problem is that we are not yet good at telling the difference. Autopsies show that upto 80% of men in their 70s have prostate cancer (mostly undiagnosed). More men die WITH prostate cancer, not OF prostate cancer.
Yes, lots of people have a story to tell about how their, or someone else’s life was “saved” by a mammogram, but mammography detects many early cancers that might never have done significant harm- we just don’t understand the natural progression of these because no one would risk a “wait and see” policy. Left to themselves many probably regress (and disappear)and others progress so slowly that they never cause symptoms.
So a woman who might have lived a long life without ever suffering the effects of the “cancer” itself undergoes painful and distressing treatment, to say nothing of the psychological suffering in herself and others from becoming a “cancer patient”. But the irony is that after all this screening-induced suffering, she is left believing that the screening “saved her life”.
If you undergo enough mammograms, there’s always a chance that all thet x-ray radiation my induce cancer!
I am not against evidence based screening, but believe the use of screening “because we have a test” is irresponsible and unethical (and completely flouts the principle of “informed consent” as potential harms are rarely discussed).
I am 40, but would refuse a mammogram as the harms would be likely to outweigh the benefits. When I get to 50 I will probably accept screening, but even then only after careful consideration. If I were male I would not accept PSA screening.



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Mike M

posted November 19, 2009 at 1:46 am


Kate: thanks for the affirmation. I’m trying really hard to pull family history and screening procedures together. Dr. McKnight’s story only seems to validate the recommendations: why provoke anxiety, depression, despair, and unneeded exposure to radiation if there is a low yield? I’d like to hear more stories: how many women without a close family history of breast cancer, under 50, died because they didn’t receive an annual mammogram? Or survived because they did?



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Kate

posted November 19, 2009 at 7:56 am


Mike M, I’m talking about general population screening. Screening of women with a strong family history is a different matter, as the risk/benefit equation is different. In the general population, mammograms of 40 year olds are problematic because the risk of cancer is low and the higher density of the breast tissue makes interpretation difficult. In women at higher risk of cancer, the benefits of screening may outwigh its risks.
In the UK, where regular mammography starts at 50 (as suggested by research evidence), the National Institute for Health and Clinical Excellence (NICE) recommend that women with high risk because of their family history should start having mammograms in their 40’s.



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ChrisB

posted November 19, 2009 at 10:20 am


I wrote about this at the above link on Tuesday. It’s important to note that there were no oncologists on this board. The argument is that it takes ~1300 mamograms to save a life of a woman in her 50s and ~2000 for a woman in her 40s. What they’re saying is not that many women will die if we stop doing screening mammograms. And that’s pathetic. When they say they’re coming at this from a “public health” standpoint, they’re saying “the needs of the many outweigh the needs of the few.” They’re trying to save money, but they can’t admit it, especially not in this political climate. I see too many patients in their 40s and even 30s for me to ever believe this is a good thing.



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Kate

posted November 19, 2009 at 11:09 am


No, Chris B, it’s not “never mind, not that many will die, lets cut the costs ‘cos a woman’s life isn’t really worth that much” but “too many women will suffer radiation and surgical and psychological damage from misdiagnosis, so screening them early is a bad idea”. It’s not cost($) vs benefit but risk vs benefit.
If screening low risk women causes more harm then benefit, it’s not a good idea, whatever the cost in $ because the cost in human terms is too high. I wouldn’t have a mammogram if you paid me, because as I am low risk I for cancer I am more likely to suffer harm than benefit if I undergo mammography. Please notice in the article who wants to keep on screening low risk women: the people being paid for doing mammography.



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ChrisB

posted November 19, 2009 at 11:50 am


Kate,
How much psychological damage would result from finding out you would have lived if only you’d caught the disease five years sooner?
The number of women “at risk” for breast cancer is only a small number of those who actually get it. Family history is a good sign you’ll get it, but the reverse is not true.
The people who want to keep screening include radiologists, certainly. They also include oncologists. We have to deal with the stage three disease that could have been caught much sooner.



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Kate

posted November 19, 2009 at 12:04 pm


OK, another way to look at mammography risks and benefits: according to the Cochrane centre, if 2,000 women undergo 10 years of screening, 1 will have her life prolonged but another 10 healthy women will undergo unnecessary breast cancer treatment. Whether you decide that the risk is worth the benefit is an individual thing, or would be if women were properly informed instead of “mammography may save your life!” For those under 50, the odds are worse.
Again, the (mythical) average woman could expect to gain one week of life after 10 years of screening, (although of course some of that would be lost due to stress over unnecessary treatment) but unfortunately the testing itself probably took most of that time…
For 40-49 year old women *with screen-detectable cancer*, the proportion wo can truthfully say “my life was saved by mammography” is less than 4%.



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Kate

posted November 19, 2009 at 12:27 pm


Chris B @ 23, sadly, it’s not that simple. As an oncologist, you know that. More than 95% of the time, mammography will not save the life of a woman with cancer, even if it is “screen-detectable”.
I am not against mammography, but I think patients should be properly informed. That one woman in 2000 who has her life prolonged can rejoice The 10 whose lives were blighted by “cancer” they could have ignored are less happy. Maybe some might even have their lives shortened by the toxic treatment they receive, or the depression that results from struggling to live with cancer.



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ChrisB

posted November 19, 2009 at 1:48 pm


Kate,
You keep saying “treatment” — even “toxic treatment.” The report does not suggest women are getting unnecessary chemo or radiation — only “unnecessary” biopsies after false positive mammograms. That’s unfortunate but hardly life-altering.
As for the stress, that’s part of life. Every time someone thinks a bone might be broken or a feverish child might have encephalitis they are under false stress. It happens.
If women don’t get mammograms, some will die unnecessarily. That’s a tragedy.



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Kate

posted November 19, 2009 at 3:17 pm


Chris B, sorry, I am not commenting on what it says on the report, have a look at what I said in my comments- many women get full blown cancer treatment (surgery, chemo, radio-) for cancers that would never have affected this woman in her lifetime ie real cancers, but ones that could safely have been left untreated.
I am *not* talking about “false-positives” (yes the biopsy is stressful, but you’ll get over it…)I am talking about “overdiagnosis”- and hence a woman becoming a “cancer patient” (unfortunate *and* life-altering)As I said, an estimated 10 cases per 2000 women screened, and only one life actually extended by catching a dangerous cancer early.
These patients do not know who they are (the doctors don’t know which cancers can be safely ignored, that’s the problem), so they count themselves “saved by mammography” when they are in fact victims of mammography. The side effects of their unecessary treatment may be severe, quite aside from the stress involved.



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Jjoe

posted November 19, 2009 at 6:45 pm


What about the women who can’t afford mammograms, who have to depend on free clinics or whatnot? There’s your rationing of life-and-death health care.
All this talk of risk and false positives and biopsies is irrelevant if the woman doesn’t generate a profit and therefore entry into the system.
On an unrelated topic, I visit a lot of blogs and this beliefnet platform is the absolute worst. Ads on top, ads on bottom, ads when you try to go to a different page. It must hurt the traffic.



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Mike M

posted November 19, 2009 at 8:14 pm


Kate @20: I was getting at that point with my comment about the importance of family history.
Logically, I can’t can’t put together the taskforce’s recommendations and Jjoe’s comment about free clinics. Except that maybe if we target screening mammograms to high-risk groups and follow the recommendations for the general population, we can afford to offer the screenings to target groups at free clinics. That’s a stretch but maybe that’s what he meant.
I’d still like to hear from the “outliers” of these recommendations: those women who are low-risk (especially no close family history), 40-49 years old, and who still developed breast cancer. I put that request up on my facebook and didn’t get one reply.



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Mike M

posted November 19, 2009 at 8:14 pm


Kate @20: I was getting at that point with my comment about the importance of family history.
Logically, I can’t can’t put together the taskforce’s recommendations and Jjoe’s comment about free clinics. Except that maybe if we target screening mammograms to high-risk groups and follow the recommendations for the general population, we can afford to offer the screenings to target groups at free clinics. That’s a stretch but maybe that’s what he meant.
I’d still like to hear from the “outliers” of these recommendations: those women who are low-risk (especially no close family history), 40-49 years old, and who still developed breast cancer. I put that request up on my facebook and didn’t get one reply.



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Mike M

posted November 20, 2009 at 12:06 am


Is there an echo in this room?



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Medical Service

posted July 22, 2012 at 10:34 pm


I like this thoughtful article. This is really the great way you discuss this kind of topic. Good job.



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