New Mammogram Guidelines: Controversy not Conspiracy
First let me say that I was as surprised by the new recommendations as anybody. I am deeply involved in the fight against cancer as a member of the board of a major cancer center. It is generally agreed that screening for all forms of cancer, other than pap tests for cervical cancer and colonoscopies, have questionable effectiveness. There are a few different issues: 1) incidence of false positives leading to early and sometimes drastic actions that prove unnecessary and risky must be weighed against the detection and treatment of dangerous early stage cancer; 2) the treatment of early stage cancers may be unnecessary for cancers that “cure” themselves and others that have such long periods of slow growth that complications from treatment may be more harmful; 3) positives, whether genuine or false, create enormous stress (been there, done that) that often lead to decisions contrary to even a doctors strong recommendation. Is there an economic issue here as well? Sure, and that’s not a bad thing, but I find it extremely hard to find this decision in any way related to the current health care reform debate or government designed preparation for future health care rationing.
Look at where this recommendation came from. The US Preventive Service Task Force is composed of independent experts from the health care community of primary care clinicians. Check out the information and makeup of the task force here. The members are senior members of major public state departments of health as well as directors and professors in health care at major universities around the country. I cannot see how a single person, not to mention the entire board, can possibly have incentive to support a new guideline which has been forced down their throats for political purposes. At the same time, I am disappointed that they have not been out in full force to support this decision. In general, a recommendation like this would be initiated by the staff of the Task Force but I find it unlikely that the board would have signed off on such a decision without completely understanding the ramifications of the policy change.
Screening can save lives – no doubt about it. But that doesn’t mean everybody should be screened. The data examined by the task force suggest that mammography, in aggregate, may be counterproductive. Why? Because the data showed that screening women in their 40s saved one life for every 1900 women screened over 10 years; but there were a significant number of false positives and overtreatment in that group that never make headlines. The data has been around and argued for a long time. Women who have found breast cancers have been all over the news denouncing the decision because mammography saved their life and, they argue, even one life saved means the procedure should continue. And most of the news coverage seems to support this view. But we’re hearing from that 1 in 1900 rather than those who were overtreated. Still, I was surprised by the decision and most especially by the recommendation to stop self-exams. That one really surprises and confounds me.
The timing of this announcement is what seems to be feeding the conspiracy theorists but this information is not new and, in fact, we’ve seen similar reports about prostate testing several times this year. The recommendation is certainly controversial and many doctors have already indicated that they will not change their view of the usefulness of mammography (and continue to earn major bucks from the procedure) but I think the idea of this being a first shot at health care rationing is off base. Is it more likely that this decision came from the White House and was forced upon an unwitting group of serious, independent health professionals or that the Task Force simply agrees that the decision is appropriate given the weight of medical evidence?
Thanks for sharing this information, Mike and your perspective. I tend to agree that this is not the first wave of health care rationing, no matter how controversial it may be. I had heard part of this story earlier, but not the part about the recommendation to stop self-examinations. That part really puzzles me.
The discussion on the Diane Rehm show this morning was great. There were several actual experts on, discussing the subject and exactly why the panel would say this, vs. why other experts reject it.
It was a great example of why I listen to NPR for discussion, too!
At the end of the show, I felt like I knew a lot more but still didn’t have a firm-set opinion on the matter.
One of the problems fueling the conspiracists right now is that a whole lot of people with absolutely no scientific background or knowledge make proclamations about such things … and the way to neutralize the statements of actual experts is to condemn them as corrupt.
Honest and well-informed people can disagree. There are different values at work (such economic terms as “risk-aversion” come to mind), and different weight is given to different arguments. That concept is lost on a lot of people.
Great post!
Wickle´s last blog ..Two Videos My Son Wants to Share
Interesting feedback from HHS Secretary Sebelius who said “My message to women is simple. Mammograms have always been an important lifesaving tool in the fight against breast cancer and they still are today. Keep doing what you have been doing for years — talk to your doctor about your individual history, ask questions and make the decision that is right for you.” In fact, that’s not much different from what the Task Force was saying but she said it a whole lot better.
I heard that in response to the conspiracy theorists Sebelius noted that the members of the Task Force were appointed by the Bush administration. I have not confirmed the quote or the fact but one would hope it would put the accusations to rest (unapologetically no doubt) and allow the critics to move on to the next Obama conspiracy.
Thank you Mike, for the post and the information.
Didn’t look for the Sebelius quote, I simply looked at the Task Force web site, picked a member at random and searched for his appointment date. Alfred O. Berg, M.D., M.P.H, the chair of the Task Force, was appointed in September 1998. Anybody who cares to can Google the rest of the members
http://odphp.osophs.dhhs.gov/pubs/guidecps/uspstf.htm#Members
Conspiracy theorists will always try to find something…But since the Obama administration has been banging on preventive care as a way to keep medical costs down…Seems a bit nuts to say that they’re the dictators of a recommendations that would be in direct conflict with their own agenda.
I hope that women do continue to talk with their doctors about what is best for them. As a woman, I’d rather deal with a false positive than be oblivious to a problem. Self-examination is also still on my agenda, as it helped my doctors to discover what ended up being a benign lump that we nevertheless continue to watch.
Its ok to issue recommendations, but to actually ration such a thing is another. This should be “patient and doctor” and not “state and patient”, unless you think big brother really does know best. I had sooner a thousand insurances companies issue various guidelines and then one could shop around , than to have one huge government coming down with guidelines with no recourse. So let the Task Force issue their finding and those who wish to listen and obey can, but I want options and the proposed Obamacare plans that I have seen will eventually limit those more and more.
Ron Russell´s last blog ..You’re Too Dumb to Buy Your Light Bulbs
Ron, it’s not that I think Big Brother knows best it’s that I think a group of experts in a given field can come up with “best practices” for treating a given ailment. This is the issue behind the charge of doctors practicing “defensive medicine”. If someone comes into the emergency room complaing of chest pains then SOP will be the understood.That doesn’t limit doctors to those tests. It’s a minimum not a maximum level of care. Right now doctors may well run tests that have little tangible relationship to chest pains just to cover their butts. I don’t see why you would have a problem if the top cardiologists in the country got together and created a minimum standard of care for such situations. A given situation may require variations or additonal tests but the patient would at least receive a minimum battery of tests. And if that procedure was followed and a patient died of one of those tangentially related issues then the doctor is protected from a malpractice lawsuit. Why is that a bad thing? And please don’t come back with, the insurance company may not cover anything beyond the minimum standard of care. THAT is where you shop around and besides, unless things change, doctors still define “necessary” and insurance companies still listen as long as the procedures are approved not experimental.
Mike,
Do you think the Task Force recommendations will cause insurance companies to re-think the usually excellent coverage for mammograms for women under 50?
You seem to be well versed on the Mike, better than me. But what does concern me is the potential for rationing and the one size fits all that will come with a single payer system. I have very little use for government panels as they are always beholding to those who appoints them in some way.
Ron Russell´s last blog ..You’re Too Dumb to Buy Your Light Bulbs
I have heard from several women that women who get cancer earlier get a more aggressive form of cancer and that early detection is vital for their survival. It seems to me that if all women wait ten years before getting screened it will lead to many more deaths.
Mike, you obviously know more about this issue than do I but I agree when Ron stated that this decision should be between a doctor and patient, the state should have nothing to do with it.
We have been taught for so long that early detection is the key to survival and we have also been told by Obama that they key to reducing healthcare costs is to live healthier and to do this type of preventative work to ensure that something more catastrophic does not happen to a person’s health. This seems to fly in the face of that.
Mr Pink Eyes´s last blog ..Independent voters abandon Obama in droves
NPR had a story about the mammography recommendations this morning. From from what I can gather, there are two different camps of opposition. One is political and comes from the Republican opposition in Congress and the other is coming from the perspective of the women in this age group or those who are associated with them. There seems to be a lot of concern about delaying regular screenings, saying it is wrong to look at statistics the way the task force did. They also mention how the task force recommendations seemed to highlight the downside of mammograms, false positives, anxiety, unnecessary surgery, etc.
It’s quite a complicated issue and although I do not think this is the first wave of health care rationing, I do have to wonder why the task force recommended changing the guidelines. Even if the number of women who are saved each year is small, isn’t that number a good thing? I know I would think so if it were my wife.
I agree with everyone about mammograms and if asked I would say 40 year old women should continue to get them; but that doesn’t mean the task force recommendation is wrong. Look at colonoscopy. We all know that when we hit 50 we shuld get one — that’s the guideline. But is there any doubt in anybody’s mind that if we started them at 40 we would catch more polyps and early cancers? Of course we would. But the test is invasive, there are risks, there are false positives, and the statistics say the risk isn’t worth the reward. But you need to decide for yourself about what’s best for you. The task force says that without any risk factors mammogram below age 50 for the general population is a bad risk/reward tradeoff. Doesn’t mean you shouldn’t have it done. That’s how they interpret the data and it’s what they’ve been asked to do.
To Laurie’s question about whether insurance companies will limit coverage — I doubt it. There are lots of other bodies with strong influence including American Cancer Society who still advocate 40. Besides, given the outrage this week I’d expect insurance companies to stay far away from this controversy.
For transparency sake, I avoid mammograms at all cost. Don’t like them and don’t think they are necessary. I actually believe they do more harm than good. However, having said that, this is from Natural News which I follow closely (especially since word has come out that the pharmaceutical companies are planning on pushing a vaccine for CFS?!) who recently wrote about this very subject. I would be inclined to agree with him.
“Any time you threaten to take away repeat customer from the businesses that make up the cancer industry, you’re in for a political fight. After the United States Preventive Services Task Force released new recommendations advising against mammograms for women under 50 (and recommending only bi-annual screenings after that), the cancer industry went berserk.
Mammograms, you see, are the bread and butter of the for-profit cancer industry. They serve two very important purposes:
Purpose #1: RECRUIT patients. Mammograms are a clever tool for recruiting patients into a highly-profitable regimen of chemotherapy drugs, radiation and surgery that, nine times out of ten, isn’t even medically justified. How’s that? Because the detection technology behind mammograms is now so advanced it can detect tiny tumors present in virtually everyone, whether they’re dangerous or not. This has lead to a huge increase in “false positives” and dangerous over-treatment of cancers that would be better off just left alone (or treated with anti-cancer nutrients and superfoods).
But mammograms are a great way to scare women into unnecessary cancer treatments. So they’re pure genius when it comes to recruiting new patients using the fear tactics the cancer industry has come to rely on.
Purpose #2: CAUSE more cancer. The second purpose of mammograms is to cause cancer by exposing women’s breasts (and heart tissues) to ionizing radiation. When subjected to repeated exposure of such radiation, the human body will undergo DNA mutations and inevitably be afflicted with cancer. This is how the cancer industry can make predictions like “one out of every three women will be diagnosed with breast cancer in her lifetime…” — they know this to be true because they are the ones causing the cancer in the first place!
If you took your car to a mechanic to have the oil changed, and that mechanic poured corrosive bits of metal into your car’s engine that caused long-term engine damage, would you continue to take your car to that same mechanic year after year? And if so, would you PAY that mechanic to repair the damage he actually caused?
That’s what women are essentially doing when they receive mammograms. Each year, as they dutifully get their mammograms, they are exposing themselves to the very kind of radiation that causes cancer, practically guaranteeing they will eventually be diagnosed with cancer. (At which point the oncologist will say something like, “See? Good thing we do these mammograms every year, or we wouldn’t have caught this tumor!”)
The false cancer slogan that “early detection saves lives” would be more accurately modified to read: Repeated exposure to radiation causes cancer.
More destructive than X-raying your feet!
Did you know that in the 1940′s, shoe stores used to have their own X-ray machines? Customers would try on a shoe, stick their foot in the X-ray fluoroscope machine, and see on the viewing screen how their bones fit in the shoes.
It seemed like a really neat idea, and it sold a lot of shoes. But at the same time, it also dosed customers’ feet with an astonishing 20 – 100+ rems per minute of radiation. (http://en.wikipedia.org/wiki/Shoe-f…). As you might suspect, a lot of these shoe store customers developed very serious health problems with their feet, including DNA mutations and cancerous lesions.
Even long after the radiation risk of such shoe-fitting machines was known to be extremely harmful, doctors stayed silent about it. The machines were never banned, either… they were quietly phased out in the 1950′s after raising the cancer risks of literally millions of people. ”
Dominique´s last blog ..more than 5.5 MILLION "we the people" PINK SLIP CONGRESS!
Wow! That’s some comment. What utter nonsense! Even your decision not to get a mammogram is odd. Not because you decided against it but because your decision was made not in consultation with your doctor but rather becasue of some garbage you read on a fringe website. We talk all the time about not letting the government come between a patient and her doctor but you seem quite content to let naturalnews.com jump right in there. Amazing.
And God forbid those evil pharmaceutical companies develop new drugs that will keep us healthy!
But tell me, is it more likely that there is a conspiracy among every oncologist, every cancer center, the American Cancer Society, The National Cancer Institute, the National Institute of Health, and every other informed person who knows anything about cancer to conceal the harmful effects of mammograms in order to attract new patients and purposefully overdose them to GIVE them cancer, or that naturalnews.com is full of crap???
Mike,
Since you brought up the “evil’ pharmaceutical companies…Next time you/Larry take up health care cost reductions, I’d be interested in hearing how you think the drug companies figure into the mix. I understand R&D expenditures etc. but would love to hear your take on the billions of dollars the companies spend advertising prescription-only meds direct to consumers, whether or not you think this is a good practice, and whether or not the companies (if they didn’t spend it on TV etc) would just funnel that money into direct marketing to physicians. Trying not to get too specific, but would be interested in a post on this on the whole.
Update on Mammogram controversy: “The task force is not against women having mammograms in the 40s,” Dr. Petitti said in a telephone interview. Rather, it is in favor of women in that age range deciding on their own, after consulting with their doctors, whether to undergo regular screenings, she said.’
article at: http://online.wsj.com/article/SB125867464145956577.html
Dominique´s last blog ..more than 5.5 MILLION "we the people" PINK SLIP CONGRESS!
There were two people who were HMO execs and one (Schwartz) who was a member of Blue Cross Blue Shield’s Medical Advisory Panel on the Task Force.
The mammogram as a scientific screening test for breast cancer is the best there is. Because it does not perform as well financially does not make it an invalid scientific test. It makes it less cost effective but not scientifically invalid. This Panel DID talk about cost. They just listed it under “harms.” Very disingenuous.
Thanks for your comments Rebecca. I expect we will be hearing quite a bit more about the members of the task force in coming days. But as I said in my post, I would be extremely surprised if the push for this announcement came from the members of the task force. This would more likely originate with the staff of the task force or the agency to which it is attached and then get raised at a task force meeting for consideration. It will be very interesting to learn the sequence of events and where the idea for an announced change in guidelines got its start.
Lot’s of different opinions about this issue, Mike. I was listening to another NPR interview this evening and two different doctors had two different opinions. It seems to be very hard to reach a consensus, even for the professionals.
Disclosure: I am a lay person with strong math knowledge and lay person’s interest in the subject and epidemiology. Nothing in this decision is surprising to me at all – several years ago I started reading the information and being a thorough person (come from working in a research lab), I read actual studies as well as “rapid responses” from other researchers to these publications. NCI and USPSTF as well – not just the sugar-coated version for lay people, but more detailed version for health professionals. After reading the actual studies, looking at studies that showed benefit as well as those that didn’t (CNBSS), criticism of CNBSS, authors’ reply, etc., looking not in meaningless “relative risk reduction” numbers but the number of actual women that need to be screened for one woman’s life to be saved (NNS), percentage of false positives, overdiagnosis, I decided that I don’t want to be screened – at least while in my 40s, but maybe later as well. This was an informed decision – I actually read the studies. It is not necessarily a decision that is right for everyone — I am sure some women would’ve chosen differently.
A couple of posts above caught my eye:
@Mister Pink eyes “I have heard from several women that women who get cancer earlier get a more aggressive form of cancer and that early detection is vital for their survival. It seems to me that if all women wait ten years before getting screened it will lead to many more deaths.”
There are two problems here. 1. younger women breasts are denser so mammograms are less likely to find these aggressive cancers – it is difficult to see white on white 2. younger women are more vulnerable to radiation risk, not just from screening mammogram itself, but also from numerous false postives and young women are more likely to have those 3. mammograms are really bad in catching exactly the most aggressive cancers as most aggressive cancers tend to spread very quickly – while they are still too small to be even seen on mammograms or they spread microscopically from the start. Mammograms tend to pick up slower growing cancers, including those that would never have spread if remained undetected. This is what is known as “overdiagnosis” – some “cancers” that never spread in woman’s life time.
This post from a doctor – completely neutral post – explains very well why not all early detection is beneficial: http://www.kevinmd.com/blog/2009/11/aggressive-cancer-screening-recommendations-patients.html#more-41016
I also strongly recommend book by H. Gilbert Welch “Should I be tested for cancer”. Note that the author is not some “fringe” guy selling vitamins, but a well-known and well-respected doctor and researcher, after of many widely-cited papers published in peer-reviewed medical journals. The book itself had positive reviews in medical journals. The author does not argue for or against screening, he is adamant that you see a doctor if you notice some symptoms. He simply explains in very easy layman language some of the complexities of early detection, overdiagnosis, concepts like “lead-time bias” or “length bias”. All in very easy lay person terms.
Thanks for your feedback Diora. You’re obviously better informed on the subject than the rest of us. Let me ask you one question about the new guidelines and your own decision not to have a mammogram: what about the recommendation not to do self-examinations? Does that make sense to you?
Yes, thanks for your comment Diora. I would echo the question that Mike just posed. Does the recommendation about self-examination make sense to you? I was listening to NPR yesterday evening and by the time the two doctors were finished bantering the subject around, I didn’t know what to think.
Thank you for the link and suggested materials. I read the referenced post by the doctor, and it appears to me that his reasoning points more toward the ineffectiveness of the current, available treatments rather than the screening itself in discussing mammography:
“While frequent mammography is more likely to diagnose cancer, there has not been a corresponding decline in breast cancer deaths”
Detection is detection, successful treatment is another matter, and I am left mostly questioning whether or not the entire discussion is being focused on the wrong thing. Did I miss something?
“Let me ask you one question about the new guidelines and your own decision not to have a mammogram: what about the recommendation not to do self-examinations? Does that make sense to you?”
I have really no opinion of the matter, but I have no reason to question the recommendations as I they are based on real studies. I don’t do self exams personally, but I allow my doctor to examine my breasts. The reason for it is that all the studies that showed clinical breast exam not to be useful compared breast exam+mammogram to just mammogram rather than breast exam to nothing. There was one very much criticised study (CNBSS) that compared mammograms to clinical breast exams and found same mortality reduction with breast exams as with mammograms but fewer false positives and overdiagnosis.
But I am not claiming to be an expert so please don’t take it as a medical advice. I am not a doctor, I am simply a lay person who maybe a bit more informed than most – because I was interested, because I know enough math to understand the studies, and can separate real medical web sites and journals from “vitamin-sellers”. So, my suggestion is to read the recommendations in details; if you are really interested, read the studies and discussions, if they sound too complicated – read the book I mentioned, talk to your doctor and decide what is right for you. The Welch’s book by the way is very easy to read, and can probably be found in any library.
Laurie – this statement “While frequent mammography is more likely to diagnose cancer, there has not been a corresponding decline in breast cancer deaths” doesn’t talk about ineffectiveness of treatments but about the fact that mammography is better in finding slow-growing cancers before they spread than really aggressive ones. The author doesn’t say that there was no decline in cancer death in years, she just says that the decline in death from breast cancer was smaller than how many more extra cancers were detected by mammograms.
There are really 4 possible cases when a cancer is detected on a mammogram. 1) it is very aggressive, so it is already too late as it has already spread i.e. it either has spread while it is still microscopic or it simply has appeared and spread in a period between mammograms. 2) it is aggressive that it spreads before you notice a tumor, but it still sufficiently slow growing that mammograms can catch it before it has spread. 3) the cancer may spread eventually, but it is so sufficiently slow growing that even when you notice a tumor it is still localized to your breast. 4) the cancer is either so slow growing that it will not spread in your lifetime or it’ll even regress or it just not going to spread at all. The reduction in mortality with mammograms comes from cancers like in (2). Mammograms make no difference in other cases, though you may say that in cases like (3), you may get less treatment with mammograms. But any advantage of less treatment for cases like (3) is offset by the unnecessary treatment for cancers like in (4). Until there is a way to determine how each cancer would behave, the more accurate the screening test is, the more non-progressive, indolent cancers (like in 4) it finds. I.e. it results in more overdiagnosis.
In terms of mortality reduction, mammograms make a difference for cases like (2). The controversy has always been about how big or small this group is. This is what the statement you referenced is about – that this group is not that large.
BTW – Dr. Michael Baum, who is a British breast surgeon, organizer of first breast screening program for the NHS who then became one of the most outspoken critics of screening, has views similar to what you said – he believes that research should concentrate on finding better treatments than more accurate tests. Not everyone agrees with all of his views, though.
Thanks for the clarification. Still left with questions- For those who have been helped by detection that mammograms provide and a successful treatment outcome, how else would they have detected the cancer? How many of those who have been helped would have died without mammograms?