Nov 23, 2009

Mammogram Madness

The U.S. Preventive Services Task Force recently advised that most women don't need mammograms as early or often as previously believed. Now you can't turn on a TV without some reporter telling us how angry Americans are about this.
What is Doctor D's take on the new guidelines?
As a working clinician I trust the USPSTF. They have no agenda-axe to grind and spend a lot of time studying mountains of data. These experts meticulously examine the thousands of studies that I just don't have time to read. They crunch numbers and come up with carefully considered recommendations.

While I can understand all the public concern, I am irritated that many doctors seem eager to jump on the irrational bandwagon.

What no one seems to comprehend is that even relatively safe tests and treatments can still be deadly. Doctor D has hurt some very nice people with the "right" treatment because all medical interventions have risks.

Men can also get Breast Cancer, just less often. Men die of this disease. Would screening every male "save lives" by catching some early cases? Probably. Would there be lots of false positives? Absolutely. Would the number of men we maim or kill with work-ups and treatments outnumber the lives saved? Almost certainly. Hence the need for evidence-based guidelines.

Breast Cancer is a horrible disease, so it was worth a try to screen women in their 40's. But now we have years of data indicating that we hurt more low-risk women than we helped. Uh-oh! It's one thing to hurt people with what we hope will be the right intervention, but when we hurt people by doing something we know doesn't work it's shameful. The same thing happened with prostate screening for men. We don't need to keep doing things that don't work.

We have a natural bias towards doing something rather than doing nothing. People expect doctors to "do something!" Doctors like to do things for patients. Hence over-testing and over-treatment run rampant in all fields of healthcare. Sometimes we make educated guesses at interventions and hope they work, but when we have evidence showing we aren't helping people, it's time to acknowledge that doing nothing is safer and wiser.

The trouble is that the guidelines are based on mountains of studies that the public, politicians, and many doctors are unequipped to evaluate for themselves. So we go for next best thing: anecdotal evidence. We base our opinions on heart-wrenching stories of women in their 40's that died of Breast Cancer. All the evidence in the world is no competition for a really moving story.

What the USPSTF needs to do is come up with a convincing narrative. Stop referring to data that nobody understands and give your arguments a human face! Parade the widowers of and orphan kids of women that died as the result of a workups for false-positive mammograms in front of every TV camera you can find. Get doctors up on stage and have us apologize, "Sorry, we did what we thought was best, but now we know we were wrong. We'll do better in the future."
Doctor D realizes he'll probably loose some readers over this post, but somebody had to defend the USPSTF against this crayzee smear campaign.

Feel free to post your thoughts, but please don't accuse me of "not caring about women's lives." I follow the recommendations because I care about women, and I've been saying the same thing about PSA in men for a while.


Helen said...

I agree.

Both my Mom and my aunt had breast cancer in their 50s (my Mom is going on 7 years cancer-free!), so it's something that is on my mind.

Reserving mammograms for women 50 and up does not leave younger women helpless. I do my self-exams regularly. I pay attention to my body.

We have this reflexive desire to always be taking action, especially with high-profile illnesses, even when that action is useless or, worse, harmful. There are a host of diseases I could get. Does that mean I should be tested for all of them? No.

Nor is this an issue of male authorities vs helpless female patients. Anything can look sexist if you squint at it in the right light.

The Good Cook said...

I think the double whammy of mistrust came when just days later "they" came out with the news that pap smears on a yearly basis are also unfounded. Women have taken a back seat to medical research and intervention for decades (correct me if I'm wrong...) we are wary of any study that advises us to be LESS diligent..

On another note, what is your experience and /or advice on uterine ablation versus hysterectomy?

Doctor D said...

Helen, with your family history I'm not sure you would be one of those low-risk women who should wait for 50. I probably should have clarified above that there are still some women who qualify for early Mammograms just not everyone.

Cook, I'm not sure what you mean by "back seat." Certainly women are still underrepresented in some research on diseases that affects both sexes, like heart disease, which we are just learning can present quite differently in women. Women's cancers have been at the forefront of a lot of screening programs (Cervical, Breast). I don't think this is because women were used as guinea pigs, but because both were such horrible diseases. "They" saw that both programs worked so they made them widespread. Only after widespread application is there enough data to really compare risks vs. benefits in different groups and see if there are places the programs should be rolled back. The question is will we roll back when the data shows we should?

Sorry about the ablation vs. Hysterectomy issue. I'm really not able to offer specific treatment advice. Also I'm not sure I know the answer--probably depends on the situation.

Helen said...

Hi Dr. D,

Don't worry - I'm planning to get them starting younger, although I did see a genetic counsellor and was told there does not appear to be a hereditary aspect to the cancer in my family.

My main point was directed at the general population, and then other diseases for which I AM low-risk and don't need, or plan, to be tested for until I'm older. I think sometimes we over-test for illness in general, just as an antedote to feeling like we're doing nothing.

But yes, I'll get them younger - blah.

Anonymous said...

Dr. D, I'm 53. A year and a half ago, my gynocologist felt a lump in my breast. I could not feel it. I was due for a mamogram anyway, so I had one done, and it did also show that lump. They did a needle biopsy, and the "lump" deflated when it was pierced -- which I guess isn't all that uncommon. The doc said if the cyst did that, then it definitely wasn't cancerous.

So I did go through a couple of months (it took that long to do all of this -- I get my health care through the VA)of low-grade worry and yes, fright. But I'd rather that than discover a cancer way too late.

I don't have any trouble with these new guidelines, as long as women are given a choice of having or not having mamograms in their 40s. It seems a shame to "miss" a cancer, but I can understand not doing them when they show so many false positives, too.

I agree with you. I just had to get to it the long way.

Celeste said...

One of my high school friends has a family history (grandmother and mother) of BC so she started early with the mammograms. Twice they found something, and twice she had it removed. Both times it was nothing but fibrous material. Each time she got worry (and so did her family and friends), pain, days off from work, and a big scar. This year she had the genetic test to see if she has the BRCA gene--it said no. So now she's got two big scars and a lot of extra radiation dose to radiosensitive tissue. She also risked picking up MRSA each time she had surgery, though fortunately that didn't happen.

I look and I look, and I'm not seeing good medicine here. It's almost a case where had she not had insurance and an easy time of getting this service, she personally would have been better off.

Anonymous said...

It’s good to hear a voice of sanity on this topic.

I’ve been annoyed at how many people righteously claim that annual mammograms for younger women are essential. As a woman who has had numerous mammograms since her early twenties (all for what turned out to be simple cysts), I think that they too easily discount the pain, the cost, the anxiety, the cumulative radiation, the disfigurement from fruitless biopsies, and worse. Supporters of annual mammograms say that the suffering of thousands of faceless women is a price worth paying to save the lives of a few other women who will discover a treatable cancer because of a routine mammogram, but how far would they extend that logic? Shall we mandate bilateral prophylactic mastectomies for all twelve-year-old girls, a move that would probably eliminate most breast cancer altogether? Do we really think that anyone should pay any price to catch some people’s cancers earlier?

And aren’t younger women sick of getting those letters after a mammogram saying the results are normal but no guarantee of non-malignancy since the breast tissue of younger women is “extremely dense” and therefore mammograms are less accurate. These letters make me wonder why I even bothered.

On another note entirely, every woman I know hates to go get a mammogram. I’ve been surprised that more of us aren’t simply relieved to hear that smart people who have combed through all the data conclude that most (not all) of us would be better off to have fewer of them at a young age.

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