Try as I might, I cannot become a policy wonk. Yesterday, I heard a health system leader say that he had given up following the politics of health care reform – he was just wasting time. Once a bill is passed, he will study it and learn how to respond.
The Sunday NY Times Magazine had a great piece on mammograms. The author, a mathematics professor, tried to explain the process the committee used to make their recommendation. The piece makes sense and should be required reading – Mammogram Math
Much of our discomfort with the panel’s findings stems from a basic intuition: since earlier and more frequent screening increases the likelihood of detecting a possibly fatal cancer, it is always desirable. But is this really so? Consider the technique mathematicians call a reductio ad absurdum, taking a statement to an extreme in order to refute it. Applying it to the contention that more screening is always better leads us to note that if screening catches the breast cancers of some asymptomatic women in their 40s, then it would also catch those of some asymptomatic women in their 30s. But why stop there? Why not monthly mammograms beginning at age 15?
The answer, of course, is that they would cause more harm than good. Alas, it’s not easy to weigh the dangers of breast cancer against the cumulative effects of radiation from dozens of mammograms, the invasiveness of biopsies (some of them minor operations) and the aggressive and debilitating treatment of slow-growing tumors that would never prove fatal.
The exact weight the panel gave to these considerations is unclear, but one factor that was clearly relevant was the problem of frequent false positives when testing for a relatively rare condition.
So this article uplifted my spirits. Someone was trying to make sense of this unnecessary debate.
Then I was watching Morning Joe this morning and heard them refer to this article. Now I am disgusted and disappointed, although I should know better than to be disappointed in politicians.
Mammograms as political weapon
Pollsters say the mammogram issue exploded after the task force’s issued its findings. A Gallup survey conducted just days after the release found 76 percent of women saying they disagreed with the new guidelines and 85 percent saying they had become aware of the recommendation.
In response to the backlash, the Senate earlier this month passed an amendment to the health care bill guaranteeing coverage for mammograms.
So where is political courage? Oops I just typed an oxymoron.
I guess physicians should share the blame. Some physician zealots have (and continue to) promised magic from early detection of cancers. They have preached the value of mammography for at least 40 years. They have "taught" woman that mammograms will save lives.
They over promised. The Preventive Task Force objectively looked at the data and made a reasoned decision.
But I will admit that the decision is difficult to understand given the background of mammogram encouragement over so many years. Medical science is not easy to comprehend. Advanced medical decision making confuses many physicians and most non-physicians. Sometimes the obvious answer is wrong.
The idea of mammograms is a seductive one. Women rightly fear breast cancer. They all know woman who have the disease. They fear their mammograms, yet they believe that having a normal mammogram is a yearly lease on life.
Trying to explain the risks and benefits of testing requires more complex thinking. Obviously our political parties are not capable of complex thinking.
We cannot control health care costs in this country if politicians and constituent groups demand certain services because they believe they are needed. i have never held the parties in high regard. Today I have disdain.
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RC, Your analysis is clear and your arguments are logical. You have approached the issue with dispassionate objectivity. That's why your view would have a half-life of 6 or 7 nanoseconds in Washington, D.C.
I posted a rant about this right after the recommendations came out:
The news that the United States Preventive Services Task Force has issued new guidelines on breast cancer screening has begun to generate ridiculous amounts of wharrgarbl. For the last day or so, I've been hearing government officials issue statements distancing themselves from the recommendations (that routine mammograms for breast cancer start at 50 instead of 40, and are done every 2 years instead of annually). Today on the radio, I heard so much stupid that I was still fuming when I got to work.
First off all, the whining about "rationed care" is just silly. If insurance companies used this as a means to limit access to mammograms for more profit at the expense of women's lives, what sense would it make to kill off the relatively healthy 40-49 age group by not screening them? Yeah, let's let the younger women who won't cost us as much in payouts die, and start screening the older ones who are MORE likely to get cancer. Also, if saving money is the real motivator, why not recommend that women just get their breasts amputated at puberty? Then they won't get breast cancer at all, and the savings will be astronomical! Besides, if we really cared about "women's lives," we'd start breast cancer screenings at 10 years old, right? Because think of all the cancers we'd catch then! It's obvious that the potential benefits of screening 10-year-olds isn't worth the cost and clinical risk. If the evidence suggests that annual mammography of a 40-year-old isn't much better, maybe we should give that consideration.
Second, the guidelines specifically say:
The precise age at which the benefits from screening mammography justify the potential harms is a subjective judgment and should take into account patient preferences. Clinicians should inform women about the potential benefits (reduced chance of dying from breast cancer), potential harms (e.g., false-positive results, unnecessary biopsies), and limitations of the test that apply to women their age. Clinicians should tell women that the balance of benefits and potential harms of mammography improves with increasing age for women between the ages of 40 and 70.
Women who are at increased risk for breast cancer (e.g., those with a family history of breast cancer in a mother or sister, a previous breast biopsy revealing atypical hyperplasia, or first childbirth after age 30) are more likely to benefit from regular mammography than women at lower risk. The recommendation for women to begin routine screening in their 40s is strengthened by a family history of breast cancer having been diagnosed before menopause.
So, if there is a reason that you and your doctor think that you should get routine mammograms beginning at 40 (or younger), you should get them. What's not to like?
I think that the majority of the people making noise about these new recommendations haven't read past the initial yellow-box statement on the USPSTF's website. What really irritates me is that the Department of Health and Services (ie: Kathleen Sebelius) is making these sputtering, indignant statements about them. If you really want a demonstration of a total lack of reading comprehension, check out some of the comments to the article. They are a total hoot.
Great post. I try to explain the issue to patients by drawing 2 sloped lines on the exam table paper, one going up and one going down. The benefits of screening are the increasing line and the harms of screening are the decreasing line. I explain that age ranges for recommendations are based on where the lines intersect, or the sweet spot where benefits outweigh the risks. Before we knew a lot about the harms of screening, that sweet spot was 40. Now that we are aware of more risks, that sweet spot has moved to 50. I explain that some individual factors may move those lines one way or the other (e.g., strong family history of breast cancer), so for them that sweet spot could be different. This approach seems to work and I can usually calm down the anxious/irritated patients with this explanation.
DB,
Politicizing mammograms is indeed worthy of disgust, and making medical coverage decisions by Acts of Congress is a horrifying prospect. In my view, however, the USPSTF brought this on themselves by producing an extremely inept explanation of their change in recommendations.
Clearly, mammograms are a mixed blessing, and they deliver lots of false positives and false negatives (which is an inherent problem with ANY screening test). And if we're to set an arbitrary age cut-off for routine mammography, it may well be that 50 is "better" than 40.
But what USPSTF did was to "take away" mammography from women under 50 (who had been exhorted for at least a decade, by highly-regarded private and government authorities, that such screening was essential) without anything resembling a reasonable explanation. I have read carefully the USPSTF document and find it disturbing that the panel was unable to articulate an answer to the simple question raised by their change in recommendation: Why is screening mammography a good idea for women aged 50, but not for women aged 40?
It seems to me, given the obvious explosive nature of what they were about to promulgate, that they should have realized that clear reasoning, clearly articulated, was the most essential piece of their deliberations.
The closest they come to an answer to that simple question was their reliance on a new British study suggesting that 40% more mammograms are needed to save a life in the older group than in the younger. This sounds like a fiscal explanation, which may explain their apparent reluctance toward clarity in the document.
If we are ever going to get healthcare costs under control, we're going to need panels of experts (like the USPSTF), to act with complete transparency, and to publicly explain their decisions plainly and unambiguously. Instead, the ineptness of the USPSTF led, predictably, to spineless politicians tripping over themselves to undermine the process.
Rich
The whole thing makes me sick too.
Women have been taken for a ride on mammograms courtsey of the pink ribbon medical-industrial machine. Why aren't they storming the Capital steps over the restrictions on their reproductive rights that House and Senate members are pushing?
Will every woman have to know someone who died in a back-alley room from a messed up abortion before they come to their senses? I'm not keen on the idea of abortion, but I'm even less keen on women without choices.
Well said. Your most salient point is about the fear of cancer, which I guest-blogged about at KevinMD <a href="http://www.kevinmd.com/blog/2009/12/fear-cancer-undermines-mammography-guidelines.html">here</a>.
This is not a black and white one size fits all issue IMO. I was the "victim" of a false positive mammogram in my 30's (first one post hysterectomy/BSO – needed a [negative] breast biopsy). But I have had friends in their 40's die of breast cancer after late diagnoses because they didn't have mammograms. Perhaps mammography should be more like colon cancer screening. You do it once at age X – and then more or less frequently depending on your personal medical situation and family history. I realize a solution based on actual patients and their histories won't please health care administrators or politicians (who love "one size fits all") - but my opinion is the mileage of all individual patients varies. Robyn
@Robyn: "But I have had friends in their 40's die of breast cancer after late diagnoses because they didn't have mammograms. "
You cannot say make this statement. Given the data on mammogram, the probability is your friends would've still died even with mammograms. Mammograms are much better at catching slower-growing cancers than fast-growing ones.
This is what "mammogram saved my live" crowd doesn't understand: just because cancer is detected on mammogram doesn't mean the mammogram made a difference. Some cancers are so aggressive that they'll kill anyway – they either grow fast between the mammograms or they spread microscopically from the start; some cancers are so slow growing that they'll still be curable when detected later and some would never cause problems. Mammograms only help for specific subset of cancers – those that grow slow enough that they can be detected before they spread yet are destined to spread between the time they can be detected on mammograms and the time you notice the tumor. This subset is not that large. The USPSTFs' cited 20% reduction for women in their 50s simply means that out of 10 women were to die from breast cancer without mammograms, 2 will not die of breast cancers, but 8 will still die. The numbers are even worse for women in their 40s.
For many many years we women haven't been told anything about the risks of screening. For as many years we got a much-too-rosy picture of benefits. Screening was not presented to us as a choice, but as an obligation. So why is this surpise that most women would still want mammograms? BTW – this woman doesn't…
I think people should read Welch's book "Should I be tested for cancer" for an easy-to-understand explanation of the problems.
Hi Diora – I agree with what you say in general. But (big but) – like I said above – I don't think is a one size fits all situation. There are certain risk factors associated with getting breast cancer in the first place – and certain risk factors associated with particular types of breast cancers (like slower growing ones versus faster growing ones – if I recall correctly – the faster growing ones are more common in younger women). My suggestion wasn't that all women should get annual mammograms starting at age 40 until the day they die. But I do think it is a good idea to get a baseline (maybe as early as age 35 – maybe as late as age 45 – again maybe taking personal risk factors into account) – and then take it from there in light of what the initial baseline shows and the patient's personal risk factors. It is certainly not a test I would eschew altogether simply because someone wrote a book you like (I have a medical-legal background and don't make important medical decisions based on anything I can read without a medical dictionary) . Just like you should get your baseline colonoscopy at or about age 50 (perhaps earlier if a close relative got colon cancer at a relatively young age).
One problem with my approach – which seems logical to me – is the absence of really comprehensive rigorous long term studies. For example – I have been on HRT since age 37 (I am now 62). Which puts me in a certain risk category. The conventional wisdom is that I need annual mammograms. But where does that conventional wisdom come from? I was part of a long term university medical school study of HRT and breast cancer until I moved from Miami in 1995. I thought I'd be able to follow up and remain a member of the study. But no dice. Once I left Miami – I was out of the study. Does this make any sense? How many people live in one place these days for 30+ years? If we don't have really long term studies – how can we evaluate the conventional wisdom? Perhaps – as with colonoscopy – after an initial negative baseline – and no big risk factors – and no lumps in her breast – a woman needs a mammogram much less frequently than once a year. I would like to see studies that "show me the money".
Also – being a retired lawyer – I tend to think in legal terms when it comes to causation. More likely than not (> 50% chance) – probable – as opposed to certain (keeping in mind the old saying that the only certain things in life are death and taxes). Can I say for sure that my friends would be alive today with mammograms? No. I can however guess that it is more likely than not (although I'd need a medical expert to be sure).
Finally – when it comes to medical stuff – it is almost inevitable that nothing is "black and white". Last month I was diagnosed with 2 pretty large Gartner's cysts (look them up if you don't know what they are – apparently they are kind of rare in women my age). A little uncomfortable (looks like I have part of a pretty pink golf ball at the top of my vagina). But no big deal. So the issue is whether to have surgery. Now there is only a very very small chance these will develop into cancers – and a somewhat larger chance they will get bigger and involve my urinary tract – and an even larger chance they will eventually become painful and affect my sex life. There is also the possibility that if I wind up needing Depends 4 years from now when I'm on Medicare – that health care to Medicare patients will be rationed – this will not be a procedure covered by Medicare (who cares whether women "leak") - or that my local hospital (which happens to be Mayo JAX) will no longer accept Medicare patients. Took me about 10 minutes to decide to have surgery now (actually end of January – I usually sit around the first couple of weeks in February doing tax work so I can afford to be out of commission then) - even though it will cost me $10-15k out of pocket (deductible and co-pays). This seemed like a logical analysis to me. Opposing points of view are welcome. Happy New Year, Robyn
P.S. I think medicine in general is very "male-centric" in terms of patients. Almost nothing is tested on women – and when we go into the OR – the parts are almost always "one size fits all". It is only in recent years that companies have started to make – for example – joint replacement parts sized for women. And when my mother (little person like me – about 5'0") had cardiac surgery years ago - the doctor had to use pediatric parts because all the normal parts were made for guys who were a whole lot bigger. We are 50% of the population – and have more of the money than guys when we're older (because the guys tend to die earlier than we do). We don't go into the men's department to buy our clothes – and I think we are entitled to female sized medical equipment – since we're paying really big bucks for it. Which is getting back to my original point – one size doesn't fit all!
P.S. Looked up this doctor Welch you mentioned and he is a board certified internist. I'd be more interested in hearing what cancer docs (all flavors) have to say about cancer screening. Robyn
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