Comments on: Politics and mammograms – I am disgusted and disappointed

By: Robyn

Robyn — Fri, 08 Jan 2010 00:45:31 +0000

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

By: Robyn

Robyn — Fri, 08 Jan 2010 00:14:59 +0000

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!

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Thu, 07 Jan 2010 13:17:29 +0000

[...] the U.S. Preventive Services Task Force, which says women should start at 50, when it came from politicians, but when scientists issue the contradictions, that’s what will leave nearly all Americans [...]

By: Diora

Diora — Mon, 04 Jan 2010 18:25:06 +0000

@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.

By: Robyn

Robyn — Thu, 17 Dec 2009 23:51:39 +0000

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

By: #1 Dinosaur

#1 Dinosaur — Wed, 16 Dec 2009 15:32:08 +0000

Well said. Your most salient point is about the fear of cancer, which I guest-blogged about at KevinMD here" rel="nofollow">http://www.kevinmd.com/blog/2009/12/fear-cancer-undermines-mammography-guidelines.html">here.

By: DB's Medical Rants » Blog Archive » Politics and mammograms – I am … EMedic

Wed, 16 Dec 2009 14:33:09 +0000

[...] more here: DB's Medical Rants » Blog Archive » Politics and mammograms – I am … By admin | category: advanced medical | tags: advanced medical, decision-making, not-easy, [...]

By: AnnR

AnnR — Wed, 16 Dec 2009 00:57:12 +0000

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.

By: DB's Medical Rants » Blog Archive » Politics and mammograms – I am … « Noya Khobor

Tue, 15 Dec 2009 21:35:12 +0000

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By: DrRich

DrRich — Tue, 15 Dec 2009 14:53:17 +0000

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