Truth Squad—Medical Reporting On Mammograms, Part 1

"Vague, fact-free, emotionally charged statements are the language of public relations, not scientific discourse.” 

Dr. Adriane Fugh-Berma, Georgetown University Medical Center, and Alicia M. Bell, member of the board of directors of the National Women's Health Network.

News reports on the mammography controversy reached a pitch of high hysteria last week, the baseline syncopated with the language of hate and fear.

Minnesota journalism professor Gary Scwitzer tracked the dismal progress (“descent” might be the better word), of the debate over the US Preventive Services Task Force (USPSTF) recommendations regarding mammography on his blog, Health News Review. There, he points to the fear-mongering and rampant exaggeration that has distorted media coverage.  For example, “On ABC’s daytime talk show, ‘The View,’ co-host Elisabeth Hasselbeck made the stunning claim that the recommendations [represent] ‘gender genocide.’” 


But it is not only women who have resorted to the language of “attack TV.” Last week, Washington Post columnist Dana Milbank crossed the border that separates advocacy journalism from simple bad taste when he suggested that: “Many oncologists, no doubt, would like to send [Preventive Services Task Force chairman] Ned Calonge and his colleagues off to Gitmo, where they could live out their years happily denying one another cancer screenings.”

Milbank ended his column with what he may have viewed as a flourish, recommending that, given the fury of the national reaction to the Task Force’s update, perhaps Congress should “take pity on the panelists and send the task force to the Death Panel for a humane end.”

“If he thought this was humorous, it wasn’t,” observed Schwitzer, who many view as the dean of health care journalism. 

Why Is the Media Response So Heated?

No question, “breast cancer” is a charged phrase.  In an instant, the two words conflate the beginning of life, when a baby feeds at its mother’s breast, and the end that so many Americans fear, “the Big C.” Sex and death packed into one phrase—little wonder that the words can unleash such strong emotions.

Compare the recent brouhaha over mammography to the media’s coverage of other USPSTF updates.  In February, when the Task Force issued a recommendation saying that there is too little evidence regarding the risks and benefits of full-body screening for skin cancer to recommend the procedure, the statement barely caused a ripple in the mainstream press.  In August of 2008, when the Task Force announced that “Current evidence is insufficient to assess the balance of benefits and harms of screening for prostate cancer,” the USPSTF update drew some fire, but nothing like the current uproar. 

Breast cancer remains a special case. Both women and men find the thought of a woman losing a breast extremely disturbing. To many, the breast symbolizes beauty, femininity, sexuality and motherhood. It’s not surprising that the public responded to the suggestion that mammograms may not offer much protection for women in their forties with confusion and fear.

What is surprising—and shocking–is the media’s overwrought reaction. In an e-mail, Schwitzer describes it as marking “a low point for journalism and for our public discussion of screening, science and evidence.” The USPSTF released its update just as the battle over health care reform had reached a crescendo of anger, fear and recrimination, and those who oppose reform seized on the Task Force statement to insist that “reform” will mean “rationing.”  Others simply saw an opportunity to sell newspapers, preying on the public’s fear of cancer and its anxiety about health care reform in double-decker headlines. Rather than explaining the science, they exploited the politics. Meanwhile, gloomy liberals took the news as proof that Americans just aren’t ready for evidence-based medicine.                        

The Media Doesn’t Just Report the News, It Helps Shape It

Let me suggest that bad cases make bad law. And the media hasn’t just been reporting the news, it has been pouring fuel on fire, shaping the public reaction. I don’t think that headlines like “More Death Recommendations From the Government Task Force”  accurately reflect  how the vast majority of patients would respond if  their doctors had an opportunity to calmly explain what medical evidence shows about the advantages and disadvantages of a great many tests and treatments. This includes talking about the risks as well as the benefits of preventive care.

Health care reformers want to make those discussions possible by beginning to compensate primary care doctors for the time they need to talk to-–and listen to—patients. Medicare already has announced it wants to raise fees for primary care doctors by 4% next year, and reform legislation would raise reimbursements by another 5% to 10% in 2013, while providing additional bonuses for primary care doctors who create a medical home or join an accountable care organization. Over the next three years, I expect to see more hikes in Medicare reimbursements for primary care. A public plan would incorporate Medicare’s reforms and private insurers will follow suit.

Americans may not respond well to fear-mongering headlines, but if our doctors have the time to begin to talk to us about the risks and benefits that comparative effectiveness research reveals, I believe that many patients will listen. In the meantime, it would help if journalists reported facts, not fiction.

Truth vs. Fact

Schwitzer suggests that the media coverage merits a Truth Squad investigation.  I agree.

No doubt many HealthBeat readers recognize that over-the-top reporting distorted the truth. Nevertheless, I’m afraid that the press has succeeded in sowing seeds of confusion and doubt. For instance, after all of the charges and counter-charges, how many HealthBeat readers know exactly what the Task Force said?

Below, my effort to clarify what is true and what isn’t regarding

  •   the Task Force’s recommendation;
  •   the  potential harms and benefits of mammograms;
  •    the science behind the guidelines
  •   and what the controversy means (and doesn’t mean) for health care reform.  

                                          ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

False Claim:  The USPSF tells women under 50 that they shouldn’t have mammograms

Washington Post, columnist Howard Kurtz helped muddy the waters by describing the USPSTF’s recommendation as “advice that women in their 40s no longer seek breast cancer screening.”
Kurtz summed up as the Tasks Force’s counsel as: “don't-worry-be-happy-till-you're-50.” 

Truth: The Task Force did NOT recommend that forty-something women skip mammograms.

Here is what it actually said:

"USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms."  The Task Froce went on to recommend biennial screening for women 50 to 74.

"So, what does this mean if you are a woman in your 40s?”  asked Diana Petitti, MD, MPH, Vice Chair, USPSTF. “You should talk to your doctor and make an informed decision about whether a mammography is right for you based on your family history, general health, and personal values.”

The key word in the Task Force’s recommendation is “routine.” The panel is saying that women in their forties should not automatically have mammograms. They should talk to their doctor, and together, make a decision, taking Context into account. Context includes family history. If your sister and mother both have been diagnosed with breast cancer this will, of course, affect your decision. You’re a “high-risk” patient.

False Claim:  “Thousands of Women Will Die . . .” 

On AlterNET, linguist George Lakoff  “frames” the issue  with a headline that screams: “47,000 Women Could Die As a Result of the New Mammogram Guidelines.”

Unfortunately, a combination of bad arithmetic (which assumes that the 80,000 females in America under the age of 40 are all equally at risk of dying of breast cancer), and a failure to recognize the difference between “cost-benefit analysis” (which focus on costs) and “comparative effectiveness research” (which considers risks and benefits for patients, regardless of cost) turns Lakoff’s essay into mush.

Truth:  “Mammograms reduce the chances of dying by a fraction of a percent”

As proof, Schwitzer offers hard numbers, reprinting a table created by Dr. Steve Woloshin, of the Veterans Affairs Outcomes Group,  which shows that over a ten-year period, a woman  age 40 to 49 has a 0.28% chance of dying of breast cancer if she goes for  regular mammograms, and a 0.33% chance of dying of breast cancer if she doesn’t.  These are “the numbers that get lost in the rhetoric,” says Schwitzer.

RiskOfDeath
But, thanks to a forty-year campaign to instill “breast cancer awareness” in the minds of American women, most remain convinced that that breast cancer represents a real and imminent danger. They believe that they must be on red alert.

Schwitzer quotes USA Today: “Forty percent of women estimate that a 40-year-old's chance of developing breast cancer over the next decade is 20% to 50%. The real risk is 1.4%, according to the National Cancer Institute." Schwitzer’s comment: “Is it any wonder that women say they'll ignore the USPSTF recommendations when they over-estimate their own risk by such a huge degree!”

False Claim:  Mammograms Cut Your Risk of Death by Breast Cancer by 15% to 20%

No doubt you’ve seen these numbers in the news. Time.com’s Kate Pickert is angry at the thought that so many lives are being dismissed. “Women are incensed that some faraway task force has decided a 15% risk reduction – i.e. actual lives saved – is not enough to warrant mass screening.”

Truth: Risk is 0.5% for 130,000 Women over 40 who Have Mammograms, 0.4% for A Group That Does Not

 The truth is that reducing risk by 15% or 20% represents the “relative benefit” not the “absolute benefit” of mammography.

In The Atlantic, John Crewdson explains the difference: “For example, the relative survival benefit of 20 percent among women ages 40-74 who had mammograms in the Swedish trials translates to 511 women dead of breast cancer out of 130,000 who were screened for 15 years—a death rate of 0.4 percent.”

Among the comparison group of 117,000 Swedish women who did not have mammograms, the breast cancer death count was 585 women, or 0.5 percent. True, that’s a 20 percent relative benefit in favor of mammography. ” In other words, 0.4 percent is 20% smaller than 0.5% .“ But,” as Crewdson notes, “0.4 and 0.5 are very tiny numbers.”

Crewdson also quotes Dr. Donald Berry, head of biostatistics at the M.D. Anderson Cancer center in Houston, who calculates that a decade of mammograms for a woman in her 40s increases her lifespan by an average of 5 days. “The estimated average of 5 days of life lost if a woman in her early forties delays mammography for 10 years is similar to that for riding a bicycle for 15 hours without a helmet,”  Berry says, “or of gaining two ounces of body weight (and keeping them on)."

The Atlantic piece illustrates how the press can use its power to educate rather than to stir up fears—if that is what it  chooses to do.

False Claim:  “Cost benefit analysis can kill”

Commentators like Kate Pickert are outraged in part because they have been told that the USPSTF made its recommendation with an eye to saving health care dollars, putting money ahead of lives.  Lakoff reinforces that assumption in the opening line of his AlterNet Post: “Cost benefit analysis can kill.”

Truth:  USPSTF Was Not Doing Cost-Benefit Analysis

In that first sentence, Lakoff offers up his first piece of misinformation. The USPSTF is not charged with comparing the benefits of a treatment to the cost—its mission is to compare benefits to risks. As Task Force chair, Dr. Diana Petitti explained on NPR: “The US Preventive Services Task Force reviewed the evidence without regard to cost, without regard to insurance, without regard to coverage.”

It is important to realize that the Task Force is not a committee of bean-counting bureaucrats. It is “an independent panel of private sector experts in prevention and
primary care, set up in 1984 by a physician then serving in the Reagan administration. The idea was to fund a group that could operate outside of government to review ongoing research and data in an effort to determine how well certain strategies to combat disease actually worked.” (Thanks to the Amherst Bulletin’s Suzanne Wilson.)

Over at Huffington Post, obstetrician and gynecologist Dr. Peter Klatsky elaborates: The USPSTF is “composed of physicians and scientists whose only motivation is to improve the health and wellness of women nationwide. Being invited onto the USPSTF is a huge honor. These are our best and brightest. They strive to determine what is best for our patients, our community, and our loved ones.”

In Part 2 of this post, I will respond to claims that: the Task Force pulled these numbers “out of the air and out of the blue;”  the only “harm” associated with mammograms is “anxiety;” cancer survivors and doctors all “denounce the new recommendations;” and under reform, “the government will use comparative effectiveness research to ration care.”

23 thoughts on “Truth Squad—Medical Reporting On Mammograms, Part 1

  1. Excellent post. Schwitzer’s blog is always on my essential reading list.
    A larger issue is in the background of this controversy, I think. That is the pernicious notion that spending less money (“rationing” is the standard negative buzzword) always means poorer care — and outcomes. Of course the opposite is often true.

  2. No one believe talking points anymore, these included. Certainly no one believes that although USPSTF says they did not succumb to suggesting cost reduction, that in fact they did. The cooincidence with moving in the opposite direction of more screening vs cost reduction and Obama’s pledge to reduce cost is too much to overcome.
    Just admit to the change in direction being prompted by a need to reduce cost. Fighting that will only make it seem worse, more sinister. If you have to, blame previous administrations and congresses for the ease to which overtreatment can be done. Tell women that less breast cancer screening is just the price they will have to pay and find some more prices we will have to all pay and add them up.
    People will HAVE TO accept less health care services if we want to reduce cost. Doctors and hospital and pharma will have top accept less profits and pay. There will HAVE TO be less services like private rooms, concierge medicine, full on desperate end of life treatment splurges, heck Grandma doesn’t even really want them.
    Everyone in America knows these things.

  3. The solution is as simple as one word Maggie, SAFEHARBOR. Most of these problems with the rollout go away and neuters opposition.

  4. Chris and Ed
    Chris– Thanks
    Yes, in heatlhcare, less is often more.
    Ed–Please read Chris’ comment. As a physician he Know that often less care is better for the patient. It’s safer and leads to better outcomes.
    There is more than enough money sloshing around in our health care system to pay for all needed and effective treatment for everyone.
    If you read what the Obama administration has to say about reducing costs (particularly white house Budget Director Peter Orszag) you will find that they understand that there are many ways to reduce costs that actually will lift the quality of care.
    We’re NOT talking about people “giving something up” that would be medically useful.
    That’s why we’re taking a close look at mammograms. It’s an area where some (not all) women are having unnecessary tests that lead to unndecessary treatments.

  5. I did this analysis on my own several years ago. The studies existed and it was clear to me that as a woman in my 40’s routine screening benefit far outweighed by false positive rates. I am just glad the task force had the guts to say what the research really shows. Maybe now we can focus on getting a more accurate screening tool. Great post Ms. Mahar!

  6. Good summary Maggie. It looks like over the weekend, you’ve also been perusing the science – not the politics – behind the recommendations. The recommendations are supported by strong data and good science. The study authors do not have any conflicts of interest, they are not connected to the government and did not have rationing of health care resources as their underlying mission. The mission of the USPSTF is to provide evidence-based recommendations and treatment guidelines for clinicians, unencumbered by cancer industry influence.

  7. The critical thing to understand here is the issue of mammograms leading to the diagnosis of cancers that would not go on to be life threatening, leading to the risks and pain of treatment that is not necessary, including a small risk of death from complications of surgery, anesthesia, and chemotherapy. Real false positives — mammograms leading to biopsy when there is no evidence of cancer of any type — are a problem as well, but not as severe as the “non-lethal” cancers, since the correct diagnosis is usually available by minimally invasive needle biopsies, which are not any fun but do not lead to much risk either.
    The problem of distinguishing between non-lethal and lethal breast cancers is huge, since at this point there are NO good markers to distinguish the two. Not getting mammograms exposes patients to a small risk of dying from a missed lethal cancer but protects them from the risk of having to go through treatment for non-lethal cancers.
    Estimates suggest that as many as 30 to 40% of cancers detected by good mammography are non-lethal (oddly enough, poor mammography actually decreases that because it cannot detect the non-lethal cancers, but it also increases the risk of death from a missed lethal cancer.) Part of the problem here is the lack of good research — there are simply no good studies out there, since all of them are flawed by either poor mammography technique or poor statistical technique or both.
    That puts us in a situation where women must decide for themselves — and in the malpractice environment that exists today, they are not likely to get much help from doctors, who are just as confused and even more spooked by this problem as the public — what to do. That decision should be rationally based on risk analysis that just does not exist as of now.
    What we are left with is a situation in which, as Maggie says, emotion will trump rational thought. Women must and will make this decision based on a combination of their tolerance of risk of various sorts — especially the risk of treatment that is not needed versus the risk of death from undetected cancer. In the environment that exists in the US, that is not going to be a logical decision, and indeed the data to make that a logical decision is not there. Even the Scandinavian Cochrane meta-analysis, one of the primary sources for the new recommendations, ends by concluding that there is not a good case for either screening or for not screening — that it is the woman’s choice.
    Clearly, we need more research. However, good quality research will require large numbers of women randomized to mammography and non-mammography groups. Good luck trying to get women to consent to that in this environment.

  8. Pat S,
    Pat S–
    You’re absolutely right, the biggest risk is that a woman undergoes surgery for a cancer that would not have killed her.
    I didn’t emphasize that in my post because I think that in this country, very few people are willing to acknowledge that some of us undergo unncessary lumpetctomies and even mastectomies.
    This is why I quoted the patient from the UK. She was willing to entertain the possibility that she had gone through all of that suffering for naught.
    In the last two weeks, I didnt’ finda single news story in the U.S. that even came close to suggesting that, following mammograms, some women undergo a needless mastectomy.
    Meanwhile we have spent so much time and money trying to persuade all women that they should have mammograms annually . . some of that money could have been used on research to find better ways to tell which cancers will be lethal.
    I have to disagree with you on just one point. You write: “Clearly, we need more research. However, good quality research will require large numbers of women randomized to mammography and non-mammography groups. Good luck trying to get women to consent to that in this environment.”
    I haven’t had a mammogram in many, many years.
    There is no history of cancer (of any kind) in my large extended family. People are relatively long-lived (for their generations) but don’t seem to develop cancer. (Or at least they die of something else.)
    I know quite a few other pretty well-educated women of my baby-boomer generation who stopped undergoing mamograms because: a) they or too many of their friends had “false positive” b) growing skepticism about
    screening and diagonstic testing c) an awareness that a great many people were making a great deal of money on “pink” campaigns. (Mammography itself is not lucrative, but businesses have found a million ways to cash in on breast cancer hysteria.)
    Since I’m not going to have a mammogram anywyay, I’d be perfectly happy to sign up for a control group.
    Admittedly, if reserachers recruited women like me it wouldn’t be a “randomized” control group. . .
    But in Europe most women don’t get screened until age 50. And there just isn’t the same exaggerated fear of breast cancer.
    (This is Not to say that breast cancer isn’t something to be feared. Of course it is. It can be a horrible death.)
    But in the U.S., as I noted in the post, women way over-estimate how likely it is that they will develop breast cancer. This is because the media and others have done such a good job of hyping the risk.
    In Europe, my guess is that it would be relatively easy to set up a controlled trial of women ages 40-50.
    That still leaves questions about the risk of breask cancer and need for mammograms among specific groups–for instance African-American women.
    I don’t know if they are at higher risk for breast cancer. I do know that observational evidence suggests that African-American men are at higher risk for prostate cancer.
    Insofar as we have some evidence that certain ethnic or racial groups are at higher risk, it seems to me that should be factored into the doctor/patient discussion about whether or not to screen. (If I had a family history of breast cancer I would have had “routine” mammograms, like clockwork.)
    Finally, it seems to me that the USPSTF recommendation might serve as the basis (or at least part of the basis) for legislation ensuring that a doctor cannot be sued if a patient dies of breast cancer and the doctor failed to urge said patient to go for a mammogram when she was in her 40s.
    At this point, the risk of breast cancer seems to me like the risk of smoking (though of course smoking is much, much more likely to lead to cancer. Not going for mammograms creates a tiny risk-
    The parallel is this: all Americans now know that smoking can lead to cancer. All Americans have now gotten the message that mammograms can lead to early detection and treatment of breast cancer.
    This is not information that you need to get from your doctor.
    Today, if you smoke and die of lung cancer, your doctor can’t be sued because he didn’t send you to a smoking cessation clinic.
    It seems to me that a similar legal argument could be made regarding mammograms and breast cancer.
    I can see passing specific legilslation protecting doctors who didn’t recommend mammograms for average-risk women at age 40–and who didn’t recommend PSA testing for prostate cancer for average-risk men.
    If doctors weren’t “spooked” about the uncertainty and the danger of being sued, I hope that many more physicians would level with patients about risks and benefits.
    This would be good for everyone.
    As we move forward on healthcare reform, it seems to me that we need to redeuce the likelihood that doctors will practice “defensive medicine” (which is all about defending themselves) –and increase the likelihood that they will practice “patient-centered medicine” (giving patients all relevant info about risks and benefits–
    i.e. “shared decison-making.”)
    If, after receiving that information, the patient wants the doctor to make the decision, that’s fine too.

  9. Dear Maggie, Of course I already agree with you, as do most of the readers here. We are a bad sample though.
    Most folks will see this as giving up treatments. Even if the screening isn’t effective for the population, it may be effective for a given person.
    Without paying for it, they are getting it “free” so they are giving up something. I think that they know that they may be giving up something that maybe isn’t worth it, but they are giving something up.
    My point is you can fight the battle all you want to deny it, or you can simply go with it and say, “Sure you are giving up something that isn’t worth the cost because it doesnt help much.” Folks will understand and accept that moreso than words they don’t trust. By denying it, you may tweek their inherent suspiscious nature.

  10. Maggie —
    Clearly, you understand the problems with randomization. No, if you volunteered for a study, you would not be allowed to choose not to have mammography, and in fact you might be randomized to the mammography group, and have to be willing to get mammograms. That’s the way things work. One of the reasons that so many of the studies, the Swedish study and the Canandian study in particular, failed was failures of patients (and their doctors) to accept the position they were randomized to. When the data about the efficacy of mammograms for finding cancers — lethal and otherwise — began to come out, women simply “broke” the randomization and went out and got mammograms. Doctors in Canada actually put patients they were suspicious had cancers in the mammogram group. Unfortunately, it does not take very many women violating the randomization to destroy the study. Just one of the problems of studying people, not lab rats.
    I do think that many doctors will try to explain the facts behind the new recommendations, but unfortunately, like the Nordic Cochrane Group, they will not be able to give the patients the type of definitive information that they want and “need.” They will be stuck saying, as the Cochrane Group does, “It may be reasonable to attend for breast cancer screening with mammography, but it may also be reasonable not to attend, as screening has both benefits and harms.”
    In a logical world, telling that to a patient might be helpful. In our world, not so much.
    A personal note. My own wife and many of her friends — many of whom are doctors’ wives and some of whom are doctors — have concluded that these new recommendations are an attempt to save money at the cost of women’s lives. I don’t think I have been able to convince her otherwise. The argument is too complicated and technical to overcome visceral reactions.
    As you said in your article, breast cancer is surrounded by a supercharged atmosphere of paranoia, sexism, and doubt about the reliability of science over “common sense.” In addition, as you point out, the news media — what a shock — has done an absolutely terrible job with this, as they have with almost every story in the last 30 years that requirs some work to find out what is actually going on and to explain it.
    BTW — researchers are attacking the question of telling the differences between lethal breast cancers and non-lethal cancers aggressively. Unfortunately, progress is slow.

  11. False positives – mammograms leading to biopsy when there is not evidence of cancer of any type – are a real problem.
    Pathology is a very visual science. The pathologists look for patterns. Cancer grows in recognizable patterns that allow for their identification. Biological characteristics are exactly what pathology reports provide. A breast cancer has a certain growth pattern that differs from a carcinoma of the lung. Benign conditions also have patterns.
    However, in between a diagnosis of benign cells and a malignancy are a dizzying array of possibilities, and sometimes more often than you’d expect, the pathology report is wrong. Researchers at Johns Hopkins have found that about 1.4% of the time, a pathologist mistakenly diagnoses cancer, gets the type of cancer wrong or misses a cancer altogether. Errors that can significantly change the type of treatment are even more common.
    Even two different pathologists looking at the same cells can reach different conclusions about who has cancer and what type. Pathologists can readily distinguish between big invasive cancers and normal tissue, but they disagree about what to call cancer in a large gray area in between.
    Usually, a pathologist will never make a diagnosis unless they are 200% sure of the diagnosis. Having said that, there are situations where a definitive diagnosis cannot be rendered. Sometimes it is because a biopsy sample that was taken by the surgeon is too small, or perhaps taken from an area that is not representative of the patient’s lesion. Other times, the diagnostic process of key cells may be obscured by inflammation.
    For years, physicians have settled on the smallest amount of tumor tissue possible, often with a fine needle aspirate that collects just a few cells for biopsy analysis. Larger bore needles are needed to perform core biopsies or even remove entire lymph nodes, so that they can collect enough live (fresh) tissue to more reliably determine the histologic and molecular features of a cancer.
    Nothing can substitute for the biologist’s thorough examination of the features of a cell, from a substantive amount of tissue specimen.

  12. Pat S, you seem to think that there is no definitive hard data on mammogram benefits vs. risks, but there is – please see:
    http://www.bmj.com/cgi/content/abstract/339/jul09_1/b2587
    This study shows overdiagnosis of 50% in screening mammography programs WHEN SCREENING IS DONE ONLY EVERY 2 TO 3 YEARS, STARTING AT AGE 50! We can only imagine how much higher it must be in the US. The cancer industry has harvested a huge pound of flesh from unsuspecting American women, all of whom believe that their lives were saved. Truly a sad, disgusting, sick situation.
    As far as legal liability for not sending women for mammograms, I think that there should be legal liability for not disclosing possible adverse effects of testing. Like that adverse effect that a women is at least 10 times more likely to be harmed by mammography than to benefit from it. And the harm is breast amputation or mutulation, huge doses of radiation, toxic chemo etc.
    Maggie (and Naomi) your posts on mammography should be required reading for all women. The truth is coming out, thanks to people like you.

  13. Ginny C —
    I am sorry, but you need to read the entire Nordic Cochrane Report, not just the abstract.
    Nordic Cochrane concludes, as I quoted earlier, that there is no definitive evidence one way or the other. The problem is that none of the studies that the Nordic Cochrane meta-study (they did not do any research themselves, but rather are summing up the results of many actual research studies) is based on is well enough constructed to be really reliable. As I said earlier, poor quality mammography and interpretation as well inadaquate statistical methods causes every study to be of poor quality, regardless of whether the researchers supported or condemned mammography screening.
    The Cochrane study itself summed up its results by saying that there is some evidence that mammography is useful and some evidence that it is not. The new guidelines from the USPSTF also say specifically that the decision as to what screening should be obtained should be the choice of the woman and her doctor.
    An argument can be made that in the event that no definitive position can be found that the more conservative approach (no screening) should be followed.
    In the end, women are being put in a very uncomfortable situation of having to decide for themselves whether they prefer the small risk of being treated for a non-fatal cancer or the even smaller risk of not being diagnosed on time with a fatal cancer. In the absence of good science, the decision becomes personal. As I said earlier, it would be nice to have good science, but we don’t, and we have an atmosphere where getting good science is hard.
    Meanwhile, Dr. Pawelski’s argument that because pathologists can and do make mistakes that biopsies should not be done in conditions in which the result may be benign is little puzzling. Almost all breast biopsies are done with core biopsie needles that are 14, 11, and even 8 gauge. The samples contain up to a cubic centimeter of tissue. There are cases in which the pathologist cannot tell what is going on, and open biopsy is needed, but those cases are much more rare than the discovery of potentially fatal cancers and are not really an issue. In my own 15 years of breast biopsies, I have seen only two cases in which an open path case disagreed with the core results, one in which the diagnosis was so difficult that the open pathology was settled only at a conference in favor of benign, and one in which I personally insisted an open biopsy had to be done because of the mammogram findings when the core returned only fibrotic tissue and which turned out to be an aggressive invasive cancer with so much fibrosis that the pathologist had to recut it even though the gross specimin was clearly a cancer in his mind.
    Many biopsies for cancer return benign findings, including open lymph node biopsies, thyroid biopsies, lung biopsies, and colon biopsies from colonoscopy. It is standard practice to do biopsies when there is a suspicion of cancer, even though they find cancer in only a small portion of cases. The true positive yields from biopsies based on mammograms compare well with biopsies from many sources, including colonoscopy, falling in the 15 to 30% range.
    The problem, as I said earlier, is not false positive mammograms. The problem is true positive mammograms that yield cancers that are non-lethal, and the absence of ways to distinguish the difference leading to surgery, radiation, and chemotherapy that is not needed. That is the data that the Nordic Cochrane Study is pointing out, and that is the data that the new recommendations are based on in the US.

  14. Pat, I’m sorry but I DID read the entire study cited below, which deals specifically with overdiagnosis in publicly organized screening programs. And one of the authors of the study, Peter Gotzsche, when asked whether it is reasonable for a woman to decide to forgo screening mammo in order to reduce her risk of breast cancer replied:
    “In the light of our estimates of overdiagnosis, I would say that we now have to consider mammography screening as a major risk factor for getting a breast cancer diagnosis. And a preventable one, too. Of course, the breast cancers overdiagnosed through screening differ from the symptomatic ones by being non-lethal, but the individual woman cannot know this and the remaining consequences are the same (the surgery, radiotherapy and psychological stress).”
    This quote is from the Center for Medical Consumers website, and is a bit stronger statement than “Maybe it’s useful, maybe it’s not”. Clearly, if Mr. Gotzsche considers screening mammo “a major risk factor” for being diagnosed with cancer, he believes that screening mammo is not a good thing.

  15. Ginny —
    The article you cited is not the Cochrane Report. It is a summary published in the British Medical Journal.
    Here is the report:
    http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001877/frame.html
    Here is the Cochrane Center’s last paragraph of their “plain language summary” of the report.
    “It is thus not clear whether screening does more good than harm. Women invited to screening should be fully informed of both the benefits and harms.”
    Here is the public information “evidence-based leaflet for lay people” Cochrane has created to inform the public about their results:
    http://www.cochrane.dk
    Here is the first paragraph of the English language version:
    “It may be reasonable to attend for breast cancer screening with mammography, but it may also be reasonable not to attend, as screening has both benefits and harms.”
    They go on to explain that for each 2000 women screened for 10 years, based on what they describe as poor quality information, one woman’s life will be saved from death by breast cancer, ten women will be treated for breast cancers that would not kill them, and 200 women would undergo biopsies with benign results.
    This ambiguity is definitely a problem, but that problem is not solved by insisting there is no ambiguity whether you are an advocate for screening mammography or an opponent of screening.
    In the absence of good scientific data that presents a clear course, each woman will have to make their own decision. They are not, in this political setting, likely to get much help from government or national medical organizations.
    You are free to decide for yourself that you are convinced one way or the other. You are not free to make false conclusions that the people who are the source of your information are unwilling to make based on their own results.
    Unfortunately, there are many people on both sides of this argument who will insist with great passion that they are right, but that is nothing new in science, medicine, or politics.

  16. Here is a link to the complete Cochrane report — all 72 pages — that does not require paying:
    http://www.cochrane.dk/research/Screening%20for%20breast%20cancer,%20CD001877.pdf
    BTW, the Cochrane group cites as “adequately randomized” at least two studies that have been recognized as poorly randomized and poorly constructed by most experts (Canada and Malm.) They are correct about the studies they cite as flawed. It also is truly amazing that people are still citing the HIP study from NYC in 1963, prehistoric in terms of mammography technique and only useful in that it started the interest in mammography (or perhaps it should be considered a bad thing for the same reason.) There is a great deal of bad research out there and, as I have said, no real good research.
    However, as Maggie noted, the most important thing is to find out not how to improve mammography, which has been tweaked until it squeaks, but how to distinguish lethal vs. non-lethal cancers. If we — and by “we” I mean pathologists — could do that, then we would have the one person in 2000 whose life was saved, 210 people who underwent core needle biopsy but were told that they were OK, and a pretty good screening test. Unfortunately, that is not on the horizon at the moment.
    Interestingly, although the Cochrane report has gotten a lot of attention, it is essentially a reiteration of another meta-study done in New Zealand over ten years ago that found the same results.
    As I have said, the take-away point here is that anyone who is telling you that this is clear is not telling the truth.

  17. The sorry fact is this: mammography is radiation. Radiation is hazardous. Mammography involves a flattening of breast tissue. If cancer is present there is a danger to the patient.
    There are better alternatives to mammography but they cost more. We care so little for the health of women that we would rather screen them and expose them to a higher risk than use resources to screen more safely. As long as health care is treated as a market commodity we will continue to have these insane debates about statistical rates of cancer among groups tested, not tested etc. Health care is a human right. We all have to contribute to its funding. We need more access and fewer middlemen and gatekeepers to care. Until we create a system of health care that treats access as a public good and not a market commodity I fear we can trust the advice of no one.

  18. Pat, I never wrote that the article on screening mammo and overdiagnosis was a Cochrane review. It DID come from the Nordic Cochrane Center, which produced the Cochrane review that you cite. Peter Gotzsche was an author on both, and he made the comments about screening mammo being a major (preventable) risk factor for a cancer diagnosis after the article came out.
    There IS good data on the risks vs. benefits of screening mammography – read the article. Your refusal to acknowledge that there is credible evidence that screening mammography produces more harm than benefit reminds me of the adage “There is None So Blind as Those Who Will Not See…”
    It seems that many of those who are most outraged about any recommendation to raise the age for screening and reduce the frequency have a lot to lose if the new guidelines are followed. After all, cancer is bad only for its victims. It’s a big moneymaker for many others – doctors, technicians, medical device makers, pharma companies etc. I’m betting that you have some skin in the game.

  19. Lauren Severn —
    Whoa. We need some references here. Please provide them. Scientific articles please, from refereed journals.
    Radiation: Yes, mammograms are radiation. Very low dose radiation, at least compared to a lot of medical exams, and to a lot of other things. For example, you get a greater increased radiation dose to your breasts flying from New York to LA than from a mammogram, and a much greater dose from CT or CT angiography of any chest structure.
    “Flattening” the breast. Yes, that is done, mainly to reduce radiation and to improve image quality. Please reference a single article showing that that is a risk if you have a cancer. A scientific article, that is, not an opinion.
    Non-radiation ways to examine the breast. I would love to learn about these, but so far the facts are that mammograms are better.
    Physical exam is not as good as mammography, as has been well shown in multiple studies (the now famous USPSTF also recommended against teaching breast self exam, for the same reasons they recommend against mammographic screening: high false positives, high numbers of non-lethal cancers.)
    Thermograms and transillumination work only on large advanced cancers and consequently have been dropped after repeated studies.
    MR has even higher numbers of false positives and of non-lethal cancers than mammography, and misses as many cancers.
    Ultrasound is only useful as an adjunct, since it misses most cancers in screening.
    Radionuclide exams have radiation doses themselves and are less sensitive and also introduce false positives.
    All of this has been studied to death. Whole careers in academic medicine have been created by studying breast cancer detection over the last 50 years.
    Sorry, there is no free lunch. There is just a big double bind here, where you pay your money and take your choice. You can get mammograms and take the risks we have discussed below, or you can not get mammograms and take the risks discussed below. No other real choices are available.

  20. Gregory & JF-
    Thanks very much for your comments. .
    Gregory–
    I appreciate your comment because I know that you know a great deal about cancer reserach and treatments.
    You write:
    “The [Task Force] study authors do not have any conflicts of interest, they are not connected to the government and did not have rationing of health care resources as their underlying mission. The mission of the USPSTF is to provide evidence-based recommendations and treatment guidelines for clinicians, unencumbered by cancer industry influence.”
    This is something that everyone needs to hear–especially those reporters speading so much misinformation.
    JF-
    Frist, welcome to HealthhBeat.
    Secondly–you’re entirely right. The reserach is not new.
    And, like you, I am “glad the task force had the guts to say what the research really shows.”
    As you say, “Maybe now we can focus on getting a more accurate screening tool.”
    I actually think that, despite the current brouhaha, that will happen.
    Health care reformers have paid attention to this update.
    Moreover—and this is very important–Patient advocate organizations that support breast cancer patiens are supporting the Task Force!
    I talk about his in Part 2 of my post.

  21. Everyone, Ginny C, Pat S.
    Everyone–
    Ultimately, what we know about breast cancer and mammograms is–like much of medicine–terribly ambiguous.
    Most importantly, we can’t distinguish between cancers that will grow and those that won’t.
    Ginny C–
    I agree that doctors should be required to disclose what we know about risks and benefits. (And they should paid for the time that it takes to do that.
    Given the fact that we have spent some 50 plus years convincing Americans that all medical tests and treatments are beneficial, it takes some time to break the news that this isn’t true.
    I also think that doctors who explain risks and benefits should not be vulnerable to a lawsuit if the patient doesn’t go for a mammogram and develops breast cancer. (“Shared Decision-Making” provides a protool for sharing risks and benefits with patients..)
    On mammograms: It’s just not at all clear what is the best advice for most patients. (That said, if I had a family history of breast cancer, I would go for mammograms. From what we know, genetics seems important in telling us who is at risk. For me, that would tip the balance.)
    Otherwise, I prefer the low odds of dying of breast cancer because I didn’t go for mammograms to the higher odds of unncessary treatment (as well as false positives) if I do go for mammograms.
    But that’s just me. This is a decision every woman needs to make for herself. (That’s what the Task Froce says.)
    We each feel differently about different risks.
    Pat S.–Ultimately, I agree, with you that “you pay your money and your take your choice.”
    Either you get mammograms and take the risks of mammograms (unncessary treatment that can even mean losing a brast unnecessarily ) or you skip mammograms and take the risk of dying of a breast cancer that might have been discovered by a mammogram. (This risk is so small that I , personally, can’t dwell on it. Too many other much ore likely risks to worry about.) )
    Here I would note that mammograms are not the only way that womens’ lives are saved.
    Women who don’t go for mammograms sometimes notice a lump -or their husband does. They go to their doctor, and often the cancer is caught in time. In many cases these are not women who are “self-examining”–the lump simply presents itself–you bump into it.) (See Gail Collins post on what happened to her in the NYT.)
    But Pat, I’m not sure I agree when you write:
    “I do think that many doctors will try to explain the facts behind the new recommendations, but unfortunately, like the Nordic Cochrane Group, they will not be able to give the patients the type of definitive information that they want and ‘need.'”
    “They will be stuck saying, as the Cochrane Group does, ‘It may be reasonable to attend for breast cancer screening with mammography, but it may also be reasonable not to attend, as screening has both benefits and harms.’
    “In a logical world, telling that to a patient might be helpful. In our world, not so much.
    “A personal note. My own wife and many of her friends — many of whom are doctors’ wives and some of whom are doctors — have concluded that these new recommendations are an attempt to save money at the cost of women’s lives. I don’t think I have been able to convince her otherwise. The argument is too complicated and technical to overcome visceral reactions.”
    Pat–
    I think that explaining the uncertainty could be very helpful to many women–and that they would be relieved to hear the truth. (Often, you can tell when people are telling you the truth.)
    I’m not sure that we all “need” certainty.
    I would be much, much more likely to trust a doctor who admitted to uncertainty. (And, from talking to friends–and even my 28-year-old daughter– I know that I am not alone on this. We don’t trust doctors who are too certain.. . pompous, arrogant, etc. )
    Many women would be relieved to discover that they don’t have to feel guilty about not going for mammograms.
    I also think that many women are able to wrap their minds around the idea of uncertainty and ambiguity.
    Granted, uncertainty makes many people uneasy.
    But as one grows older, I think that we tend to realize that ambiguity tends to take us closer to truth than all of the black and white thinking that appeals to the very young.
    I think of the endng of a poem by Wallace Stevens.
    In the final lines, he describes how as a young man, he thought he knew how to judge mankind:
    “I Observed, when young, the nature of mankind,
    In lordly study. Every day, I found
    Man proved a gobbet in my mincing world.”
    Later, as a somewhat older man,Stevens set out to define first principles:
    “Later, I pursued,
    And still pursue, the origin and course
    Of love,”
    But it wasn’t until he grew older that Stevens
    began to understand the human condition. .
    ” . . . but until now I never knew
    That fluttering things have so distinct a shade”
    There, he celebrates change, and all of the ambiguity that change entails. LIfe itself is about change, and uncertainty.
    This is what makes it interesting–and perilous.
    Stevens discoverd this truth earlier than most of us. He wrote this poem (“Le Monocle de Mon Oncle”) when he was 40.
    Pat, I should add that your wife is likely to be reluctant to believe a Task Force that says that what most doctors (perhaps her own doctors) have been telling us is only half of the truth becuase she is married to an excellent and honest doctor.
    That gives her a different perspective on these things.
    I’m much more skeptical about docors (When I was growing up–and even in my twenties, family members, who had little money and no power received very poor treatent. .
    Medical errors, very bad advice, and, when they couldn’t cure, doctors made very little attempt to comfort.
    This didn’t skew my vision of all doctors. But it did teach me that there is something very wrong in our heatlh care system.

  22. Ginny —
    Please re-read what I have written.
    I do not disagree with the notion that there is good evidence that screening mammography may do more harm than good. I also do not disagree with the notion that there is good evidence that screening mammography does more good than harm. That is also the position of the Cochrane Report. The fact is that the science, as the Cochrane Group makes very clear in its report, is mixed. There are good arguments for both positions and good arguments against. The fact that this argument is continuing is good evidence that Maggie’s idea that people can be comfortable with ambiguity in a situation with this much at stake is not true for some people.
    Once again, I urge you not to depend on opinion articles and brief capsule reviews, which is what the BMJ material is. It highlights part of the report but ignores other parts in order to make its argument, and is fact just as bad as the many articles accusing the USPSTF of trying to kill women to save money. The source material is easily accessed. Read that.
    The bad thing here is that the case is not clear. That is a problem for the hundreds of millions of women and doctors who are now in that position.