As Naomi has pointed out below, the news about mammograms is not brand-new information based on one study that just can out.
The recommendations that the Preventive Services Task Force (PSTF) has released is based on research that experts have known about for some time. Thanks to reader Greg Pawelski for calling attention to this post by Dr. Herman Kattlove, a retired medical oncologist who did research on mammograms in the early 1990s. For the last seven years, Kattlove has served as a medical editor for the American Cancer Society where he has helped develop much of the information about specific cancers that is posted on the website at www.cancer.org
On his cancer blog, Kattlove writes:
“Many years ago, the National Cancer Institute (NCI) tried to convince us all to not screen women younger than 50 and were given such a tongue lashing by Congress that they went home, licking their wounds, and withdrew their recommendation.” Of course, Congress should not have become involved in telling the NCI what information it should make available to the public. Few Congressmen are either M.D.s or scientists trained to analyze and critique medical research. But this illustrates just how politically charged the question of diagnostic testing has become—especially when companies like GE that are making large profits on the sale of diagnostic testing equipment, and their lobbyists are helping to finance Congressional campaigns. (It’s worth noting that, for doctors, mammograms are not very lucrative. For decades doctors have urged patients to undergo mammograms because they sincerely believed that mammograms saved many lives. They, too, were not receiving all of the information they needed about the risks. Powerful forces stood in the way of widespread dissemination while millions of dollars were poured into the Mammogram campaign.
As Kattlove observes, “Likewise, the American Cancer Society also avoids looking clearly at the data and continues to recommend screening for younger women. And this morning’s paper carried lots of outrage from breast cancer specialists and other docs who are committed to screening younger women. Some of the reasons for this are political and financial. The ACS doesn’t want to enrage its donor base, Congress didn’t want to upset constituents and breast cancer specialists have faith in the procedure. I’m sure all the pink breast cancer organizations are also organizing their protest. Why this emotion and outrage? I think because we feel helpless when we see women die of breast cancer, sometimes while still young. Indeed, deaths in these young women hit us hard. So we want to do something and our only tool is mammography.
“But mammography is not the answer for these women.” As Kattlove points out in his post, when young women die of breast cancer they are usually killed by very fast-growing aggressive cancers that grow too quickly to be caught by early detection. The tumors crop up, and spread in between annual mammograms. Kattlove continues: “The unfortunate side effect of this delusion [that screening and early detection is the answer] is that we avoid the hard choices like healthy life styles and avoiding cancer-causing drugs such as hormone-replacement treatment.
I would add that while I applaud the PSTF for bringing this research to our attention, I wish that they had done this two or three years ago. From a political point of view, the timing is unfortunate because inevitably, those who oppose health care reform will exploit this report to suggest that, under reform, the Government will use “comparative effectiveness research” to deny necessary care—and as a result patients will die.
In fact, both health care reformers, the government and Medicare understand that, after thirty years of telling women that they must have annual mammograms, we cannot turn on a dime and expect them to suddenly absorb the information that for most average-risk women under 50, mammograms pose more risks than benefits.
No one is going to stop covering mammograms. But responsible physicians will begin giving patients more information about what the medical research shows, including the fact that for most women, the danger of undergoing unnecessary radiation –or an unneeded mastectomy or lumpectomy –far exceeds the likelihood that a mammogram will save their lives.
Moreover, it is important to remember that the “comparative effectiveness information” that the government plans to generate will serve to create guidelines—not “rules”—for doctors. In the U.K., doctors use such guidelines about 88 percent of the time, which seems appropriate, giving how much variation there can be in individual cases.
Finally, under reform it is extremely unlikely that insurers (including the public plan) will stop covering treatments and tests (including PSA tests), that have been in use for a long time. More likely, they will lift co-pays and lower reimbursements for procedures that are less effective—while lowering co-pays and lifting reimbursements for procedures that the medical evidence shows are more effective. In this case, unfortunately, we don’t yet have a good alternative to mammograms—a further reason why insurers will not suddenly stop covering the tests.
I am convinced that our biggest challenge remains convincing the AVERAGE American health consumer that “more is not always better” in medicine.
We who follow medical science know that but it will take years or decades to convince the public.
But we still must deliver this basic truth with compassion.
Dr. Rick Lippin
Southampton,Pa
Why cant we reduce the cost of each mammogram rather than reducing the number of mammograms?
Why the heck doesnt ANYONE seem to ask that question???
I am encouraged to see the transparency with which these guidelines are formulated.
Dr. Rick, Ed, Adam
Dr. Rick– I agree completly
But I am disappointed with Sebelius. She shouldn’t be telling women “You should have mammogams every year begining when you’re 40.”
She should be saying: “We will continue covering mammograms. But women should discuss risks as well as benefits with their doctors.
We are just beginning the look at the fact that tests can pose risks, and we want to share what we know with patients.
Ed–
Mammograms are Not expensive.
AND THIS IS NOT ABOUT SAVING MONEY.
THIS IS ABOUT PROTECTING WOMEN AGAINST AN UNNCESSARY MASTECTOMY__i.e. losing a breast for no reason.
Please read Naomi’s original post (see links to it in her last post.)
For every woman whose life is saved by a mammorgram, 10 women undergo unncessary radiaton and/or an unneeded mastectomy or lupectomy.
Adam– Thanks, I agree. Although people are upset–and I wish the timing were diffcult– I think this annoucement is a sign that the government and its medical panels and agencies are going to be more open with the American people.
Kathleen Sebelius taught us a lot last week, and the lesson shouldn’t make anyone optimistic that real reform is possible. She was given solid data on comparative effectiveness research (CER) from the USPSTF – under her own agency – and she trashed it. If the government rejects its own task force, a group known for its objectivity, then what hope do we have for real CER? Sebelius caved and we lost. More thoughts at http://bit.ly/656CwP
Michael Kirsch–
Kathleen Sebelius does not represent the administration’s position on health care.
Unlike Orszag or Zeke Emmanuel she does not (and will not) have the President’ ear when important decisions are made about reform. I very much doubt she will be in the room during the final conference.
She is not a M.D. She is not a medical reseracher.
She was chosen, as a pleasant moderate, who could be a “spokesperson” for the administration.
In this case she was trying to stem panic and defuse the fear that conservatives were generating that the government (or private insurers) were suddenly going to stop covering mammograms.
Breast cancer is an extraordinarily charged subject. This is not where you begin to educate the public about comparative effectiveness research.
But this does not mean that the administration has given up its commitement to comparative effectivevness reserach.
CER is already funded, and a panel of physicians and medical experts has already been set up.
Re, convincing Americans that “more is not always better.” Good luck with that.
I am increasingly convinced that the Left/Right ideological split is doing a tremendous disservice to this issue, and the disservice is coming from both sides. The Right accuses the Left of restricting care based on cost effectiveness. The Left cries out, ‘No! We’d never restrict care based on cost effectiveness! How dare you make such a paranoid accusation!?!’
Why can’t someone with common sense stand up and point out that so long as the supply of health care is finite, we will have to make some decisions about what to cover and what not to cover, and cost effectiveness is one important factor to consider in those decisions?
From antibiotics for viral URIs, to routine fetal ultrasound, to aggressive ICU care for the terminally ill, Americans are passionately devoted to unnecessary medical care. This is not a Right-Left phenomenon.
Maggie–
“THIS IS ABOUT PROTECTING WOMEN AGAINST AN UNNCESSARY MASTECTOMY_”
–Although I haven’t seen it raised much, I also think it’s about shielding women from unnecessary ionizing radiation, which is also carcinogenic. Frankly, I have avoided mammograms for this very reason, and am willing to go for one every 4-5 years to minimize the risk. The US is obsessed with testing for breast and colo-rectal cancer, yet from what I have seen, the rate here is no greater than in many European countries where testing is relatively rare.
1. The recommendation was about screening tests, not diagnostic testing as you claim several times in your column (although the quote from Kattlove’s blog correctly refers to screening mammographies). There is a difference–in invasiveness and cost, to mention only some differences. Screening tests are utilized by people who have no symptoms of disease (hence, the ambiguity of their usefulness). By the time a diagnostic test is recommended, there is reason to suspect the presence of disease. Here are some definitions:
http://www.realage.com/check-your-health/disease-prevention/screening-tests-vs-diagnostic-tests
2. Gary Schwitzer has links to some good articles about the history of this issue. It goes back as far as at least 1993. These articles insert some reason and science into the hype: http://blog.lib.umn.edu/schwitz/healthnews/
3. IMHO, Sebelius has set back the feasibility of doing and APPLYING comparative effectiveness research in the US by decades.
Maggie,
“Kathleen Sebelius does not represent the administration’s position on health care.” Sorry, but I don’t accept this. She is the Secretary of Health and Human Services. When she opines on health issues, of course she speaks for the adminstration. That is why I found her remarks so troubling. You noticed that no adminstration official or the president distanced himself from her remarks. Their silence supports my point. With regard to your point re breast cancer being too ‘charged’, I disagree. This was an opportune ‘teaching moment’ that was squandered.
I agree it’s kind of ridiculous to think she wouldn’t be involved. By that line of reasoning Robert Gates would have even less reason to be involved with military decisions since he is a Bush appointee. That certainly is not the case.
Dear Maggie,
I fear you are losing it.
Its all about the money and how to get the money drivenness out of medicine.
Sincerely,
Can you give a concrete example illustrating the risks of overscreening? I think when people read that the risks are “anxiety and overtreatment,” many roll their eyes. Anxiety is a risk that many people are probably willing to take.
And overtreatment? What does that mean to people? “Better than undertreatment,” maybe… Further, diagnosis does not equal treatment. How much of the overtreatment that’s being characterized as a risk of screening couldn’t be addressed by changing treatment guidelines, rather than screening guidelines?
So far I’ve seen examples of ductal carcinoma in situ, but AFAICT the issue there is with overly aggressive treatment of DCIS, not with the screening itself.
I don’t think it’s only conservatives who will oppose this. Yesterday I heard George Lakoff talking about his opposition to the new guidelines.
I don’t consider anxiety a risk. It’s an emotion. I hope it wasn’t considered during the final number crunching. Quantifiable risks should have been the only ones considered. There was an arbitrary human component in picking these guidelines. Disease doesn’t happen on nice even round numbers like 40 and 50. If science was the only factor used it would much more likely to be a number like 43 or 47 where the risks of overtesting outweighed the benefits. The larger problem is the huge PR issue during the rollout and think about it, this was SCREENING not even treatment. Which will be an enormous obstacle to implementing comparative effectiveness guidelines. Unless you get 90% plus physicians on board with the rollout, ie. Safeharbor. Otherwise there is no reason to think that we will carry the water for this administration and multiply this week by about a thousand.
The other side of the coin is radiation risk imposed by mammography. It is not simply of negligible value in younger women, but may have a net harm effect, if women who have mammograms at age 40 start having higher rates of cancer in irradiated breasts 25 or 35 years later.
The recommendation not to begin mammography until age 50 has to do with medical issues, more than cost effectiveness issues. Mammography is not harmless. You are subjecting women to annual doses of ionizing radiation to the breasts, with some unavoidable scatter to chest wall and lungs. We do not know how many women who are irradiated by mammography in their 40s will develop radiation-induced breast cancer (or even lung cancer) in their 60s, 70s, and 80s.
The other problem is that women in their 40s tend to have very dense breasts, making it more difficult to get an accurate exam. These women often are called back for additional views, giving them even more radiation. There are more false positives, leading to breast biopsies and sometimes unnecessary lumpectomies, in cases where the biopsies are technically suboptimal.
In contrast, in older women, their breasts are less dense, making the examination more accurate, with fewer false positives, and there are fewer years of remaining life to develop a radiation-induced malignancy.
The fact is that we have no truly long term follow up studies to determine very long term risks of carcinogenesis from radiation exposure in mammography.
1. J Radiol Prot. 2009 Jun;29(2A):A123-32. Epub 2009 May 19.
Mammography-oncogenecity at low doses.
Heyes GJ, Mill AJ, Charles MW.
Department of Medical Physics, University Hospital Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK.
Controversy exists regarding the biological effectiveness of low energy x-rays used for mammography breast screening. Recent radiobiology studies have provided compelling evidence that these low energy x-rays may be 4.42 +/- 2.02 times more effective in causing mutational damage than higher energy x-rays.
The risk/benefit analysis, however, implies the need for caution for women screened under the age of 50, and particularly for those with a family history (and therefore a likely genetic susceptibility) of breast cancer. In vitro radiobiological data are generally acquired at high doses, and there are different extrapolation mechanisms to the low doses seen clinically. Recent low dose in vitro data have indicated a potential suppressive effect at very low dose rates and doses. Whilst mammography is a low dose exposure, it is not a low dose rate examination, and protraction of dose should not be confused with fractionation. Although there is potential for a suppressive effect at low doses, recent epidemiological data, and several international radiation riskassessments, continue to promote the linear no-threshold (LNT) model.
Ed said:
“Why can’t we reduce the cost of each mammogram rather than reducing the number of mammograms?”
Maggie said:
“Mammograms are Not expensive. AND THIS IS NOT ABOUT SAVING MONEY.”
As a wise man once said: “Whenever anyone says that it’s not about the money – it’s about the money”
With respect to the cost of mammograms Maggie is correct, relatively speaking Mammograms are not expensive. In the practice of Radiology/Diagnostic Imaging, plain Xrays, Fluoroscopy and Mammography are low margin studies. CT, MRI, etc. are high margin studies (although the government is working to change that). You could probably drive down the cost of mammograms slightly, but not a lot. (One of the reasons that Mammography costs what it does is the unprecedented regulations that apply to Mammography. Our group has whole “Mammography Follow Up Department” that employs 3 or 4 people. That and other record keeping requirements add $10 to $20 to the cost of every Mammogram. There are no such record keeping requirements for tests that detect more dangerous diseases like Lung and Colon Cancer. This is part of the hysteria surrounding Mammography and Breast Cancer.)
Here is why screening mammography is expensive:
1) There are many false positives (as well as a significant number of false negatives). The number of false positives is greater than the number of true positives.
2) Each false positive gets an extensive workup including; further views (a Diagnostic Mammogram), Ultrasound, a visit to a Breast Surgeon and possible surgery.
3) The cost of this further workup is frequently at least 10 times the cost of the screening mammogram
And this does not even count the patient’s anxiety, lost time, etc. etc.
And despite what has been said on this blog, Breast Self Exam is not free or even cheap if looked at in the same manner. Here is why:
1) There are a huge number of “false positive” breast self exams.
2) A “false positive” will frequently get an extensive workup including; further views (a Diagnostic Mammogram), Ultrasound, a visit to a Breast Surgeon and possible surgery.
3) The cost of this further workup is much more than the cost of the screening mammogram and infinitely more than the cost of the “free” breast self exam.
Finally, I don’t believe Maggie’s statement :”For every woman whose life is saved by a mammogram, 10 women undergo unncessary radiation and/or an unneeded mastectomy or lumpectomy.” Women do not undergo mastectomy, lumpectomy and radiation without a diagnosis of cancer. The problem with DCIS and other low grade lesions is that, just like prostate cancer, we do not fully understand the natural history. It is possible that some or even many of these low grade lesions will never progress into invasive breast cancer, but we don’t know enough to say which of them will or won’t over the course of the next 40 years and that is why they are removed.
Nascar Daughter, Jenga, Gregory, Ed,
Alath, ACarroll, Riggavde
Nascar Daughter–
Good question. Here’s the answer:
Over the years, a number of studies have shown the serious risks that follow from mammograms. We’re talking about more than anxiety. We’re talking abou unncessary surgery.
For instance, one study, published in the British Medical Journal “found that one in three breast cancers wer “over-diagnosed” in publicly organized mammography screening programs’ (This is from Naomi’s earlier post on HealthBeat.
She explains: “What this means is that one out of three cancer diagnoses turned out to be lesions that either went away on their own or otherwise never progressed. In some cases, patients would have died of something else before their symptoms progressed.
(For sources, see Naomis’ most recent post and links there to her earlier posts.)
“Meanwhile, the women who received these diagnoses went on to have surgery to remove the lesion or the entire breast, radiation and chemotherapy. This seems a substantial cost—both in terms of a woman’s psychological and physical health and in terms of health care dollars—for questionable gains.”
Another very large study shows that for every 1 woman whose life was saved by mammograms (after 2,000 women had a mammogram every year for 10 years ) one omwan’s life was saved and 10 women in this gorup had either an unncessary mastectomy, or an unncessary lumpectomy, and unncessary radiation.
In other words, one woman’s life was saved, 10 women were unncessarily mutiliated and often radiated. (This is from the very large Cochrane Collaboration study done in Sweden.
It’s worth noting that the Swedes invented the mammogram, used it for many years, but have now discovered (and publicized the fact) that, for most women, it creates more risks than benefitsl.
Sweden run a non-profit heatlh care system, system, so lobbyists are not pressuring their government to suppress these findings.
Jenga–
I’m afraid that you are spreading misinformation on this thread.
The “risk” is not simply anxiety.
As Naomi explained in her posts,and as I said in my post and just above ( in my comment to Nascar Daugher) the risk is unncessary surgery (mastectomy or lumpmectomy) and radiation.
How would you feel if your daughter lost a breast needlessly?
Gregory– Thanks for providing very useful facts about the radiation risk which is, indeed, a worry.
I greatly appreciate your input.
Ed
On this blog, we try to offer facts, and arguments based on evidence.
Telling someone that they are “losing it” doesn’t quite meet the standard.
If you looked into it, you would find that the remibursement for mammograms is very low.
And if you looked at the research, or read Naomi’s posta, you would realize this is not about money.
Finally, there is a huge difference between “comparative effectiveness” and “cost effectiveness.”
U.S. health care reformers are interested in “comparative effectiveness” See my reply to Alath.
Alath–
First, “cost-effectiveness” and “comparative effectiveness” are very different.
Please see this post: http://takingnote.tcf.org/2008/06/comparative-vs.html
In the U.S. we spend $2.6 trillion on healhtcare– 50% more than the average developed country.
There is enough money in the system to cover all effective care for everyone in the U.S..
Right now 1/3 of our healthcare dollars are wasted on ineffective care that either provides no benefit–or the risks and side effects far outweigh the benefits.
The UK has much less to spend on healthcare, and so must worry about cost-effectiveness.
At this point, we don’t have to do that.
What we need to do is to eliminate the wasteful overtreatment. .
ACarroll–
I agree– Schwitzer’s posts on this are great.
He & I have been e-mailng about this. Will include links to his posts in my next post.
Mammogram screenig is considerd diganotistic testing when they go back for the second screen–after finidng what appears to be a tumor.
This is why Dr. H. Gilbert Welch and others at DArtmouth include it in their writing about excessive diagnostic testing.
Re: What Sebelius said. She put it very poorly.
I wish she had said: “Don’t worry, we will continue to pay for mammograms because we understand that many U.S. doctors recommend them.
“But” (she should have added) “the Task Force rerpot will call your doctors’ attention to new information. You should talk to him about this, and what it means for you.
Everyne should understand the possoble risks as well as possible benefits of mammograms. This is something that you and your doctor need to discuss in order to decide what is best for you.”
The truth is that if women have had breast cancer in their families, they should have mammograms. In those cases, the potential benfits probably outweigh the risks. (The Task Force agrees on this.)
But someone had to reassure the American public that reformers don’t plan on pulling the plug on mammograms.
We can’t educate the public by terrifying them and pulling the rug out from under them.
Riggsveda–
I’m with you. I haven’t gone for mammograms since I saw the reserach some years ago.
And I’m wary of diangotic testing–both the radiation and testing leading to unncessary treatments.
But that’s just me.
If we want more Americans to avoid excessive screening and testing, doctors will have to take the resarch into account, and change the way they counsel their patients.
Radiation risk? My wife has a higher radiation risk from flying to business meetings than from her annual mammogram.
A better understanding of genetics may help select out a group of women who are truly at high risk and therefore should undergo more frequent screening. Until then, we are blind men groping in the dark.
As far as money is concerned, since when has it not been about money? And I find the timing of this release unfortunate as well.
Finally, as I’ve stated before, not having oncologists on a panel setting guidelines for screening for cancer does little to allay suspicions. With this panel, no oncologist but an MFM? Can you say versimilitude?
Doc 99
We can’t have someone from every suspecialty on the panel or it would soon become unweildy.
Moreover, if there were any oncologists on the panel, most likely they would recuse themselves in this case because they have a financial interest in the procedures that follow mammograms.And, having recommended mammograms for so many years, it might be particularly difficult for them to acknowledge that the risks appear to outweigh the benefits for some (not all) younger women.
Most importantly, the panel is not about having represenatives of various specialites to “protect” the interests of their specialities.The panel is supposed to protect the interests of patients.
MedPAC has suggested that perhaps the physicians on such panels shold l be doctors who work on salary, rather than fee-for-service, and so are less likely to view reducing the volume of tests and treatments as a threat to physicians’ incomes. .