Truth Squad: Medical Reporting on Mammograms—Part 2

Part 1 of this post described how the US Preventive Services Task Force’s (USPSTF’s) message about mammograms has been distorted by the press. Despite what you may have read, the Task Force did not recommend that women in their 40’s skip mammograms; it advised them to discuss the risks as well as the benefits with their doctors. And the USPSTF was not trying to save money; it is not charged with cutting the cost of care. Its only goal is to give women full information about the benefits and the limits–of mammography screening.

Below, I explain that what the task force just explained about the risks of mammography is something that it tried to tell us years ago. But Congress stood up and said “No—we don’t want women to know that.” Why? Because lobbyists for those companies who make mammography equipment did not want women to know that mammograms can lead to unnecessary surgery.

Below, I also note that some patient advocates as well as many disinterested physicians applaud the Task Force’s message. It’s just not as controversial as the media pretends. Indeed just one month ago the chief medical officer of the American Cancer Society was questioning the advantages of mammography in the pages of the New York Times.

Finally many in the media have claimed that under reform, the government will use “comparative effectiveness research” to ration care. This is totally untrue.  Reform legislation is very clear: neither  the USPSTF or any other government agency can use such research to deny coverage.

False Claim: The Task Force Pulled These Numbers Out of the Air and “Out of the Blue”

Washington Post columnist Dana Milbank suggests that the Task Force blindsided the American public with a radical recommendation: “In one cruel and clumsy blow . . .” the task force went “rogue with [a] surprise recommendation.” 

Milbank offers a simple solution to the problem: Congress could “abolish the task force and turn it into a group that is more accountable to the public.”

Truth: This Is a Long-Standing Debate

University of Minnesota journalism professor Gary Schwitzer  responds to Milbank’s charge that this was a “cruel and clumsy blow” on Schwitzer’s outstanding blog, Health News Review:

“How ‘cruel’ to try to ensure that women are fully informed about benefits and harms, and that this should be an individual decision based on individual values.” He quotes Fran Visco, president of the National Breast Cancer Coalition, a Washington-based patient advocacy group: “Women deserve the truth . . . and the truth is the evidence says that [screening for breast cancer] is not always helpful and can be harmful.”

Moreover, the Task Force report was far from a “surprise recommendation.”

“Read your own paper,” Schwitzer advises Milbank.  “Don Eggen and Rob Stein reported that ‘the findings underscore a decades-long debate in the medical community about the risks and benefits of routine breast cancer screening for younger women. So this is not ‘rogue’ and it is not surprising for anyone who has made an attempt to follow the issue.” Schwitzer goes on to point out that Slate recently reprinted a 5-year-old article which included the the same warnings about the potential harms of mammograms:

“Though many believe that there can never be enough testing [for cancer],” Schaffer explained back in 2004, “the risks of false positives, overdiagnosis, and overtreatment are real.”

As to Milbank’s suggestion that the independent task force that bases its recommendations on medical evidence should be turned into a group “that is more accountable to the public,” Schwitzer writes:

“Oh that would be a grand idea. Make science accountable to the public? Let’s make science ignore the evidence and tell us fairy tales that we want to hear. That everything is terrific, risk-free and without a price tag? And let’s make the independent task force subject to federal government oversight. Then we can make science ignore the evidence and only spew out what is politically popular at the moment.”

This is, in fact, what happened in January 1997 when the National Cancer Institute sponsored a conference to discuss mammograms. Independent experts representing researchers, clinicians, statisticians, epidemiologists, and consumers testified and 12 independent experts reviewed the data. Their conclusion was "that the data currently available do not warrant a universal recommendation for mammography for all women in their forties." They recommended that women decide with their doctors on the best approach to take.

“Immediately a storm of acrimonious protest broke out,” reports pioneer woman’s health care activist and breast surgeon Susan M. Love.  “Within days of the conference and with heavy lobbying by various special interest groups, the Senate voted 98 to 0 to endorse a nonbinding resolution that the presidentially appointed National Cancer Advisory Board recommend mammography screening for women under 50.  By March, a press conference was held to announce the NCAB's recommendation that the NCI advises women age 40-49 to have screening mammograms.”

Thus the recommendations that preceded the recent update were “far from being scientifically based,” Love observes, but instead “were based on lobbying by interested parties.”

False Claim: The Only “Harm” Associated With Mammograms Is Anxiety

“What is the ‘harm’?” asks George Lakoff in his AlterNet post. “Anxiety and unnecessary biopsies from false positives are listed as the harms. My wife had such a false positive.   . . . The biopsy when it came was simple: a needle inserted to withdraw fluid, like taking a blood sample. No harm.”

Truth: Mammograms Can Lead to Unnecessary, Invasive Treatments

First, biopsies are not always so simple. On its website, the Mayo Clinic lists the risks of biopsies for breast cancer: “Infection or bleeding at the biopsy site” and “altered breast appearance, depending on how much tissue was removed and how the breast heals.”

Meanwhile, Mayo reports, “In the U.S., 80 percent of women who undergo a breast biopsy learn that they don't have cancer.” This makes one wonder: how many of these biopsies were unnecessary?

Secondly, sometimes mammography discovers small tumors that if left alone, would never have developed.The Task Force notes that “Screening detects not only cancer that could lead to a woman's death but also cancer that will not shorten a woman's life. Women cannot benefit from—but can be harmed by—the discovery and treatment of this second type of cancer, which includes both cancer that might some day become clinically apparent and cancer that never will.” 

Research published in the British Medical Journal (BMJ) this year, reported that if 2,000 women are screened regularly for 10 years, one life will be saved but 10 healthy women will be treated unnecessarily. “This treatment includes removal of part or all of their breast, radiotherapy or chemotherapy.”

A month before the USPSTF update was released, the New York TimesGina Kolata reported on the serious risks of overtreatment following screening: “The dilemma for breast and prostate screening is that it is not usually clear which tumors need aggressive treatment and which can be left alone. And one reason that is not clear, some say, is that studying it has not been much of a priority.

“‘The issue here is, as we look at cancer medicine over the last 35 or 40 years, we have always worked to treat cancer or to find cancer early,” the American Cancer Society’s chief medical officer,  Dr. Otis Brawley, told the Times. “And we never sat back and actually thought, ‘Are we treating the cancers that need to be treated?’ ”

Kolata continues: “The very idea that some cancers are not dangerous and some might actually go away on their own can be hard to swallow, researchers say. ‘It is so counterintuitive that it raises debate every time it comes up and every time it has been observed,’ said Dr. Barnett Kramer, associate director for disease prevention at the National Institutes of Health.  But Kramer points out that once screening was introduced, breast and prostate cancer rates soared—because th
e tests could detect those insignificant cancers. The result: overdiagnosis labeling innocuous tumors cancer and treating them as though they could be lethal when in fact they are not dangerous.

“‘Overdiagnosis is pure, unadulterated harm,’” Karmer told the Times.

“Dr. Peter Albertsen, chief and program director of the urology division at the University of Connecticut Health Center, said that had not been an easy message to get across,” Kolata reported: “‘Politically, it’s almost unacceptable,’ Dr. Albertsen said. ‘If you question overdiagnosis in breast cancer, you are against women. If you question overdiagnosis in prostate cancer, you are against men.”

Meanwhile, Dr. Esserman expressed the hope “that if research continues on how to advance beyond screening, distinguishing innocuous tumors from dangerous ones, people will be more realistic about what screening can do. Someone may say, ‘I don’t want to be screened,’ she said. Another person may say, ‘Of course I want to be screened.’ Just like everything in medicine, there is no free lunch. For every intervention, there are complications and problems.”

Over at the Atlantic, John Crewdson points out that in the article Kolata published just last month, Brawley, the Amercian Cancer Society’s (ACS’s) chief medical officer, admitted:  "that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated.'' But, Crewdson notes, since the task force released its recommendations on mammography, Brawley has backed off, telling The Times that “the cancer society had concluded that the benefits of annual mammograms beginning at 40 ‘outweighed the risks’ and that the ACS was sticking by its earlier advice.”

According to Crewdson one of Brawley's colleagues explained: “"He's trying to save his job. He was broiled at home for the interview in which he said that we (the medical establishment) are 'overselling' screening."

False Claim: Cancer Survivors Are United in Denouncing USPSTF Guidelines

The news has been filled with statements from horrified cancer survivors who are convinced that they would be dead if they had not had regular mammograms. In truth, of course, no one knows how many of these tumors would have been discovered in some other way. And some of those tumors would never have spread.

Truth:  Not all Cancer Survivors Support Routine Mammograms

The New York TimesGail Collins reports that she had breast cancer back in 2000, and mammograms never helped her. “I had mammograms every year like clockwork, and I had just gotten a clean bill of health from my latest one when I found a lump on my left breast while watching a rerun of ‘Buffy the Vampire Slayer,’ multitasker that I am.

“It turned out to be cancer, of a fairly low-grade variety. My oncologist felt strongly that it never would have developed if I hadn’t taken estrogen replacement therapy — another one of the medical marvels that has now been consigned to the Seemed Like a Good Idea at the Time category.

“So, in summary, the cutting-edge of medical thinking of the 1990s may have induced my cancer, and then the universally recommended testing protocol failed to detect it.”  (Hats off to Collins who managed to write a low-key, funny, and truly informative piece on such a fraught topic.)

Collins adds: “I am going out on a limb to say that the real problem with a test that creates a lot of false-positive results is that it leads to a lot of other medical procedures, some involving hospitals. Unless you are genuinely sick, there is no more dangerous place to be hanging around than a hospital.”

Jane Flanders goes a step further. She regrets ever having been screened. Timesonline.co.uk reports that Flanders believes she was the victim of over-diagnosis.

The 56-year-old math teacher was diagnosed with ductal carcinoma in situ, a dormant cancer which was not spreading and may never have caused problems.

Doctors advised her to have radical treatment — including a mastectomy — in case it might spread.  (In the U.S., more than 62,000 cases of DCIS are diagnosed annually, making it the most rapidly increasing type of noninvasive cancer. The majority of DCIS cases — about 90 percent — are discovered during routine mammograms. DCIS usually has no outward signs or symptoms.  “DCIS isn't considered life threatening, but it should be treated,” the Mayo Clinic advises. “If not detected and treated, it can progress to a more serious form of invasive cancer. The best treatment approach is still being debated.” 

Flanders doesn’t agree. “‘Screening has caused me considerable and lasting harm. It has certainly not saved or prolonged my life. The reality of this diagnosis has been two wide excisions, one partial mutilation (sorry, mastectomy), one reconstruction, five weeks’ radiotherapy, chronic infection, four bouts of cellulitis (a bacterial infection), several general anesthetics and more than a year off work.’”

In the UK, the National Health Service is publishing leaflets that explain the risks of screening and the facts about “ductal carcinoma in situ”:

“Much of the ductal carcinoma in situ diagnosed will never surface clinically. Therefore it constitutes overdiagnosis — that is, you are diagnosing something that would not have become an issue. Ductal carcinoma in situ accounts for 20% of the diagnoses made through screening. Less than half of the dormant cancers will progress to become invasive but 30% are treated with mastectomies.”

False Claim: U.S. Physicians Tell Women to Ignore the Task Force’s recommendations

have highlighted statements from oncologists who are “worried” or even “disgusted” by the USPSTF update. Few disclose possible conflict of interest.

Truth: Many Doctors—and Patient Advocates—Applaud the Task Force

Despite what some in the media report, U.S. oncologists are not uniformly opposed to the guidelines. “Dr. Amy Abernethy of the Duke Comprehensive Cancer Center told Fox News that she agreed with the task force's changes."Overall, I think it really took courage for them to do this," she said. "It does ask us as doctors to change what we do and how we communicate with patients. That's no small undertaking."

Over the past month, while turning a long-standing scientific debate about the risks and benefits of mammograms into a populist political fight centered on health care reform, the media has exaggerated the controversy within the medical profession.

Well-informed physicians and medical researchers are just not that far apart on this issue. Writing in the most recent (November 25) issue of the New England Journal of Medicine, Doctors Ann H. Partridge and Eric P. Winer, of the Dana-Faber Cancer Institute explain: “The updated recommendations sparked substantial controversy and have had a polarizing effect in the breast-cancer community. There has been confusion, fear, and anger on the part of patients with breast cancer, their families, and women's health advocates. The intensity of the controversy is unfortunate,” they add “because there is far more agreement than disagreement about breast-ca
ncer screening
.

“How do we interpret the USPSTF's new recommendations, reconcile the divergent opinions, and advise patients?” Partridge and Winer answer their question: “First, we need to reassure our colleagues, our patients, and the public that the task force did not suddenly turn the long-debated topic of breast-cancer screening upside down. There has long been controversy about screening for women in their 40s, and in our view, these recommendations represent a modest adjustment.

Granted, some large professional organizations have been vociferous in their attacks on the Task Force–including the American Cancer Society, the American College of Radiology, the American Society of Breast Surgeons and the American College of Obstetricians and Gynecologist.

What newspapers rarely report is that many of these groups have financial ties to companies that manufacture breast imaging products and equipment.

The Hastings Center Bioethics Forums reveals what the media fails to mention. There, Dr. Adriane Fugh-Berma, of the Georgetown University Medical Center and Alicia M. Bell, a member of the board of directors of the National Women's Health Network, note that “donors to the American Cancer Society Cancer Action Network (ACS CAN) . . . include Hologic, which makes breast imaging products, and Johnson and Johnson, which makes an image-guided breast biopsy product. Donors to the American College of Radiology Imaging Network (ACRIN) Fund for Imaging Innovation include Siemens, GE Healthcare, Phillips, Hologic, and many others that make mammography machines or related products.”

According to the American College of Radiology Web site, “the leaders of the ACR and ACRIN have been meeting with industry leaders from key donors to the ACRIN Fund to strengthen the relationships between the organizations and better determine how both parties can maximize this relationship.”

Individual physicians may also have vested interests. Fugh-Berman and  Bell report that “Daniel Kopans, a Harvard professor of radiology who told Reuters that  the new guidelines ‘are scientifically unjustified and will condemn women ages 40 to 49 to unnecessary deaths from breast cancer’ holds patents on imaging systems.” 

 “None of these conflicts of interest have been mentioned in news coverage.” 

Meanwhile, the American Academy of Family Physicians, which has no apparent financial interest in mammography, has endorsed past USPSTF recommendation on breast cancer screening.

In 2007, the Academy recommended that screening mammography decisions in women aged 40 to 49 years should be based on individualized assessment of risk for breast cancer; that clinicians should inform women aged 40 to 49 years about the potential benefits and harms of screening mammography; and that clinicians should base screening mammography decisions on benefits and harms of screening, as well as on a woman's preferences and breast cancer risk profile. The Academy has not yet commented on the recent update.

Perhaps what is most striking is how many patient advocacy groups agree with the task force's guidelines.  Recently, Barbara Brenner, executive director of the San Francisco-based Breast Cancer Action, told Fox News that her group was "thrilled" with the revisions.  . . .  “Mammograms, like all medical interventions, have risks and benefits,” she said. “Women are entitled to know what they are and to make their best decisions . . .  These guidelines will help that conversation."

Brenner is not alone. The National Breast Cancer Coalition, Breast Cancer Action and the National Women’s Health Network (which Fugh-Berman and Bell note, is one of the few national health advocacy groups that takes no money from industry) all support the USPSTF update.

False Claim: Under Reform, the, Government Will Use Comparative Effectiveness Research to Ration Care

The Obama administration has already set aside funding for a panel of medical experts to review “comparative effectiveness” research which looks at the risks and benefits for alternative treatments for a particular disease.

Those who oppose reform claim that the administration plans to use this research to deny care, and they have seized on the USPSTF update as an early example of what reformers plan to do.  The LA Times quotes Rep. Phil Gingrey, a physician: “This is really the first step toward that business of rationing care based on cost.”

Both Fox News' Glenn Beck and conservative author David Horowitz have chimed in, declaring that Democrats are responsible for the recent (USPSTF) update and citing this as proof that Democrats are, in Horowitz's words, "imposing a rationing system."

In fact, the Task Force is an independent panel. Members of the group are medical professionals, all of whom were seated or selected during the Bush administration.

Truth:  Reform Legislation is Explicit: Effectiveness Research Cannot Be Used To Deny Coverage

First, it is crucial to distinguish between “comparative effectiveness research” and work which considers  the “cost-effectiveness” of a particular treatment. When researchers compare the “effectiveness” of two procedures they are trying to determine which would provide the greatest benefit for patients who fit a particular profile—regardless of cost. Sometimes the most effective product or procedure is cheaper; sometimes it’s most expensive.

“Cost-effectiveness” research goes a step further to ask:  Do the benefits of a given treatment justify the price tag?

This is how the UK determines what its single-payer system will  and won’t cover. For instance, in 2007 the agency responsible for ruling on reimbursements decided that four drugs for patients suffering from early-stage Alzheimer’s disease (Aricept, Reminyl, Exelon and Ebixa ) were not “cost-effective” because they had “only a small clinical effect” on patients suffering the symptoms of early stage Alzheimer’s. The drugs would be covered only for patients in the later stage of the disease.

Are Americans ready to let a panel tell Medicare or other insurers which Alzheimer drugs should and shouldn’t be covered based on price alone?  Probably not.

If we were going to apply cost-benefit analysis to healthcare, we would have to face up to some sticky questions. First, how much is an extra year of life is worth—in dollars? Is an extra year worth more for a twelve-year-old than an 80-year-old?  How much more? What if the patient is bed-ridden?

Luckily, the U.S. does not have to confront such imponderables. The UK’s healthcare budget is much smaller than ours. This means that the UK must make some very difficult decisions.  Because we have so much more money sloshing around in our bloated health care system, we can save billions just by concentrating on effectiveness. There is much low-hanging fruit to be picked.

Years of research suggests that one-third of our health care dollars are squandered on unnecessary treatments. If we redirect those dollars to products and procedures that actually benefit patients, we will have enough money to provide effective care for all Americans. This is of course does not mean that we should over-pay. Medicare has already announced that it plans to reduce how much it reimburses for certain tests because medical evidence suggests these tests are being done too often—which means that risks are beginning to outstrip benefits.

The administration recognizes that the majority of Americans don’t want to see health care rationed based on co
st. Its comparative effectiveness panel would only disseminate information about risks and benefit, creating guidelines (not rules) that physicians can follow, as they chose.  When drawing up these guidelines the panel would not be looking at cost. It’s only goal: to help physicians choose the right treatment for the right patient at the right time.

Indeed, as the American College of Physicians (ACP, the organization that represents internists) explains, the legislation is explicit on this point: “Under the bills being considered by Congress, the USPSTF will have an important role in making evidence-based recommendations on preventive services that insurers will be required to cover, but the bills do not give the Task Force — or the federal government itself — any authority to put limitations on coverage, ration care, or require that insurers deny coverage. Specifically, the House and Senate bills would require health plans to cover preventive services based in large part on the evidence-based reviews by the USPSTF, but no limits are placed on health plans’ ability to offer additional preventive benefits, or in considering advice from sources other than the USPSTF in making such coverage determinations. Accordingly, patients will benefit by having a floor – not a limit – on essential preventive services that would be covered by all health insurers, usually with no out-of-pocket cost to them. . . . The bills specifically prohibit use of comparative effectiveness research to limit coverage or deny care based on cost.”

How did I find this information?  By Googling.

I can remember a time when journalists who wanted to track down the truth had to go to a library, and crank through pages and pages of microfilm to find one fact.

Today, when search engines do the work for you, I have one question:  Why are our newspapers, magazines, news shows and blogs filled with so much misinformation? 

16 thoughts on “Truth Squad: Medical Reporting on Mammograms—Part 2

  1. Maggie, a very fine post. I see 2 issues at play: the science of mammography and the process of formulating medical guidelines. With regard to the former, I offer no opinion. While mammography is beyond my field, we are all aware that the clinical benefits to younger women are quite slim. In fact, the reductions in mortality to women over 50 are quite modest also, yet one would think otherwise based on the puff press that mammography receives. Guideline formation in medicine is sausage making The process can be riddled with politics from medical societies and advocacy groups who have an agenda and various conflicts of interest. This is one reason why different medical organizations often have conflicting guideline recommendations on the same clinical issue.
    While the USPSTF is not perfect, it is known for its caution and non-partisan deliberations. They have earned a reputation for a conservative approach to medical care. They don’t extrapolate data, but are bound by it. They were thrown under the bus unfairly. They were falsely accused of pursing a cost control agenda. They were tarnished by mammogramophiles who used politics as a weapon, when the medical evidence didn’t support their objective. Even the Secretary of Health and Human Services pushed back against the task force in a shameful political ploy.
    This is a body blow to comparative effectiveness research (CER). I agree that CER is not supposed to address cost, but we all expect that this will become part of its mission in the future. Cost needs to be a factor, as we don’t have enough resources to pay for every available medical test or treatment on demand, particularly when they are costly and not supported by medical evidence. More thoughts at http://bit.ly/656CwP which I hope you won’t categorize as another blog that spews misinformation.

  2. False: Citizens don’t believe that CER will lead to less options on care and less screening at times.
    Truth: Citizens believe that CER will lead to less options on care and less screening at times and that we can’t afford everything.
    Why fight it? Why not just go with it?

  3. Maggie et al –
    This is an excellent discussion of the issue with one thing that I disagree with strongly.
    Please do not depend on the British Medical Journal short review of the Cochrane Report as a source for information as to what the science of the situation is. It is a biased article that chooses to highlight one part of the Cochrane Report and ignore other, equally important parts.
    If you are really interested, here is a link to the entire report — all 72 pages. The report does contain an excellent brief “plain language” summary that explains the report in a non-biased way.
    http://www.cochrane.dk/research/Screening%20for%20breast%20cancer,%20CD001877.pdf
    Or, if you want something short and sweet and aimed at lay people, take a look at the Nordic Cochrane Center’s own brief brochure explaining the facts and implications of their meta-study. Look at the English language version of the brochure.
    http://www.cochrane.dk
    BTW, ductal carcinoma in situ is not always a dormant cancer that will not spread. It is the stage at which all invasive ductal cancers begin. Some ductal carcinoma’s in situ will in fact go on to become lethal tumors, others will stay dormant. When the British NHS says that less than half of ductal carcinomas in situ do not go on to be dangerous cancers, the clear flip side is that almost half of them do. And the big problem is that there is not a good way to tell which is which. The terrible problem is WE CANNOT TELL the difference. The burden is, unfortunately, on the woman herself.
    What not getting screened does is protects you from that burden, but at the potential cost of not detecting a lethal cancer at a treatable stage. Since the information is unclear, the choice is yours, and both positions are sensible, as Maggie said in her earlier comments and as the USPSTF made clear in its statement.

  4. Pat S.
    Thanks for the advice on the Cochrane Collaboratio reprort
    I understand that many ductal carcinomas in situ do spread (about half, as you say) –but half don’t.
    So why isn’t this a situation that calls for “watchful waiting”–the strategy that we use for prostate cancers when we don’t know if they are going to spread.
    Even if a woman had to go in for mammograms every 3 or 4 months (at least at first) this would cause far less suffering (and be far less expensive) than unncessary surgery, reconstruciton, treatment for oomplications, etc.
    Perhaps there is something I’m missing here–some reason why “watchful waiting” wouldn’t work medically?
    (I realize that many women would have a problem dealing with it psychologically, but a great many men now choose “watchful waiting” for prostate cancer. . . Why couldn’t women?)
    Good decision-making coaches could explain the pros and cons of watchful waiting to women, just as they do with men.
    Michael–
    You wrote: “While the USPSTF is not perfect, it is known for its caution and non-partisan deliberations. They have earned a reputation for a conservative approach to medical care. They don’t extrapolate data, but are bound by it. They were thrown under the bus unfairly. They were falsely accused of pursing a cost control agenda”
    I agree completely.
    As to whether we will, at some point in the future, need to ration healthcare based on cost (saying that some treatments are just too expensive for society to help pay for and will have to be reserved for the rich) I’m not comfortable with that idea. And I am convinced that, at this point in time we don’t need to debate that point..
    There is so much low-hanging fruit to be picked (expensive treatments that are less effective than much cheper treatments treatments–or just not effective at all, even if there is no alternative.)
    I also think that under healthcare reform, the U.S., like other countries will begin to make it claer to those who develop drugs, devices and surgical techniques that we as a society just are not intersted in exorbitantly expensive products and procedures that provide minimal benefits t patients..
    Taxpayers won’t pay hundreds of thousands for a product that gives the average patient an extra three months of low-quality life.
    If those who profit form these treatments realize that, then going forward, the market will be very very smalll, and both companies and entrepreneurs will turn their attention elsewhere.
    (There are cancer drugs that provide minimal bneefit and are sold in this country that don’t find a market in other developed countries. Over time, I am hopeful that the U.S. will cease to provide a market for costly products and procedures that provide little benefit

  5. Concerning the need for citizen education on Evidence-based Medicine.
    After 8 years of science denial during the Bush administration, it isn’t surprising that many ordinary citizens have difficulty understanding the difference between an opinion and an evidence-based recommendation. Our common culture does not make this distinction consistently, and most people are accustomed to believing people they trust, or agree with, regardless of the evidence. Even Maggie’s excellent review of the coverage of this issue in the media places more emphasis on the credibility of the sources, than on the meaning of the research to the average reader.
    It will take time to lead citizens in a new, more enlightened direction. Until then, most people will not want to accept less coverage for screening services than they had before, and vested interests on every side will take advantage of our ignorance.
    The method of communication is the real problem here; more planning should have gone into making such an announcement. For years women and their families have been convinced that mammograms are saving their lives, and they are not ready to accept that they may just be keeping away tigers. Even so, most women over 60 can tell you about the week that time stood still, while a suspicious screening was explored, to the point that diagnosis was benign or inconclusive.
    Usually people are more willing to relinquish something when they are told that they do not have to do so. Perhaps physicians will have to take the lead in this effort, by telling their patients: “My examination suggests that you may not need this mammogram every year, so it is your decision whether to have it.”
    A detailed discussion of the risks and benefits, including unnecessary surgery and other treatments would necessarily precede the decision. I can assure you that some of us would be delighted to forgo a few of the tortuous procedures, especially since they do such a poor job of finding small cancers that have not been located manually by the woman herself, or her partner. (Of course medical providers would also require protection from lawsuits by people who think they can be guaranteed a no-risk outcome.)
    When science classes and other education programs give the concept of evidence-based decision-making as much attention as dissecting frogs, citizens will have the practical guidance needed to use financial and health care resources without wasting them.
    Finally, if the news media could spend even a fraction of the time that is spent on frivolous celebrity stories, explaining that real life is not without risks, and teaching us all how to judge the level of risk we face, many people would improve their understanding of these recommendations in only a few years.
    Changing our understanding is surely one of the most important challenges of health care reform.

  6. Following the uproar of the past few weeks over the new screening recommendations, an interesting and potentially important new development has emerged in media reporting – evidence that the radiation dose involved in mammography, while low, nevertheless increases breast cancer risk to an extent that might be meaningful in women at high risk, even if minimal in women at normal risk. The quandary posed by this possibility is the following. The Task Force has advised against a recommendation for routine screening in the 40-49 year age group, but suggests that each woman consider her individual circumstances in consultation with her physician. One individual circumstance that has been inferred from all this is the advisability of screening if a woman is at elevated risk on the basis of family history or other factors. However, it now appears as though the elevated risk of missing a cancer in the absence of mammography must be weighed against the elevated risk of developing a cancer because of mammography.
    In this cirucmstance, and until further data emerge, women in this category might wish to explore the possibility of avoiding routine mammographic procedures in favor of MRI breast imaging, which involves no radiation exposure.

  7. Thanks, Maggie, for you comments. “As to whether we will, at some point in the future, need to ration healthcare based on cost … I’m not comfortable with that idea.”
    This is th elephant in the room. While we all would desire that every individual could have access to what medicine can offer, this is not reasonable or possible. I think this should be part of the debate now, as folks need to get their arms around this concept. With regard to your ‘low hanging fruit’ metaphor, this is not as easy as it sounds. One person’s definition of waste is someone else’s income. I see wasteful care every day on hospital rounds, tests that are not medically needed, but that are easily justified. There may be orchards of this ‘low fruit’, but stakeholders won’t give any of it up willingly.
    Finally, your comment, “Taxpayers won’t pay hundreds of thousands for a product that gives the average patient an extra three months of low-quality life”, makes sense. It sounds like you are okay with the rationing concept, if I understand your comment correctly. http://www.MDWhistleblower.blogspot.com

  8. Maggie –
    Watchful waiting does work to some extent. There are four problems with breast cancer however.
    The first is that, as you say, the strategy would lead to even more frequent mammograms — as many as four a year and certainly two a year — to avoid missing a significant interval change. Over the life of a woman that could be a lot of mammograms, since unfortunately, unlike some other cancers, breast cancer can remain quiet for years — as many as fifteen to twenty years — and then become aggressive.
    The second is the danger of some cases — certainly small numbers but also unfortunately definitely real — where the cancer becomes aggressive and spreads to lymph nodes or elsewhere during waiting intervals.
    Third is the establishment of a reliable trigger that would allow doctors to decide on time when to act, a trigger not available now.
    Fourth is the psychological situation for women who are told “yes, you have cancer. Yes, it might develop into a lethal cancer. But for now let’s just wait and see what happens.” Obviously, there are some who would tolerate that. However there are some who would go crazy. It turns out that when this type of strategy is used, many patients reject it and go elsewhere.

  9. Bravo Maggie! We really need some sanity and truth around this issue right now.
    The nutty tone of the protests about the change in screening guidelines shows how woefully misinformed the American public is about screening mammography. Amazing how easy it is to manipulate people into doing something that is 10 times more likely to harm them than help them.
    We need to stop the unethical sales effort behind mammo screening. Women are literally never told that there is any downside to screening – informed consent is not respected. This is mind-boggling considering the life-altering consequences of unnecessary cancer treatment.
    In England, the National Health Service was recently forced to re-write their mammography promotion leaflets to include info about harms. This happened after a group of prominent MDs, patient advocates etc. wrote a letter to the London Times – see it here:
    http://www.timesonline.co.uk/tol/comment/letters/article5761650.ece
    My hope is that something similar happens in the US – it’s time to stop all the lies. Widespread screening mammography is a failed experiment that has needlessly taken the breasts, health and happiness of trusting women for too long. The cancer industry needs to bite the bullet and admit they were wrong and that thousands have been harmed due their greed.

  10. Fabulous post! Thanks so much, I will share this with some of my fellow physician non-believers (you’ve explained it much more eloquently than I have been able to do). I’m one of the physicians who applauds these new recommendations. I do believe that although more information is often confusing, in the end it’s better for patients to know what they’re getting into. I hope some of the people who are upset about this, MDs included, will read this. It’s time to stop practicing by anecdote and start practicing by evidence (when good evidence is available)

  11. Fantastic and well-thought out article, Maggie! As an OBGYN who specializes in wellness-based medicine, I have spent a great deal of time over the years thinking about breast cancer prevention. I believe that your article is right on the money.
    I have also recently posted an article about breast cancer screening and prevention on my blog: http://fdnhhealth.com/articles/19-breast-cancer-screening-and-prevention
    In this article I detailed nutritional supplements and lifestyle considerations that I believe can be of benefit to women with breast cancer concerns. I hope you find this article helpful also!
    Best wishes, Dr. Rawls

  12. Barbara, Fred
    Barbara–
    Welcome to HealthBeat.
    You write: “After 8 years of science denial during the Bush administration, it isn’t surprising that many ordinary citizens have difficulty understanding the difference between an opinion and an evidence-based recommendation. . . .The method of communication is the real problem here; more planning should have gone into making such an announcement”
    Yes, I agree on both counts.
    Though I would add that it was up to journalists and bloggers to do a much better job of translating the message to the public.
    The folks on the Task Force were not picked for their PR skills. And I would hate to think that a PR person was making the decisions about what they should tell the public, when and how.
    I blame the media for not doing a better job of acting as a translator, explaining what the Task Force was saying.
    It’s true that, as a reporter, I put an emphasis on the credibility of the sources.
    When people have a financial interest in what they are saying–and don’t disclose that conflict of interest–I am very, very wary.
    When people have no financial interest and take an unpopular position, that’s worth noting.
    Good journalists cover many areas where we are not experts. I know quite a bit about medicine; I read medical journals.
    But I’m not an MD–have never gone to medical school, dont’ have years of experience treating patients.
    This means that when interviewing experts, jouranlists needs to sort out the liars from the truth-tellers. Many b-s artists have prestigous titles and can talk a good game.
    But, unfortunately, in our society, when sources lie, their lies are usually motivated by self-interest and money.
    These are the sources you can’t trust.
    And this is why jouranlsits have to “follow the money” and pay attention to what vested interests might be influencing a source.
    Finally, yes, our colleges as well as our med schools (even our high schools) need to teach that medicine –and science–is filled with uncertainties and ambiguities.
    Physicians need to level with patients about this–and I think that doctors need to lead the way.
    But this is going to be very, very hard if the society as a whole (including reporters) refuse to acknowledge risks. Jouranlists should be helping experts get the truth out there. Our mission should be to tell people what they need to know–even if it isn’t want they want to hear.
    Fred–
    There does seem to be some evidence that many mammograms could lead to
    a risk that too much radiation could increase the chances of developing breast cancer.
    From what I know, though, the evidence is not entirely certain.
    Meanwhile, we do know that MRIs are more likely to detect those very small lesions that might well never develop and cause a problem.
    For that reason, I would be wary MRIs for most women.
    So many variables to weigh here . .

  13. 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 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 (J Radiol Prot. 2009 Jun;29(2A):A123-32. Epub 2009 May 19).

  14. I’m really bothered about how the cancer industry is using fear and hysteria to prevent reasonable discussion of data, especially data that threatens the vast and growing mammography market.
    It would be good to see more balance in this discussion including statistics on health risks associated with regular mammograms, especially when follow-up testing and unnecessary treatment is ordered.
    It’s crazy that discussion of costs is off the table; part of the “pulling the plug on granny” theme. With breast cancer it seems we’ve learning more, but understanding less.
    http://www.marketwatch.com/story/story/print?guid=0BE98350-9FCA-41B1-A4C0-05D9175303C2

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