“Early detection saves lives.”
Remember how I started a post a year and a half ago saying just this? I did it because that is the default assumption and has been so for quite a while. It’s an eminently reasonable-sounding concept that just makes sense. As I pointed out a year and a half ago, though, the question of the benefits of the early detection of cancer is more complicated than you think. Indeed, I’ve written several posts since then on the topic of mammography and breast cancer, the most recent of which I posted just last week. As studies have been released and my thinking on screening for breast cancer has evolved, regular readers have had a front row seat. Through it all, I hope I’ve managed to convey some of the issues involved in screening for cancer and just how difficult they are.
This week, all I can say is, “Here we go again.”
On Monday evening, the United States Preventative Services Task Force (USPSTF) released new recommendations for screening mammography, which it published in the Annals of Internal Medicine, that have, let me tell you, shaken my specialty to the core. I must admit I was surprised at the recommendations. No, I wasn’t surprised that recommendations to scale back mammographic screening were released. I saw it coming, based on a series of studies, some of which I’ve discussed right here on this very blog. What surprised me is how much of a departure from current mammography guidelines the USPSTF recommendations were and, even more so, that they were released this year. I hadn’t expected recommendations like this this soon. But I have to deal with them, and so I might as well try to help my readers understand them too.
The first thing that women need to understand is that these recommendations are for asymptomatic women at average risk for breast cancer undergoing routine screening for breast cancer. They are not for women judged to be at high risk due to genetic mutations, strong family history, or other factors producing a high risk for breast cancer. Neither are they for women who are not completely asymptomatic. If you’re a woman, particularly if you’re over 40, and have felt a lump, it needs to be worked up. Period. Screening by definition is administering a test to an asymptomatic population. These recommendations should not be used as a reason to delay or forego the evaluation of masses or other breast abnormalities. I mention this because I sometimes see confusion between screening and diagnostic mammography.
The second thing that needs to be understood is that these recommendations do not usurp the current standard of care, although it may seem that way. The American Cancer Society and other cancer organizations have not adopted them. That being said, I do rather suspect that they are the first shot in a battle that is likely to change how we screen for mammography. How much, I doubt that we will know for quite some time. That always leaves the question of what to do in the meantime, and I’ll discuss that after I discuss the actual recommendations.
First, it’ll make a lot more sense if I mention right now that the USPSTF grades its levels of evidence using this grading scale:
And ranks its level of certainty using this scale:
And here are its recommendations summarized:
- The 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. (Grade: C recommendation.)
- The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. (Grade: B recommendation.)
- The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. (Grade: I Statement.)
- The USPSTF recommends against teaching breast self-examination (BSE). (Grade: D recommendation.)
- The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. (Grade: I Statement.)
- The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. (Grade: I Statement.)
The summary for patients states:
The USPSTF found fair evidence that women who have screening mammography die of breast cancer less frequently than women who do not have it, but the benefits minus harms are small for women aged 40 to 49 years. Benefits increase as women age and their risk for breast cancer increases. However, there are relatively few studies of mammography for women aged 75 years or older. The potential harms of mammography include anxiety, procedures, and costs due to false-positive results and receiving a diagnosis and treatment of cancer that never would have surfaced on its own within a woman’s natural life time. They found that the benefit of mammography every 2 years is nearly the same as that of doing it every year, but the harms are likely to be half as common. They found no evidence that self- or clinical examination reduces breast cancer death rates.
There are two bombshells here. The first is the recommendation against routine screening mammography in women between 40 and 49. That’s the change that’s caused all sorts of controversy. Almost as big a bombshell is the recommendation for screening every other year, rather than every year. Add these two together, and it’s a recipe for confusion and controversy. After all, we’ve been recommending for a long time that women undergo mammography beginning at age 40 and then every year thereafter. It was a simple message, easy to transmit to women, easy to understand, simple to promote, although I would point out that it was anything but easy to convince women to undergo screening. That may be part of the nearly universally negative reaction to the recommendation that I’ve seen thus far from advocacy groups such as the Susan J. Komen Foundation and the American Cancer Society. I can understand how these new recommendations could be profoundly confusing to women.
That’s why it’s important to understand on what evidence these recommendations are based. It might help if you go back and read a post I wrote last week that discusses a review of the literature that urged a rethinking of screening mammography. In that article, it was estimated that, for women between the ages of 50 and 70, 838 women have to be screened for over 5,866 screening visits to sayve one life. It often shocks people to hear these sorts of numbers, but they are not beyond the pale for screening programs. More importantly, the USPSTF based its update of its 2002 recommendations on newer studies, including a study included in the same issue of the Annals of Internal Medicine that used several models to estimate breast cancer risk reduction using various screening paradigms, as well as newer randomized clinical trials, such as the Age Study and updated Gothenberg trial data. These models and results are consistent with randomized clinical trial results that indicate that there is a reduction in breast cancer mortality that results from beginning screening at 40 years but the reduction is “modest and less certain than mortality reductions observed from screening women aged 50 to 69 years.” By using data from randomized clinical trials, the USPSTF estimates that averting 1 death from breast cancer requires screening 1,904 women aged 40 to 49 years; 1,339 women aged 50 to 59 years; or 377 women aged 60 to 69 years. As described above, there was little difference in the benefits between screening every year versus screening every other year, but there were considerably more harms.
The USPSTF’s recommendation not to teach breast self-examination (BSE) is another point of controversy. Despite a lot of enthusiasm for the practice, Cochrane Reviews and other evidence have failed to find convincing evidence that routine regular BSE saves lives. I wish it were otherwise, but it appears not to be, even though there are compelling anecdotes out there of women who did find a lump on BSE and it turned out to be cancer. Unfortunately, overall, the evidence to support BSE is weak. On the other hand, even the Cochrane Collaboration, which I have in the past sometimes accused of methodolatry and “nihilism” with respect to screening concluded:
Some women will continue with breast self-examination or will wish to be taught the technique. We suggest that the lack of supporting evidence from the two major studies should be discussed with these women to enable them to make an informed decision. Women should, however, be aware of any breast changes. It is possible that increased breast awareness may have contributed to the decrease in mortality from breast cancer that has been noted in some countries. Women should, therefore, be encouraged to seek medical advice if they detect any change in their breasts that may be breast cancer.
Indeed, on a purely practical level, I see nothing wrong with women being taught to be aware of how their breasts normally feel and to bring to a physician’s attention any changes that concern them and still encourage that, but there really is no good evidence to support BSE.
So what are the harms of screening? First, there are “unnecessary” biopsies. I used quotation marks because we don’t know that the biopsies were unnecessary except in retrospect because our imaging technology is not good enough to differentiate benign from malignant as well as we would like, with as many as 80% of biopsies being negative. Second, as I’ve discussed before, there is a significant rate of overdiagnosis. Overdiagnosis is the detection of tumors that would never lead to life-threatening disease over the lifetime of the woman. Overdiagnosis leads to over treatment because, again, we can’t identify which of these diagnosed tumors will and won’t progress; so we have to treat them all. The question then becomes: What is the risk-benefit ratio of screening. For ages 40-49, the analysis of the results by the USPSTF showed a 15% reduction in breast cancer mortality, which was similar to the risk reduction for women aged 50-59 while the risk reduction was 32% for women aged 60-69 However, given the lower incidence of breast cancer in the younger age range and the higher chance of false positives and overdiagnosis, the absolute number of lives saved is considerably smaller and comes at a higher cost.
But enough of all these numbers. From my perspective, these new recommendations are a classic example of what happens when the shades of gray that make up the messy, difficult world of clinical research meet public health policy, where simple messages are needed in order to motivate public acceptance of a screening test. It’s also an example where reasonable researchers and physicians can look at exactly the same evidence for and against screening at different ages and come to different conclusions based on a balancing of the potential benefit versus the cost. The USPSTF simply came down on a side more like how many European nations screen for breast cancer. Depending on how women undergoing screening and we as a society balance the risks and benefits of screening, how this all plays out is an open question. The only prediction I can make is that the standard of care for breast cancer screening will almost certainly change. I doubt it will change all the way to the USPSTF’s new guidelines, but likely they will move in that direction, although I cannot predict how much. In any case, it’s always messy when that happens and leads to blowback. For instance, a professional society to which I belong issued a highly embarrassing press release, a case study in the wrong way to respond to a new set of recommendations like this. The worst part of this press release was this:
We believe these recommendations effectively turn back the clock to pre-mammography days by making the diagnosis of breast cancer occur only when the tumor is large enough to be felt on a physical exam. The Society will continue to advocate for routine annual mammography screening for all women beginning at age 40. Mammography screening reduces breast cancer mortality and saves lives.
By this logic, I suppose much of Europe is “pre-mammography,” given that several countries in Europe use guidelines for screening mammography very much like what the USPSTF recommended. Nothing in the guidelines even suggests going back to those days. Reasonable physicians and scientists can disagree over whether the new guidelines represent a reasonable attempt to apply current evidence about screening mammography to public health policy, but demonizing the USPSTF’s recommendations with such inflammatory language is neither productive nor reasonable. If you’re going to argue against the new guidelines, at least try to argue the evidence and counter what the guidelines actually say, as the American Cancer Society did, rather than exaggerating and and engaging in fear mongering. Indeed, I was so annoyed by this press release that I whipped off a rather strong response to it expressing my disappointment and embarrassment. I did that even though I don’t yet advocate giving up the current screening guidelines until more evidence is available. However, I do support being more flexible with women between the ages of 40-49 who are not at increased risk for breast cancer. Key to achieving that is to be very clear about what the benefits of mammography are and are not and what the risks of screening are and are not.
That’s why I think the response from the American Society of Clinical Oncology (ASCO, a society to which I also belong) was much better. It did what I support, namely defending the availability of mammography to women over 40, while suggesting a more personalized approach to screening:
Today’s recommendations from the USPSTF recognize the value of mammography in reducing breast cancer deaths, affirm the importance of mammography among women aged 50 and older, and emphasize that mammography should be seriously considered in women 40 to 49 after assessment of the risks and benefits. It is therefore of concern that at present more than a third of women who are now recommended for screening are not getting regular mammograms. While the optimal scheduling of regular mammograms is being discussed by experts in the field, ASCO would not want to see any impediments to mammography screening for any woman age 40 and above.
From ASCO’s perspective, the critical message is that all women – beginning at age 40 — should speak with their doctors about mammography to understand the benefits and potential risks, and determine what is best for them.
And that’s what it’s really about. The patient. Indeed, the current recommendations of the USPSTF are no less arbitrary, nor are they clearly more scientific than previous recommendations for screening, although they do include more recent studies as their basis. More than taking into account more recent studies, what they appear to reflect is a different attitude towards the risk-benefit ratio, in which the modest benefits of mammography in women between ages 40-49 are judged not to be worth the harm caused. Others may look at the same data and decide that the benefits of screening in this age range are worth the potential harms. What we should all agree on is that women should be aware of and understand as much as possible those tradeoffs. In the meantime, I’m not entirely buying these new recommendations, at least not the argument that they are more “science-based” than the older recommendations when, in actuality, they also arbitrarily decide that screening 1,300 women to save one life is an acceptable cost but screening 1,900 to save a life is not. As I’ve written before, I sincerely hope that better technology and the discovery of new biomarkers can decrease these high numbers by increasing the specificity of mammographic screening and, possibly, even allowing us to identify which mammographically detected tumors don’t need treatment.
In the meatime, screening asymptomatic people for disease always comes down to a balance of risks and benefits, as well as values. In the case of breast cancer, starting at 40 appears only to modestly increase the number of lives saved but at a high cost, while screening yearly only increases the detection of breast cancer marginally compared to screening every other year, also at a high cost in terms of more biopsies and more overdiagnosis. Whether the cost is worth it or not comes down to two levels. First and foremost, what matters is the woman being screened, what she values, and what her tolerance is for paying the price of screening at an earlier age, such as a high risk for overdiagnosis, excessive biopsies, and overtreatment in order to detect cancer earlier and a relatively low probability of avoiding death from breast cancer because of screening. Then there’s the policy level, where we as a society have to decide what tradeoffs we’re willing to make to save a life that otherwise would have been lost to breast cancer. Although screening programs and recommendations should be based on the best science we currently have, deciding upon the actual cutoffs of who is and is not screened and how often unavoidably involves value judgments. Such decisions always will.
133 replies on “Really rethinking breast cancer screening”
I also read (though I don’t remember where–perhaps the NYT?) that the value of manual breast examinations were being questioned. If so, does that mean that every form of detection is no longer considered helpful in diagnosing breast cancer prior to it metastasizing?
Not at all. The USPSTF states unequivocally that mammographic screening saves lives between ages 50 and 70, as well as between the ages of 40-49, although less so in the latter group as an absolute number given that the incidence of breast cancer is considerably lower in younger women.
The reason for the rethink, however, is that screening hasn’t saved as many lives as we had hoped and comes at a higher cost than we had appreciated. That’s why it’s a balancing act.
The USPSTF recommends against teaching breast self-examination (BSE). (Grade: D recommendation.)
I find this to be the most surprising recommendation, honestly. I’m not really familiar with the literature on this topic, however. Does BSE have too high a rate of false-positives or -negatives? It seems like the cost and discomfort of BSE screening are minimal, so the benefits must just not be there, right?
I wonder if the similar investigations will reveal the same about, say, testicular self-examination?
Excellent post. Judgments of risk-benefit can (and should) be informed by science (to obtain increasingly accurate estimates of NNT/NNH), but will always remain value-laden.
What do you think of the idea of using simple genetic markers (common alleles, not BRCA) to stratify recommendations for mammography, as described in NEJM last year?
Isn’t this an area where personalized medicine has significant potential to avoid overdiagnosis?
Is there any overdiagnosis that could already be avoided today if, say, the BRCA1/BRCA2 patents from Myriad Genetics get overturned and screening for those genes becomes inexpensive (and covered by insurance)?
HuffPost is already portraying this as “rationing” of care. I didn’t read the article because I have stopped looking at that section in order to preserve my hard won blood pressure readings.
what is the cost of mammogram screening? Seems one life saved per 1900 women screen is not a low number.
also, the paper in annals is horribly written, numbers are embedded, leading to it being very hard to really tease out “lives saved” differentials between age groups.
also, this is a case of really really really horrible framing of the issue. It is going to be a loss for science-based medicine. Alties win with horrilby written and reported data such as this one.
What about partners doing it? 🙂
One issue that I think is creating some outrage relates to the qualitative differences between the risks and benefits. The risks of screening are described as overdiagnosis, anxiety, excessive biopsies, unnecessary treatment, and cost. The benefit of screening is preventing deaths.
I think a lot of people intuitively object to the idea that a collection of risks that do not include death could outweigh the benefit of preventing death.
As far as I can tell, a lot of the issue boils down to a necessity to be sensible about screening, and what “sensible” actually means in different contexts. The problem with this is the reason why bright-line, simple rules and messages are developed:
The fact that, in aggregate, the instruction to “be sensible” works about as well as the instruction to teenagers “don’t have sex.”
The cost of mammogram screening includes the (low, but nonzero) radiation burden from each mammogram, and each woman’s time and physical discomfort.
That burden is there whether the mammogram is screening or diagnostic. It’s in addition to the risks of false positives and overdiagnosis and Orac discussed.
Another thing I wonder: given that mammograms are unpleasant, are women who have been patiently having them every year since age 40 going to say “I can’t take this anymore” and stop as they’re entering the age group where screening is more clearly beneficial? (If convincing someone to get a mammogram at 40 or 45 means she’s less likely to have one at 50 or 55, that doesn’t look like a good idea.)
Oh, and what qetzal said. Totally.
Not sure how to feel about this.
I was diagnosed with stage II BC when I was 39. I found the lumps myself, even though I didn’t do routine screening. One tumor was 3cm, the other 2. I was very lucky that it was only stage II, as before surgery they thought I’d be at least stage III.
I can’t help but think that if I had a mammogram at 35, or even practiced self exams, I might have been able to keep my breast, and maybe even avoid chemo and all the long lasting side effects.
I had NO family history at all. So where does someone like me fall on this continuum? Would it have been harder for me to have gotten my insurance company to pay for a mammogram after these guidelines? Am I that one in 2000 that is the acceptable collateral damage in these new guidelines?
One point I haven’t seen yet in the media or anywhere else: women in their 30s whose DCIS is caught by mammogram are VERY different than DCIS in 60 year old women. I’ve known a lot of those younger women and see that DCIS metastasize or be the precursor to aggressive cancer. And those small tumors in 30 year old women tend to be much nastier – triple negative or her2 positive. I can’t help but think that baselines for all women at 35 should be added to this guideline if they’re not going to be screened again until 50.
Also, is it just my imagination, or are a lot more young women getting breast cancer? My oncologist said that 15 years ago they saw maybe three young women a year with BC, now it’s a quarter of their practice.
I guess if missing my diagnosis would spare some women unnecessary anxiety and maybe a few unnecessary biopsies, not to mention all that money the insurance industry pays for screening, then my death would be worth it in their eyes.
Please, tell me why needless anxiety and unnecessary biopsies are more important than saving lives? I really don’t get it.
Not sure how to feel about this.
I was diagnosed with stage II BC when I was 39. I found the lumps myself, even though I didn’t do routine screening. One tumor was 3cm, the other 2. I was very lucky that it was only stage II, as before surgery they thought I’d be at least stage III.
I can’t help but think that if I had a mammogram at 35, or even practiced self exams, I might have been able to keep my breast, and maybe even avoid chemo and all the long lasting side effects.
I had NO family history at all. So where does someone like me fall on this continuum? Would it have been harder for me to have gotten my insurance company to pay for a mammogram after these guidelines? Am I that one in 2000 that is the acceptable collateral damage in these new guidelines?
One point I haven’t seen yet in the media or anywhere else: women in their 30s whose DCIS is caught by mammogram are VERY different than DCIS in 60 year old women. I’ve known a lot of those younger women and see that DCIS metastasize or be the precursor to aggressive cancer. And those small tumors in 30 year old women tend to be much nastier – triple negative or her2 positive. I can’t help but think that baselines for all women at 35 should be added to this guideline if they’re not going to be screened again until 50.
Also, is it just my imagination, or are a lot more young women getting breast cancer? My oncologist said that 15 years ago they saw maybe three young women a year with BC, now it’s a quarter of their practice.
Someone wrote: “Is there any overdiagnosis that could already be avoided today if, say, the BRCA1/BRCA2 patents from Myriad Genetics get overturned and screening for those genes becomes inexpensive (and covered by insurance)?”
BRCA is only responsible for about 10% of hereditary cancers. It’s hard enough for women with a family history to get mammograms, this will make it impossible for many. Kaiser refused to give a mammo to my 39 year old friend even though she had a 5cm palpable lump. She paid out of pocket and sure enough it was a nasty BC that had spread into her lymph system. Just more collateral damage. I guess they were just trying to spare her needless anxity.
I guess if missing my diagnosis would spare some women unnecessary anxiety and maybe a few unnecessary biopsies, not to mention all that money the insurance industry pays for screening, then my death would be worth it in their eyes.
Please, tell me why needless anxiety and unnecessary biopsies are more important than saving lives? I really don’t get it.
This IS rationing – the recommendations include cost as valid consideration. Would the recommendations be the same if a mammogram cost three cents? I doubt it.
Why do I doubt it? Look at the other “harms” that are listed as being significant to counterbalance the life-saving potential of the test: patient anxiety and false positives/negatives. Are they joking?
C’mon – smell the coffee. These recommendations, like so many others, place cost as a major consideration. In other words, the best and brightest of medical professionals, who should have no other considerations than the well-being of patients, are doing the work of insurance lobbyists free of charge.
@#3:
That is what I meant to say. I said “manual examination” when I should have said “self examination”. I do not understand this at all. Orac?
Of course it’s rationing, and every country with a health care system does it. If you perform tests that produce little gain at great costs, that takes away money from those tests that produce great gain. Someone pays the cost of every procedure performed, whether it’s a government or an insurance company.
These findings are new and I think any entity, whether or government or business, who advocates for wholeheartedly reducing coverage of screening mammography is jumping in too quickly.
@15 I see your point, but you, your friend and me all found the lumps regardless of having a mammogram. There would not have been routine mammograms at that age anyway. Not to mention, there is a real risk of triggering cancerous growth from all the over exposure to radiation. They should be definitely be screening in the under 50 age, but not everyone needs to increased risk from mammograms. It is not just increased anxiety, the radiation is increased risk to all! In my case there was increased radiation risk from multiple mammograms, anesthetic risk, increased risk to embolism, and post surgical complications.
Yeah, there’s no harm in telling someone they have breast cancer when they do not. Total beach vacation there.
and yes, thank you Joseph, I was told mine was probably the worst kind b/c of certain things they saw, and it turned out to be nothing. So the stress of thinking I might die early with 3 very young children definitely did damage to my health too.
Orac,
There’s a problem with your overall premise. Women have been told not to bother doing breast self exams and are now told to not have screening mammograms. There aren’t many symptoms of breast cancer until a tumor is found. Most women who have breast cancer have neither a strong family history or a genetic mutation.
With the exception of nipple discharge or skin changes there aren’t many other symptoms until the cancer has progressed to an advanced stage. Most cases of colon cancer are diagnosed in people in their 60s and 70s. With that being the case why would we be doing colonoscopies beginning at age 50?
In 2003 there were 62,000 women under the age of 50 diagnosed with breast cancer. 62,000 wives, mothers, daughters and sisters.
The paternalistic statements about protecting me from anxiety makes me want to laugh. You want a real cause of anxiety? Try being 38 and diagnosed with breast cancer.
So if mammography is not the answer what is? Why is our screening stuck in the same place it was 40 years ago?
@ Joseph C the rate of false positive diagnoses of breast cancer is miniscule if a biopsy is performed. And anyone who tells a woman she has breast cancer without a biopsy should lose their license.
@MLB:
@15 I see your point, but you, your friend and me all found the lumps regardless of having a mammogram.
To paraphrase a classic question, though, “who speaks for the ones who didn’t find the lump themselves?” — because these are the ones who might not be around to speak for themselves, after all.
@aftercancer
But it’s not just “anxiety.” I really wish that angle hadn’t gotten played up so much in the press, as worry about psychosocial distress strikes me as a small part of the recommendations. Indeed, the accompanying documentation states that anxiety and distress “fortunately are usually transient and some research suggests that these effects are not a barrier to screening.”
It’s mainly the overdiagnosis and overtreatment of women who have indolent or small cancers that would never have threatened their lives but because we don’t know how to differentiate the ones that will progress from the ones that won’t get treated as though they are dangerous that drive the recommendations.
Re: Breast Self-Examination
Cochrane review says no statistically significant difference between self-examination and no intervention. Also suggests increased harm with increased numbers of benign lesions identified and then biopsied.
http://www.cochrane.org/reviews/en/ab003373.html
I’m 34 and in the high risk group (brother died of cancer at 33, mother pre-menopausal breast cancer, early period, no kids, took the pill). I already had two friends diagnosed with breast cancer at ages 27 and 32; one did not not make. Reading this article is highly disturbing. People are debating over the lack of screening for ages 40-49; what about those of us in our 30s? I’m aware and I make sure to get seen by a professional twice a year. But as Laura said above, she was NOT in the high risk group and was fortunate enough to be treated while treatable. Instead of taking care more towards prevention there is a move towards more dire cases. Perhaps money will be saved that way- if women are diagnosed with termimal breast cancer due to severity, you certainly save a lot of money by simply letting them die. “Comfortably,” of course.
Joseph C and MLB
You think that a density seen on a mammogram means you will be told that “you have cancer”? Do you know anything about medicine?
And anxiety and false results also occur in the other strata of patients, btw. Is the somewhat decreased false pos/neg rate in these populations that anodyne?
Please, the reason the new recommendations don’t raise the same objections as being as important is because the 49+ year old strata have a higher true positive rate. The panel has created an arbitrary threshold based to a large extent on cost.
Can the panel say that their new guidelines will not cause more women to die from undiagnosed cancer?
Ummmm…. but cost is a major consideration, even if there were no such thing as insurance lobbyists. There is a finite amount of money to spend saving lives, and if that money spent in a different way could save more lives…. this is not cold and calculating, it is the most compassionate way to go about it.
Now, we can debate the wisdom of these guidelines given that the current guidelines aren’t even being followed… maybe it is better to say you should be screened more, in the hopes that it will balance out to some kind of optimum. (I read once that the amount of water the American military in Iraq tells recruits they need per day is double what they actually need, because then maybe most of them will actually reach the minimum…)
But saying that cost should not factor into a cost/benefit analysis? Ummmm……
I’ve sat for a few days with radiologists while they read mammograms and apparently sometimes it is pretty clear just from the read. At least that’s what they told me. Obviously, work ups still have to be done.
Laura, aftercancer,
Is it your argument that all women, regardless of age, should have screening mammograms every day?
If not, then there’s necessarily a cutoff before which it’s not worthwhile, and after which it is. Where that cutoff is most optimally placed is a very important question, and careful science is the only way to go about answering it. Objecting to what the science says is counterproductive.
And if it is, what is your response to all the women who will develop cancer due to the radiation of the mammograms, all of those women who go through extensive pain and discomfort for false positives, and all of the people who will die because so much of the available health care budget is being spent on mammograms?
@ Greg #25:
Then how, exactly, is breast cancer to be detected? No self exams, fewer mammograms… the link you posted stated that women should see their doctor if they notice breast changes. What *type* of changes? If you are not examining your breasts what changes will you notice? The women I have known that have/had breast cancer saw their physician because they found a lump. How is a cure even a remote possibility if breast exams are not done?
Orac: THANK YOU. I hope you really do understand how much I and others appreciate your careful sanity in the public bedlam stories like this raise. This will be of special help and use fir close members of my family who were asking me about this. I knew you’d be there for us. 🙂
To a few commenters: Of COURSE financial cost is a factor. Face up to it, folks. It is utterly asinine and irresponsible to pretend money isn’t or shouldn’t be an object in healthcare. It unavoidably is, and given our non-science-fantasy reality wherein we do not have unlimited resources it would be fundamentally irresponsible for us NOT to consider money. I completely share your suspicion of possible efforts to put money first. I don’t trust the insurance companies, etc, any more than you. I dunno if that’s what’s going on here or not, though per Orac’s post it looks more complicated than that. But in my opinion we really need to stop freaking out when money is mentioned, while retaining good logic and skepticism.
I think that the majority of the “costs” the study outlines are ridiculous. So 1900 women have to get screened to save one life of one 40-49 yr old. If we’re looking at costs, what’s the cost to society of one woman, in the prime of her life, quite possibly the mother of young children? I, for one, think it’s one we should collectively bear.
Unfortunately, as a result of this study, mammograms likely won’t be covered by insurance in short order, and many women who would be willing to assume the personal “risk” of mammography may not be able to afford it.
The one set of costs that I do think is valid are the costs of treatment (down-stream physical side effects) for cancers that would not become deadly in a patient’s lifetime. So it baffles me why the recommendations of the study aren’t to focus research on distinguishing between virulent and passive breast cancers to tackle this cost head-on.
Hm. I was expecting an earthshaking change. This is current practise in Canada for screening.
Re: breast self examination: it used to be encouraged that you pick a time of the month and do an official feel of your own breasts. There was an official way to do it. Personally, I couldn’t keep track of that. I encourage my patients to be familiar with their breasts and to come in if they note a changed lump, bump, change in the skin, change in the contour, or any manner of discharge. This is not “breast self examination”, but is much more doable.
Screening asymptomatic women over age 40 is reserved for people in high-risk groups. You can get a mammo at any age to investgate a lump, and that’s not screening, it’s investigation. We don’t screen men, but I have seen two men in the past month who have needed mammography.
Cost and number needed to detect are always considerations, as much as we wish they weren’t. For example, suppose there were a test that could detect a deadly disease, but to save one life by early detection using this test we had to test 10,000,000 people. Let’s further assume that the test cost the same as mammography. Would that test be worth it? OK, then what about 1,000,000? Or what about 100,000? Or 10,000? Or 1,000 (which is in line with mammography for some groups)?
The point is that there has to be a cutoff, and, no matter what, that cutoff will be to some extent arbitrary and determined by cost-benefit analyses. We don’t have unlimited resources. This is reality. We can argue and disagree about where the cutoff should be, but there will be a cutoff and we will have to decide on it.
I do understand the concern about whether insurance companies will continue to cover mammography for women under 40, but note that the guidelines don’t say that women under 40 shouldn’t get mammography, just that the decision should be more individualized. Also note that the American Cancer Society and other organizations are, for the moment, sticking with the current guidelines, and I doubt insurance companies will risk the public outcry that dropping mammography coverage for 40-49 year olds would cause unless there are more major cancer organizations issuing recommendations like those of the USPSTF.
Your comments about mammography screening advice in Europe is appreciated, but why don’t you list the recommendations in these countries? You could also try the Canadian Government site for the recommendations in Canada, which have been for several years almost identical to the “new” USPSTF advice.
what is cut off for prostate, what is cut off for colon? sorry, doesn’t jive with me.
1 in 1900 pretty good return, I don’t see this as even a close call.
to the idiot who takes makes the stupid argument “so we should screen every woman everyday” dumbass. of course not there is NO BENEFIT to such.
reducing screening makes sense, more informed decision making (talk to doc before screening) makes sense, what makes no sense is the damn paper. 1 in 1900 vs 1 in 13000, 15% to 14%, life years saved, regardless of “absolute numbers” of cancer incidences. this panel screwed up.
this is the type of crap that will KILL science based medicine.
regarding overtreatment: the majority of overtreatment would still get treated, just at age 50 instead of between 40 and 49. what will the rise in mortality be? 1 in 2000?
I don’t know, what is it?
In fact, medical ethicists struggle with this question all the time. The number I heard recently is that current actions indicate that our society puts that cost at about $50K/year of life saved. My interpretation is that this is an empirical result, based on analysis of our current practice.
My main point is to say that you shouldn’t assume this question hasn’t been asked.
I have found two lumps- one at 20, one at 38. I had the first needle aspiration biopsied (AT MY REQUEST). They told me I could just wait and see if it got bigger and if it did to come back. I asked if there was anyway we could just check NOW. They said, sure, a biopsy. It was cheap at the time ($100) took less than 15 minutes, and rather than considering it an “unnecessary” biopsy, i personally considered it a small price to pay for being able to SLEEP at night for the next six rather than wondering if it was cancer or not. Since there was blood in the lump, they were able to tell me on the spot it was nothing. Huge relief and well worth the inconvenience TO ME.
Next time the lump turned out to be two lumps right next to each other and I had a core needle biospy. Waiting for the results was not fun, but I have never been an “ignorance is bliss” kind of person. I want to know so I can decide what to do. I personally am willing to make the tradeoff for a little more pain to be sure.
As far as breast self exams go, since I found both of my lumps, I certainly do it! No one else, (even doctors and nurses) was able to feel the lumps that I found the second time even when I told them what quadrant it was in. To me, it’s totally obvious and I can easily find it with two fingers. This makes me very nervous about relying on anyone else to do a BSE for me. No one has a better chance at finding a lump than a woman who is familiar with what normal feels like FOR HER. I understand they mostly aren’t very good at it but I wonder if using the forms for practice wouldn’t improve women’s ability and I think that should be investigated.
I let 6 interns feel my first breast lump which was only about 1 cm. They told me that almost NO ONE finds a lump that small and they were very happy at that teaching hospital to be able to let the interns feel an actual breast with that size lump. Hopefully I helped save a life because it wasn’t the most pleasant thing to do! I felt like it was the right thing to do, though.
People keep talking about the harm of overtreatment, but they defined the harm. The WOMAN needs to define what she considers harm. I don’t
Really? How do you determine that? Trying to parse what you mean, it sounds like you are suggesting that daily exams do not provide a benefit compared to … annual? Monthly? Every 6 months?
Where is the line where benefit begins? What is the benefit of doing annual exams for those over 50 to bienniel?
Again, we are talking about screening, not diagnostic.
“Ummmm…. but cost is a major consideration, even if there were no such thing as insurance lobbyists. There is a finite amount of money to spend saving lives, and if that money spent in a different way could save more lives…. this is not cold and calculating, it is the most compassionate way to go about it.”
Finite money? Whose money are we talking about? The insurance industry’s? Tax dollars? Who is setting the limit on these numbers? The people who argue that it is ethical for the head of a major HMO to take home a billion dollar bonus? The people who feel it is imperative to spend a trillion dollars a year on defense, but impossible to justify a screening mammogram for 40-49 year old women?
And, even if we agreed that we must ration screening mammograms (and I am happy to see that we have at least admitted that we are indeed talking about rationing), why is that necessarily part of the mission of the United States Preventative Services Task Force, a part of the AHRQ, the Agency for Healthcare Research and Quality. (I suppose quality means quality ways to restrict health care delivery?)
The mission of the AHRQ is “… to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Information from AHRQ’s research helps people make more informed decisions and improve the quality of health care services”. I guess by “efficiency” they mean rationalizing decreases in health care delivery, not actually improving patient outcomes.
I am reminded of the insurance industry’s rationale for not covering smoking cessation therapy. It would seem that smokers die very ‘efficiently’ from cancer which cuts short their lives, avoiding the high cost of the treatment of chronic conditions suffered by the more elderly.
How long before the pressure from the “finite…money” supply for healthcare makes it acceptably “efficient” to recommend against screening mammograms for the next decade of women, the 50-59 year olds?
We spend twice as much as for our rotten healthcare as other more truly ‘efficient’ health systems. Surely that would entitle us to save a few more, not less, women’s lives with screening mammograms.
Cost should not be part of the calculus of healthcare “research and quality”. There are plenty enough dollars to fund proper healthcare here, if only we have the will to insist upon it.
If we keep arguing that denying health care is “the most compassionate way to go about it” we will continue to see exactly what we have seen over the past ten years in the US – the quality of medical care for the average American slide into the toilet. If we want real efficiency in our healthcare system, it will not come from denying mammograms to 40-49 year old women, but rather from a wholesale restructuring of how, and how well, we fund our healthcare system.
Let me ask, who do you think has good quality healthcare for their average citizens? Canada? Europe?
The reason I say that is because, as has been noted, the proposed guidelines are actually very similar to those used in Canada and Europe.
No one is suggesting to “deny mammograms to women 40 – 49 who need them.” The question that is being debated is, who really needs them? Does everyone need them? Or is there a subset of the population for whom they are much more beneficial?
You’re swirling around from one position to another. Those “efficient” health care systems you talk of most certainly take cost into consideration. Ever heard of NICE in the UK?
@gingerbaker
Actually, cost is not even really mentioned as a factor as far as the USPSTF recommendations go, except very briefly and in passing. From my reading of the report, it does not appear to have been a major factor in the recommendations.
I’m sorry too, but at the risk of angering you this has to be said. Your comparison of the USPSTF recommendations to insurance companies and tobacco is not only off base, but offensive.
It is interesting that no one is mentioning that the cost of treating “overdiagnosed” tumors is not just psychological (and monetary). Cancer treatment is not good for your health. While they say that screened women aged 40-49 were less likely to die _of breast cancer_, they did not say that they were less likely to _die_. I seem to recall that there was a large study some years ago showing that there was an increased risk of death from heart disease from breast cancer treatment (I think that was from the chemo), so screening for younger women did not save lives, it just shifted the cause of death. It is also well known that radiation therapy increases the risk of second cancers. And this does not include the radiation in the mammogram itself.
Nobody has made such an argument. As a rhetorical device I inquired whether Laura and aftercancer were making that argument, but the (I believe) clear implication was that such would be foolhardy.
This is not even wrong. Gross foolishness and ignorance taken to the extreme, in fact.
Resources are limited. They will always be limited. Denying this incontestable fact is hugely immoral, since the limitation on resources means that it is a profound moral imperative to deploy those resources in the way that will produce the greatest benefits.
This sort of thinking is, in fact, a major contributer to WHY health care costs are so high in this country! Whether you like it or not, “rationing” is inevitable, necessary, and ultimately beneficial to everyone.
Orac – I think your point about 40 being a point for a woman and her doctor to have a discussion is really the salient message.
I am sorry this recommendation had to come out in the middle of the health care “reform” debate. It brings out every anecdotal story and undermines the idea that we can control costs by sticking to evidence-based guidelines.
How can we extend coverage without devoting our entire economy to health care if we continue to pile requirements onto coverage that aren’t beneficial?
Thanks Orac for the thoughtful discussion of the recommendations. When I first heard about them, I knew to turn here for a level-headed analysis. That said, I still have a few questions:
* Do the guidelines focus on mortality to the exclusion of morbidity? In other words, is death the only endpoint, as opposed to also considering whether interventions can improve treatment/quality of life (breast-conserving strategies, surgery alone vs. surgery+chemo, etc.)? If that is the case, should morbidity have been considered as well?
* When any kind of arbitrary age limit is drawn, there will always be outliersâin this case, women with no known risk factors whose cancers were picked up on routine screening, even though they were younger than current or USPTF guidelines. Does this change in recommendations essentially write them off as not worth worrying about? Does the recommendation to stop BSE mean that, for a nonsymptomatic woman with no risk factors, she runs a risk of a cancer cropping up before starting mammograms at age 50?
* I understand that family history, late or no childbirth, obesity, etc. are some of the common risk factors. How does fibrocystic breast disease figure in? Is that something which would justify screening in a younger woman?
Oh, also, Orac, I think you may want to fix something. The last paragraph states that “screening yearly only increases the detection of breast cancer marginally compared to screening every year” … you mean every *other* year, right?
Poor phrasing there. They’re not “written off as not worth worrying about,” but rather it’s concluded that trying to catch those cases would result in greater harm to others than the benefit to the few.
It’s all statistics, when it comes right down to it. There will always be people who come out on the wrong end of the dice, in both directions (those who would have been better off with more aggressive screening, and those harmed by the screening – e.g. getting cancer due to the radiation from the mammograms). Acknowledging that isn’t writing anybody off, it’s accepting reality.
I’m impressed by how well a TV show actually got the idea – “I take risks, sometimes patients die. But not taking risks causes more patients to die, so I guess my biggest problem is I’ve been cursed with the ability to do the math.”
Dr Cox?
I get your point, Scott. And I know this is the struggle that health policy folks have to deal with constantly. It just seems that at some point, somebody’s getting thrown under the bus, that the guidelines more or less come across to younger breast cancer victims as, “Sorry, sucks to be you.”
I am surprised that in all the coverage of this, I’ve seen barely any talk about the increased risk of cancer from repeated mammograms. To my mind, that’s a more serious consideration than anxiety or false positives. And it would strengthen the argument toward steering away from routine screenings in younger women.
I know when I have heard discussion of this topic on Dr Radio (XM 119, Sirius 114 – definately NOT your typical media source), this is a big point that always gets mentioned. In particular, the idea that x-ray radiation is generally considered to be cumulative, so lots of little doses add up to equal one big dose. I should note, this topic has been making the rounds on that station quite a bit in the last couple of months.
Unfortunately, I have never paid close enough attention, but they do talk about advances in techniques that allow for lower dosage.
House.
scott I know it was a rhetorical device. rhetorical devices are for philosophers who don’t have DATA. that is was dumbass. See, you bought right back into my rhetorical device of calling out yours.
as for other arguments, in general population screens, do you really consider 1 in 2000 to be the outliers?
It’s been funny/annoying watching the conspiracy theorists try to pin all of this on Obama and “socialized medicine” and “rationing”. Sebellius has already sent out a press release saying that she doesn’t agree with the recommendations.
I’m the one thinking immoral thoughts?
We spend double what Europe does, basically, per capita, yes? Let’s say we went with the most efficient, highest quality, best outcome hybrid system. Our costs would still be cut in half. Yet we are comfortable right now in the US spending twice that amount. Let’s say we switched to the new system, and still kept our health spending the same. Do you now think we might be able to afford screening mammograms for all without rationing – spending what we spend already, today – or would that be immoral too?
This mind set you have repeated, that “Resources are limited. They will always be limited. Denying this incontestable fact is hugely immoral…” is ubiquitous. And I say that it is that mind set which is immoral.
It is a Grover Norqist-esque meme which assumes exactly what the insurance industry wants us to believe – that the system is stretched to the limit, that we have no obligation to demand more from taxpayers or corporations, and it is patient care that must properly be sacrificed. And the very people who have a sacred obligation to protect their patients are the ones throwing them under the bus. Doctors! What exactly is the mission of the AMA again? What does the Hippocratic Oath say about the obligations of physicians? Is that too “offensive” a question, Orac?
Resources are limited because of collusion and lack of social justice. They are limited because agencies have been cutting their own budgets for years in aid of the very meme you have voiced so pompously as being moral. It is Orwellian – patient care must be cut to improve patient care.
And by playing this game, we now longer even know what level of health care is actually adequate. Is what we deliver to patients today acceptable? Because it would not have been ten or twenty years ago. But because every year more and more sacrifices to ‘better patient care’ are made – like a frog in a pot on the stove – the standard of care goes down. Would it have been acceptable, say in the ’60’s, to have thousands of people dying every year because they were refused admission to overcrowded or underfinanced hospitals? I don’t think it would have been tolerated.
But what do I know – I am an “immoral” guy with “offensive” thoughts.
again I would like to point out that this paper was written poorly, esp. knowing it was going to hit the world hard. All of us 40 somethings not only know someone treated for breast cancer pre-50 years old, most of us know someone who has died from breast cancer pre-50 (and many with few known familial risk factors). In my mind, looking at the data presented, it would seem very arbitrary moving the screening to 50, why not 55 (midpoint between 50 and 60)? that seems to be where the slope really shifts.
of course we don’t have unlimited funds, and of course overly agressive treatment is disadvantageous, but maybe we can find ways to reduce these costs rather then eliminate them. I guess my take is, the task force’s solution looks at the wrong part of the fraction. Lets increase benefits by adjusting treatments and other costs.
@GingerBaker
Whether you like it or not there will always be a limited number of doctors with a limited number of work hours. From the sounds of it you are advocating that these doctors waste a lot of their time and effort on unnecessary tests and procedures. At some point we have to draw the line and decide the most productive way to use our resources. Doing mammograms on every single woman over the age of puberty every 6 months would definitely save lives but also waste time, cause many false positives, and expose many women to harmful radiation.
You also haven’t addressed the fact that you agree that other countries have better healthcare while having similar cost-risk recommendations. Do you agree, for instance, that Canada has a better system and has the same recommendations as USPSTF?
Earth to Gingerbaker, are you there?
*static*
Since we’ve now learned that health care resources being limited is just a pernicious lie by “the man”, can we now just start transplanting organs into whomever? Any 55-year-old crackhead that wants a kidney will get one. Nevermind the younger person that might take better care of the kidney, we’ve got total resources now!
I believe that Gingerbaker’s point is simply, the fact that there are limited resources is being used as an excuse to cut patient care rather than tackle the hidden(sortof) waste in the system. It would not be unreasonable to say that, given that the US spends double the amount of its GDP of any other industrialised nation on healthcare, that perhaps the cuts need to be made to the bureacratic overhead and illogical systems of pricing which sucks away so much of this money, rather than say “it’s not economic to fund screening of these groups any more.” If the system could be run in the style of efficiency as in European systems, but with twice the money that is spent in European systems, then surely screening the younger groups would still be possible within existing levels of resource.
It’s undeniably true that there are limits to resources, but when speaking of monetary costs, in America there are lots of places where money gets sucked away that do not contribute anything to patient care. Surely we really ought to tackle those first, before cutting patient care and options.
I have to say, I’m surprised at the amount of emotion based arguments coming up in this thread. I feel for those who have been diagnosed with breast cancer at a young age and feel like screening saved their life. I’m young and relatively healthy – something like a breast cancer diagnosis would completely knock me on my ass.
But… I can’t see the difference between these breast cancer stories and the same stories anti-vaxxers like to tell in an attempt to change the vaccination schedule. Your personal stories are heart-wrenching, but their not an appropriate basis for making screening policy.
Gingerbaker, jesus christ, could you possible misrepresent my comments more????
Sigh. Okay, fine. Finite resources, okay? Jesus fucking Christ. Why do I even have to defend this point????? There are a finite number of hours in the day. Should we screen every single person for every single possible disease, once per week? Cost ain’t a factor, right??? Goddamn, I can’t even believe I have to defend this point. THERE ARE FINITE RESOURCES. Live with it.
Wow, not even close to what I said. I agree with the rest of your post about how our healthcare system is so inefficient here. But the word “efficiency” has no meaning unless we agree there are finite resources!!! Fuckall, I can’t believe I even have to explain this…. If you deny that there is a finite amount of resources, and that cost has to be part of the equation, then why are you concerned about the inefficiency of our healthcare system here? Just throw more money at it, right! There’s an infinite amount!!!
Welcome to planet fucking Earth, where you can’t do everything all the time and have to make tradeoffs. Jesus H fucking Christ, I can’t believe it… you’re usually a non-retarded commenter. How can you possibly be arguing that cost should never be a factor in healthcare???? Okay, you know what, if cost is never a factor in saving lives, then I propose we change the speed limit to 1MPH. Sure, it will decimate our economy, but cost is not a factor! And it will save tens of thousands of lives per year!
ARGH!
I just want to say, it blows my goddamn mind to see Gingerbaker making an argument that basically boils down to: Our healthcare system in the US is hugely inefficient, therefore, we should stop considering efficiency when it comes to healthcare. WTF?!?
The fact that resources are limited is THE reason to get off this bullshit privatized insurance we have. It is THE reason to get a workable universal healthcare plan figured out, and to shoot down this idiotic townhall-rhetoric we keep hearing from the right.
Coverage has to be denied sometimes. This is REAL LIFE. However, decisions on when to deny and when to grant coverage should presumably be based primarily on achieving optimal benefit for society, balanced against our uniquely human concerns about fairness and decency (e.g. we would likely spend more to save a life than a purely utilitarian view of societal cost-benefits would dictate). In the current system, the decisions on when to deny and when to grant coverage are, at best, based on what will improve the bottom line of health insurance companies(*) — and at worst, the decisions are just fucking random.
That’s got to change, but the reason isn’t because cost shouldn’t be a factor… it’s because cost is ALWAYS a factor, so we damn well better get it straight.
(*) And BTW, this doesn’t make the companies evil. They are beholden to their stockholders, and it would be unethical of them to compromise this responsibility. The problem is not that insurance companies are big meanies — they are, but under current regulations they could not possibly be anything but. The problem is that health coverage is an endeavor that doesn’t do well in a capitalist model.
Insanity. If we had total social justice, then we’d be able to fly everyone to the moon and back once per year, right? No? Why not? I mean, we’ve done it before with a handful of people, so we know that it’s possible… so why can’t we just fly everybody to the moon? Is it really just because we have “collusion and a lack of social justice”? Can that be?
Oh yeah, it’s because RESOURCES ARE ALWAYS LIMITED.
I’m just flabbergasted. I thought Gingerbaker wasn’t one of the idjuts…
Gingerbaker,
The economy is finite, there are many needs in addition to health care. All needs, all functions in our society will have limits on how many people, how much equipment, how much money can be devoted to them.
We can not afford our overpriced health care non-system as it is let alone give everyone every screening test at every age.
The question – as has been clearly and repeatedly stated by others – is what resources do we use when?
Not only does over screening cost more than we can afford, but it takes resources away from places where greater good can be done.
And there is also the issue that many screening tests are not without risk. Even something as simple as drawing blood – eg infection at the puncture site.
And drop the snide name calling. Facing reality is the opposite of rethuglican philosophy.
As far as medical organizations making outrageous statements, the American College of Radiologists’ was even worse and fear-mongering than your breast surgeon organization:
http://www.acr.org/HomePageCategories/News/ACRNewsCenter/USPSTFMammoRecs.aspx
Of course they have blatant self-interest in maximizing screening as much as possible:
http://bioblog.biotunes.org/bioblog/2009/11/17/the-uspstf-deals-with-data-not-hyperbole/
But one thing no one seems to be discussing is the idea that breast cancer surgery itself can cause cancers that might have not progressed to become metastatic, which I ran across here:
Retsky M, Demicheli, R., and Hrushesky, W. 2003. Breast cancer screening: controversies and future directions. Current Opinion in Obstetrics and Gynecology 15(1):1-8.
(Link: http://elopt.com/Retsky-etal-Current-Opinion-2003.pdf)
This is something that a cancer surgeon might be reluctant to talk about, but surely you have an understanding/opinion about how often this can happen?
This is an interesting point, and in principle I agree… but in practice, we may end up having to compromise with the devil (or move to Canada…).
If the worst case scenario happens, and healthcare reform gets completely stymied by right wing assholes and pandering Democratic congresscritters wanting to appeal to the moronic attendants of their townhall meetings… should we then completely give up and say, “Oh, well as long as there’s that much waste in the system, we won’t try to fix anything!”?
BTW, I’m not saying I think breast cancer screening should necessarily be scaled back… I’m just saying, it’s not off limits to talk about the costs. Even if we are stuck with private insurance companies with the primary incentive being to increase profits (which, uniquely among the insurance industry, turns out to be exactly opposite to what would benefit consumers — in what other industry does the bottom line explicitly depend on making sure you routinely fail to deliver the promised product???) that still doesn’t mean we should throw up our hands and not try to get them to allocate coverage more efficiently…
@aftercancer, I really resent you blowing off anxeity as a trivial factor.
I’m 35. My mother had pre-menopausal breast cancer and a reoccurance a number of years later. She is not a BRAC carrier.
I’ve been told I need twice annual professional breast exams and yearly mammographs starting at 35.
I’ve spent weeks sweating out being able to see a specialist to follow-up on the tiniest of something that might possibly maybe be a lump or might possibly be normal tissue. That was really some of the most awful time of my life.
Not only is it my stress, it’s talking my mother down because she feels guiltly like this is her fault. My sister retreats into “what me worry?” mode and tells me I’m being silly. It’s not really fun, when you either end up comforting everyone around you or have them telling you that are being silly, which is what in my experience happens.
Most of this I susepct has been fueled by an overly agressive better safe than sorry mentality. Plus, I have health insurance that will pay for this.
I’ve never been organized enough to manage twice yearly professional exams. I find these new recommendations to be rather refreshing. I don’t want being the daughter of a breast cancer survivor to take over my life.
I am not confused at all. Overdiagnosis is a blight on the lives of far more women than are ever saved by mammograms. Please see http://www.screening.dk/folder_uk.pdf for unbiased info on breast screening.
The average woman does not understand enough about the harms of screening, and this is not explicit in the new guidelines. It should be made clear that if 2000 women are screened for 10 years, one woman will avoid a breast cancer death. BUT 10 women will be harmed by unnecessary cancer treatment; another 200 women will have a false alarm and be subject to additional radiation and biopsy. If women knew this THEN they might stop and think â is it worth subjecting 10 women to mutilation, massive irradiation, chemical poisioning, side effects like lymphedema, negative effects on insurance eligibility and on and on in order that one may avoid a breast cancer death?
As a functional matter the question is this – is it worth giving 10 women cancer to save one life? This frames the matter in the most exact functional way. Why? – BECAUSE OVERDIAGNOSIS MEANS THAT THE 10 OVERDIAGNOSED WOMEN HAD A “CANCER” THAT WOULD NEVER HAVE HARMED THEIR HEALTH OR EVEN BEEN DISCOVERED IF THEY HAD NOT BEEN SCREENED.
So ladies, which one do you think you will be â the one treated for nothing or the one whose life is saved? You are literally 10 times more likely to be treated for nothing. It would appear that very few US women understand this. We have been lied to for too longâ¦
The cancer industry’s hostile reaction to the new evidence-based guidelines for screening mammography is disheartening, but perhaps not unexpected. Whenever independent research about the harms of screening mammography emerges, it is vigorously attacked and dismissed by those whose livelihood depends on women falling victim to breast cancer. They have the most to lose, after all. For an excellent discussion of the resistance of the scientific/medical community to information that runs counter to current beliefs see:
http://www.bmj.com/cgi/eletters/339/jul09_1/b2587 – toward the end of the page see:
It is time for a new paradigm for overdiagnosis with screening mammography
Karsten J Jørgensen, Peter C. Gøtzsche (20 August 2009)
These eminent researchers do not benefit when women get cancer, unlike the various factions who are screaming about these new science-based guidelines.
Very well explained, balanced and rational post, such writing is greatly appreciated.
From the cancerscreening.gov.au site, in the BreastScreen FAQ section.
The Australian guidelines promote women 50â69 to have a free mammogram every 2 years. Women 40 â 49 or 70+ can get them if they wish. Younger than 40 it’s only if you have family history or some symptoms, and not ‘screening’ style of mammogram.
I think the guidelines are very reasonable. Those with strong family history and/or palpable lumps are to continue to be tested. The super low risk and asymptomatic pts where no benefit was found are carved out.
“and yes, thank you Joseph, I was told mine was probably the worst kind b/c of certain things they saw, and it turned out to be nothing. So the stress of thinking I might die early with 3 very young children definitely did damage to my health too.
Posted by: MLB”
Well poor you, MLB You had STRESS. Wow.
I’m glad it turned out to be nothing, but for many of us, that wasn’t the case. Sorry, but you’re not allowed to say your health was damaged by your STRESS. What are you saying: that they shouldn’t have investigated your abnormality? Just because your scare was nothing, that doesn’t mean that it shouldn’t have been found and followed up on. My scare turned out to be a big fat something – and I might very well die because of it. I don’t feel the list bit sorry for your f-cking STRESS.
“Laura, aftercancer,
Is it your argument that all women, regardless of age, should have screening mammograms every day?”
Scott, that’s your straw dog and you can play with it on your own. I’m saying that every woman should have a baseline at 35, then follow ups maybe every five years or whatever their doctor thinks they need. Yes, I agree that every year is overkill, but no mamos until 50? How many women will die because of that? I certainly would have. How dare you marginalize the thousands of women who get breast cancer before 50.
“I think the guidelines are very reasonable. Those with strong family history and/or palpable lumps are to continue to be tested. The super low risk and asymptomatic pts where no benefit was found are carved out.
Posted by: DrWonderful”
How do you know if you have a palpable lump if your not doing self exams? What about the insurance companies who refuse to pay for mamos under the new guidelines?
And by the way, i was in a super low risk group: in my 30s with no family history, in excellent health and slim. And I got a boob full of cancer. Go figure.
But, I guess I’m just not worth the investment under everyone’s scenario. Men will get viagra paid for by insurance, but us women, no mammograms. What a surprise.
From Dr. Len’s Cancer Blog:
“The United States Preventivec Services Task Force (USPSTF) today released a series of reports updating their guideline recommendations for screening mammography for the early detection of breast cancer. Their conclusions are bound to raise another round of intense discussion about the benefits, risks and harms of screening for breast cancer.
There is certainly nothing wrong with that, with the exception that if we make the wrong decisions or offer women the wrong guidance about the early detection of breast cancer, we could reverse the considerable progress that has been make in reducing deaths from this disease over the past twenty years.
Unlike the Task Force, the American Cancer Society is not changing its current recommendations that women at average risk of getting breast cancer should get a mammogram every year starting at age 40.
In this era of health care reform, these new Task Force guidelines could have real implications for how insurers, government programs and maybe even the pending health care reform bills will cover screening mammography in the future.
Before I actually discuss the guidelines, I would like to set the stage with the very last sentence of the report that came from one of the evidence reports written by researchers from the Oregon University Health Sciences Center (OHSU). I do this because I think it puts the issue into context:
âMammography screening at any age is a tradeoff of a continuum of benefits and harms. The ages at which this tradeoff becomes acceptable to individuals and society are not clearly resolved by the available evidence.â (emphasis mine)
With that as a starting point, here are the short versions of the Task Forceâs new recommendations for screening mammography:
1) The Task Force recommends against routine screening for women ages 40-49. Whether to start screening before age 50 should be an individual choice.
2) The Task Force recommends screening every two years for women between ages 50 and 74.
3) The Task Force canât make any recommendations on whether women ages 75 and over should be screened, because there is not enough evidence upon which they can base a recommendation.
4) There is not enough evidence to make a recommendation about the value of clinical breast examination (a careful breast exam done periodically by a trained medical professional) for women 40 years of age or older
5) There is no evidence that teaching women how to do breast self examination makes an difference, so they recommend against teaching women how to do it
6) There isnât enough evidence to say anything about the value of digital mammography and MRI screening in women at average risk of breast cancer
So now the recommendations of the Society are considerably different from the Task Force, whereas in the past the only real difference was whether a screening mammogram should be done every year (ACS) or every one to two years (Task Force). Until now, both organizations had recommended starting screening for breast cancer at age 40.
Those recommendations had been in place for many years. These changes are bound to confuse women and health care professionals who must now make a professional and a personal choice as to which recommendations to follow. The worst outcome would be if the confusion leads women to do nothing since the experts canât seem to make up their minds.
The Task Force believes their new recommendations can retain most of the benefits of mammogramsâthat is, decreasing deaths from breast cancerâwhile reducing the risks and harms of the procedure, which includes such things as having to get additional studies to clarify a suspicious finding on a mammogram, or getting a biopsy of a suspicious lesion that turns out not to be breast cancer, or perhaps having a woman embark on a treatment for an actual breast cancer that would never have interfered with her life.
The review of the various clinical trials as reported by OHSU showed that mammography reduced deaths from breast cancer by about 15% in women ages 40-49. They also found that 1904 (range 929-6378) women had to be screened over 10 years to save one life. For women ages 50-59 years, the reduction in deaths was about the same (14%). The number that needed to be screened was 1339 (range 322-7455). In women ages 60-69, the reduction in deaths was 32%, and the number who needed to be screened over 10 years was 377.
What this means is that mammograms are indeed successful in reducing deaths from breast cancer in all age groups, especially women between 60 and 69 years old. But since the actual incidence of breast cancer is less in women ages 40-49, the absolute/actual numbers of lives saved is also less. So you have to screen more women to get the same benefit.
Stated another way, the Task Force agrees that mammography reduces deaths in women ages 40-49. It just doesnât save enough lives, in their opinion.
What about those risks and harms of getting a mammogram? Here is what did the OHSU investigators have to say:
* No significant damage was seen from the radiation associated with mammograms.
* Mammograms can be painful, but âfew (women) would consider this a deterrent from future screening.â
* There was no consistent effect on most women with regards to the anxiety associated with mammograms, but it was an issue for some women.
* âFalse positiveâ mammogramsâwhere the screening mammogram suggests there may be a cancer, but eventually none is foundâare an issue, with more of them in younger women compared to older women. But false positive mammograms that lead to an actual biopsy are less common in younger women than in older women, which means that younger women may need more extra mammograms or ultrasounds to take a look at a suspicious area but donât actually have to have a biopsy done when compared to older women where the opposite is true. (In more precise terms, according to the paper, in women ages 40-49, for every case of invasive breast cancer that is diagnosed 556 women have a mammogram, 47 have additional images, and 5 have biopsies.)
* Overdiagnosis was a difficult issue to address, because there really is no direct way of determining which breast cancers we treat are cancers that might lead to a womanâs death as compared to breast cancers we treat that would never cause a problem. They concluded that overdiagnosis rates in various studies ranged from 1% to 30%, with most falling between 1% to 10%.
As the Oregon researchers point out based on this analysis, âThese estimates are difficult to apply because, for individual women, it is not known which types of cancer will progress, how quickly cancer will advance and expected lifetimes.â
The largest burden of overdiagnosis probably occurs in the population of older women, where you can diagnose and treat a breast cancer but woman wouldnât have a problem with the breast cancer because she had another serious disease and died from something other than breast cancer. If that is where the bulk of the problem lies, then that is a different situation than having overdiagnosis in a young woman, where it could impact the quality of her life for many more years.
What about new technologies such as digital mammograms (which are quickly becoming the only type of mammogram available in many cities in this country) and MRI screening for women at average risk of breast cancer?
Here is what the OHSU researchers to say about those topics as well as a comment about how often mammograms should be done:
âNew technologies, such as digital mammography and MRI, have become widely used in the United States without definitive studies of their effect on screening. Consumer expectations that new technology is better than old may obscure potential adverse effects, such as higher false-positive results and expense. No screening trials incorporating newer technology have been published, and estimates of benefits and harms in this report are based predominantly on studies of film mammography. No definitive studies of the appropriate interval for mammography screening exist, although trial data reflect screening intervals from 12 to 33 months.â
Letâs now focus on the other research report which was based on a very sophisticated computer model designed and supported by the National Cancer Institute. The purpose of this model was to try and determine at what age screening mammography should begin, when it should end, and how often it should be done.
The model actually looked at 20 different age/frequency âscenarios.â Six different institutions around the country that participate in this project looked at each of these scenarios and came up with their own estimates of how the different combinations of age and frequency impacted the benefits of getting a screening mammogram.
I suspect to no oneâs surprise, each of these six complex computer models came up with different answers for the same questions.
For example, in one model, if you screened only women from 50-74 and did it every two years, you reduced breast cancer deaths by about 28%. If you did it every year from age 40 to 84, you reduced mortality by about 54%. In another model, the same numbers were about 22% and 38%. In the first study, doing mammograms every other year for more years made a big difference. In the second study, it still made a difference, but not quite as much. And there were still other studies where it made little or no difference
And, not unexpectedly, the later you started getting a screening mammogram and how often you did it resulted in a significant difference in the number of mammograms a woman would have over her lifetime. Start later, end earlier and get it every two years required many fewer lifetime mammograms than starting at 40, screening to a later age, and getting it every year.
So what did these experts conclude from their computer models?
âThis study uses 6 established models that use common inputs but different approaches and assumptions to extend previous randomized mammography screening trial results to the US population and to age groups in whom trial results are less conclusive. All 6 modeling groups concluded that the most efficient screening strategies are those that include a biennial screening interval. Conclusions about the optimal starting ages for screening depend more on the measure chosen for evaluating outcomes. If the goal of a national screening program is to reduce mortality in the most efficient manner, then programs that screen biennially from age 50 years to age 69, 74 or 79 years are among the most efficient on the basis of the ratio of benefits to the number of screening examinations. If the goal of a screening program is to efficiently maximize the number of life-years gained, then the preferred strategy would be to screen biennially starting at age 40 years. Decisions about the best starting and stopping ages also depend on tolerance for false-positive results and the rate of overdiagnosis.â
The bottom line of this research was that you could get somewhere between 70-99% of the benefit of screening mammograms (that is, reducing deaths from breast cancer) while reducing the harms by about 50% if you started screening at age 50 and did it every two years as compared to starting at age 40 and doing it every year.
Eventually, someone has to take this information and make some recommendations, and that is exactly what the Task Force did.
We probably have learned as much as we are going to learn from large clinical trials of mammography. If we are going to extend our knowledge about the benefits, risks and harms of mammography, it probably wonât come from new, large clinical trials. We have to find other ways to answer our questions about the early detection of breast cancer, and one of the ways to do that is through computer models.
The question, however, is whether or not the models are sufficiently accurate to tell us with reasonable certainty what would happen under a particular situation. It is one thing to try to predict the future or support a theory. It is quite a different thing, in my opinion, when you take computer models and make public policy that affects millions of women with respect to a life threatening disease. Even though the models may be very well designed, there are always questions about how well they truly reflect or predict âreal life.â
Aside from the confusion this report is going to sow in the minds of women about when (and maybe even whether) they should be screened for breast cancer, there is the question about how we are going to provide insurance coverage for women who need mammograms.
It remains to be seen how insurers, Medicare, Medicaid and states where insurers are required to cover screening mammograms are going to react to these recommendations. Hopefully, they will continue to recognize that other respected organizationsâsuch as the American Cancer Societyâhave different thoughts on this issue and are still appropriate benchmarks to use when determining whether or not to pay for screening mammograms.
And then there is health care reform, where the influence of the Task Force may be considerable under the various legislative proposals currently wending their way through Congress.
If the Task Force recommendations become the benchmark in the new legislation, then we may have a problem. If that turns out to be the case, hopefully Congress will realize that recommendations from other organizations that have looked at the same evidence and who have come to different conclusions should also be considered as valid when making coverage decisions for new or existing insurance plans. If not, then it will be much more difficult for a woman to get a mammogram if she is between 40 and 49 years old, or if she wants to get one every year as we currently recommend.
The American Cancer Society is not changing our recommendations for breast cancer screening as a result of this report. Based on our initial review of this new guideline, we see no reason to change a strategy that has proven effective in reducing the death rates for breast cancer in all age groups, including those women ages 40-49.
We will review the evidence offered by the computer modeling approach since it represents new research, and we will continue to examine information from other sources as it becomes available. And, if that information or research is compelling, we will always be open to updating our recommendations. But until such time as we are convinced that such evidence supports such a change, our guidelines will remain as they have been for the past 12 years.
What we knowâas noted in the Task Force reportâis that deaths from breast cancer have declined 2.3% per year for all women and 3.3% per year for women aged 40-50 years beginning in 1990. That may not seem much year to year, but the total impact over 19 years has been significant, and cannot be ignored. This is especially true when one considers that the death rate was absolutely stable for the preceding six decades. Screening mammograms and better treatments are responsible for that success.
We do no agree that 70% of the benefit from screening mammograms is the right way to go. We do believe that we should aim to choose 100% of the benefit. We should not forget that the âbenefitâ in this situation is reducing deaths from breast cancer. A 30% reduction in saving lives is not acceptable.
We also recognize that mammograms are not perfect. We realize that women do have to get additional studies for suspicious lesions. We realize that some women have biopsies that do not show breast cancer. We realize that our predictive tests are not perfect, so that we canât say with certainty which breast cancers are aggressive and require intensive treatment and which wouldâif left aloneânever cause a problem.
We realize that we need better screening tools, and that we must work diligently to improve the quality of screening mammography across the country.
Until we have something better, what we have to work with to detect breast cancer early is the screening mammogram. Is it imperfect? Yes. Has it saved lives and reduced deaths from breast cancer? Absolutely.
And that is the fact that simply cannot be ignored.”
That’s actually exactly the point. Better screening methods would reduce chasing non-problems. Obviously, we’re not there yet. Nowhere near there.
Go here:http://www.cancer.org/downloads/STT/CAFF2003BrFPWSecured.pdf
look at table 2, tell me where cut off should be.
1 in 1900, 5 “unneeded” biopsies, one saved life (mmmm, how many extended lives?)
vs.
1 in 1300. (I don’t think I saw the “unneeded biopsy” rate for this age group.
overtreatment will always be an issue, but we will mostly just be shifting that treatment from 45 to 55. How many deaths will result from undertreatment?
I can stare at the paper all day, I don’t see how they come up with such a drastic recommendation. It would seem baseline early, mid 40s check and biennial beginning 50s. yearly would seem to be overkill, but waiting to 50 giving incidence rates in the 40s seems like underkill.
I’m a 47 year old woman with no special risk factors. Last year after my mammogram I was called back to get additional views, and an ultrasound. At the time I was uninsured. I ended up spending around $550 for the tests, radiologist review, etc. Conclusion was that I had a cyst.
It was expensive for me as I was unemployed, and did cause me some anxiety.
Just my personal story/anecdote to illustrate that sometimes a mammogram results in more procedures and significant expense to the patient, and no cancer is found.
James Sweet @66
I think there are some people who would disagree with that last sentence. I also suspect that such people are much more prevalent among the anti-vax crowd. 🙂
How does the tendency of cancers in younger women to be more aggressive figure into these recommendations to eliminate screening for younger women.
>SCREENING SAVES LIVES
It should be on every bumper sticker in North America.
Quite a few of the anecdotal stories I’m reading involve women not affected by this change in recommendation, ie, women under the age of 40.
And I’m one of the women whose experience with the 40 year mammogram was so horrible that I am reluctant to have another one, though my rational brain tells me, that at 56, I should.
Yet… say… a yearly mammogram costs $500. (I am guessing). At every two years from 40 to 50 and yearly since then, I’ve skipped 11 mammograms. That’s $5500 that could go toward research for better screening techniques for women under 40.
I’m one of those genealogy nuts and I have death certificates going back several generations for my female ancestors on both sides of my family. None of them died of any kind of cancer. I had children before age 30, breastfed, didn’t use BC pills for more than 3 years and used HRT for only 3 months. I’m a fairly low risk for breast cancer.
Why should any type of health care system spend money on regular mammograms for me? It doesn’t make sense.
I am well aware that I may die of breast cancer regardless the risk factors, but the odds are something else will kill me first.
Every penny saved from women like me not getting mammograms could go toward research for better screening for younger women and better treatment for all women who have breast cancer. I think about my daughters whose first child was born after they were 30, the one who wasn’t physically able to breastfeed… and how their chances of breast cancer are enhanced by those things.
And… for young women today who will not have children until they are 30+ years old… are we, as a society not responsible for that increased risk? How do “we” “pay” for that?
::stepping off the soapbox now::
As a healthcare worker the new recommendations were very troubling to me. The paternalistic days of medicine are over and I find that patients have less and less trust in what doctors have to say – some of it based on irrational paranoia about “big business” agendas but other parts of it frankly justified. There is a mountain of medical data to sift through out there, if we had the time, BUT WE DON’T. We do the best we can. Remember, we are on the phone to your insurance company for 30 minutes trying to get “authorization” for that diagnostic test we feel you need (in between trying to figure out a really convoluted designer vaccination schedule with NO basis in Evidence-Based Medicine, at the request of a neurotic parent). Breast cancer outcomes are known to be worse in African American women, many of whom feel rationed care will work against them. So now instead of giving clearcut rules, you are asking women to “talk to your doctor”. No woman is going to feel that 5 (or less!) minutes out of that 15 minute visit (not MY choice folks, if my hospital goes out of business altogether, who do you think is going to see you and how long will the wait for an appointment be NOW?), is sufficient to discuss a loaded topic like this. If I really don’t feel comfortable trying to objectively cover this topic as a primary caregiver, how the hell is my patient supposed to feel about going on my opinion?
Orac,
Do you have the names of doctors who are on the USPSTF?
Dr. Daniel Kopans has stated that there were “no oncologists or nationally-known radiologists” included in the task force. I watched him on CNN last night. He was visibly angry by the new recommendations.
I spent 15-20 minutes talking to three different women about these recommendations. It wasn’t what they were in for, but it is what we ended up talking about. By the end of the day I was about an hour behind. So it goes.
I don’t do self-breast exams, but my breasts do get examined in the shower and by my husband. I have an idea of what my breasts feel like. The data doesn’t support clinicians teaching women to do clinical breast exams, but the recommendations do not say never touch your breasts. My take is that women should be encouraged to examine their own breasts however it makes them feel comfortable and look for what is different.
The USPSTF level of recommendation about screening before age 50 is that they feel the data doesn’t show benefit overall. It’s not enough that they think it causes true harm (that would be a D level). There is a lot of room left open for women before age 50 to get screening mammograms. I think that there is going to be a lot more discussion and dissection of the data. This is one organization making recommendations. Not everyone agrees, though my sense is that the USPSTF is more conservative in their recommendations than some others. Fundamentally this ends up as a discussion between a patient and a physician about what is comfortable for both.
Laura, I’m sorry to hear that you have breast cancer. I don’t know if a mammogram at age 35 would have found your cancer earlier. I have had patients with clean mammograms diagnosed with cancer less than a year later. I hope that you gain remission and do well. Many women do.
It’s never going to be an easy issue to deal with, until we come up with a better way to deal with breast cancer. It’s always a balancing act, and would be even if it didn’t cost a dime to do a mammogram. There are only so many qualified radiologists who have only so many machines to work with and only so many hours in a day to do their work in. Sorry to be “captain obvious” here.
@gaiainc , how’s that you had healthy patients and less than an year they were diagnosed with breast cancer ? what are the causes,why does it appear so suddenly ?
Regarding the difference in healthcare spending between the US and europe: why is it that the US spends so much more (approx 50% more than the next highest spend) and yet has mortality figures that are average at best.
Is this because:
A: The health system in the US is geared towards offering all sorts of testing that is of limited use except preventing malpractice suits for doctors
B: Rich Americans who can pay for healthcare are indeed living longer and healthier, but the stats are being skewed by the poor Americans who don’t have healthcare and die early
My guess is a bit of both, but certainly the medical testing that is performed in the US (as compared to treatment) is far, far higher than most comparable countries.
A couple of random thoughts about this debate…
1. A mammogram in a 30 year old woman with a lump in her breast (or a 30 year old man with a lump in his breast, for that matter) is not screening. It is case finding. There is no recommendation against mammograms at any age for symptoms.
2. The recommendations are for low risk women only. Women with family history of breast cancer or other risk factors should be screened at an earlier age. Depending on their level of risk, more aggressive interventions up to and including prophylactic mastectomy should be considered.
3. Not screening younger women is not just about anxiety and cost. Mammography involves ionizing radiation. Although the risk of any given radiation exposure is low, over a lifetime it can add up. Furthermore, treatment of breast cancer or suspected breast cancer is not entirely benign. People die from surgery. They also die from chemotherapy and radiation and even hormonal therapy. Of course, more are saved by surgery and adjuvant therapy when they genuinely have an aggressive cancer. This idea that some cancers aren’t aggressive is intriguing, but I hardly think anyone is going to let one sit around to see what happens just yet…
4. On a slightly different topic, colon cancer screening. It starts at 50 because that’s when the risk of colon cancer really starts to take off. But colonoscopy isn’t just about detection, it’s also about prevention by removal of adenomas. Maybe colon cancer screening should start at 40 or 45, rather than 50. Sort of the converse of the changes in breast cancer recommendations. Anyone have any thoughts on this?
Alex, first clean mammograms does not equal healthy patients, nor does it mean that they are not healthy. They are who they are and I don’t think that my patients’ underlying health played a roll in their breast cancer. Some breast cancers act really fast. My understanding is that mammograms can only show changes when the cancer is of sufficient size. If you have your mammogram before there are sufficient cells to show the changes, then you would have a clean mammogram but still have cancer that shows up less than a year later. It’s not all my patients, it’s rare, but it happens.
“1. A mammogram in a 30 year old woman with a lump in her breast (or a 30 year old man with a lump in his breast, for that matter) is not screening. It is case finding. There is no recommendation against mammograms at any age for symptoms.”
Well said, Dianne, and it brings up another thing in my mind.
The folks who say this is “misogynistic” because anything that saves one woman’s life is good are not, I notice, complaining that there is no routine screening, at any age, for breast cancer in men. Nor are they complaining that 30-year-old women aren’t routinely screened for breast cancer. (Yet I had an aunt who died of breast cancer in her early 20s. I suppose screening all 20-year-olds might have saved her life, but it wouldn’t make any sense to screen healthy, asymptomatic 20-year-olds for breast cancer.)
So they understand there should be a cutoff, an age below which it isn’t necessary to get a mammogram unless you have a particular risk factor (family history, for instance, or actual symptoms like a suspicious lump). What they don’t seem to understand is that at this point, it’s just haggling over the price, so to speak. Is 40 better than 50? It’s a question a lot like whether you’re willing to spend $40 or $50 for a particular item — science can tell you the risks and benefits of each course of action, but which way to go is still a matter of opinion. The statistics show that screening all women annually at age 40 doesn’t reduce breast cancer deaths. It will certainly catch some cases and save some lives, but it’s apparently not very many. Is the added radiation exposure, discomfort, risk of unnecessary biopsy, and risk of unnecessary treatment in the event of misdiagnosis worth the lives saved? Maybe. Maybe not. I don’t think science can answer that question, which is why this remains controversial.
I don’t think it would’ve been possible for the USPSTF to have picked a worse moment to unveil these recommendations, however.
@rb,
Ok, at the cost of being called names, others have established that screening all women daily is far too much (or ‘dumbass’) but 1 life saved for every 1904 women screened between ages of 40 and 49 is a pretty good return. Somewhere between these two is your cutoff point presumably, and it would be interesting to hear from you where (roughly) it is.
And I should perhaps say that even though I’m a philosopher, this isn’t a rhetorical device; I would just be interested to know the answer.
How dare you marginalize the women who get breast cancer before 35? How dare the existing guidelines marginalize the women who get breast cancer before 40? How dare most of the rest of the world marginalize the women who get breast cancer before 50?
How dare you marginalize the women who get cancer from mammogram radiation exposure? How dare you marginalize the women who undergo, are harmed by, and potentially die from unnecessary treatment after misdiagnosis or for indolent cancers?
I trust the point has been made.
For that matter, the women who get breast cancer before 50 happen to include an immediate family member of mine, who was stage III before anything was noticed, stage IV within a month after surgery, and isn’t really responding to treatment (except in the negative sense of suffering particularly strong side effects). Probably due to a mutation known to have been inherited by OTHER immediate family members. Unlike you, however, I’m able to recognize that individual cases and emotion are NOT proper ways to address the question.
Vicious personal attacks against anyone who dares admit that there are actual questions to be asked are quite inappropriate.
How dare you marginalize the women who get breast cancer before 35? How dare the existing guidelines marginalize the women who get breast cancer before 40? How dare most of the rest of the world marginalize the women who get breast cancer before 50?
How dare you marginalize the women who get cancer from mammogram radiation exposure? How dare you marginalize the women who undergo, are harmed by, and potentially die from unnecessary treatment after misdiagnosis or for indolent cancers?
I trust the point has been made.
For that matter, the women who get breast cancer before 50 happen to include an immediate family member of mine, who was stage III before anything was noticed, stage IV within a month after surgery, and isn’t really responding to treatment (except in the negative sense of suffering particularly strong side effects). Probably due to a mutation known to have been inherited by OTHER immediate family members. Unlike you, however, I’m able to recognize that individual cases and emotion are NOT proper ways to address the question.
Vicious personal attacks against anyone who dares admit that there are actual questions to be asked are quite inappropriate.
thanks,yes
@TriathNanEilean
you misread me. I have said repeatedly, 1 in 1900 is a GREAT return rate and strongly SUPPORTS screening 40-49 women. 1 in 1900 vs 1 in 1300, combined with cancer stats I posted from the ACS, undermines the task forces statement that screening 50s is supported due to a much higher incidence rate. The drop off for women in theirs 30s would suggest that they should only be given mammograms in response to other factors.
That said, I don’t believe in any “screening” that occurs outside of serious conversations between patient and doctor.I think the data strongly supports (in DISAGREEEMENT with the task force and the task force defenders) that women and doctors very strongly consider some mammograms in the 40s.
The very first comment above asked why they would actively discourage breast self-examination (by recommending against teaching it). I don’t think that’s been answered.
Women aren’t going to be taught to examine themselves at any age, and gynecologists are going to be discouraged from manual exams at any age, and no mammograms are to be performed before age 50 unless there is some special reason…. How does this make sense?
BSE costs nothing to perform and does not involve harmful radiation or drugs, and the teaching usually consists of handing out pamphlets. What justification is there for actively preventing women from learning it?
LW, I don’t anyone is going to *actively* prevent anyone from learning anything. It’s just not the end all be all that some people thought it might be. Plus, it acknowledges some realities that earlier recommendations didn’t. One of those is that many young women have dense, kind of naturally lumpy breast tissue that shifts normally. The range of normal is greater than some people originally acknowledged, especially when you start including younger and younger women.
@#96:
I have asked that question several times in this thread and have yet to get a response. If all forms of early detection (BSEs, clinical exams) are no longer considered important than how will cancer be discovered? Certainly not by mammogram if you are under 50. You can’t find a lump if you don’t examine your breasts. You can’t treat it if you don’t know it’s there.
@ 96 & 98 I asked the same thing, generally, at #3…check out the link posted by Greg at #25…
“The USPSTF recommends against teaching breast self-examination (BSE).”
I learned BSE in school. I am given a pamphlet every time I see the gynecologist. If, however, the school obediently ceases to teach it, and the doctors obediently cease to hand out pamphlets, where exactly would a young woman learn it?
I concede that they haven’t recommended that “you must actively prevent young women from learning BSE”; they have just recommended that all the normal sources of that information cease to provide it. This appears to me to be a distinction without a difference.
I agree with Serena @98; under these recommendations it would appear that breast cancer in women under 50 with no known risk factors (like, say, my sister and the wife of my best friend) would simply go undetected until it metastasized and the metastases could no longer be ignored. Fortunately, my sister and the wife of my best friend were treated under the old recommendations, and are thus still alive.
Scientizzle, I read the abstract at the link posted by Greg, but it includes this:
“Women should, however, be aware of any breast changes. It is possible that increased breast awareness may have contributed to the decrease in mortality from breast cancer that has been noted in some countries. Women should, therefore, be encouraged to seek medical advice if they detect any change in their breasts that may be breast cancer.”
So how exactly does one “detect any change in their breasts that may be breast cancer” if one has never been taught any methodical way of examining them? I suppose once the tumor gets large enough it will be visible to the naked eye, but my impression was that it was really better to deal with it before it gets that large.
“George Poste pointed out that baby boomers are going to bankrupt the system as they reach the end of their lives, and about 70% of the $2.3 trillion in healthcare spending is spent in the last 2-3 years of life, with many treatments costing $60K-$100K per treatment cycle on drugs that add 2-3 weeks of life.”
From: http://lippard.blogspot.com/2009/10/personalized-medicine-research-forum.html
What bothers me about the recommendation not to teach BSE is that it seems entirely backward given the other recommendations. That is, right now, there’s a backstop — if a young woman is casual about doing BSE and misses a tumor, well, the doctor does an examination and then there’s a mammogram to pick it up. But with the other recommendations, there’s no backstop — if she misses a tumor, she dies.
So it seems to me that the recommendation should be for thorough, careful, repeated teaching of BSE, all through high school and reinforced with every doctor’s visit (to any doctor, not just a gynecologist). I imagine PSAs: “Only YOU can detect breast cancer!” “Examine your breasts like your life depends on it … because it DOES!”
BSE wouldn’t have saved my sister, as the tumors were already spreading before they got big enough to detect via BSE — she’s just one of the expendable 1/1900s — but perhaps some of the other expendables would be saved by BSE if it were aggressively promoted.
It seems a little extreme. I think if you are going to say that people with risk factors should get early screenings, then we have to be better about identifying risk factors. Screenings for risk factors, including for genetic ones, would need to be offered at about age 30. And those with high risk need screening in their 30’s. The rest of us should maybe have a baseline done at 35 and then another at 40 and then go every two years until 50. Maybe we could try that and see how it works. They are essentially saying breast cancer is so uncommon in women under 50 and so much harder to detect accurately that we can’t recommend any of the tests that are available. That isn’t an acceptable answer.
@Katsky
Your mention of screening for genetic risk factors brings up something I was discussing with a coworker the other day. Suppose we do genetic screening, and the test comes back suggesting that the individual has an elevated risk. How will that affect getting insurance coverage down the line if they actually develop cancer? What about life insurance? In other words, what’s to stop the insurers from denying coverage because it was a “pre-existing” condition?
This:
http://www.genome.gov/24519851
But, yes, if you get actually get cancer, your insurance premiums are going to suck.
Quick question: My mother (a retired actuary who worked in malpractice insurance) told me that the worst forms of breast cancer tend to show up in younger women, and added that the new screening recommendations are sensible for this reason. Do you think this is accurate?
@Joseph C.
Thanks for the link. Good to know that people are actually thinking about these things. 🙂
It seems, as many defending these recommendations have said, that the “anxiety” angle has perhaps been overplayed, and has given the recommendations a paternalistic tone that may not be warranted. But my question is this:
If the key harm is that of overtreatment — i.e., the risk of “treatment of cancer that never would have surfaced on its own within a woman’s natural life time” — how do these recommendations change that, or avoid the harm of that treatment? Under today’s practice, a woman has a first mammography at age 40, discovers a mass at that or a subsequent mammography, and has it biopsied and (if malignant) treated. Under the new guidelines, the exact same finding, biopsy, and treatment take place at age 50. There is no net reduction of “harm” — the harm is only delayed. And the price of that delay is the death of all the women whose masses are in fact malignant and aggressive, of which there are many…
The mass may disappear within those 10 years, for one thing. For another, the benefit of the later screening is significantly increased so the risk/benefit ratio changes even if the risks don’t.
Most masses do not disappear (persistance will be at least 80% and new ones will replace some old ones), and in fact, regarding overtreatment, the USPSTF even states that the overtreatment is more likely in 50s than 40s. In 40s risk is more about rescreens and biopsies So overtreatment will increase likely is my prediction.
Look the data really says this…..either continue screening from 40s (but less frequent) or delay general population screens to the 60s AND encourage 30s to 50s to have serious talks with doctors (assumes women visit doctors or have good access to good docs) about whether you should or should not get mammograms in a model of PERSONALIZED healthcare. the data to me does not show significant increase in benefits nor significant loss of risks in the 50s vs. 40s. (at least not nearly the shift that one sees from 30s to 40s)…..maybe just shift to 45….why are we so fixated on decades.
Re 107, yes, in many cases worst forms of breast cancer hit young, but by young generally it is meant pre40s.
False positives can be incredibly traumatic, especially for young women. I doubt I can convey how much anxiety can occur, especially in age groups where the mortality rate is very high. Not to mention that biopsies and the like aren’t my idea of a good time. I know many people who were stressed and anxious for years after various false positives, with the anxiety lasting long past the time when the worst was ruled out.
What I haven’t seen mentioned are guidelines for women who have worked in industries involving chemicals that can cause breast cancer. In Silicon Valley, out of my circle of friends and co-workers, three got breast cancer, one in her twenties and two in their forties. Both ladies in their forties died. Also, I think some regions have more pollution, which may contribute to breast cancer. So maybe where someone lives should be taken into account when these guidelines are given.
I’m pretty sure that “occupational exposure to chemicals known to cause breast cancer” would be considered a risk factor. (As long as the relationship is properly established and not speculative.) So they’d fall under the general guidance to consider individual women’s risk factors.
That’s one of the harms, but another is the harm of unnecessary biopsies. It’s true that this risk is delayed, not eliminated, but if we wait until 50 for routine screening, then we are at risk of unnecessary biopsy over a shorter period of time. Biopsy isn’t to be sniffed at as a risk. It’s not like a throat culture or even a vaccination. It’s a minor surgical procedure, and I’m told it can be quite painful. (Not just the biopsy itself, but during the recovery period afterwards.)
I think it’s fine for people to decide they want to spend boatloads of money on procedures that give minimal or negative health benefits. Just don’t make me pay for it.
There are lots of people who want to ride the crazy train of trying to fight off every possible disease forever. A big part of freedom is letting them do that. But those of us who don’t want to pay for that nuttiness need an escape hatch.
dan, did you even read the report?
I think it’s fine for people to decide they want to spend boatloads of money on military expenditures that give minimal or negative defense benefits. Just don’t make me pay for it.
There are lots of people who want to ride the crazy train of trying to fight off every possible country forever. A big part of freedom is letting them do that. But those of us who don’t want to pay for that nuttiness need an escape hatch.
Those who consider anxiety to be negligible in this equation, underestimate just how much time and mental energy it can absorb. I had to deal with a prostate biopsy this year. It took a lot of mental energy dealing with all the possibilities, and deciding how I would react to various results. As it turns out it was positive but at the low end of the Gleason scale and in only a small part of one of the cores. So I am doing nothing for the time being. At some level it is good I know and keep monitoring the situation, but I am not young and probably would live for another 15 years even it took a normal course of progression. It has certainly occurred to me that there are benefits to not having PSA tests.
Everyone’s health should be their own responsibility, what you need to make the right kind of judgment is information. In this I think this report is enormously helpful.
Thanks for the useful post and the mostly civil comments, everybody!
I LOVE the last paragraph of the original post, especially ” First and foremost, what matters is the woman being screened, what she values, and what her tolerance is for paying the price of screening at an earlier age, such as a high risk for overdiagnosis, excessive biopsies, and overtreatment in order to detect cancer earlier and a relatively low probability of avoiding death from breast cancer because of screening.”
Beautiful, nuanced. Thorny.
For the public policy piece, one thing that has not entered into the post nor the comments are the details of we should make public policy. Should we do QALYs like the NICE commission in the UK? ~If~ we can put a dollar value to ALL the costs — the actual costs of the tests (what too many people focus on and what is not really the point); the total cost of follow up tests (both on the provider side and the patient “pain and suffering and lost time” side); the total cost of anxiety over false positives; the total cost of treatment for over-diagnosed growths (both the provider side and patient “pain and suffering and lost time” side); and weigh that against the cost savings for the years that the “saved” patient wins….. what would you find for the various age groups? What is the actuarial answer?
This seems to be the only rational way to arrive at a public policy on the issue. Otherwise you end up with wild/romantic valuations of “saving a single woman’s life” compared to the smaller costs to many many (hundreds!) of other women.
And I wonder what happens (or would happen) if doctors really explain the statistics to their patients… “If I give you this screening test, chances are it will show nothing. If it does show something, it is unlikely we will know if it is bad or not, and we will have to schedule you to come in for a biopsy — I will have to take a chunk of it out of you so we can test it. You will be worried and the biopsy will hurt some. And chances are 80% that the growth will turn it out to be benign. Overall, in your age group, (1900/1300/337) women will be screened and one — one — life will be saved. That life could be yours. But chances are it will not be. So. Would you like to have the screen or not?” How many women would do it? Would they CHOOSE to disrupt their lives to be statistical “fodder”?
One of the factors in this debate is: Who takes the risk? Who benefits? Who pays?
The risk of screening is taken primarily by all women who could be screened.
The primary benefit goes to those who actually have breast cancer that is detected by screening and not by any other method.
The payer is the insurance provider (or all their clients), or the public, or all women who get screened, depending on your scenario.
Who gets to decide whether a risk is undertaken? The risk-taker, or the payee? Is there a moral or just an economic question here?
We haven’t even discussed whether the strong attachment to radiography as a screening method misses other potentially less risky and more accurate methods of cancer detection, such as thermography.
We also haven’t discussed whether emphasis on post-occurrence detection takes resources away from educating women about those risky behaviours that still remain within their control, age at first pregnancy, number of children, length of time breastfeeding, hormonal treatments, etc.
Whatever it is we do, we need to do something. QALY, DALY, total years, just some metric that we can use to decide which procedures are worth it and which aren’t.
Yes, it will be crude. That’s why this should be decided by the government for the government-funded portion. Private citizens need to be able to buy out if they want.
Now, I would really love it if private companies could manage to run with this kind of model, but they are few and far between. People don’t like to hear “they refused to perform magic test X!”, especially when, like most people, they are insulated from the cost of their health care through 2 separate intermediaries.
The whole point of this seems to grow out of the dubious idea of having insurance pay for mammograms. To me a mammogram is a normal expense of life, like oil changes and rent. Women who aren’t destitute, should just pay for it. It isn’t a public policy issue any more than brushing your teeth.
Hey Orac,
Our old friend Bernadine Healy has sounded off on this issue:
http://health.usnews.com/articles/health/healthday/2009/11/23/women-should-ignore-new-mammogram-guideline-ex.html
I’m sure you can guess what side she’s on:
I think that women over 40 should be getting breast exams whether they have felt a lump or not. Ignoring the fact that the possibility is there just based on a self exam can be very hazardous.
I’m cautious when it comes to cancer screening. I don’t allow doctors to push me into screening, I do a risk v benefit assessment and if I don’t think I’ll benefit from screening or think it might harm me, I pass…
It means doing my own research, but I’m used to that..
I have decided to pass on mammograms. I found it hard to find unbiased information out there, but found a really helpful brochure put together by the Nordic Cochrane Institute. This group have been highly critical of the information being released to women, basically half the story missing risk information altogether. You’ll find “the risks and benefits of mammograms” at their website.
I’ve never allowed breast exams, because there is no evidence they reduce the death rate from cancer, but they cause biopsies. Some believe biopsies are a risk factor for cancer.
Our doctors don’t routinely examine breasts anyway…the research has been clear for years.
So, what to do? Self-examination just leads to more biopsies and doesn’t help…
I’ve decided to be breast aware – simply taking note of the look and shape of my breasts when I get out of the shower.
Sometimes if everything available is useless or likely to harm you or increase your risk, you’re safer to be watchful for changes and symptoms.
Breast cancer is a common cancer, but sadly, in my opinion, CBE’s and mammograms don’t help…and are more likely to harm us.
Then you are following the revised protocol. Big whoop.
i’m 23 and i have a lump in my left breast it has appeared just a day ago it is just like marble in its size…do i need to consult doctor?is this a cancer tumor…i’m very healthy i have no other problem….
please answer me soon i’m very scared of this
Do not consult random people on the internet for medical advice, even though the owner of this blog is a cancer surgeon. He has a life that may take him out of town, and he cannot help you unless he actually sees you in person.
So, yeah, go to your doctor if your are worried. If you do not have a doctor, then get a referral to a local doctor in your area.
Go to you doctor.
And what Chris said. This post is very old; I might not ever have even seen your comment.
I’m doing the same as DLB
Never had clinical breast exams or mammograms.
Now at 52 I’m being “breast aware”…not breast-self-examination, but just keeping a watchful eye for changes.
This method was devised by the late Dr Joan Austoker from Oxford University.
Breast biopsies are no fun and the anxiety is awful and definitely bad for your health.
I think over-detection and over-treatment issue are a major thing to consider – they may be worth it if it’s a common cancer and a reliable test or you’re high risk for something…otherwise quit smoking, exercise, maintain a healthy weight and diet and enjoy life.
All the focus on screening and cancer is turning us into a nation of not-sick-yet people.
Tina, do not tell that to the carpenter who is presently working on my house. Last Christmas he felt an odd lump on his chest.
He was diagnosed with breast cancer, and had major surgery less than a month later. He spent over six weeks in recovery.
He does not smoke. If you consider that he does mostly exterior work that involves climbing up the side of my house and on my roof.. he gets regular exercise. He eats a good diet. He figures that at some time he was exposed to environmental toxin (he was actually tested for the genetic cause, but those genes were not present).
Oh, newsflash… anyone with a breast can get breast cancer. Even men.
And seriously, why this compulsion to comment on old threads? What is wrong with the more recent blog posts?