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Really rethinking breast cancer screening

“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:

i-b291ff27d7a522cd1df08bae35cbc3fa-USPSTFgrades-thumb-450x162-22398.jpg

And ranks its level of certainty using this scale:

i-ff0ccf5890bbb0b4669fd330a8783f46-levelsofcertainty-thumb-450x222-22401.jpg

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.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

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.

The USPSTF recommends against teaching breast self-examination (BSE).

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.)

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.

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?

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.

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?

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.

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……

You think that a density seen on a mammogram means you will be told that “you have cancer”? Do you know anything about medicine?

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.

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.

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?

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 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

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.

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.

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.

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?

We spend twice as much as for our rotten healthcare as other more truly ‘efficient’ health systems.

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.

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.

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.

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.

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.

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 outliers—in 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?

When any kind of arbitrary age limit is drawn, there will always be outliers—in 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?

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.”

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 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.

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?

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.

“…Resources are limited. They will always be limited. Denying this incontestable fact is hugely immoral,…”

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?

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.

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????

Finite money? Whose money are we talking about?

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.

If we keep arguing that denying health care is “the most compassionate way to go about 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.

Resources are limited because of collusion and lack of social justice

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?

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

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 – 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 – 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 long…

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.

From the cancerscreening.gov.au site, in the BreastScreen FAQ section.

The Australian guidelines promote women 50–69 to have a free mammogram every 2 years. Women 40 – 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.

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