I knew when I first heard about them that the new United States Preventative Services Task Force (USPSTF) recommendations on breast cancer screening would be controversial. I tried to discuss these guidelines and the issues involved in a calm and rational way, relatively devoid of Insolence, Respectful or not-so-Respectful, yesterday, pointing out that screening guidelines were clearly due for revision but also recognizing the problems with the USPSTF recommendations and valid criticisms of them. In the end, I concluded that, among the critics, the ASCO discussion of the proposed guidelines was the most reasonable At the same time, this being Orac and all, I couldn’t resist snarkily dissing at least one overblown and unjustified criticism of the guidelines, coming from, embarrassingly, a professional organization to which I belong.
One day later, I realize that the example of a brain dead and hyperbolic attack of the new guidelines was nothing compared with what was to come and, I suspect, still is to come. Although some attacks are just misguided and based on erroneous information, a lot of them are truly nothing more than appeals to emotion and logical fallacies. Indeed, the stupid is flaming fast and furious, flowing down the sides of the volcanoes of stupid spewing forth lots of heat, until the lava of stupid is finally lapping at the last walls defending rational discourse over what is a very difficult issue, both in terms of science, medicine, and policy. In fact, some of the attacks on the new guidelines carry distinct echoes of the same rhetorical techniques of Mike Adams and Joe Mercola. They have been truly painful to read, so full of neuron-necrosing nonsense that I wonder if those conspiracy theorists in tin foil hats might have a point, even though I realize that mere tinfoil will not stop such powerful waves of stupid. Worse, a lot of the press coverage has given free rein to the very same sorts of flaws that so irritate me in the coverage of alternative medicine.
Let me just say right now that I am more forgiving of the press coverage that emphasizes anecdotes over data, stories like this one, which follows a pattern that I’ve seen emerging in the coverage of this story, namely the highlighting of an anecdote of a woman under 50 (or even under 40) who had a breast cancer that was detected either by screening mammography or by self breast examination. Another example is this story. This is lazy journalism at best, where finding the “human interest” angle trumps a science-based discussion of the pros and cons of the new recommendations, what they mean to women, and how they might be applied. It’s the triumph of pure emotion over science. Meanwhile, Congress is getting involved, specifically Rep. Debbie Wasserman Schultz (D-FL), who is threatening to hold Congressional hearings on the matter. (Now there‘s something that’ll shed a lot of light on the science!) Wasserman is a breast cancer survivor; so I can understand her emotional investment in the issue. I can understand the emotional involvement of anyone who’s life has been touched by cancer. Unfortunately, she’s just plain misguided to try to meddle in the development of science-based medical guidelines this way. Her activities are far more likely to interfere with the scientific debate that must occur now regarding screening than they are to facilitate a new scientific consensus based on the strongest data available.
I’ve made my position clear on the new guidelines. They are imperfect and most definitely do not mean that women under 50 should not be screened. Rather, they will most likely serve as reasonable, albeit flawed, starting point for a debate that has been brewing for the last several years as more and more studies have questioned how beneficial screening mammography is for younger women relative to its risks and documented the problems of overdiagnosis and overtreatment. I’ve also pointed out how I know that women will be confused by this change. In fact, if anything failure to communicate such a monumental change in recommendations in a manner that would mitigate some of this controversy is clearly the USPSTF’s biggest failing in the matter. The task force did an absolutely execrable job of laying the groundwork for its announcement, so that it didn’t appear to come out of nowhere. Even so, as I said before, an update of our screening guidelines was expected, and there is much to discuss. However, there is a relentless drumbeat of attack that is not based on science and strikes me as knee jerk. Some of it is downright idiotic; there’s just no other way to put it. I feel obligated to address it because, as a skeptic, I find such bad arguments and misinformation an offense to my intelligence.
Overall, the idiocy falls into three general categories:
1. The misogyny gambit
A disturbing tack being taken towards the guidelines is the misguided urge to cry, “Misogyny!” No, I’m not saying that there hasn’t been misogyny issuing from the government and other regulatory and academic bodies over women’s health before. There’s been a fairly long history of that, and we are only starting to overcome it. I’m just saying that this isn’t one of those times. The problem with this gambit is that those invoking it jump on news reports about the task force report without actually having read the report. For example, Feministing described the guidelines thusly:
New patronizing guidelines for mammograms have been implemented by a government task force, recommending that women over 40 shouldn’t get routine mammograms because of certain risks like women’s “anxiety.”
Bridget Crawford at Feminist Law Professors writes:
The government task force’s reasoning? Because the “anxieties” caused by mammography, false positives and biopsies do not decrease mortality.
If the federal government is so concerned about women’s anxieties, how about more jobs, affordable child care, lower tax rates, clean air to breathe, and an end to discrimination?
I can control my own anxiety about having my breast squished by a mammography machine, thank you.
To which a commenter named CD Dorsey responded:
Just who is this government task force? Probably a bunch of men… Why havent they given the people an updated stating that men should only be screened for testicular cancer when they turn 50?
I won’t bother to point out the ignorance of cancer biology that the above comment reveals unless you really want me to. Suffice it to say: They’re entirely different diseases and not comparable as far as screening goes. I’d also point out that science-based recommendations for screening for prostate cancer suggested scaling back PSA screening long before these mammography guidelines were published. In fact, for most men over 50, routine PSA screening is no longer recommended. Clearly, medicine hates men.
So that I don’t have to (much), the ever inimitably skeptical Skepchick slapped down these knee-jerk examples of such accusations, pointing out that the new guidelines are not “patronizing” in the least. Bridget might have had a point if anxiety and psychological distress due to false positives were actually the primary reasons that the USPSTF made the recommendations that it did. They weren’t. In fact, mentions of psychological distress were actually few and definitely not the primary concern in drafting the new guidelines. The harm from overdiagnosis and overtreatment relative to the benefit of early detection was the primary evidence used. Bridget clearly didn’t bother to read the actual guidelines and relied on news stories that played up the “anxiety” angle, probably because either the reporter didn’t understand the concepts of overdiagnosis and overtreatment or didn’t think readers could understand the concepts. I must admit that I, too, cringed a bit reading some of these stories. However, whenever I read a news account of report or paper and want to blog about it, the very first thing I do is to go to the primary source to read the actual document. That’s Blogging 101. Moreover, the supporting article containing the models used to determine harms under various screening regimens doesn’t even mention psychological harms. Lots of mentions of overdiagnosis, extra testing, and more biopsies, but little or no mention of psychological harms.
Whatever problems I have with these new guidelines, misogyny is not one of them. In fact, the guidelines explicitly state:
The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.
The Task Force encourages individualized, informed decision making about when to start mammography screening.
The American College of Physicians recommended in 2007 that screening mammography decisions in women aged 40 to 49 years should be based on individualized assessment of risk for breast cancer; that clinicians should inform women aged 40 to 49 years about the potential benefits and harms of screening mammography; and that clinicians should base screening mammography decisions on benefits and harms of screening, as well as on a woman’s preferences and breast cancer risk profile.
Whatever their debatability from a scientific viewpoint, if anything the new USPSTF guidelines are arguably less “patronizing” than some of the old guidelines in that they emphasize far more strongly that screening should be a decision to be made collaboratively between a woman and her physician. Even though I have some problems with the guidelines and don’t think that they should mean that women shouldn’t be screened between the ages of 40 and 49, I do like their placing more emphasis on informed consent and collaborative decision making for women regarding screening. The charge of “patronizing” is just plain misguided.
2. We’re going to turn into a Third World country with women showing up with big nasty incurable cancers.
Another seriously deluded attack (not to mention a form of “slippery slope” fallacy) is the overblown expression of fear that, if these new guidelines were to take hold, American women would be relegated to the same status with regard to breast cancer screening as sub-Saharan Africa. No, really. There are people out there saying that, some of them even doctors! Here are some examples:
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. (American Society of Breast Surgeons)
That’s the one that irritated me enough to write a complaint to the ASBS, but it’s mild in comparison to some other statements I’ve seen, for example, the American College of Radiology:
“The USPSTF recommendations are a step backward and represent a significant harm to women’s health. To tell women they should not get regular mammograms starting at 40 when this approach has overwhelmingly been shown to save lives is shocking. At least 40 percent of the patient years of life saved by mammographic screening are of women aged 40-49. These recommendations are inconsistent with current science and apparently have been developed in an attempt to reduce costs. Unfortunately, many women may pay for this unsound approach with their lives,” said W. Phil Evans, M.D., FACR, president of the Society of Breast Imaging (SBI).
“I am deeply concerned about the actions of the USPSTF in severely limiting screening for breast cancer. These recommendations, in combination with recent CMS imaging cuts, jeopardize access to both long proven and cutting-edge diagnostic imaging technologies. Government policy makers need to consider the consequences of such decisions. I can’t help but think that we are moving toward a new health care rationing policy that will turn back the clock on medicine for decades and needlessly reverse advances in cancer detection that have saved countless lives,” said James H. Thrall, M.D., FACR, chair of the American College of Radiology Board of Chancellors.
Truly despicable. Lots of heat, but no light. But this sort of fear mongering is only warming up compared to others, for instance, Anthony Elias, MD Martha Cannon Dear Professor of Medicine, Medical Director, Breast & Sarcoma Programs, Associate Director; Cancer Center for Clinical Sciences, University of Colorado Denver School of Medicine:
This is quite disturbing and I fear I will be busier than ever caring for incurable neglected breast cancers similar to what happens in Africa, Southeast Asia and China.
Wow. Just wow. I guess that means that Canada is just like Africa, Southeast Asia, or China. Europe, too. After all, Canada and much of Europe recommend screening protocols much like what the USPSTF recommends. I guess that means they must have most of their women with breast cancer showing up with big, neglected cancers instead of mammographically-detected cancers. Those bastards! We don’t want to be like them! (As an aside, let me point out that I rather like Australia’s approach, which appears to be basically a fusion between what we in the U.S. do and what most of Europe does. In Australia, screening is still recommended to start at age 50 but women from 40 to 49 can still have mammographic screening paid for if they wish to be screened earlier.) Responses like this reveal an immense chauvinism, at least to me. It’s assumed that the American way must be the superior way. It may be, but I prefer to look at the evidence. Oh, and Canada and Europe must be hopelessly misogynistic, per gambit #1 above.
Some of the responses I’ve seen also appear to reveal a disturbingly shallow understanding of screening and cancer biology. I have yet to see anyone actually mention lead time bias, length bias, or the Will Rogers effect all incredibly important concepts in screening that suggest why early detection does not always save lives and why the detection of more and more early tumors may give the appearance of improving survival without actually improving it as much as we think. Again, something about these guidelines has made physicians who should know better either forget or ignore everything they should know about cancer biology and screening.
But these previous two gambits pale in comparison to the next gambit.
3. Obama’s settin’ up death panels to kill grandma
Like an undead zombie that just won’t stay dead, the difference being that even if you shoot it in the head it keeps getting up again, the “death panel” lie keeps shambling on, to eat the brains of many a pundit and make them just as ignorant as Sarah Palin, the populizer of this myth. The timing of the USPSTF’s recommendations, released right in the middle of a major political battle over reforming our health insurance system and providing a government-funded option to insure the uninsured, is very unfortunate in that it’s given free rein to conspiracy theorists, the wildest of whom think that the USPSTF’s part of a plot by the government and the cleverer of whom see it as some insidious infiltration of some sort of vile health care rationing. Here are some examples:
Why has this recommendation come about now? Could it have anything to do with the public option that is now on the table and this is a pre-cursor to the rationing that will most definitely ensue as a result of that public option? Why would this panel make these recommendations now after so many years? If you take a look at who the panel is made up of you will see not one breast cancer expert and interestingly these recommendations are very similar to the guidelines that are currently in place in Canada. Obama owns this report. These recommendations are coming under HIS Administration. Obama’s Breast Cancer Panel is truly a ‘Death Panel’ for American women.
I’m tellin’ ya, it’s teh Socialism! It’s obvious, given that these recommendations are much like those of…Canada! Oh noes! It’s a conspiracy! Damn that Obama! See:
What a difference six months — and a health-care overhaul proposal — can make! Just six months ago, the U.S Preventive Services Task Force, which works within the Department of Health and Human Services as a “best practice” panel on prevention, sounded a warning signal over a slight decline in annual mammograms among women in their 40s. In fact, they warned women of this age bracket that they could be risking their lives if they didn’t get the annual preventive exam
Uh, no. If you go to the primary source, you’ll see that the USPSTF was mentioned but only in the context of describing its previous guidelines before this update. In reality it was not the USPSTF that sounded the alarm but the CDC and the NIH:
A Centers for Disease Control and Prevention study published in February noted a slight decline in the proportion of women having annual mammograms in just about every state, including Maryland and Virginia, as well as in the District.
The drop is so small, that researchers hesitate to call it a trend; they call it a “declining tendency.” But it echoes similar findings in recent years. A National Institutes of Health study published in 2007 found that while the percentage of women 40 and older having yearly mammograms grew steadily between 1987 and 2000, those rates leveled off for three years and then declined. “The 2010 target for all women, 70 percent, was met in 2000, but the proportion fell to 66 percent in 2005,” says Stephen Taplin, a senior scientist at the National Cancer Institute.
Ed Morrissey, living up to his blog’s name Hot Air, blathered on:
What changed in six months to change the USPSTF from a sky-is-falling hysteric on a 1% decline in testing to Emily Litella? If the administration gets its way, the government will be paying for a lot more of these exams when ObamaCare passes. That will put a serious strain on resources, especially since many of the providers will look to avoid dealing with government-managed care and its poor compensation rates.
The motivation for HHS will be to cut costs, not to save lives. The sudden reversal in six months of the USPSTF, especially after it made such a stink over a relatively minor decline in screening, certainly makes it appear that they have other priorities than life-saving in mind here.
Funny, but the U.S. Department of Health and Human Services Secretary Kathleen Sebillius just issued a press release that dissed the new guidelines. My cancer center e-mailed it to everyone here yesterday:
“There is no question that the U.S. Preventive Services Task Force Recommendations have caused a great deal of confusion and worry among women and their families across this country. I want to address that confusion head on. The U.S. Preventive Task Force is an outside independent panel of doctors and scientists who make recommendations. They do not set federal policy and they don’t determine what services are covered by the federal government.
“There has been debate in this country for years about the age at which routine screening mammograms should begin, and how often they should be given. The Task Force has presented some new evidence for consideration but our policies remain unchanged. Indeed, I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action.
“What is clear is that there is a great need for more evidence, more research and more scientific innovation to help women prevent, detect, and fight breast cancer, the second leading cause of cancer deaths among women.
“My message to women is simple. Mammograms have always been an important life-saving tool in the fight against breast cancer and they still are today. Keep doing what you have been doing for years – talk to your doctor about your individual history, ask questions, and make the decision that is right for you.”
Damn, that Obama Administration is clever! The Secretary of HHS, the government agency that would be most empowered by any health care reform, slapped down the USPSTF! Of course, the USPSTF is not even a government agency:
The U.S. Preventive Services Task Force (USPSTF), first convened by the U.S. Public Health Service in 1984, and since 1998 sponsored by the Agency for Healthcare Research and Quality (AHRQ), is the leading independent panel of private-sector experts in prevention and primary care. The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the “gold standard” for clinical preventive services.
The mission of the USPSTF is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care.
Again, I blame the USPSTF for its horribly botched communication of its recommendations. True, there would still be cranks out there, but if the USPSTF had been better at laying the groundwork for these changes, at least the idiocy level of the responses might have been lowered.
The undead beast continues to lumber on, though. In fact, it shows up in places where you wouldn’t necessarily expect it. At least, I wouldn’t have. Indeed, it can eat the brains of bloggers that I used to consider fairly reasonable, creating a new zombie. In this case, though, the new “death panel” zombies are rather like the running zombies in 28 Days Later, not the shambling, dripping, drooling zombies of yore. But they’re just as relentless. He’s the new, improved, cleverer zombie, like the ones in The Return of the Living Dead who, after feasting on the brains of paramedics and then later cops, picked up the radio from their car and asked the dispatcher to send more paramedics and cops. But at the heart, the zombie lie continues on, eating brains and reducing the level of debate from the merits of science to raw emotions manipulated by fear of government.
However, as this post has gotten too long and the particular zombie I have in mind has a post that is long enough to require a separate post to fisk it; you’ll have to wait until my next post to find out of whom I speak.