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RE: Article from New York Times - Quandry for women over breast screenings

MarionBCDIY
  • By MarionBCDIY
  • Posted November 5, 2009 at 2:09 pm · 20 replies
  • Shared with the public
1 Recommendation

In our local paper today, there was an article regarding the controversy over mammograms -- after reading the whole article I think the most important statement came from Dr. Larry Norton, deputy physician in chief for breast cancer programs at Memorial Sloan-Kettering, Cancer Center in Manhattan who indicated: "Just because a test isn't perfect is no reason to abandon it while better tests are being developed. The bottom line is that if an individual woman wants to reduce her odds of dying of breast cancer (by at least 24 percent, which is no small effect), then she should follow the current screening guidelines."

My feeling is: why through the baby out with the bath water. Like Dr. Norton indicated - until something better is developed (the thermal imaging is looking really great) then don't tell women to stop mammograms, when we KNOW that they have saved a lot of women's lives.
I hate these types of articles - because they seem to give women who are looking for an excuse NOT to have a mammogram, confidence that they are not needed, and we know this is not the case.

Explore topics in this journal entry and replies:

Cancer Hysterectomy Abortion Diabetes Cervical cancer Breast cancer Menopause Lung cancer High blood pressure

20 replies

gpawelski

USPSTF mammogram recommendation is not new

The news about mammograms is not brand new information based on one study that just came out. The recommendations that the Preventive Services Task Force (PSTF) released is based on research that experts have known about for some time.

Dr. Herman Kattlove, a retired medical oncologist did research on mammograms in the early 1990's. For seven years, until his retirement in 2006, Kattlove had served as a medical editor for the American Cancer Society where he had helped develop much of the information about specific cancers that is posted on the society's website.

On his own personal cancer blog, Kattlove wrote, “Many years ago, the National Cancer Institute (NCI) tried to convince us all to not screen women younger than 50 and were given such a tongue lashing by Congress that they went home, licking their wounds, and withdrew their recommendation.”

Of course, Congress should not have become involved in telling the NCI what information it should make available to the public. Few Congressmen are either M.D.s or scientists trained to analyze and critique medical research. But this illustrates just how politically charged the question of diagnostic testing has become, especially when companies like GE that are making large profits on the sale of diagnostic testing equipment, and their lobbyists are helping to finance Congressional campaigns.

For decades doctors have urged patients to undergo mammograms because they sincerely believed that mammograms saved many lives. They, too, were not receiving all of the information they needed about the risks. Powerful forces stood in the way of widespread dissemination while millions of dollars were poured into the Mammogram campaign.

Kattlove goes on to say, “Likewise, the American Cancer Society also avoids looking clearly at the data and continues to recommend screening for younger women. And the morning’s paper carried lots of outrage from breast cancer specialists and other docs who are committed to screening younger women.

Some of the reasons for this are political and financial. The ACS doesn’t want to enrage its donor base, Congress didn’t want to upset constituents and breast cancer specialists have faith in the procedure. I’m sure all the pink breast cancer organizations are also organizing their protest.

Why this emotion and outrage? I think because we feel helpless when we see women die of breast cancer, sometimes while still young. Indeed, deaths in these young women hit us hard. So we want to do something and our only tool is mammography.

“But mammography is not the answer for these women.” As Kattlove points out in his post, when young women die of breast cancer they are usually killed by very fast-growing aggressive cancers that grow too quickly to be caught by early detection. The tumors crop up, and spread in between annual mammograms. Kattlove continues: “The unfortunate side effect of this delusion [that screening and early detection is the answer] is that we avoid the hard choices like healthy life styles and avoiding cancer-causing drugs such as hormone-replacement treatment.

I would add that while I applaud the PSTF for bringing this research to our attention, I wish that they had done this two or three years ago. From a political point of view, the timing is unfortunate because inevitably, those who oppose health care reform will exploit this report to suggest that, under reform, the Government will use “comparative effectiveness research” to deny necessary care—and as a result patients will die.

In fact, health care reformers, the government and Medicare understand that, after thirty years of telling women that they must have annual mammograms, we cannot turn on a dime and expect them to suddenly absorb the information that for most average-risk women under 50, mammograms pose more risks than benefits.

No one is going to stop covering mammograms. But responsible physicians will begin giving patients more information about what the medical research shows, including the fact that for most women, the danger of undergoing unnecessary radiation, or an unneeded mastectomy or lumpectomy, far exceeds the likelihood that a mammogram will save their lives.

Moreover, it is important to remember that the “comparative effectiveness information” that the government plans to generate will serve to create guidelines—not “rules”—for doctors. In the U.K., doctors use such guidelines about 88 percent of the time, which seems appropriate, giving how much variation there can be in individual cases.

Finally, under reform it is extremely unlikely that insurers (including the public plan) will stop covering treatments and tests (including PSA tests), that have been in use for a long time. More likely, they will lift co-pays and lower reimbursements for procedures that are less effective, while lowering co-pays and lifting reimbursements for procedures that the medical evidence shows are more effective.

In this case, unfortunately, we don’t yet have a good alternative to mammograms, a further reason why insurers will not suddenly stop covering the tests.

gpawelski

The other side of the coin - radiation risk

The other side of the coin is radiation risk imposed by mammography. It is not simply of negligible value in younger women, but may have a net harm effect, if women who have mammograms at age 40 start having higher rates of cancer in irradiated breasts 25 or 35 years later.

The recommendation not to begin mammography until age 50 has to do with medical issues, more than cost effectiveness issues. Mammography is not harmless. You are subjecting women to annual doses of ionizing radiation to the breasts, with some unavoidable scatter to chest wall and lungs. We do not know how many women who are irradiated by mammography in their 40s will develop radiation-induced breast cancer (or even lung cancer) in their 60s, 70s, and 80s.

The other problem is that women in their 40s tend to have very dense breasts, making it more difficult to get an accurate exam. These women often are called back for additional views, giving them even more radiation. There are more false positives, leading to breast biopsies and sometimes unnecessary lumpectomies, in cases where the biopsies are technically suboptimal.

In contrast, in older women, their breasts are less dense, making the examination more accurate, with fewer false positives, and there are fewer years of remaining life to develop a radiation-induced malignancy.

The fact is that we have no truly long term follow up studies to determine very long term risks of carcinogenesis from radiation exposure in mammography.

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

Mammography-oncogenecity at low doses.

Heyes GJ, Mill AJ, Charles MW.

Department of Medical Physics, University Hospital Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK.

Controversy exists regarding the biological effectiveness of low energy x-rays used for mammography breast screening. Recent radiobiology studies have provided compelling evidence that these low energy x-rays may be 4.42 +/- 2.02 times more effective in causing mutational damage than higher energy x-rays.

The risk/benefit analysis, however, implies the need for caution for women screened under the age of 50, and particularly for those with a family history (and therefore a likely genetic susceptibility) of breast cancer. In vitro radiobiological data are generally acquired at high doses, and there are different extrapolation mechanisms to the low doses seen clinically. Recent low dose in vitro data have indicated a potential suppressive effect at very low dose rates and doses. Whilst mammography is a low dose exposure, it is not a low dose rate examination, and protraction of dose should not be confused with fractionation. Although there is potential for a suppressive effect at low doses, recent epidemiological data, and several international radiation riskassessments, continue to promote the linear no-threshold (LNT) model.

ious1Tjed6247

Pondering: PSTF (Preventative Services) (Task Force).... FREEDOM OF SPEECH. I love AMERICA!!

EDUCATION: 101
Why HAS IS BEEN so widely PROMOTED AND accepted .....for the past twenty five years that "Preventative
Medicine".... IS the cornerstone on which all other services are DETERMINED by the powers that be.....aka THE INSURANCE COMPANIES??????? ( B/Cross, Kaiser, Aetna, Mass. Gen., Hartford, to name a few.. Etc.)

ANSWER: Because BACK THEN....they wanted us to INITIALLY prevent these DISEASES/ILLNESSES so that it would not cost them excessive dollars & our overall health would be one of "wellness".

NOW ....the conglomerates will be conferring and RE-FOCUSSING ON .....DISCONTINUING these services, YOU JUST WATCH for these once preventative GUIDELINES which have been in place for umpteen years will not be covered. JUST....Rip that rug out from under you and leave you with NO CHOICES! NOT!!!

I can speak from experience. After losing two to B/C, one to lung, and another CA still alive......JUST CALL & ASK any insurance carrier what their policy is on 'Quality & Control' - aka known in hospitals as the "Utilization & Review Committee".....regarding a patient's LEVEL & CARE for a specific procedure.

They will tell you what specific time allocations are for your diagnosis. (It's called cost effectiveness) or keeping costs down for a certain illness/disease/procedure.
However, when it's life threatening ... we assign our benefits over to Hospice or Pallaitive Care - in the end don't we?
AM I DEAF....that the mantra I've heard over and over by Physicians, Specialists, HMO's (Health Maint. Orgs.) TV Shows (Dr's Oz & The Doctors) Newscasts, AMA Journals & Periodicals focused entirely on just that to now come up with a new strategy.

So...it's ok to prevent diabetes, prevent high blood pressure, prevent plaque build up, prevent strokes, prevent colon cancer, etc. and I could go on and on.

So prevent breast cancer? Wait til 50! ABSURD.
My opinion......Sounds like genocide all over again.
Tara

susanrose55

I am very pleased that our website has postings on this topic
"changed current screening guidelines for mammograms"
What's this world coming to...........
The mammogram saved my life 6 years ago-I had calcifications in my right breast.
How lucky I am to be alive today!
Susanrose55

ious1Tjed6247

Thank you for that piece of information. Anyone else care to lament?
Tara

MarionBCDIY

Even though all 3 of my cancers were NOT detected by mammogram, and lots of my friends found their own lumps via self exam. Mammograms still do find a lot of problems. Personally, I started mammograms at 40, had clean ones EVERY TIME -- at 57 they still had no clue that I had BC when then looked at my films.
Even after the pathology reports were in, they went back and looked, still couldn't see it. But for those whose lives were saved BECAUSE OF a mammogram, I say, until Thermal Imaging is available in more places, mammograms are the best we've got. Let's not throw the "baby out with the bath water" or something as stupid as that. Soon they will be telling us to stop mammograms entirely, just what some women would love to hear, then they'd have an excuse not to get them, then watch the death rate go up again! and they will wonder WHY>???

gpawelski

I'm sure a life would be saved here and there if routine mammograms were recommended and covered for the 20-year-old crowd.

According to the Atlantic's John Crewdson, the only American reporter at the Stockholm news conference in 2002, on The Lancet publication of the Swedish meta-analysis, analyzing and updating the half-dozen Swedish mammography studies that told us nearly all of what we knew about the value of mammography, last month, Dr. Otis Brawley, the cancer society's chief medical officer, was quoted in the New York Times admitting "that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated."

Crewdson wasn't surprised by Brawley's statement, since he had expressed the same view to him when they met at a cancer symposium in Milan in 2003.

Following the task force report's release, however, Brawley appeared to change direction, telling the Times that the cancer society had concluded that the benefits of annual mammograms beginning at 40 "outweighed the risks" and that the ACS was sticking by its earlier advice. One of Brawley's colleagues said, "He's trying to save his job. He was broiled at home for the interview in which he said that the medical establishment was 'overselling' screening."

Dr. Donald Berry, head of biostatistics at the M.D. Anderson Cancer Center, points out that if the Swedish update is read carefully, the benefit for women 40-50 is really only 9 percent, which is not statistically significant, meaning it could represent the play of chance and not a real advantage. What Brawley failed to mention is that the numbers the news media are flinging around are the relative benefit. Utterly obscured is the number that really matters, the absolute benefit.

http://www.theatlantic.com/doc/200911u/mammograms

http://www.ahrq.gov/clinic/3rduspstf/breastCancer/brcanrr.htm

ious1Tjed6247

I betcha' not one person on this website opts to wait for age 50 detection - do ya? Hmmmm....

JillAline

I guess I'm your one person, and it looks like there area few above. I think avoiding mammography until age 50 might have helped me. Mammography certainly didn't catch my cancer. It doesn't catch cancer in younger women with dense breasts, so there ya go.

It's a long story that I won't enter blogged about it at: http://jillsblahblahblog.wordpress.com/2009/11/17/i-know-ill-get-flamed-for -this/

So far nobody's flamed me, but these are my friends so who knows?

nutrachris

I discovered my original cancer while doing a self exam in the shower, 3 months earlier I had a clear mammogram. I also discovered my recurrence the same way.

Read the recommendations very carefully as it pertains only to low risk women. I had been high risk as I had lost my Mom due to MBC 8 months before I was diagnosed.

Most tests are not perfect. Tumor markers vary from patient to patient and rising markers do not always mean increased activity.

Pet scans also have many false positives.

Hugs
Christine

momx4TNBC

43, premenopausal, very dense breast with severe fibrocystic breast since a teenager. Did not screen till 40 but thank God I did.....my mammogram not only stated the size,location etc of my tumor, but it and the ultrasound suggested Malignant lesion.....So in some cases it definitely does show early breast cancer and mine was triple negative so yes it did grow really fast, but I am so glad I got mine when I did because if I had waited till even every other year, I would have probably been stage 4 from the get go.....they caught it at stage II but within a year after double mastectomy and chemo, it was stage IV but with only 1 met...I may only be one life, but as a mother of 4, I am glad I didn't have to fight my insurance company starting at 40 for the "right" to have a mammogram since I had no family history etc. I am an RN and I have worked for insurance companies. These "guidelines" do lead to policies and procedures on payments of certain benefits. This is one reason why my insurance will not pay for my BRCA 1/2 test, since I have no "family History." On the other hand, MD Anderson etc suggest I get it done because there are not enough women in my family to compare it to.....problem...I don't have $3000+ to get the test....all because of a "policy." Enough Said....LOL

MarionBCDIY

Thank you, you are only one of many who would have been in trouble with this new guideline. I'm really hoping that they decide that each case should stand on it's own merit - not just denying mammograms to women under 50, sometimes we just have to fight for what we know we need to get done. Never give up fighting - wish I knew some place that was less expensive for the genetic testing - I need to get it done also, but alas $3K is not in my budget!

MarionBCDIY

It's not the girls on this website that I worry about, it's the ones who are complacent, and use the new edict to wait -- and maybe be stage 4 by the time they get a mammogram. I am 1000% behind self exams, and fighting for what you know you need to have done. Never give up fighting for what your body is telling you it needs you to do. If I had brushed it off, I would not be the "loudmouth advocate" I am today!
I would have already been dead about 7 years.

ious1Tjed6247

FYI: QUALIFIER - Key word.
If you take a Certified Death Certificate ( a copy will do) of your deceased loved one to get the BRCA1 & BRCA2 to your doctor to have this test you can get screened and your mammogram too.....the insurance will reduce your BRCA1 & BRCA2 to less than $3,000.00 due to a family member being deceased/dying. In California I paid $ 275.00.
That's the "qualifier". Someone in your family (immediate ...has to have the diagnosis). Tara

LaGata

Gregory,

I undertand the argument about mammograms and radiation eposure but why are they suggesting that women not do self-exams? There is no exposure there.

Also, along with the discussion on breast cancer, they're "against" cervical screeening. I had cervical cancer diagnosed at age 42, a hysterectomy and no other follow-up treatments but looking back now, the pathologist said the cancer was "boarderline" for needing further treatments.

Will both of these screening tests be used only for insurance companies to deny coverage of the testing or will people have to argue with the doctors to get the tests if they want one?

Being on Medicaid, will it allow Medicaid recipients under the age of 50 to be denied payment for these screenings?

thirdofseven

On this issue I'm a sceptic and believe they are preparing us for some of the new regulations under the Health Reform that is being pushed through. Amazing -- now we can get an abortion, but not a mammogram.

gpawelski

The benefits of self-exams are best understood by oberving large and statistically significant populations of women.

In 2002, final results were made available from a huge and careful trials involving more than 260,000 female Chinese factory workers, a near-perfect homogenous and regimented environment in which to conduct such a study.

Half the women, chosen at random, were taught by trained nurses to do breast self-exams. The other half were not. After more than a decade, there was no difference in cancer mortality between the groups.

http://www.ncbi.nlm.nih.gov/pubmed/12359854

According to the big national gynecologists' group guidelines, it notes that women in their 20's should be screened every other years, instead of every year. Cervical cancer tends to be slow-growing and the group says studies have suggested that annual pap smears offer little advantage over screening every two or three years. Again, ACOG said studies showed no increased risk of cancer developing in women in their 20's if they "extended" Pap screening from every year to every two years.

As with the mammography guidelines (not restricting tests), the pap smear guidelines say it should be according to the individual and take into account patient context, including the patient's values regarding specific benefits and harms.

Screening isn't prevention. Screening is early detection. There's a big difference. Catching cancer early isn't the same thing as preventing cancer. Stopping smoking is prevention. Giving annual x-rays to smokers in hopes of catching lung cancer when it's treatable is early detection. Not taking hormone pills after menopause is prevention of breast cancer. Mammography is early detection. It does nothing to prevent the disease.

Dr. Kattlove wished that they had come out with these new recommendations two or three years ago. From a political point of view, the timing is unfortunate because inevitably, those who oppose health care reform will exploit this report to suggest that, under reform, the Government will use "comparative effectiveness research" to deny necessary care, and as a result, patients will die.

Health care reformers, the government and Medicare understand that, after thirty years of telling women that they must have annual mammograms, we cannot turn on a dime and expect them to suddenly absorb the information that for most average-risk women under 50, mammograms pose more risks than benefits.

It is important to remember that the “comparative effectiveness information” that the government plans to generate will serve to create guidelines—not “rules”—for doctors. In the U.K., doctors use such guidelines about 88 percent of the time, which seems appropriate, giving how much variation there can be in individual cases.

frannyv

In a recent newsletter issued by The Sidney Kimmel Comprehensive Cancer Center, at Johns Hopkins, there was an open letter sent to media agencies, in regard to the new mammograpy screening guidelines suggested by the US Preventive Task Force Service. The letter was written by doctors at the Avon Foundation Breast Center at Hopkins. It basically refutes the new guidelines and recommends that women still have mammograms at the age of 40. Here is a link to the newsletter.
http://www.hopkinskimmelcancercenter.org/index.cfm/cID/1684/mpage/item.cfm/ itemID/1154

gpawelski

The Washington Post addressed the mammogram recommendations by asking some questions to Kay Dickersin, director of the U.S. Cochrane Center and the Center for Clinical Trials at the John Hopkins Bloomberg School of Public Health (and a breast cancer survivor).

http://www.washingtonpost.com/wp-dyn/content/article/2009/11/23/AR200911230 1801_pf.html

LaGata

Excellent artcle from the Washinton Post. Thank you.

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