Why health reformers should be worried about the breast cancer screening backlash

What if a non-partisan, authoritative entity wrote a robust, evidence-based guideline, but nobody followed it?

That is precisely what’s happening with the USPSTF’s recent revision of their breast cancer screening recommendations. The change most find problematic is their recommendation that women younger than 50 not undergo any breast cancer screening, such as with a mammogram.

Here are their reasons explaining why:

The harms resulting from screening for breast cancer include psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results. Furthermore, one must also consider the harms associated with treatment of cancer that would not become clinically apparent during a woman’s lifetime (overdiagnosis), as well as the harms of unnecessary earlier treatment of breast cancer that would have become clinically apparent but would not have shortened a woman’s life. Radiation exposure (from radiologic tests), although a minor concern, is also a consideration.

Adequate evidence suggests that the overall harms associated with mammography are moderate for every age group considered, although the main components of the harms shift over time. Although false-positive test results, overdiagnosis, and unnecessary earlier treatment are problems for all age groups, false-positive results are more common for women aged 40 to 49 years, whereas overdiagnosis is a greater concern for women in the older age groups.

They’re completely right, of course. As I previously wrote in a USA Today op-ed on this issue, “For every inspiring story of a person cured from cancer made possible by early detection, there are untold stories of many more who suffer from the side effects of unnecessary invasive procedures stemming from false positive test results.”

But some patients are rebelling against these new guidelines, as noted in this article from The New York Times, New Mammogram Advice Finds a Skeptical Audience. A few doctors, too, are refuting the new recommendations as well. Suspiciously, they are mostly radiologists and oncologists. Cynics may wonder whether there is a financially-motivated basis for their dissent.

What’s fascinating is how mammogram screening has now turned rabidly political, with conservatives making the ridiculous link to “rationing.” And Kathleen Sebelius, the secretary of health and human services, tried to distance herself from the USPSTF, stressing that, “I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action,” and that, “our policies remain unchanged.”

What, then, is the point of making any guidelines at all, if our government urges everyone to ignore them?

Progressive reformers, who generally espouse comparative effectiveness data and evidence-based medical practice as a means to control costs, should be very worried about the backlash these guidelines are eliciting.

If recommendations from an entity like the USPSTF – as non-partisan and robust as it gets – gets so much resistance from doctors, patients, and even the government itself, findings from a comparative effectiveness body stand absolutely no chance of changing medical practice.

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  • http://webseitz.fluxent.com/wiki Bill Seitz

    Just because *some* doctors, and *some* patients, and *some* whackjob politicians are objecting, doesn’t mean most people won’t go along with it (once they actually pay attention to it).

    (Of course, if patients actually *paid* for the test, and the false-positive biopsies, compliance would increase more…)

  • Cancer surgeon

    It is fascinating that the women’s lobby is so much stronger than men’s health advocates. There was a similar debate about PSA and prostate cancer screening and not many bloggers cried out when the rationeers suggested that PSA screening should not be done.

  • arb

    Take a look at breastcancer.org if you really want to experience the vitriol in the backlash. It is overwhelming and being fed by a HUGE number of leaders in the field (yes, radiologists, oncologists, breast surgeons and their handmaidens, lackeys and acolytes).

    They are even attacking physicians who have long been tireless advocates for women and breast cancer. They are tearing down anyone and everyone that opposes them.

    The megaphone that places like Johns Hopkins, Memorial Sloan Kettering, BreastCancer.org and others has will be the death of this. They could use their hugely public platform to explain the meaning behind the report – the real meaning – that many more women are harmed by the existing guidelines than by the newly recommended ones.

    But, no – it’s all about protecting their investments (do you know how many new dedicated “Breast Centers” have opened in the past five years? – seems like a lot – I’d love to see the real #’s. It’s a hugely profitable business). They’re using the guise of “saving lives,” but I believe their real agenda is to protect their incomes.

    Don’t tell me they haven’t crunched the #’s and realized that the financial impact of following the new guidelines would be significant.

    These places really know their customer base – they know how to rile them up and use their patients’ own emotions to twist the truth. Disgusting. And, a complete failure of leadership from those who purport to be the leaders in this area.

  • Cheryl Crichley

    This issue is not new. There was a lot of anger in the early ’90′s the Canadian National Breast Screening Study opened the debate on over screening. Anthropologist, Patricia Kaufert, wrote an “economic, political, and moral history,” of mammography at that time. Many people have been pumped up to support too much medicine. The are sincere and passionate, of course. Others have been able to rake in fortunes because of excessive screening. It is difficult to sort out the players and their motivations, which leaves women feeling confused and anxious. All in all, the backlash reminds me of the movie line, “You want the truth? You can’t handle the truth!” Apparenlty we cannot. The guildelines clearly state that women with higher risk or concerns should talk with their doctor and that their care should include more screening. As for the rest of us, I would happily give up unnecessary screening so that my younger sister could just have the basic health insurance she so desparately needs.

  • ann moravick

    While the panel recommendation is based on a good understanding of available science, the decision was made without a good understanding of women as a driving force in healthcare and without a good understanding of the confusion such a recommendation would create. When scientific bodies make recommendations NOT to do something, they have a responsibility to the public health to offer a better alternative. Clearly, better diagnostics are needed. This recommendation is premature, leaving women with even more anxiety about what to do, not less. That might have been responsible science, but irresponsible communications and irresponsible ethics.

  • H

    “This recommendation is premature, leaving women with even more anxiety…

    All the poor women with anxiety…is this anxiety better than the false positive anxiety? or the medical procedure anxiety?

    This whole mammography thing just illustrates that US healthcare isn’t really interested in controlling spending with evidence based medicine…just everyone protecting their financial interest.

  • SarahW

    You don’t get it. Cutting costs, not improving health, is the point of the panel reccomendations. The panel bases its recommendations on ITS OWN CALCULATION that it is not worth bothering conferring the increased survival to women between 40 and 50 that early detection of cancer provides. Some women between 40 and 50 might disagree that preventing the “anxiety” of thinking for a few days they might have breast cancer is a fair trade for their lives. And mortality will increase in those women by the panels own findings.

    This is a cost cutting measure and nothing more. If you want patients of any variety to weight the cost, make non-catastrophic and routine care something patients pay directly from their own health accounts, make their individual care a priority for their physicians, not some mythical herd that must be husbanded with other people’s money.

  • http://evimedgroup.blogspot.com Marya Zilberberg

    The fact that women are being left behind economically and socially in the US cannot be disputed. So, it is no wonder that this ostensible “pulling back” of the long-standing recommendations is viewed with passionate suspicion by the masses — it just looks like the extension of the left-behindedhess. The fact that these recommendations have precipitated such a maelstrom attests to the fact that the USPSTF does not get involved with politicking on these issues. If they had, I am sure that the communication and the response would have been much less thorny.

  • Dave

    Ann and Sarah-
    “When scientific bodies make recommendations NOT to do something, they have a responsibility to the public health to offer a better alternative.”
    Depending on what you define as a “better alternative” the scientific body HAS recommended something better, which is see your doctor if you have a concerning symptom (mass, skin changes, nipple discharge) or family history of early breast cancer, but otherwise DO NOTHING until you are 50 years old. The USPTF believes that doing nothing IS better, if you consider the number of unnecessary biopsies and lumpectomies performed and the potential complications from those procedures. The bottom line is that “better” is a subjective, highly personal definition, and only you know what you consider “better” and you should make sure you speak at length with your doctor in order to make an informed decision. However, when “we” are all paying for “your” treatment (we = taxpayers if you are medicare/medicaid, or co-workers if you are insured) then “we” only pay for what “we” think is better. You are welcome to get more care, in line with your definition of better, but you will have to pay for it out of pocket.

  • R Watkins

    “make their individual care a priority for their physicians, not some mythical herd”

    And that is EXACTLY what the USPSTF is recommending: that the decision to screen with mammograms be made individually by each patient in consultation with her physician, not be done because of a blanket recommendation for the “mythical herd.”

    To claim that the USPSTF makes this and other decisions for primarily economic reasons indicates a profound lack of understanding of the scientific method.

  • Mr L

    What’s fascinating is how mammogram screening has now turned rabidly political, with conservatives making the ridiculous link to “rationing.”

    No, what’s fascinating is how anyone thinks this is at all surprising considering that coverage of mammograms for women as young as 35 regardless of circumstances is required by law in nearly every state and that any attempt to question this policy has been met with rabid screeching and accusations of misogyny. I’m not exaggerating in the least; the recently defeated Jon Corzine ran ads targeted at women with precisely this message, to name but one of many examples.

    As far as I’m concerned, conservatives are just returning the favor; the (usually progressive) backers of these policies should have to answer for the enormous human and financial costs, but barring that seeing them unjustly tarred is sauce for the goose.

  • ann moravick

    For me, this group made a big mistake in its communications strategy. I’m only looking in from the outside, but it would’ve made a lot of sense for them to communicate to key government officials, cancer advocacy organizations, women’s groups, bloggers and survivor organizations well in advance of issuing their recommendation so that they didn’t create mass uproar about their recommendations. They have hurt their credibility and reputations by thinking they could simply announce their results and let science speak for itself. In today’s politicized world, that is no longer enough.

  • http://blog.insweb.com Robert

    What’s the problem with getting checked early and often for breast cancer? I guess I just don’t see the problem with it.

  • R Watkins

    “it would’ve made a lot of sense for them to communicate to key government officials, cancer advocacy organizations, women’s groups, bloggers and survivor organizations well in advance of issuing their recommendation”

    I think that would be a VERY poor policy for the USPSTF to take. They currently have an outstanding reputation for scientific rigor and impartiality (unlike, say, the American Cancer Society, which dedicates enormous resources to fund-raising). To go in the direction that you suggest would represent the politicization of the Task Force, and would greatly diminish their credibility.

  • SarahW

    The reasons for the guidelines speak for themselves.
    The objections in the top post about “reform” are code for “reigning in testing”.

    The bottom line is individuals should have this screening covered without an insurer resorting to some panel saying what is better overall for containing costs. (Including costs of anxiety or discomfort to women who have followup tests and no cancer) The panels own findings indicate that some women will lose years of life. The age cut-off is arbitrary. The benefits gained by patients are things patients are perfectly capable of choosing or evaluating for themselves without help from third parties.

  • SarahW

    And lest that be mistaken for an inclusive statement of everything wrong with the guidelines, let me clarify it’s most certainly not meant to be.

  • Patricia MD

    According to Cochrane:
    http://www.cochrane.org/reviews/en/ab001877.html

    For every 2000 women screened over 10 years:
    200 false positives
    10 unnecessary diagnoses–>mamms made no difference in outcome
    1 woman helped with life prolonged

    Who should we advocate for? The 1 helped or the 200 harmed? This is the public health issue. Prima non Nocere? Or anything to save a life?

    Unfortunately, every one of the 10, in whom screening made no difference, fiercely believe that it saved their life, that they are the 1. Many of the testimonials you read are from women who think they are the 1.

    The real problem, which we can’t solve, is that there was political pressure to change the prior recommendations in the past, when they changed it from 50 down to 40 without good data to support it. The current recommendation is perceived as taking something away, instead of righting a previous wrong.

    Until we have pink ribbon campaigns for people who are mutilated because of a false positive mamm, we will lose the PR battle.

    The politics of this are just shameful.

  • Blake

    This is where the ethical dilemma arises between the whole “be your own health advocate” patient mentality and the idea of social justice and health care costs. These new guidelines probably do have a financial component to it, but they are exactly what the White House were hoping for and sold us all on–the curbing of health care costs by the elimination of “unnecessary” tests and procedures as determined by objective, scientific evidence. Except this evidence showed that “unnecessary” tests are something which many women find absolutely necessary. So what wins, the cost-cutting evidenced-based guidelines that are supposed to help us extend health insurance to every American, or the self-interested “be your own advocate” mentality that every patient is encouraged to gain?

    I am disappointed that the White House is backing away from this. It’s not important to me whether the guidelines are correct or not (for the purposes of this discussion on health care reform, at least), but operating under guidelines are EXACTLY what the White House proposes under health care reform. I am appalled to see them back down so quickly over the idea they champion simply because it is not politically expedient or popular with voters.

    If the government picks and chooses from supposedly “evidenced-based guidelines”, well, then they aren’t evidence-based at all are they? Oh wait, unless we just choose evidence or form guidelines that are popular or not too terribly upsetting. Wait… isn’t that what we do now?

  • http://curbside.posterous.com Nuclear Fire

    @Robert: Good question. The reason is that the response to some positive tests can carry significant damage. With any test there is a false positive rate, a percentage of time that the test says you have a disease when you don’t. If the response to that positive test is non-toxic, like drink an extra glass of water a day, then no big deal, but if the response has significant risk, like a chemotherapy drug with 5% stroke risk, then the more you test, the more normal people get falsly labeled as having a disease and get treatment and the more normal healthy people are given strokes by their doctor. And that’s only a part of the problem. It certainly isn’t as simple as the above posters would have you believe nor is it just about money. Hopefully the inappropriate backlash won’t prevent future unbiased recommendations.

  • Diora

    @Robert:
    ” What’s the problem with getting checked early and often for breast cancer? I guess I just don’t see the problem with it.”
    Google for “overdiagnosis in mammography” and you’ll find your answer.

    Ann and SarahW – I don’t know what you mean what you question “reasons behind the guidelenies”. The guidelines are based on scientific data that shows that harms from early mammograms are higher than risks. And false positives and radiation exposure are not the most important harms. The real harm is overdiagnosis – being diagnosed with cancer, going through treatment, suffering with side effects of the treatment maybe for life for a slow growing or indolent leision that would regress or not cause you any harm if remained undetected. This may be as much as a third of all cancers detected with mammography. Think about overdiagnosis in this way too: a lot of the women who claim that their lives were saved because their cancer was discovered early may have actually had cancers that wouldn’t have ever spread. If you don’t want to examine the rationale for USPSTF decision yourself, you can do so – look their guidelines on the web, click on recommendations and rationale and check referenced studies…Then see if you don’t agree.

    In terms of false positives only – do you know the statistics? Do you know that your chance of having at least one false positive within 10 years is over 50%? More for women under 50, less otherwise. These false positives lead to additional tests, about of fourth of them leads to biopsy, some biopsies are surgical that have real risks. It’s not just “anxiety”. And talking about anxiety, are you aware that the reduction of mortality they talk about is only breast cancer mortality. Nobody has ever showed it translates into a reduction in all cause mortality. Sure, a study that would show a reduction in all cause mortality would require a very large number of people given that breast cancer death represent a small percentage of all deaths. But still, how do you know that all this extra anxiety doesn’t have bad effect on your overall health?

    USPSTF is not a political organization. It simply looked at the data available and concluded that for women in their 40s, the probability they’ll be harmed is higher than that your life will be saved. Incidentally, I looked at some of the same data for myself some years ago, and I choose not to have mammograms. Now I am 50, and you know what – I am now even sure I’ll have them now… Sure, the mortality reduction is higher for women in their 50s and 60s. But it is still small at least for those of us who understand the difference between relative risk and absolute risk. But false positives and overdiagnosis are still there.

    One thing I recommend is for SaraW and Ann to read book by H. Gilbert Welch “Should I be tested for cancer” This was published a few years ago and it gives a clear explanation about both benefits and risks of screening tests; it also describes in a very simple manner the tests’ limitations, evidence, and some epidimiological concepts you should really learn before you talk about screening and survival – such as lead-time bias, length bias, etc.

  • Diora

    patricia MD – interesting that their number of false positives seems so low. I read in the past that it was about 10% for the first mammogram, and somewhat less for each subsequent one. Calculating the probability of at least one false positive in 10 years of screening based on this number gives way over 50% for yearly screenings. NCI says it’s about a third.

    I wonder if 200 out of 2000 is only number of biopsies or some subset of all false positives. It is also based on European data where the mammograms are performed less often and there are fewer false positives.

  • ann moravick

    In reading the above comments @Diora and @robert, it is clear to me that the full scope of the recommendations and the rationale behind them — all very scientific and evidence-based and logical — cannot compete with the emotion around a very sensitive issue for women. I hate to make comparisons around health issues, but this reminds me of autism and vaccines where scientific studies showed that vaccines did not cause autism but women with children with autism, not having conclusive information about the causes, did not believe the science and felt the medical establishment was pulling one over on them. It is very difficult to put forward scientific arguments on issues that carry such emotion and fear and the unknown. Breast cancer is one of a woman’s foremost health concerns. Risk/benefit information may indeed show that the risks of unnecessary biopsies are greater than not having mammograms for women who are not at risk. But, that story has not effectively been told to the majority of women like me (non MDs) who are struggling to understand through the filter of the news media what to do now. To my earlier point, if a federal independent medical advisory group was tasked with assessing this issue, more due diligence should’ve been don (by someone) in educating women about the problems of over diagnosis prior.

  • Dave

    @ Diora: very well written synopsis of the rationale behind the new recommendations and why the prevailing belief that “More = better” is harmful.

    Here’s some links to:

    1. One of many articles that supports the new recommendation. Please excuse the AHRQ link, the study was done independently and published in an independent journal; I see no conflict of interest. I only use the AHRQ link because it is free and allows access to everybody.

    http://www.ahrq.gov/clinic/uspstf09/breastcancer/brcanart.htm

    Table 4 (http://www.ahrq.gov/clinic/uspstf09/breastcancer/brcantab4.htm) compares mortality reduction for different screening starting ages and shows that there isn’t much additional benefit from lowering the age of initial screening from 50 (20% mortality reduction) to 40 (22% mortality reduction). However, initial screening at 50 is associated with 1,350 false positives; lowering the initial screening age to 40 almost doubled the false positives to 2,250, with a similar increase in unnecessary biopsies.

    2. Information about how the USPSTF makes their decisions:
    http://www.ahrq.gov/clinic/uspstf08/methods/procmanual5.htm
    (note – they DO admit that economics is a factor, but specifically state that the primary driving factors they consider are potential benefit and potential harm.)

    3. Information about what USPSTF is and who they are:

    http://www.ahrq.gov/clinic/uspstfab.htm
    Note: the AHRQ, which “sponsors” the USPSTF IS a government entity, and I suppose some could say that means they are trying to “limit” medical care. But the MEMBERS of the USPSTF are independent MDs or PhDs who are not beholden to the AHRQ or the federal government and I see no potential for conflict of interest. They are NOT a cost-cutting tool, and as RWatkins rightly points out are a remarkably APOLITICAL body in the midst of many overly politicized organizations with their own agendas.

  • jsmith

    Give it time. Give it five years and people will come to terms with the new recommendations. Remember the dust-up a while back when estrogen replacement therapy went by the wayside? Now most people are OK with the recommendations on that.

  • Dave

    @ann: Without a doubt this is a confusing issue that raises contention even among medical professionals, which makes things even more confusing to a layperson. I hope you don’t see these posts as me attempting to browbeat you into one camp or the other. Rather, I’m trying to provide information you can take, discuss with your primary care doctor, and make the decision that is right for you.

    The BAD news is that this fight is gonna continue for awhile, with some doctors advocating more frequent screening and some advocating less frequent screening.

    The GOOD news is that when an issue splits people this evenly, it’s usually because there is no clear cut “winner” and both sides have evidence to support them.

    At the end of the day, you need to gather information, evaluate that information based on it’s content and source, discuss it with the medical professional you trust with your care, and make the best informed decision you can.

  • R Watkins

    “more due diligence should’ve been don (by someone) in educating women about the problems of over diagnosis prior.”

    Ideally, the main stream media would have presented this in a more responsible manner, explaining the science behind the recommendations. Instead, they have chosen to sensationalize it, giving wide spread coverage to the most emotional and unreasonable responses. It all comes down to “he said, she said,” reporting, and Marsha Blackburn is seen as qualified to discuss the value of screening mammograms.

  • I have a question

    In the new data that the new recs are based on, there is a 15% mortality reduction (relative risk) for mammography for women in their 40s, which is basically the same for women in their 50s(14%). So why not leave the recs as they were- (every 1 or 2 years after age of 40)?

  • ann moravick

    @dave — not feeling browbeaten. Enjoy the dialogue. And @RWatkins agree that the media didn’t do a very good job of covering this issue in a way that told the full story. I believe that will come — at least I hope so — as the issue unfolds further.

  • Patricia MD

    Regarding the Cochrane numbers–the false positives seemed low to me as well but, even with them being low, 200 to 1 is still pretty striking.

  • a follow up question

    I understand that there are more false positives with earlier screening. Usually this leads to more imaging and follow up, sometimes to biopsy – usually a fine needle biopsy – not terribly risky. I don’t think it’s a good idea to scare women in their 40′s into not getting a mammo. I do think that it’s reassuring that I can wait until I’m 50!

  • SarahW

    It.is.about.the. money.

    “under health-care reform legislation pending in Congress, the conclusions of the 16-member task force would set standards for what preventive services insurance plans would be required to cover at little or no cost.”

  • H

    “It.is.about.the. money.”

    So if evidence based medicine saves the system money, we can disregard it because it might lower costs?

    Maybe it’s about money for the radiologists, oncologists, and drug companies that make billlions of dollars off needlessly treating women for breast cancer. In the end, everyone has these warm fuzzy feeling that lives were saved. The evidence tells us otherwise.

    Why bother doing any research on any current medical practices?

  • Doc99

    I find two things curious about this USPSTF release – One, the absence of an oncologist on the panel and two, the timing. A wise man once said: Follow the money.

  • SarahW

    The “system” Whose system?

    And who is being needlessly treated for breast cancer?
    I see people being screened and tested for the presence of breast cancer, but when cancer IS found, the early detection. by the panels own findings, confers mortality benefits that are equivalent to those of those past the arbitrary revised cutoff age. It protects life, real lives, of women in the prime of life raising families.

    Are you arguing that many breast cancers are never life threatening or clinically significant, won’t advance? Is this your premise? Because one criticism of this assumption is there isn’t evidence to support that assumption. Evidence-based, really?

  • Anonymous

    One of my clients was just diagnosed with stage IV colon cancer. She is 44 years old with no family history and no obvious risk factors – she’s white, active, not obese, no prexisting related illness, educated (husband is a PA). It could be argued that colonoscopy would have caught the cancer at a much earlier stage, but colonoscopy is not recommended for those younger than age 50 with no family history or risk factors. She may die of her cancer. It’s scary and sad, but it’s no one’s fault.

    The revisions to mammography recommendations are based on a similar risk/benefit analysis. Why is everyone so hysterical? Two reasons: breast cancer is a highly emotional and political disease AND breast cancer screening is a highly profitable business.

    For the record, I’m female, and I refuse to have a screening mammogram OR a screening colonoscopy until I’m 50. I’ll take my chances.

  • H

    “Are you arguing that many breast cancers are never life threatening or clinically significant, won’t advance? ”

    Yes. I would suggest you read the research.

  • Patricia MD

    Beware of anything reported as a percentage change without seeing the actual numbers.

    The 15% decrease is not of the women screened but of women who die. It all depends on the absolute rate without the screening test.

    Using the Cochrane numbers as our basis, that means that of every 2000 women screened, 6 will die instead of 7. That would be a 14% drop. That’s not an overwhelming number.

    If 2 per 2000 dies and you dropped it to 1, that would be a 50% decrease, although still just 1 per 2000 screened.

    A much more clinically significant number is the number needed to treat (NNT).

    The NNT for mamms in 40-49 yo women is 2000. That’s screening over 10 years, 5,000 to 10,000 mamms.

    Per Newsweek/NYT:

    “The task force concluded that one cancer death is prevented for every 1,904 women age 40 to 49 who are screened for 10 years, compared with one death for every 1,339 women age 50 to 74, and one death for every 377 women age 60 to 69.”

    An NNT of 377 isn’t great but it’s way better than an NNT of 2000.

  • Frank Coburn

    So if these recommendations are based on scientific data alone, why are they always round numbers – ie mammogram after 40 or 50. In my experience data doesn’t usually progress in strict groups of 10. What about starting screening at age 43 or age 46? The point I’m making is that while scientific data was used for these recommendations, an arbitrary human factor was introduced when the panel decided to decide how many additional breast cancer deaths was acceptable or how many extra dollars were too much to spend. To try and portray this as purely scientific is inaccurate.

  • SarahW

    H, how was this quantified by the panel and what research was relied on? One of the chief criticisms I have seen of the panel reccomendations by experts is that they assumed that a significant proportion of detected disease will not become clinically significant, and that this assumption is not well supported.

  • Jenga

    Excellent point Frank.
    Probably the best post of this entire discussion.

  • H

    “One of the chief criticisms I have seen of the panel reccomendations by experts is that they assumed that a significant proportion of detected disease will not become clinically significant, and that this assumption is not well supported.’

    Have you not read Patricia MD’s posts of the Cochrane Collaboration?

  • Tristan Phillips

    Some help for Kevin and the posters here:
    - How many oncologists are on the board that made this recommendation? Free clue: less than one. Second free clue: None of the board members have any medical qualifications to authoritatively speak on breast cancer, making their recommendation even more silly
    - Everyone questions the financial motives of the backlash. What about the financial motivations of the board? Free clue: the board would have the force of law when it comes to medical payments should Obama/Pelosi/ReidCare be passed. No financial motive there. Second free clue: Look at Canada and England for many examples of treatments being denied solely because of cost while they ignore the efficacy of the treatment. Still looking forward to having bureaucrats decide how much your life is worth?

  • http://curbside.posterous.com Nuclear Fire

    @ Frank & Jenga: The reason that the numbers are “always round” is not due to a disregard for the scientific process but a byproduct of it. With respect, you seem to not understand what science is and how it is done. When designing a study, you need to “power” it enough to be able to detect differences between two groups. The larger the number of people in each population being compared, the easier it is to detect a difference. When designing these types of studies, the groups will often be seperated into either qunitiles, or by decade, of by half-decade ahead of time and then these categories compared. They are NOT looked at on one continuous spectrum. So when it comes time to make decisions, the numbers are already round because the data was set up, collected, analyzed and reported that way.

    Now, someone else could go back and do what is called a post hoc analysis and whereas the initial study showed 50 good, based on the design of the study (not the bias of the guideline writing committee) they might find in their analysis that if appears that is good. It would be BAD (or not) science to they use these non-round numbers to make a policy statement or even a scientific statement. It would be good science to use this post hoc analysis to generate a new hypothesis and do a new study with these categories.

    You’re right Frank, data isn’t always is nice neat categories, but we do design our research trials that way.

  • Patricia MD

    Regarding the round numbers, there’s only so many ways to do research. They are screening women, based on age, over a 10 year period. The best data comes from prospective studies, rather than retrospective studies.

    I think the real question is whether screening the decade before menopause is helpful versus the decades after menopause. Since we don’t know when menopause will start in any individual women, we can’t judge when to start the study. The average age of menopause is 51yo.

    I think many doctors view the 50yo cutoff as a surrogate for the onset of menopause. Many view the recommendations as premenopausal versus postmenopausal screening.

    That’s not purely based on the data but, since the data can’t be obtained, it’s based on the available data and the average woman’s physiology.

    Do other doctors agree?

  • SarahW

    H. Tell me yourself your understanding of the assumptions, and support for them you find.

  • Dave

    @ Patricia & Frank – I agree wholeheartedly. Frank, a subtle point I think you are missing is that these numbers are based on large studies that have to be designed prospectively. So if the question is “What age should we start mammograms?” the study design needs to compare two different mammography start ages. The study designers can choose any ages. They can compare 39 and 39.5 years. They can compare 10,000 days old to 15,000 days old. The bigger the difference in ages, the bigger the POTENTIAL difference in benefit, and the fewer patients need to be collected per group in order to adequately “power” the study to detect that difference. So the reasons the numbers are all so “round” is that the study designers arbitrarily chose them, and people usually choose round numbers. Nobody is saying that 50 is the OPTIMUM age to start screening; the study wasn’t designed to detect that. They are just saying it is a better age than 40. Why didn’t they choose to compare 40 vs 41 vs 42 vs 43 etc.? Because that study would require an inordinate number of women and be prohibitively expensive to do. Statistical analysis s by no means intuitive, Frank, and I do not claim to be an expert. If you are genuinely interested there are many good statistical texts out there but I wish I knew of a good “statistics for the layman” type text I could recommend that explains in plain english – I am sure it exists but I am not aware of the title.

    @ Tristan: I am curious why you seem to be so angered by this. Do you really think the board had a motive to deny care to people? You said it yourself, there isn’t an oncologist on the board. I would argue that having an oncologist, or a breast surgeon, or a radiologist on the board would raise a red flag to me that there was indeed a conflict of interest. Looking at the committee credentials I see an epidemiologist, an OB/GYN, many internists, and a geriatrician, all of whom I trust to understand the relative merits of screening and breast cancer in particular. On the other hand, the surgeon who announced the ACS disagreement with the new guidelines is the current chair of breast center accreditation. I do not know this physician personally or professionally and I am sure he/she is a dedicated medical professional, but I do have to wonder why they didn’t choose someone with less seeming bias to make the statement. Even if I am a lowly resident member of the college.

    Back to what I said looking at the numbers from before, lowering the age of first mammography does lower mortality, but it seems (to me) the benefit plateaus at age 50. Below that you don’t reduce mortality by a great deal more than mammography starting at age 50 but you DO increase the number of false positives and unnecessary biopsies. At the end of the day, I hope the decision for each woman is made after a thorough discussion with her physician (or other health care provider) and she decides what is right for her.

  • Frank Coburn

    NuclearFire, the process you described is exactly what I was trying to emphasize – as you said yourself every study has limitations. In this case the authors concluded it is better to begin screening at 50 not 40. As for 50 vs 45 or 50 vs 43? These recommendations do not answer this question because of the way the data was collected and analyzed.

    The point is this type of study will not tell you the optimal age to begin screening. It just tells us that 40 probably isn’t the optimal age and 50 is more optimal than 40. Could the optimal age be 44? Sure, maybe, but this wasn’t studied.

  • http://www.108DAYS.com Lisa Lindell

    Good grief, let’s just throw evidence and common sense right out the window. Why stop at routine mammography? How about routine annual chest xray, MRI, CT Scan, ultra sounds every 6 months, and annual exploratory surgery, just to have a look. Keep going, patients should get a RX for any medication they want. It might hurt them, but it also might help them, and who are we to deny anybody anything that might help them? How about an annual HIDA scan for everybody? A minor nuclear procedure to look at your plumbing. Why annually? Every 6 months sounds better. Everybody’s DNA should be screened for any disease we *might* develop, and treatment should being immediately, before any symptoms are present. Medicial or scientific evidence be damned, give the people what they want.

  • R Watkins

    This recommendation is based on a thorough review of every major study on the subject and, based on epidemiological and statistical analysis, making recommendations regarding mass, routine screening (not treatment). This is the area of expertise of this board, and complaining that there is no oncologist (who treats cancer in individuals after it has been diagnosed) is a complete red herring.

    All the task force members are completed vetted for financial conflicts of interest before they are appointed. They serve as volunteers and they have no financial stake in this issue (unlike all the participants of the enormous breast cancer industry).

    The ACP made the exact same recommendations two years ago, and most oncologists are members of this organization.

  • SarahW

    Lisa, your attempt to extend screening possibilities into the absurd is frustrating.

    But I’ll go so far as to agree with your sarcastic conclusion, “give the people what they want.” What I mean is give individuals and their doctors control over the health care dispensed to an individual. Doctors can relate risks and benefits to patients of routine screening, including the downside, limitations, or advantages for that one patient.
    Patient’s can way their own preferences and tolerances, and unique life situation in addition to those reccomendations or that advice.

    One reason your attempt to conflate mammography screening into some absurd no-benefit, all risk activity is uncalled for is that THE PANEL ITSELF found a clear mortality benefit for mammography screening among women ages 40-49, just not as many cancers as in older women. when cancer is found, the mortality benefit is not less than for older women.

    The downside is a higher rate of false screen positives; these women may choose biopsies, and feel scared while they wait to hear the result.

    The subjective relative importance of “anxiety” and relatively low risk procedures, vs a mortality benefit gained, is something that ought to be decided by physicians and patients; and payment from insurers or any public health program should be based on that unique relationship, not an overseeing panel managing a herd.

    You seem to think it’s impossible that any patient would refuse an annual screening. Many women do. I do.
    But if my doctor says its a reasonable precaution for me, I agree, after knowing the ups and downs, there should not be someone else blocking my access to such a test.

    I repeat: If screening and other routine care goes to cash only, via tax exempt medical savings accounts, saving the system money is no longer the concern. Political points, cost issues, public health reccomendations take their proper place.

  • Diora

    @Tristan – regarding presence of oncologist, etc. on the panel.
    Oncologists see individual patients but they don’t see the overall picture that comes from studies of thousands of people, nor are they particularly qualified to analyze the data. They see a lot of anecdotal data, but like Kevin and others have mentioned many times in the past “plural of anecdotes isn’t data”. This evaluation of data has ALWAYS been the realm of epidemiology. This applies to everything – who do you think evaluates the effectiveness of new drugs? Studies provide information about how many additional diagnoses of cancer were made in screened vs non-screened women; whether or not this increase was accompanied by a corresponding decrease in the number of advanced cases diagnosed later (hint: it was not), differences in breast cancer mortality in screened vs non-screened groups. You need to know statistics to analyze this data a lot more than medicine.

    On the other hand, oncologists see actual cases. So they see early diagnosis and say “oh, it’s easier to cure early cancer”. But is it easier to cure because the cancer was slow growing to begin with? Maybe a particular cancer would’ve never spread. Lab cannot give answers to these questions. Additionally, one extremely misleading metric oncologists may use is 5-year survival after diagnosis. This number is misleading because of what is known as “lead time bias”. Think about it this way – say someone dies of cancer at the age of 50. The cancer may be diagnosed later – e.g. at the age of 48 or earlier – e.g. 42. The result is the same, but in one case the person survives longer after diagnosis. Only long term data from studies that compare mortality means anything, not survival after diagnosis, and only epidemiologists who have knowledge of medical statistics are qualified to evaluate this data.

    @SaraW — overdiagnosis is not an “assumption”. It is a well-known and well-proven, and it has been known for quite a while. People have provided links for you in the past — I remember posting the link to one of the study of overdiagnosis years ago in a similar discussion here. What is new now is more information about the magnitude of this phenomenon. Dave’s post (#23), item 1 contains a link to USPSTF rationale which in itself contains references to study.

    It’s not like this information is difficult to find. I found it years ago and I am a lay person too. Google for “overdiagnosis in mammography” and read papers in medical journals. A lot of them can be read in their entirety.

  • BD

    Lisa Lindell:

    >>Medicial or scientific evidence be damned, give the people what they want.>>

    Exactly! :-) No matter how many tests one performs on whom, it’s impossible to reduce risk to zero.

    “Diagnosis” does not equal “cause of death”.

    Consider: if I develop a slow-growing breast tumor at age 47 then die of a heart attack at age 49, the breast cancer (even if undiagnosed and untreated) will be an incidental finding on the autopsy. Breast cancer won’t be my cause of death but I’ll count as “1 in 9″.

    Further consider: lung cancer is less common than breast cancer, but far more deadly; many more women survive 5 years with a diagnosis of breast cancer (around 90%) than lung cancer (around 15%). Sure, lung cancer is more common in smokers, but lung cancer isn’t unknown in young non-smokers (remember Dana Reeve, Christopher Reeve’s wife? terribly sad story – she was only 43 at diagnosis and a lifelong non-smoker). Still, physicians don’t routinely order screening chest radiographs. Pancreatic cancer has 5-year survival of only about 5% and we don’t screen for that, either.

    To further complicate matters, not all breast cancer is equally deadly – DCIS does NOT have the same prognosis as IBC!

    It’s critical to look the raw data (American Cancer Society, CDC, etc.) because it is difficult to determine who is saying what in the current babel of indignation. I work with statistics in the medical field and am infuriated by the rampant twisting of facts in the news media by “professionals” with various agendas. I find it especially repellent that physicians with a financial interest in maintaining current screening levels are so blatantly stoking the fears of women who are terrified of cancer.

  • http://www.108DAYS.com Lisa Lindell

    I was being sarcastic. Nobody said anything about reducing risk to zero. It’s risk vs benefit. If the risk outweighs the benefit for the general population, then the general population should not contribute to the expense or carry the burden. Many specialists in many fields would foam at the mouth at my absurd suggestions, and find plenty of “data” for pre-screening everything for everybody.

  • R Watkins

    BD:

    “I find it especially repellent that physicians with a financial interest in maintaining current screening levels are so blatantly stoking the fears of women who are terrified of cancer.”

    Best post yet on the subject (and I would add to ‘physicians,’ numerous non-profit organizations)!

    Worst media coverage to date:

    Eleanor Clift (who is usually smarter than this) on NPR, arguing in favor of continuing screening for women in their forties:

    “I personally knew two women who had breast cancer diagnosed by mammograms in the 40s, and they died!”

    Tragic for those women and their families, but what in the world is the logic behind her argument?

  • BD

    Lisa Lindell:

    >>I was being sarcastic.

    Yeah, I know. Liked your Modest Screening Test Proposal.

    >>Many specialists in many fields would foam at the mouth at my absurd suggestions, and find plenty of “data” for pre-screening everything for everybody.>>

    I don’t doubt it. Scary, no?

    R Watkins:

    >>“I personally knew two women who had breast cancer diagnosed by mammograms in the 40s, and they died!”

    Tragic for those women and their families, but what in the world is the logic behind her argument?>>

    She didn’t prove my point, but she definitely cast doubt on hers!

  • http://pharm-aid.blogspot.com Pharm Aid

    I’ve spent over 30 years in medicine and I’ve never seen such sham science before. I’m sure the pediatric providers (all 4 of them – 25% of this “robust” expert panel) have a wealth of real-world experience in dealing with the highly evolving area of adult oncology. There wasn’t a single, real expert in breast cancer on this panel.

    Kevin, like nearly everyone else, is focusing on the lower bound – the controversial recommendation not to screen women from 40-49 (or 39 to 49 if you go back to the original study). The upper bound is more interesting. The recommendation that women older than age 74 are too old and not worth screening/saving. Economically this makes sense. However, ethically, we have moved into different territory that is unusual in this country – a government-sponsored recommendation not to screen for fatal disease. When it comes to oncology, I’m concerned that “First, do no harm” is quickly becoming “Do not intervene.” We’ve seen it with other cancers, now it comes to breast cancer.

    I absolutely support evidence-based science – even if that science calls for scaling back on (or totally eliminating) screening. Let’s not embarass the profession with garbage research and claim it’s wonderful evidence-based medicine. Read it for yourself. This wasn’t it.

    This was politics posing as medicine. I’m embarassed for the USPSTF. And I’m shocked at HHS’ funding of such a, frankly, crap study.

  • Blake

    @R Watikins–that may be the worst coverage of the story. I think this is one of the fairest:
    http://www.msnbc.msn.com/id/34040273/ns/health-cancer/from/ET

  • R Watkins

    Pharm Aid:

    “The recommendation that women older than age 74 are too old and not worth screening/saving.”

    That is not what the USTFPS said. Your statement is a total falsehood, and discredits everything in your post.

  • Patricia MD

    “The upper bound is more interesting. The recommendation that women older than age 74 are too old and not worth screening/saving.”

    No, absolutely, that is not what it says. It says mamms haven’t been shown to be helpful in that population. To say we don’t want to save seniors from breast cancer is inflammatory and without any basis in fact.

    There seems to be this religious faith in mamms, that they are some amazingly useful tool. They are not. The data has never said they are.

    If a tumor is slow growing, as are most breast cancers in that population, finding it on exam is more helpful than finding it on a mammogram. It is just as curable and the risk over overdiagnosis and overtreatment is much lower.

    There’s a wide range of functional capacity in seniors. A woman’s doctor can make the best judgment as to likely effectiveness of a screening tool. That’s why the rec is to discuss it with your doctor and not just tell everybody to do something which won’t help the vast majority.

  • Disgrace

    DIora, I think it’s important to distinguish what you mean by “overdiagnosis”. The panel’s assumption that I speak of, is an assumption that cancer will not advance in a significant portion of cases, that cancer is there, perhaps, at age 40, but it is not and will not become clinically significant.

    This assumption does not appear to be quantified or well supported according to many critics of the panel’s reccomendation.

    I think you mean something else by overdiagnosis – am I correct? You are referring to that percentage of women who have a suspicious mammography, in whom cancer is not detected in follow-up tests.

    For me the question is the one previously asked in BC screening controversies: whether there is any mortality benefit for women between ages 40-49 as a result of screening. The goal-posts have been moved. The question for this panel is no longer “is there any mortality benefit at all”, but whether that benefit is worth the “downsides” of screening.

    They make a subjective assessment that the pain and discomfort of biopsies and the anxiety a woman might feel over suspicion of cancer, and this isn’t their call.

    What this panel is about is to set guidelines for PAYMENT of services. What should the system pay for. There is another underlying assumption – that overtesting is costing the big bucks, money that could be used to fund other things.

    I think one way to make this issue rest in its proper place is to change “the system” so that screening and preventive care is a self-pay matter: to be paid for from private or employer funded medical savings accounts that are tax-sheltered.

  • Peter

    No, DIsgrace, Diora is referring to the very real issue of diagnosing cancers which will never be clinically significant. The other problem is called “false positives” and it’s an entirely different issue. This is a well documented and supported phenomenon despite what you may have read. That’s not to say it isn’t controversial – it most definitely is – but to completely dismiss it as irrelevant is to ignore a decent volume of evidence. She referred to links that may point you to the research documenting this phenomenon so you can decide for yourself.

    And the goalposts for any screening program is, and have always been, mortality benefit relative to “side effects”. This is nothing new.

  • http://pharm-aid.blogspot.com Pharm Aid

    @R Watkins and @PatriciaMD – read the full recommendations, not the political spin that AHRQ has beeen putting out for the last week. USPSTF has downgraded their recommendation for screening in women age 75+ to just an “inconclusive evidence.” The did not issue the recommendation against screening in ages 75+ because they were worried about the political backlash.

    If you’ve spent years telling people to do something and now you don’t say anything, in the mind of a patient, it’s like telling them not to do it. Tell a patient don’t smoke for years. Then one day, tell them, the benefits or harms of smoking are not totally conclusive. See the response.

    The guidelines state, “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.”

    The guidelines also state “NO RECOMMENDATION” for screening (in the world of Finance with buy, hold, sell – the guidelines have gone from a buy to a hold).

    I’m completely in favor of evidence-based medicine, but let’s have evidence. If the evidence in favor of or in opposition to mammography is inconclusive, then hold on a recommendation and gather evidence. This is a step backward. And I’m serious, I’d love to know that the 3 pediatricians and the one pediatric nurse practitioner brought to the USPSTF recommendations on adult breast cancer.

    This wasn’t science, this was trying to get the recommendations in before healthcare reform gets finalized.

  • Diora

    Disgrace – No you are not correct. I don’t understand why you assume that I don’t know what “overdiagnosis” is and how it is different from false positives. What I mean by “overdiagnosis” is exactly what everyone else who have bothered to read any study of screening (as opposed to media reports) means by “overdiagnosis”. There is only one definition of “overdiagnosis” in epidemiology. “Overdagnosis” refers to early cancers that are diagnosed as cancers and are treated as cancers but that would’ve never progressed had they remained undetected.

    Unlike you, I’ve actually followed the mammogram debate for a while and read a number of papers that tried to estimate overdiagnosis. Like for example this one for example. This earlier paperhas lower estimates of overdiagnosis; however, as anybody with any knowledge of math and logic would understand, their math computations were flawed – this is noticed in “rapid responses” to the paper if your math knowledge isn’t good enough to notice the flaw yourself. There have been reports of overdiagnosis for quite a while with estimates ranging from 5% to 50% of all mammographically detected cancers and most researchers putting it around a third. So no, “overdiagnosis” is not “assumption”, it is a well-known phenomenon and its estimates are based on real data such as for example increase in the number of detected early cancer with no corresponding decrease in number of advanced cancers; or comparisons between excess of detected early cancers in screened vs non-screened population and no corresponding increase in non-screened population after screening has ended.

    Overdiagnosis is the most important harm of any screening program since unnecessary cancer treatment has real risks. False positives cause less harm, but it’s still more harm that you think – I think you simply don’t realize how high the cumulative probability of having at least one false positive after years of screening is. Keep in mind that, as I mentioned before, no study showed all cause mortality benefit from screening; so if there is more heart disease in screened group because of this extra anxiety, they wouldn’t be shown in the study. This is by the way an interesting paper on the subject of cancer-specific mortality numbers vs all-cause mortality in mammogram trials. Also correlation between mortality reduction and extra number of detected cancers, show in how many cases mammograms had no effect – this correlation shows more than just overdiagnosis: in addition to overdiagnosed cases it includes cancers that are detected later in unscreened group but are still curable as well as cancers that are so agressive that early detection doesn’t make a difference. It is still useful.

    Now, as is noted in USPSTF as well as other reports, overdiagnosis applies to women of all ages, not just those 40-49. However, false positives – and if you bother to read the statistics you’d know how common they are – apply to everyone. Biopsies have risks too. As I said, I think Cochrane numbers don’t include all false positives. Other estimates are much higher – between 30 and 50% with the lower numbers in Europe that has less screening and higher numbers corresponding to the US.
    Keep in mind that false positives lead to more tests, including more mammograms and more radiation which is not exactly harmless.

    I don’t know why you ASSUME that USPSTF’s main reason is cost rather than balance of benefits and harms – in spite of all the evidence to the contrary icluding no political affiliations of the researchers. Mammograms for women of 40-49 has always been a subject of controversy because of a smaller probability of benefit. In fact in 2002, NCI didn’t want to recommend mammograms for women 40-49; USPSTF recommended them in 2002 simply because of a political outcry. This year there simply was more data as to how small the benefit is for women 40-49… IMHO – this USPSTF decision is actually long overdue.

    They make a subjective assessment that the pain and discomfort of biopsies and the anxiety a woman might feel over suspicion of cancer, and this isn’t their call..
    If this is the case, why have guidelines at all? They tell you what they recommend or not based on balance of benefits and harms. You are welcome to follow or not. For example, earlir guidelines recommended mammograms, but after careful look at studies of both benefits and harms, I choose not to. And I do have insurance. Let’s just have every person decide which tests they want…. a well as which drug. [/sarcasm]

  • R Watkins

    Pharm Aid:

    “The did not issue the recommendation against screening in ages 75+ because they were worried about the political backlash.”

    Evidence, please.

    “The guidelines also state “NO RECOMMENDATION” for screening (in the world of Finance with buy, hold, sell – the guidelines have gone from a buy to a hold).”

    Faulty analogy. “Insufficient evidence” is absolutely not the same thing as “hold.” “Hold” is a positive recommendation; “insufficient evidence” is the absence of a recommendation. Very different.

  • Diora

    Pharm Aid: Pharm Aid November 20, 2009 at 10:58 pm
    I’ve spent over 30 years in medicine and I’ve never seen such sham science before. I’m sure the pediatric providers (all 4 of them – 25% of this “robust” expert panel) have a wealth of real-world experience in dealing with the highly evolving area of adult oncology. There wasn’t a single, real expert in breast cancer on this panel.

    Interpreting the research data from studies that involves 1) number of women screened 2) number of early cancers detected 3) numbers of false positives 4) numbers of advanced cancers detected later 5) mortality reduction is not a job for oncology experts, but epidemiologists – researchers with knowledge of medical statistics. Much like pediatricians aren’t the ones evluating effectiveness of drugs from control studies for the pharmaceutical companies – statisticians do, oncologists aren’t the ones who interpret results of studies of screening or cancer drugs. Oncologists look at individual cases, but they don’t interpret the data. It’s not their job. If you really know anything about medicine, you should know this. Pray tell what specific expertise oncologists gain from their job that would enable them to evaluate the data? Oncologists have anecdotal information from their personal practice, but as has been repeated zillion times “plural of anecdotes is not data”.

    As to sham or not sham science, I fail to see how your work as a pharm aid gives you any qualifications to make this determination.

  • BD

    Diora:

    >>Oncologists look at individual cases, but they don’t interpret the data. It’s not their job. If you really know anything about medicine, you should know this. Pray tell what specific expertise oncologists gain from their job that would enable them to evaluate the data?>>

    You are 100% correct. Physicians receive only very basic training in epidemiology in medical school. They are not epidemiologists, a field which requires advanced graduate work in the field of epidemiology (the best-trained usually have a PhD in epidemiology, or at least an MPH or Master’s degree in epidemiology).

    i can assure you from personal experience that sitting through a basic epidemiology class comprised of doctors-to-be when one has had ANY training in study design and statistics is excruciating. The basic epidemiology course is designed to help doctors become more discriminating readers of journal articles and leaves one ill-equipped to do much more without further training.

  • Lee Smith

    Science is based on hypotheses, predictions and evaluations of predicted results. It begins with observation which the epidemiologists can do, but that is only the starting point. Hence I object to these conclusions of epidemiologists being labeled as scientific – they are making observations which is the starting point of science, not the endpoint. I agree that the data show that there is a problem. However, they don’t show what the problem is or that the problem is mammograms, rather that there is a whole process that needs investigation, but that its time for the observationalists to step down and let medical science take over. What a scientific group would/should do is trace the steps from mammogram, or PSA reading or other screening technique through biopsy, interpretation, treatment or non treatment decision, and evaluate which paths lead to desirable outcomes, which to undesirable. This of course requires serious input for the vast amount of data collected by radiologists, breast surgeons, oncologists, and geneticists. Then, in a scientific approach various control experiments would be performed to see how the number of desirable and undesirable outcomes changes. In any case, I wouldn’t go to an epidemiologist for advice on my health – would you? I recall when my college was having financial difficulties. One wise professor came up with a proposal which would reduce our deficit to zero. It’s simple he said, let’s close down the college. Similarly the epidemiologists have a fairly useless conclusion if the goal is finding the proper approach to breast cancer. They should be thanked for getting their average data together – and now lets let the professionals who deal with real individuals and the substantative components of diagnosis, disease course and treatment take over and utilize there experience and observations of actual people not mass statistics.

  • pat

    I am not a medical person, and I tend to try to avoid medical care as much as possible although I do go for my annual mammo as part of my annual maintenance visit. I thought it was great that less screening for younger ages was recommended and was a little taken aback by the blowback. The release of the study at the height of the healthcare debate might not have been the best thing. I think the ACS and maybe the imaging industry has really oversold the mammo thing and the effectiveness of lots of tests and treatments that really aren’t that wonderful. We all view medical care as more is better, but it isn’t and we need to start talking about that. And I am not in favor of government involvement in healthcare. I am in favor of the healthcare we used to have back in the 60s…personalized and accessible.

  • BobBapaso

    Pat,

    Then you want a Health Care Savings Account. Pay cash, and you will get what you want, and you don’t have to worry about the government rationing it, as the insurance companies do now.

  • BD

    Lee Smith:

    >>It begins with observation which the epidemiologists can do>>

    Do you know what an epidemiologist is?

    >>Hence I object to these conclusions of epidemiologists being labeled as scientific – they are making observations which is the starting point of science, not the endpoint.>>

    The endpoint in this case was mortality. Not sure how one could use a more final endpoint.

    >>I agree that the data show that there is a problem. However, they don’t show what the problem is or that the problem is mammograms>>

    What the data showed is that in a large group of women who had mammograms, doing so did not significantly impact mortality in younger age groups but did generate significant rates of false positives and false negatives in this age group. Morbidity rates are more complex but I can expand if you’d like.

    >>its time for the observationalists to step down and let medical science take over>>

    The irony is that much of what you call “medical science” IS observation and anecdote. That is why so much of “medical science” is not actually very scientific. Sad but true.

    Individual clinicians generate anecdotes (case studies or case series), also known as qualitative data, which is only as good as the individual clinician. Large groups of individual clinicians generate quantitative data, the quality of which may also vary or be impacted by confounding factors, some obvious and some not.

    >>What a scientific group would/should do is… evaluate which paths lead to desirable outcomes>>

    That’s what was done here. Desirable = high sensitivity and specificity of test detecting a condition, treatment of which results in statistically significant lower mortality and non-treatment of which would not result in significantly lower mortality.

    This was not a study comparing treatment protocols, which may be where your confusion lies.

    >>Then, in a scientific approach various control experiments would be performed to see how the number of desirable and undesirable outcomes changes.>>

    Okay. So you’re suggesting that a large number of people should be recruited as subjects for a randomized study. How would this group differ from the group studied by the task force?

    >>In any case, I wouldn’t go to an epidemiologist for advice on my health – would you?>>

    Sure, if the epidemiologist was also an MD. The epidemiologists I know are smart people.

    >>Similarly the epidemiologists have a fairly useless conclusion if the goal is finding the proper approach to breast cancer. They should be thanked for getting their average data together…>>

    Well, it may be just a little more complicated than looking at “average data”. Incidentally, most epidemiologists frown upon meta-analysis.

    Question: do you think men should be screened for breast cancer? If not, why not?

    >>…and now lets let the professionals who deal with real individuals and the substantative components of diagnosis, disease course and treatment take over and utilize there experience and observations of actual people not mass statistics.>>

    Okay. How does this differ from the task force’s recommendations?

  • BD

    >>Desirable = high sensitivity and specificity of test detecting a condition, treatment of which results in statistically significant lower mortality and non-treatment of which would not result in significantly lower mortality.>>

    That should read: “non-treatment of which would not result in significantly higher mortality”.

    I apologize for any confusion.

  • Lee Smith

    BD: Do you know what the scientific method is? In any case, epidemiologists should certainly present their approach for consideration by the public. The problem is that this is being labeled “science” when it doesn’t seem to me to be science and having an apparent governmental “seal of approval”. And yes I have a bit of knowledge of the scientific method having a PhD in biomedical science. I admit to being biased by the unbelievably poor recent and highly contaminated “studies” of PSA screening. Talk about confusing the public! I have read a significant amount about DCIS and about prostate cancer (since these things directly impacted on my family) and realize there is a lot of confusion out there but would certainly recommend to anyone I knowto not forgo PSA testing or mammograms and to begin relatively early, following the recommendations of consensus groups of experts in the disease being considered such as NCCN. The flow charts that they develop are much more important, in my opinion, than anything that USPSTF generates.

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