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

I apologize for any confusion.

>>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?

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.

>>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.

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.

“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.

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]