Breast cancer screening has been scaled back, according to the recent recommendations of the USPSTF.
That’s the right move. Although women aged 50 to 74 years should receive a mammogram every 2 years, evidence of breast cancer screening in other age groups has been marginally conclusive at best, and non-existent when it comes to clinical self-exams.
Furthermore, the guidelines implicitly acknowledge the downsides of cancer screening, including the possibility of biospies for eventual benign lesions, which introduces the risk of complications that more invasive studies bring.
In other words, evidence has been introduced into the guidelines, resulting in the recommendation for less testing.
Some patients, predictably, aren’t happy. I went through the comment section of the story in The New York Times, and found responses to be all over the map. Although some agree with the revised guidelines, the majority did not.
The reason being that a single case of life-saving, early breast cancer diagnosis will garner far more emotional airplay than the complications stemming from overscreening.
The thought that “more medicine is better testing” is so pervasive in the mindset of the American public that it’s going to be extremely difficult to scale back testing in this country. Even if it’s the right thing to do.
That’s the principal challenge facing health reformers today, who want to apply evidence, like results from comparative effectiveness studies, to medical decision making. Most doctors I know are already practice strict evidence-based medicine.
Whether patients accept this is still in question.
Related posts:
- Will patients accept the limitations of prostate cancer screening?
- Radiologists don’t agree with the USPSTF breast cancer mammogram screening guidelines
- Breast cancer screening: Orac’s take
- Nancy Snyderman: Is she aware of any evidence-based guidelines?
- Why health reformers should be worried about the breast cancer screening backlash
- An oncologist takes on the recent breast and cervical cancer screening controversy
- "The great majority of women in the United States should not be getting MRI scans for breast cancer screening"
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Cancer Surgeon + Sarah W get to the core of the problem – 3rd party payment. The reason this is so controversial is bcs patients are concerned their insurance will not pay. If HSAs were expanded and promoted (instead of attempting to legislate them away), this would be a non-issue.
The root of the heathcare problems in the USA is 3rd party payment. BTW, if patients were to pay for these out of their own HSAs, the cost would come down as on a cash basis in San Diego area, patients are only paying $70 for the mammogram.
How’s that for bending the cost curve down?
R Watkins:
Re: P4P: I’m sure that physician was in such a program, as she pushed me to be tested for STDs (I agreed despite being low risk with a low risk partner who had already been tested – “better safe than sorry” – I tested negative) and also pushed for cholesterol screening (I refused, as I’m only 40 with no risk factors or family history) and CBC/Chemistry (I refused, all but useless in a healthy person).
We were not a good match. On a basic level, P4P or not, she never asked when my last tetanus booster was, and I forgot to ask her about it while trying to discuss her agenda (1996, I think, and I work in a high-risk profession). No biggie – I can go anywhere for that – but this was indicative of a lack of individual approach to patients in this practice.
I really wasn’t looking forward to explaining why I was going to refuse a pap smear this year!
I just can’t forget that somewhere there is a person or committee who decides what is evidenced-based and what is not. Who are these people? Who chooses them? How do we know they are free of bias or conflict of interest?
“The real issue is to prevent Susan’s death, 14 other woman would have to go through radiation and chemotherapy, their lives forever altered and perhaps shortened.”
The chairman of the task force cited no such statistic. No one is put on chemotherapy for breast cancer without tissue confirmation. If 33 women have needless biopsies then everyone receiving chemotherapy must have had tissue confirmation. How do you establish the chemotherapy was not needed for the treatment of biopsy proven breast cancer.
Women need to be given accurate information of the potential harms, whatever they are, and decide whether the benefit justifies the risks.
Ultimately, women will be given no choice but to pay for the test. The suggestion that after discussion with a physician a woman has a choice under the new guidelines is misleading. If routine screening is not recommended why would a physician have such a discussion? And after discussion there is no reason except the desire to have the benefit of screening, isn’t that the very kind of screening the recommendations are calculated to prevent?
“The real issue is to prevent Susan’s death, 14 other woman would have to go through radiation and chemotherapy, their lives forever altered and perhaps shortened.”
‘The chairman of the task force cited no such statistic. No one is put on chemotherapy for breast cancer without tissue confirmation. If 33 women have needless biopsies then everyone receiving chemotherapy must have had tissue confirmation. How do you establish the chemotherapy was not needed for the treatment of biopsy proven breast cancer.’
But that IS what the supporting documents state. Though it goes against our basic instincts, early detection of many cancers does not increase life span. This is becoming especially clear for prostate cancer, and to some degree for breast cancer. The cancer is detected early, meaning that the patient is subjected to more years of aggressive and unpleasant treatment, with no prolongation of lifespan.
Lots to think about here!
“No one is put on chemotherapy for breast cancer without tissue confirmation.”
There is a growing amount of evidence that every cancer isn’t deadly. If a cancer is found, current medical understanding doesn’t know which cancers kill, which ones grow so slowly that they would never be an issue, and which ones will go away on their own. Prostate cancer screening is facing similar issues.
So much for tissue confirmation if medicine can’t tell me if the cancer is fatal or will go away on its own.
It might make American women happier to know that other countries don’t offer screening to women younger than 50.
It has been known for some time that mammograms for 40-49 year old women have very limited benefits and a high risk of unnecessary biopsies for benign conditions.
I know the call for fewer smear tests to reduce the very high rates of colposcopy and biopsies in the States has been widely ignored by doctors…I assume the same will happen again.
I think when women have been told for many years that annual smears and mammograms yearly from age 40 is the best way, with absolutely no mention of risks…it’s hard for the profession to suddenly turn around and say something different…
Women immediately assume it’s about cost cutting and taking risks with their lives.
I have American friends and they all receive their healthcare in HK (where we all work a couple of times a year) to avoid the US health system and the excess…
They prefer a balanced approach that protects them from over-examining, over-screening and over-treating. One friend was told her script for the BCP would be held until she had a mammogram. That is really shocking…your informed consent is required for cancer screening as there are risks as well as benefits in all testing. You cannot ethically or legally demand someone have cancer screening of any sort.
I’d recommend any woman thinking about mammograms at any age, to look at the Nordic Cochrane Institute brochure which sets out the facts…the good and the bad.
Sadly, in the past…we’ve only heard the good and no mention of the bad.
Totally agree with the change…
I just read a great book called, “Should I get Tested for Cancer” by Gilbert Welch.
It really helped me understand the dilemma we all face with more and more testing being pushed onto us.
We may all have cancer in our bodies that will never bother us, it’s called pseudo-disease. For example, thyroid and renal cancer is uncommon…yet during autopsies they have found lots of cancerous lesions in these areas.
It seems these lesions very rarely progress to cancer, so if discovered, a “watch and wait” appoach is often taken..rather than dashing in and removing something.
A screening test would be disastrous for either of these cancers because you’d be treating thousands of people for something that was most unlikely to ever bother them.
I think we’ve lost perspective with all of this focus on cancer.
I think if we all lost a bit of weight, exercised more, stopped smoking and had a balanced diet, we’d be far better off…whereas the benefits of a lot of this testing is debatable and in some cases, more likely to hurt us.
I don’t understand why the USPSTF approach is called “evidence based”. Pardon my ignorance but it seems to be after the fact statisical correlation studies, not controlled scientific studies. I would hypothesize that these massive average studies bring home the point that on average medical advice probably isn’t very good, so each individuals goal should be to find the best Dr’s they can, get multiple opinions, avoid panic, but always SEEK KNOWLEDGE that screening clearly provides in many many cases. If you are willing to go to a USPSTF member for medical advice then take their recommendations, but DON”T expect any individualized approach. On the other hand if you go to an expert in the field, someone with lots of experience in the disease you are facing, you are, in my humble layman’s naive approach bound to get a better outcome than the USPSTF can provide you with. According ot USPSTF medical approaches are like going to the Casino, and you cannot beat the odds. However, I believe if you go to a knowledgable practitioner you can fix the odds in your favor and increase the chances of winning — i.e. avoiding metasticizing cancer that screening has revealed.
To Lee Smith,
I think you are missing the point. Finding someone to “fix the odds” is not how it works. Simply put, the USPSTF looked at large studies and devised these rec’s. Going to a so called “expert” will either follow his/her interpretation of this data or more likely his/her own intuition. As reflected in the recent NYT article about Intermountain, physicians often use recent experience to determine their practice. It is simply human nature. For example, if I diagnosed a patient with breast cancer in their 40’s and she was “cured,” I will be much more likely to recommend screening to a patient than a colleague without that same experience. It is human nature.
The point of these rec’s is to remove a physicians bias from screening rec’s to which I say “Good Job USPSTF!”
In residency, we are taught by so called to “experts” to ignore the experts and focus on the data. Expert opinion is considered level III data (certainly nothing to hang your hat on).
I delayed mammograms until I was 45, because I have fibrocystic disease and I knew it would not be normal. I was right–it wasn’t–so then I had to have a breast ultrasound and then another “bigger, better” mammogram on top of that—all to give me a decision that “everything’s fine, come back and see us next year.”
Since then I have only had mammo’s every 2 years instead of yearly, at my own insistence. I am low risk, and I have a firm belief that radiation exposure is cumulative over a lifetime. I don’t feel compelled to over-radiate my breasts. (Were I high-risk, I’m sure I might feel differently)
All of that aside, I believe that we have an emotional attachment to our breasts that’s probably not present in other less visible parts of the body. For instance, would the public outcry have been as loud if these recommendations to decrease testing frequency had applied to colonoscopies?
I wonder…..
Surgical resident: I hope that you learn from your surgeries, and with all due respect, no matter how many surveys you read, I’m not going to go to you until you have some experience.
Let me try to explain my perspective in a different way:
By way of analogy to USPSTF recommendations on screening, let’s imagine a socio economic group that on average does poorly in higher education. If we followed the “task force” approach of the USPSTF we would say, let’s not waste money and resources trying to educate these folks — look at how bad the outcomes are for so many of them. Is that really the world we want to live in or should we see how to create more successful outcomes. The same goes with screening in my opinion. It clearly provides important life defining information for some of us — so why is USPSTF so ready to throw us out as meaningless exceptions? It would seem to me that the successes, even if a minority, prove the worth of screening and USPSTF should study those and compare them to the failures, and then draw conclusions as to what to do right, rather than trying to reduce screeing because of the failures. If you had the unfortunate experience of being diagnosed with breast cancer or prostate cancer, would you go to the USPSTF to get an opinion on what to do next? Of course not, because they only deal with statistics and averages. We all seek ways to be above average and to raise the average. If you want to be average and bellow, follow the USPSTF suggestions. However if you want to be treated as a unique individual, and to get the best possible treatment, and to have your own variations in diagnosis and disease taken into account go to specialists in the disease, several for a range of opinions. Read up all you can, check out the latest research papers (scientific papers with specific details of the patients, treatments, etc , not mass undifferentiated outmoded population surveys.
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