Will patients accept the new, evidence-based, breast cancer screening guidelines?

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.

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  • http://www.speakhealth.org Caroline (SpeakHealth.org)

    Hey there, I’ve been following this scaling back of cancer screenings story, and I am trying hard not be one of those people who immediately hears “less testing” and panics. I, like a lot of people, am scared scared scared. bottom line. terrified of cancer. (ironically, im also terrified of biopsies, but would rather have one than not, if it means knowing for sure something is benign.)

    i would think there would be a lot of other places to trim the fat, if this is a matter of money, but i’d like to know what other doctors and nurses think.

    I realise that this measure is meant to protect patients from unnecessary invasive tests (complications) and the emotional and psychological stresses of false alarms, but this still seems so trivial compared to possibly catching something early… Part of me sort of wonders if this is an “attack” (lack of better word) on womens’ health, since this scaling back seems to be aimed at breast cancer screenings. heck, i guess getting men to go in for a single prostate cancer screening still requires commercials on TV, so i suppose no ones worried about THEM getting too many.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    I think patients will be accepting of the relaxed guidelines. The benefits of much of our preventive medicine has been exaggerated. For example, the public views mammography as a strong shield against breast cancer The data, however, show that it produces ony modest clinical benefits. This may be quite true of my own procedure of colonoscopy as well. Sure, we save a few folks, but we end up tunneling through lots of normal colons.

  • SarahW

    I think most will recognize this recommendation for the cost-cutting measure it is.

    We all know mammography screening is imperfect, but this herd-based BC screening change ought to raise some alarms of its own on that score.

    One flaw that glares is that the new recommendation is based on screening carried out with outmoded equipment. The figures cited to support the reccomendation may well be inaccurate.

    Another is the cut-off age is arbitrary – and that while younger women don’t have the same number of lesions found, they gain the same benefits in mortality the older women gain when a lesion is found early.

    I think women want to decide for themselves with the help of their physician what test ought and ought not be endured.

    Giving third part payers a hook to hang a refusal to pay on is improper, though. Third party payers should have no say in whether a test is useful or not, only physicians and the patient together. The insurer should have to pay when the physican decided a test is useful to his treatment of one patient.

  • http://neuropathologyblog.blogspot.com Brian E. Moore, MD

    Kevin Pho writes: “Most doctors I know are already practice strict evidence-based medicine.”
    I propose a revision to this statement as follows:
    “Most doctors I know are already practicing strict evidence-based medicine, except when they’re practicing CYA defensive medicine.”

  • Cancer surgeon

    Will patients accept the new, evidence-based, breast cancer screening guidelines? Easy answer: Only if they have to pay for it.

  • R Watkins

    Will physicians who were dunned by pay-for-performance programs because a few patients didn’t get yearly mammograms now get their hard-earned money returned to them (with interest)?

  • http://www.birdsonawireblog.com Paula Cohen

    Will patients accept the new, evidence-based, breast cancer screening guidelines? I think it will depend on 1/their age, and 2/how many women they know who have breast cancer or have died from breast cancer, under the age of 50. I, for one, know many. It’s easy to accept the value of evidence when it’s mirrored in your own life experience. When it’s not, it will be a tough sell.

  • Linda

    As a woman who was diagnosed with aggressive triple negative breast cancer at age 30, I would love to see more emphasis placed on self-screening and sonograms performed more routinely than mammograms. More and more people my age are developing cancer and falling through the cracks. I wouldn’t even have gone to get my lump checked were it not for the insistence of my husband, and I’m glad I did since it was fast growing (2.3 cm to 3 cm in 10 or 11 days, from core biopsy to surgery).

  • arb

    It’s going to be a tough sell. Some medical professionals are using their very loud voices and prominent positions to disparage the new guidelines. Check out Johns Hopkins Breast Center’s Administrative Director. She is openly discouraging women from listening to the new guidelines. She’s not the only one.

    Color me cynical, but I’ve got to wonder how many of those disparaging comments are coming from an economic perspective. It’s absolutely got to influence finances when you’re potentially losing 50% of your annual revenue (for women over age 50 who will now be imaged biannually) and potentially 100% of the 40-50 crowd (those without other risk factors). Who to trust? An independent panel or those with big voices and broad reach who are invested financially? Talk about a conflict of interest…

  • stargirl65

    I think patients are going to freak out. I have a hard enough time showing them that they don’t need yearly pap smears with the HPV test and after hysterectomies or after a certain age.
    I do not think this change is financially motivated. But I think the public will think so and many will use these fears to stir up problems. This controversy is why “evidence based medicine” is so hard a sell. It doesn’t matter what you can prove, only what people want to believe.

  • Jen

    As noted above, the individual’s experiences are going to color whether this is a tough sell. I have very dense breast tissue, which makes it very hard for my physician to detect any abnormalities. At 40, I’ve been receiving fairly regular mammograms since I turned 30 for this reason (due to moves I’ve also had a number of PCPs during that time, all of whom ordered mammograms). What is baffling to me is the pullback on self-exams. I’ve been told repeatedly by health care providers that due to my dense breast tissue, I’m more likely than anyone else to notice if any new lumps appear. I also have a friend who was recently dx’ed, after a self exam.

    Add to that the recent study that showed women with dense breast tissue have a higher recurrence of breast cancer, and yes, it will be a tough sell–to me at least.

  • H

    I have been following the mammography controversy for quite some time. I decided years ago that routine screening wasn’t for me because I would rather risk a fatal cancer than have a tenfold chance of becoming a unnecessary cancer patient. I have received much flack for my decision from medical professionals. I now listen quietly to their recommendations and nod but never go in for that mammogram. I wonder if I am still going to be hassled about this. My insurance covers this and money has no bearing on my decision.

    Mammography and the unnecessary cancer treatment is a big cash cow for somebody. I would guess that those with a financial stake in treating breast cancer will be the last one to support the new guidelines.

    The most effective way to get this information across to the public would be to feature it on “House.”

  • Doc99

    I noticed that the USPSTF had no oncologists on the panel. Curious …

  • http://www.malpracticelawfirm.net jimeyers

    Kevin, you call this evidence based medicine. I disagree. The statistical presentation is evidence like. The chairman of the task force asserts that for every thousand who they now recommend not be screened “Just 0.7 women” will suffer a preventable death. 0.7 women have no name. It is easy to dismiss an unnamed fraction. Put a different way, for every 1429 women who now will not be screened, one woman will die. To prevent the death of that woman (lets call her susan jones) 47 women would have to suffer needless biopsies. To prevent susan’s death, many women with false positive findings would suffer needless anxiety while awaiting the good news that they are in fact cancer free.

    The problem is that the basis for such critical and for some, life ending decisions should be based on something as subjective as attempting to value and balance anxiety and the pain and suffering of a needless biopsy against the death of a woman (whether or not she has a name).

  • Bruce Small

    I watched NBC news this evening very carefully as they reported on the new guidelines and the reactions from doctors and patients. Not one word on the downside or dangers of testing. No wonder people are confused if they think testing is risk free.

  • H

    “To prevent susan’s death, many women with false positive findings would suffer needless anxiety while awaiting the good news that they are in fact cancer free. ”

    If having to the anxiety of waiting for additional testing was the only down side of screening, I would gladly be screened. 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. Should we give names to those women so we feel for them, too?

  • Doc99

    n response to today’s US Preventive Services Task Force (USPSTF) statement that recommends against routine mammography screening for women in their 40s and recommends screening only once every two years for women ages 50 to 74, The American College of Obstetricians and Gynecologists (ACOG) maintains its current advice that women in their 40s continue mammography screening every one to two years and women age 50 or older continue annual screening. The USPSTF revised recommendations are published in the November 17, 2009, issue of Annals of Internal Medicine. (Read more.)

    As the organization representing the nation’s ob-gyns who provide health care exclusively for women, ACOG welcomes these new review data on breast cancer screening. However, the implications of the USPSTF’s recommendations for both women and physicians are not insignificant and require that ACOG evaluate both the data and the USPSTF’s interpretations in greater detail. All women, along with their physicians, should individually assess the benefits and as well as the risks of mammography screening.

    The USPSTF also recommends against clinicians teaching women how to perform breast self-exams (BSE). At this time, ACOG’s position is that ob-gyns should continue to counsel women that BSE has the potential to detect palpable breast cancer and can be performed.

    ACOG strongly supports shared decision making between doctor and patient, and in the case of screening for breast cancer, it is essential.

    Source
    American College of Obstetricians and Gynecologists (ACOG)

  • TrenchDoc

    No one is saying what the malpractice lawyers are thinking. They are sitting back licking their chops waiting to see what they can sink their teeth into next.
    Until there is some sort of malpractice protection by following “guidelines” this all is just academic.
    CB

  • skepticus

    Why are notions of cost-benefit analysis so alien to doctors?

    NO ONE (or rather no economist involved in this sort of stuff) is saying that 1429 avoided screenings has an equal value, monetary or otherwise, to one lost life.

    The analysis USPTF draws upon is that we will all accept an increased probability of death in exchange for some benefit.
    Thus, we will tolerate an increase in the likelihood of death if we avoid useless procedures and anxiety.

    This is the same analysis we use when we get into a car: we tolerate an increased likelihood of death (by car accident) in exchange for avoiding walking to the supermarket and carrying the bags home.

    The idea of comparing the value of people dying of cancer vs. those unnecessarily treated vs. those free from anxiety is very much a distraction.

  • SarahW

    There’s no reason congress can’t encourage and create tax incentives for MSA’s so that screening tests are usually paid directly by patients.

    Also, an individual patient is perfectly capable of deciding whether anxiety can borne. Why would anyone care to “helpfully” decide that for someone else?

    And biopsy is not always “mandatory”. Some women do refuse biopsy and ask to be imaged more frequently. I might myself in some limited situations.

  • SarahW

    I think I object to someone determining what emotions I am to be spared. I think I can manage that without kind uncles so concerned for my well-being.

  • H

    It seems the question is “Will doctors accept the new, evidence-based, breast cancer screening guidelines?”

  • R Watkins

    “Also, an individual patient is perfectly capable of deciding whether anxiety can borne. Why would anyone care to “helpfully” decide that for someone else?”

    And that is exactly the point of the new recommendations. The USPSTF has taken a position again routine, mass screening (the “postcard in the mail-come get your mammogram”) that is not based on an informed discussion between the patient and her physician.

    Just follow the money trail as this discussion continues.

  • Anonymous

    Last year I informed my PCP that based on guidelines of evidence-based medicine, I refused to have a mammogram until I turned 50, at which point I’d think about it. This provoked pressure, fear tactics, and implications that I might be dismissed from her practice… amazing!

    I dropped that physician. Wonder what she’s telling her patients now?

  • R Watkins

    Anonymous: That physician may have been in one of the ridiculous pay-for-performance programs, where some of her (already small) payment was withheld for every patient who did not get a mammogram.

    Lots of problems with P4P: false endpoints, enormous administrative costs, discourage indivualized treatment for complicated patients, no evidence that they improve patient health.

  • Evinx

    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?

  • Anonymous

    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!

  • Brad

    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?

  • http://www.malpracticelawfirm.net jimeyers

    “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?

  • R Watkins

    “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!

  • H

    “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.

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  • Sam

    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.

  • Julia

    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.

  • Lee Smith

    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.

  • Surgical Resident

    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).

  • avid

    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…..

  • Lee Smith

    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.