Mammogram screening divides doctors and patients

Mammogram screening for breast cancer continues to simmer in the news.

The recent USPSTF guidelines, no longer recommending a routine mammogram for women between the ages of 40 and 49, continue to stir controversy between physicians and their patients.

In a recent survey from the Annals of Internal Medicine, it looks like the debate between doctors and patients will continue for the foreseeable future:

. . . a divide has emerged between doctors and patients — with the doctors more inclined to accept the new recommendations and the patients wanting to stick to early and annual screening . . . Most of the 345 doctors who responded said they would stop offering routine mammograms to women in their 40s, and most said they would advise women 50 to 74 to have mammograms only every other year . . .

. . . most of the 241 patients who responded said they did not believe in giving up routine mammograms in one’s 40s — even if the doctor recommended a change — and were not likely to switch to an every-other-year routine.

This is entirely unsurprising. There continues to be a perception among patients that more screening and tests equate to better health care — despite the evidence that says otherwise. False positives that arise from more aggressive screening can lead to more harm than good.

The media firestorm caused by mammogram screening is a good first step to educate the public that there indeed can be such a thing as “too much” medicine.

Policy experts and health reformers tend to blame the medical profession for American’s embrace of expensive and unnecessary tests. Instead, they should help find ways to help doctors educate patients and reduce the demand for these studies.

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  • msr

    Shortly after the new guideline came out, one of the large hospital based medical centers sent me a flyer encouraging me to get a mammogram at their center. It appealed to my fear that if cancer wasn’t detected early, I was going to die.

    My guess if you let the medical field decide, they would continue to do what they have always done, recommend the procedure that makes the most profit. Isn’t that what the radiologists are doing? Why would you not pay $200 for a mammogram when the expert say you are going to die if you don’t get one?

  • arb

    It doesn’t help that certain powerful segments of the medical community have used this inclination among patients to feed the emotional response – most likely due to the considerable financial impact it would have on their business models.

    All the dedicated “Breast Centers” that sprang up to open – staffed by radiologists that specialize in mammography (and all those stereotactic biopsies of indeterminate findings) and a surgery group to automatically refer patients to (and all those unnecessary open biopsies) – face a remarkable decline in income if 40% of their patient base stop getting routine yearly mammograms. There will be a marked decline in the high value procedures that follow those mammograms.

    I don’t buy the faux concern and outrage the ACR (and others) is touting – and the very vocal response from supposed leaders in the field – Johns Hopkins for example – contributes to the confusion. It’s all based on the number crunching that went on immediately the guidelines went public – all to mitigate the financial impact. It is truly shameful that these “leaders” abuse their position to feed the emotion of the issue.

    This is a slightly complicated issue. The guidelines don’t say no woman age 40-50 should get a yearly mammogram. Women with other risk factors should be getting yearly screening.

  • BladeDoc

    Policy “experts” should have stayed the hell out of it in the first place. If the new guidelines had come out to doctors as most do (i.e. in scientific journals) AND people had to lay out some cash for their routine medical care this imbroglio would have never happened. It’s the difference between “Mrs Jones the government says you can’t get a mammogram this year because your insurance company is following these guidelines.” and “Good news Mrs. Jones, your last mammogram was fine and according to some new data that just came out you don’t need another one until you’re 50 — so you won’t need to spend that $50 this month.” Which do you think flies better with the average American?

    Once every medical decision is made by the government, every decision becomes political by definition.

    • AnnR

      I think this is a most reasonable way to “help” people decide what’s important to them when screening guidelines aren’t cut and dried.

      When my kids were little and we went to DisneyWorld, the first time, I was bombarded with requests for this and that junky toy. The second time we went I said – “kids, here is $100 (!) each for whatever you want on this trip.” Nobody had to pay for meals with that, it was all free spending money. Both kids came home with extra cash and I heard no sad stories about what they hadn’t gotten.

      I say, give everybody “credit” and let them spend it at the doctor. Then it’s not some nameless thing rationing care, it’s Carol-Consumer making a choice. If she skips the mammo and gets breast cancer it was her decision.

  • BD

    I had this conversation with a physician over two years ago (prior to the release of the new recommendations, but following publication of papers questioning the utility of annual mammograms for 40-49 yo women with no risk factors). I informed the physician that I was waiting until age 50. She tried some scare tactics. I changed physicians.

    As others have pointed out in past discussions, it’s likely mammogram rates were tied to an incentive program and patients like me threatened this physician’s annual bonus.

    Education was the key to my understanding of the risk/benefit of mammograms for a person in my situation. I’m capable of educating myself, but those who don’t regularly peruse medical journals as part of their daily routines rely on medical professionals for education. Unfortunately, the marketing tactics by large “breast centers” are designed to promote the business, not to educate patients. Direct-to-consumer advertising is a particularly odious – and successful – mode of selling medical products and services.

  • DrLemmon

    I just present the facts to my patients. I present NNT, number that will be treated unnecessarily and that USPSTF and ACS differ. About 50% decline the mammogram. I have a blog post on this topic.

  • msr

    “I just finished seeing my third recent case of screening detected cancers in women in their early 40’s, none of whom had any risk factors. ”

    Yes, women get cancer in their forties.

    Where is your evidence that the mammogram changed the outcome of treatment for these women?

    Also, how do you know that detecting the cancer resulted in aggressive treatment of a cancer that never would have endangered the woman’s life and health?

  • Doc99

    I tend to disregard guidelines for cancer screening formulated by panels which do not include a single oncologist – the only physician whose area of expertise IS cancer.

  • DJ

    First off, let me give the disclaimer that I am a breast radiologist who has financial incentive for more people to get mammograms. However, the leaders in my field who are most vocal about this, are senior academics who get paid the same whether they read 60 or 90 mammograms per day.

    I just finished seeing my third recent case of screening detected cancers in women in their early 40′s, none of whom had any risk factors. Two were only detected because of subtle changes from their mamograms the previous year. The other had skipped a year and the change was much more dramatic. I know it’s anecdotal, but I see this often.

    The USPTF did not include a single breast radiology or surgical expert. Dan Kopans, one of the major figures in this field and based at MGH, was interviewed on CNN after these recommendations came out at stated that he knew all of the major experts in the world in this discipline. He did not know a single person on this committee.

    They did not clearly evalute the relatively new data regarding the added benefit of digital mammo in younger women with dense breasts. It is very rare in civilized metro areas for a women to undergo surgery now for an imaging or clinical finding. Almost all findings are evaluated with a needle biopsy which most patients (especially the younger ones) sail through and are back to working out the next day. Benign needle guided biopsies just don’t cause much harm. Patient anxiety is an issue, but not as often as you might think. Are we really damaging society by sampling multiple likely fibroadenomas with a needle to try and catch a breast cancer in a woman with pre-teen children?

    Sure, it is reasonable to ask, do these detected findings in younger women matter to the population as a whole? or change outcomes?

    Two groups of people with different bias can come to different conclusions over a set of data. Two different groups can interpret data differently, especially given experience (or lack thereof).

    Finally, as we all know, if you want to reduce false positives among all fields, reform the medical liability system.

    • Sharon MD

      They didn’t include an oncologist or a breast radiology expert because oncologists and radiologists are not experts in screening a healthy population. The panel is made up of epidemiologists and primary care doctors who specialize in early detection (in those cases where lives are saved and morbidity is decreased) and in preventive care. I find the guidelines have more credibility because the experts are not the ones that see 40-year-olds with breast cancer all the time. Regardless of financial incentives, those cases are likely to haunt anyone in the field and subtly influence their decision-making.

      If we’re talking about treatment guidelines for women with breast cancer, or about which imaging techniques to use, I absolutely want the experts (oncologists and radiologists, who consider individual patients) involved. When we’re talking about screening and prevention, I similarly want the experts (preventive medicine docs and epidemiologists who consider the entire population) to be the ones who make the recommendations. Screening and treatment are two very different things, and I think each is left to

  • Drew

    Is the ‘selling’ of unnecessary check-ups by doctors limited to just mammograms?

    • Anonymous

      As far as check-up frequency goes, there seems to be surprisingly little consensus about how often one should visit the doctor for check-ups, other than to get recommended screening tests or if one has a condition that requires monitoring at a specified frequency.

    • BD

      >>Is the ’selling’ of unnecessary check-ups by doctors limited to just mammograms?>>

      No. Pap smears are just one example.

  • BD

    >>Sure, it is reasonable to ask, do these detected findings in younger women matter to the population as a whole? or change outcomes?>>

    These are precisely the questions that interest me. Early detection is meaningless if it doesn’t change outcome. It’s actually harmful if it results in treatment of neoplasia that may either regress spontaneously or behave, biologically, in such a manner that survival time is increased only by earlier detection, not by actual treatment.

  • Tex Bryant

    I briefly reviewed the statistical data on the AHRQ website as reported in the Annals of Internal Medicine. One thing stood out–biennial testing achieved 81% of the effectiveness of annual testing with less than half of the false positives. In my opinion, a 19% reduction in detection effectiveness is large, even if false positives are greatly reduced. As DJ reported, a needle biopsy will certainly ascertain whether the mammogram was a false positive or not, and with very little resulting complications either medically or to resumption of normal activity.

    I do think the statement by Dr. Diana Petitti–”So, what does this mean if you are a woman in your 40s? You should talk to your doctor and make an informed decision about whether mammography is right for you based on your family history, general health, and personal values.”–is the correct conclusion of this report. It is between a woman and her doctor.

    • Healthcare Observer

      ‘It is between a woman and her doctor.’

      No one is disputing that anyone can’t go and pay for a test themselves if they so wish. The question is whether 100% screening of a huge, healthy population is advocated for this group on the basis of current evidence. The answer is no.

  • SarahW

    Doctors should be offering, and explaining the downside as well as the upside.

    To do otherwise is to fail at doctoring tailored to individuals.

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