Mammograms: Breast cancer screening as an individual patient decision

Mammograms: Breast cancer screening as an individual patient decision

In a major cancer screening development, a study from the British Medical Journal found that an annual screening mammography didn’t result in a mortality benefit:

Women screened annually by mammography for 5 years had had a breast cancer mortality hazard of 1.05 compared with the control group during the screening period. During follow-up for a mean of 22 years, the mammography group had a breast cancer mortality hazard of 0.99 versus the control group. Neither value was statistically significant.

Worse, mammograms overdiagnosed cancers, leading to unnecessary mastectomies, radiation therapy and chemotherapy: “After 15 years of follow-up, the mammography group had an excess of 106 breast cancers attributable to overdiagnosis.”

Undoubtedly, the media will be all over this one.  It’s already the most emailed article in the New York Times.  What does this mean for patients?

Mammograms are slowing approaching PSA territory, where PSAs also show no mortality benefit, and cannot predict which cancers are dangerous or not.  Physicians soon will encounter similar issues when discussing mammograms with women as they do with discussing PSAs with men.

The USPSTF currently suggests annual mammograms starting at age 50 and a discussion of mammograms starting at age 40.  Will these recommendations change?  Probably not immediately.  Guidelines normally take a few years before adjusting to disruptive study findings.

But as we’ve seen with other screening tests, it’s difficult to reduce cancer screening once the proverbial cat’s out of the bag.  Consider this comment from the Times article, which is representative of a significant proportion of women:

I’m a creature of the baby boom generation, trained to have my baseline in my early 40s, and annually after that. Because I have certain health issues based on early menopause–as well as a strong family history of cancer — I will continue to follow the “old” guidelines (being debated and revised as I type).

Another factor left out of this study, and indeed the whole discussion which is emotional, political, and deeply personal, is the plight of women with dense breasts who find it hard to do monthly self-exams. There is a certain security in knowing each year that there have been no changes on my films from year to year.

No nothing is certain in life. But my comfort level is exactly that: my comfort level. So until they tell me screenings are 100% harmful, I will continue to have them.

You will undoubtedly hear many stories of patients who would rather be 100% informed and risk overdiagnosis than live with the unknown.  Peace of mind cannot be quantified, yet still has value for many patients.

My approach?  Same as always with cancer screening issues shaded in grey.  Make mammograms an individual patient decision.  Inform patients of the USPSTF recommendations and the results of the BMJ study, then get a sense of their values and how important it is that they know their breast cancer status.

Then make a shared decision whether to order a mammogram or not, which may be different for each individual patient.

Mammograms: Breast cancer screening as an individual patient decisionKevin Pho is an internal medicine physician and co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is on the editorial board of contributors, USA Today, and is founder and editor, KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • southerndoc1

    “Make mammograms an individual patient decision”

    But physicians will continue to have their pay reduced if they fail to hound a sufficient number of women into having a screening done that may be harmful to their health.

    Makes sense to me.

    • Kristy Sokoloski

      But in the end it is still the patient’s decision on whether or not they want to have the mammogram done. And of course one of the things that many patients get told (especially if they have a family history of breast cancer) that mammograms save lives. Well, as we can see that’s been a matter of opinion and now the opinions are starting to change. But family history of breast cancer or not we as women are prone to getting breast cancer. One year I had a mammogram that came up as abnormal because of some density. But it is normal for younger women to have dense breasts. At least this is the way I understand it. Well, with the mammogram I just had not too long ago it came back normal. Yes, I have a first degree relative that had breast cancer but several years ago I refused to get a mammogram. My doctor at the time was like “aren’t you concerned about this since you also have a family history” and the answer is no. Because like I say family history or not I am at risk for getting breast cancer.

      Linda McCartney (the second wife of Paul McCartney) did all the right things: eating right (including cutting out animal products and some other things that I can’t remember), exercising, had regular mammograms but she still got diagnosed with breast cancer. She went through all the treatments to try and get the breast cancer in to remission, and she still ended up dying of breast cancer.

      • southerndoc1

        “But in the end it is still the patient’s decision”
        Exactly. Which is why pay-for-performance scams are the exact opposite of patient-centered health care.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          NQF 0031 – Breast cancer screening (included in MU1, MU2, PQRS, HEDIS, VBPM)

          …and this is how things work at NQF (brand new article today) http://www.propublica.org/article/payments-to-ceo-raise-new-conflicts-at-top-health-quality-group

        • Kristy Sokoloski

          I agree with you about the pay for performance scams being the exact opposite of real-patient centered healthcare. Now with that said how do we as the patient make it understood that this is our decision to make but yet we are not going to sue them for the fact that we made a particular choice.

          Based on the statistics just how many lives vs those whose lives are not saved even though they had the screening? From what I am seeing the statistics are pretty even. If someone told me that the number of lives saved outweighed the number of deaths from cancers such as Breast Cancer then I could understand. This discussion not only about this but the issue of annual physicals and wellness exams brings me right back to my question of how does it benefit those that have chronic illness? The reason I ask this is because those with chronic illness are not well and when they see the doctor it is for sick visits not well visits even when they go in for a check-up such as an annual physical even though it is billed to the insurance as a well adult or well baby/child visit.

      • querywoman

        Paul’s mother also died of breast cancer. The causes of breast cancer are still unknown. But I wonder if he was attracted to a breast cancer susceptible woman like his mother?
        Who knows?
        Vegetarian meals are not necessarily right. I have food intolerances including all legumes and many grains. I tolerate meat better than many plant foods, though sometimes the though of meat really grosses me out!

        • Kristy Sokoloski

          That’s interesting about Paul’s mother dying of breast cancer. So for sure he has a family history of it and of course so do his kids by virtue of the fact that she had it and died.

          I also agree with you that vegetarian meals are not necessarily right. And one reason why I agree with you on this is because sometimes we can miss out on very important vitamins and minerals. Unfortunately, you have too many people that think that it is the only way to go at trying to prevent cancer of any kind breast being just one example. But you have made an excellent point that not everyone can benefit from an all vegetarian or vegan type diet. I am with you on that. I would not be able to handle it. And I definitely understand about the food intolerances as I am allergic to peanuts. Because of that allergy I also stay away from tree nuts. Of course that now means I have to carry an Epipen with me to be on the safe side.

          • querywoman

            In all the unknown things of life, was Paul McC attracted to a woman like his mother, who would also develop and die from breast cancer? I’ve always been fascinated by that. How long did treatments prolong, or did they prolong, the lives of his mother and wife?
            I’m not so bad that I need an Epipen. My younger brother’s throat closes when he eats some foods, so I do know that I need to be careful.

  • Steven Reznick

    Patients deserve to know the facts and make the appropriate informed decision. As clinicians we discuss mortality as the endpoint but what about options for treatment and their effect on quality of life? If you accept the hypothesis that mortality was no different in the mammogram group and the control group what about the need for major surgery vs lumpectomy? need for reconstructive surgery and or use of radiation? The answers to mammograms effect on these choices and the quality of life for the patient during the time they are fighting the disease are worthy of discussion and consideration and are not discussed in this article.

    • Jewel Markess

      “need for major surgery vs lumpectomy” is important, but it needs to be balanced by overdiagnosis which is “need for lumpectomy/mastectomy/treatment” vs nothing. Not having a diagnosis of cancer = much better quality of life than having this diagnosis.

  • Lisa

    This study, in my opinion, illustrates the myth of early detection. Finding smaller and smaller breast cancers does not mean that fewer women die from breast cancers, it means that more women are treated for breast cancer. I believe that the research dollars need to be spent on determining which cancers are life threatening and which are not, which tumors need to be treated and which do not.

    Since my breast cancer diagnosis, I’ve alway wondered what would have happened if I didn’t have the mammogram that led to my diagnosis. Would my non aggressive tumors eventually become large enough to be felt, would they have spread beyond my breasts or would they have remained local and not caused me any problems? I wonder if I was over treated. The problem is, given the current understanding of breast cancer, you don’t know which cancers need to be treated so you treat all of them.

    • Suzi Q 38

      Sounds like me. Some cancers are tiny and would take years to grow and become troublesome or deadly.
      I think about all the hysterectomies that are done to women who should have been presented with other options.
      Ditto for prostate cancers.

      • elizabeth52

        With more sophisticated screening machines we’ll be finding smaller and smaller things. That gives me a sinking feeling even more women will be over-diagnosed, but of course, we’ll call it “early detection” and “catching it early”.
        Hysterectomies…the States have a problem there, 600,000 are performed every year, 1 in 3 will have one by age 60, more than twice the rate of countries like the UK, Australia, The Netherlands and others. I know some believe it’s the American obsession with the routine pelvic exam, which is not recommended in many other countries. I’ve never had one and would run at the very suggestion.

        • Kristy Sokoloski

          The issue of overdiagnosis of cancer is already happening right now when it comes to the issue of breast cancer. That’s one reason why the definition of what is considered “cancer” has to change. And I recently read somewhere (can’t remember where right now) that very thing is being looked in to right now.

          And as far as the issue of the pelvic exam, well, I made the decision last year to cut out my well woman visit. I am sure my gyn is not too happy about it but oh well.

  • betsynicoletti

    Frankly, I find this good news. I don’t have to take a half day off for a screening. The only thing that would be better is if they now said colonoscopy, instead of saving lives, was a waste of time. I’m not holding my breath for that.

  • buzzkillersmith

    Whether testing makes scientific sense is only one factor in decision making. I lament that, but it is true.

    I’m over 50 and have never had a screening PSA and I never will, unless the evidence ( and not some bonehead urologist!) says I should. I hasten to add that not all urologists are boneheads, just the ones I know.

    I might die of prostate CA without screening, but if I do, I would probably have died of it with screening anyway. I have had a screening colonoscopy, however.

    People’s understanding of scientific medicine, which is what we have tried to practice over the last 100 years or so, is rudimentary at best. Hell, people’s understanding of multiplication is not all that solid. I except those who read this blog, enlightened folks all.

    A number of years ago a Virginia doc, a Dr. Merenstein, was sued for following USPSTF and ACP guidelines on prostate CA screening. Kevin posted on this back in 2004. The doc lost the case because the “standard of care” in his area was to order the test and not waste time discussing the pros and cons. Scientific evidence and standard medical recommendations be damned.

    Not that standard medical recommendations always or even usually have a scientific basis. Medicine is of course an intellectual and scientific mess (psychiatry anyone?), but this particular study is about as good as it gets, and that’s very good indeed.

    Ordering of this lousy, worthless test will likely decrease in the future, but it’s going to take some time and might not even happen to the extent that we would hope. As all the XYs here know, women can be very persuasive.

    • Lisa

      RE: women being persuasive – I absolutely hate it when I hear women, particularly those diagnosed withDCIS or early stage breast cancer, state that having a mammogram saved their lives. Who knows if their lives were saved (I tend to doubt it), but those women are convinced and become part of the pro-mammogram lobby.

      • buzzkillerjsmith

        The saying in medicine is “true, true, and unrelated.” You had a mammogram: true. You did not die of breast CA: true. But are those 2 things related?

        The statisticians tell everyone they know about this: “Correlation does not prove causation.” I hear they say this in their sleep.

        But try explaining that in a soundbite on national tv

        • Lisa

          In my experience, many doctors do not understand statistics. I remember trying to explain to a my oncologist that the probability of either of one of two independent events occurring is not additive. My husband also tried without success. So you are right – explaining that correlation does not prove causation in a soundbite would just be an exercise in frustration.

          • buzzkillerjsmith

            Many docs have only rudimentary quantitative skills. All it takes to get into med school is a semester of calculus. The Univ. of WA doesn’t even require that, and it does not require a statistics course. They teach a dumbed-down biostats/epidemiology course and call it good.

            There are a fair number of engineering, chemistry, and physics majors who go to Univ. of WA med school and they get it of course. But the biology majors aren’t too good. The ones who majored in psych or English or whatever are hopeless–and they talk too much.

          • Lisa

            I am a financial analyst. I took several statistics courses; I remember a fair amount. But I always call a friend who is an applied mathematics prefessor if there are lapses in my memory.

      • elizabeth52

        Second only to the HUGE number who think they were saved by a pap test. of course, that’s impossible given the cancer is rare and carries a 0.65% lifetime risk. Here in Australia thanks to serious over-screening, the lifetime risk of referral for colposcopy/biopsy is a huge 77% and many will be “treated”. It’s the program that is causing the problem, not the cancer. How is it helpful or good medicine to deceive women in this way? So many go on to consider themselves survivors from this mythical epidemic.
        The dead giveaway is when a young woman says 4 of my friends have had cc, umm, highly unlikely, over-treated, VERY likely. 1 in 3 pap tests are “abnormal” in those under 25 even though the cancer is VERY rare in that age range, and rare in all age ranges. At this rate we’ll all be survivors, aside from those of us who’ve chosen not to screen and stood firm in the consult room.

  • Anne-Marie

    Even when you factor out the incentive payments, a tremendous number of doctors seem to believe fervently in the power of mammograms to save women’s lives, almost as if the technology were some kind of magic talisman.

    Sure, we have the right to say no, and the evidence supports that opting out of the screening is not unduly risky. But a lot of doctors still push the message, implied or otherwise, that the only right decision is to be screened. And that attitude tends to be promoted in the advertising and awareness campaigns, even from reputable medical institutions.

    It is very hard to get people to look at this issue more rationally.

    • southerndoc1

      “Even when you factor out the incentive payments, a tremendous number of doctors seem to believe fervently in the power of mammograms to save women’s lives”

      No, a tremendous number of doctors fervently believe that they’ll get their asses sued off if they don’t order a mammogram on every female patient between 35 and 110.

      Most docs are quite aware that screening tests are as gray as dishwater.

      • Anne-Marie

        True enough, but that is often not the message being given to patients. My primary care clinic continues to push annual mammograms starting at age 40, and recently hosted a big ad campaign trumpeting the addition of walk-in mammograms.

        Here’s a direct quote from their website: “Mammograms are the single most important method for early detection of breast cancer… Don’t put it off. Take responsibility for your well-being.”

        If that isn’t coercion, then what is it? If most docs recognize that the benefits are ambiguous, then why aren’t they more up front in saying so? Do they think we’re too dumb or too easily scared to handle the truth?

        • buzzkillersmith

          Sad to say, but a lot of pts are too dumb or easily scared to handle the truth. I have seen literally other thousand of people like that. Not you, but other pts. Not most pts, but a lot of them, especially is certain areas.

          Following a doc around in the clinic might be an eye-opening experience for you. Maybe not a good experience, but an eye-opening one.

          That said, unless they change their website, your primary care clinic is run by lunkheads who don’t keep up with the literature. Sometimes the pt is not the true lunkhead in the exam room.

          • Anne-Marie

            Yeah, I hear you. I work with the public a lot (not in health care though), and the deficiencies in people’s critical thinking skills are often painfully apparent, to put it diplomatically.

            My guess is that much of the stuff that appears on provider websites is probably written by nonclinical PR types and/or has been distilled down to the lowest common denominator.

            Like I said above, it’s hard to have a rational conversation that balances cost, benefit and harm… especially when the conversation is continually dumbed down. But how do we ever come to a better understanding about harm vs. benefit if we DON’T move the discussion to a higher level?

          • buzzkillerjsmith

            I’m not sure who writes the website stuff at CorpMed, but in small groups it is the docs. We edit the stuff at our website. A lot of it is off-the-shelf, but we look it over carefully. If your doc’s group is small, don’t let it off the hook.

      • Kristy Sokoloski

        If I as the patient choose not to get the annual physical or well woman visit and the screenings associated with the visit that is my choice. I would not sue the doctor because that’s a choice I made. I understand that the doctor may not realize that I am not one of those types, but because it’s me that makes the choice if there’s a consequence because of that choice I am the one who must live with it. That is not my doctor’s fault because I choose to say no to these “necessary” exams and screenings that come with it.

      • querywoman

        Fear of lawsuits doesn’t impress me. I have never seen a single doctor who was afraid that I would sue him or her for neglecting my serious skin disease.

      • querywoman

        How many docs actually get sued?
        I think a tremendous number of women are afraid of dying and actually believe mammograms will “save” their lives.
        No doctor “saves” a life. Doctors only prolong life.
        I remember one doctor who asked me, “Do you want to die?” when I refused a mammogram.
        I told her I was going to die.
        She was a pretty good internist who helped a lot of people. Sadly, she has already died, at a younger age than whenever I will die, of ovarian cancer.

        • Suzi Q 38

          My 100 year old aunt outlived both her PCP’s.

          • querywoman

            Ha! And modern medicos don’t know why certain people live so long. Why did medical treatment “save” Nancy Brinker from breast cancer and not her sister, Susan G. Komen?
            My father’s last surviving sister just celebrated her 97th birthday. She’s been diabetic and frail for years, but functions well except for her hearing. She lives with her daughter.
            Current American medicine revolves around, “Don’t do this, and you’ll live longer.” If they could unlock the magics of stamina and will to live, they could really do something.

          • Suzi Q 38

            George Burns used to answer this question with a “joke.”
            The question was: “What does your doctor say about your smoking?”

            “I don’t know,” he would say…”because he’s dead.”

            I used to see one of her doctors on my sales route. He died in 1986. The second one died in the early 90′s. When the second one died, his son took over his practice, so she is has the second generation physician as her doctor now.

            I talk about her in the present, but sadly she died on January 30, 2014. I miss her greatly, as she was someone to be loved and admired.
            She drove until age 99 and worked until age 85 (full time).

            Her centennial birthday celebration was in July.
            It was as if she was determined to make it to her 100th birthday. Soon after, she started having heart problems and pneumonia.

          • querywoman

            I treasure my elderly aunt as much as you do yours. I asked my father, who was the baby, once before he died, “I wonder if you’ll live as long as her?”
            He said, “I hope not.”
            His lights went out at 85. That was a very long life, too.
            If docs could find the “essence of longevity” and bottle it up and inject us with it, they might really be on to something.
            Sometimes diabetics outlive other people because they go to their docs for more routine maintenance. That’s true in my aunt’s case.
            She has three daughters who know they are sooo lucky!

          • Kristy Sokoloski

            Suzi Q,

            My maternal grandmother lived to be 91 1/2 years old. She died in Sept 2000. She did not go through all of these various screenings and such like we have now. And for a good number of years I went through the physicals and such because that’s what I thought I was supposed to do, but yet no one ever really explained to me why it was necessary. Unfortunately, as is the case with a lot of things in life it is a matter of opinion. And those change as quickly as we change clothes every day it seems.

          • Suzi Q 38

            So true.

            I thought I was so smart, doing everything the doctor said to do, including my surgeries.
            I realize now that we have to be very careful these days, as sometimes surgeries and tests are not always necessary.

            Remember all the “lawyer” jokes?
            Our attitude about doctors have changed so much that soon we will also have a list of doctor jokes.

    • guest

      “Incentive payments?”

      Would you care to provide any data to support the assertion that your typical PCP gets an “incentive payment” to recommend mammography to patients?

      • Suzi Q 38

        Please clarify “incentive payments.”

  • Suzi Q 38

    I was supposed to get my mammogram last month.
    I think I will wait a few months longer.

  • querywoman

    Isn’t Medicare also promoting mammograms? I need to write the feds to complain.

  • elizabeth52

    Yet another study basically saying the same thing, little benefit with significant over-diagnosis. The Nordic Cochrane Institute, an independent, not for profit, medical research group, came to that conclusion over a decade ago. Their website has a rare summary of all of the evidence, the actual benefit and risks with mammograms. The NCI say that 50% of screen detected breast cancers are over-diagnosed and any benefit of screening is wiped out by women who die from heart attacks and lung cancer after treatment. (Professor Michael Baum also, did an article last year in the BMJ concluding the risks of screening exceed any benefit when you factor in deaths caused by treatments)
    Interesting the same people, who in my opinion, have a vested interest in screening, try to discredit anything that might threaten the screening program. It sounds like they’re protecting screening, not women.
    Here we’re told the study is flawed, does not apply to Australia, it’s only one study (it’s not, it’s one of many) and they focus only on those studies that support screening, cherry-picking research. These people will say anything to protect their turf, a fortune is made from screening. The cherry-picked studies have been discredited by the NCI long ago.
    I’ve declined breast screening. The discussion here is only just starting with most women still in the dark and Breast Screen still pushing for their target.
    There is a shocking lack of respect for women in cancer screening, no real information is provided, we get a one-sided sales pitch and are just expected to screen. There is no respect for informed consent, a legal and ethical requirement for all cancer screening and in my opinion, vested interests influence/control and protect these programs. (and benefit from them)

  • querywoman

    Perhaps we should stop glamorizing women who have had breast cancer treatment. Lots of other patients have had treatment to help them survive major illnesses and get no deification.

  • querywoman

    I went to a gyn for the first time in years today. I went to an older kindly male one, who no longer delivers babies. I’ve been to some really awful female ob/gyns. He said, “That’s too bad, since I trained some of them.”
    I have always refused a mammogram. Of course, he wants me to have one since they have picked up stuff he has been unable to feel.
    We discussed the Canadian study some. I even told him about a letter to the editor that one woman wrote the New York Times about her mother having had a stroke and died when she got a breast cancer dx. Of course, he thinks those tiny suspicious lesions found on mammograms aren’t being over-treated.
    What do women have to do to get our viewpoints heard? Why does being a woman in the the US mean that we must squeeze our breasts into plates and get radiation nuked?
    I saw one study that said white women are the most likely to get dx’d with breast cancer. They are probably also the most likely subjects to be coerced into mammograms.

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