Save mammography or save women? Supporters face a quandary.

Sometimes, we play a little politics on this blog.  I am a student of current events and enjoy following the dysfunction and absurdities in American politics.  To paraphrase the legendary former British prime minister, “never has so little been done by so many to benefit so few.”

Readers know how skeptical I am about medical dogma.  When I was an intern a quarter century ago, I didn’t grasp why routine measurement of prostate specific antigen (PSA) was standard medical practice since it was true back then that more men were harmed than helped by its use.

A recent study in the British Medical Journal (BMJ) has concluded that mammography does not save lives.  This study will become political dynamite as breast cancer is as much a political issue in this country as it is a medical subject.  Remember mammogate?

I have no agenda here beyond a search for the truth.  I favor any reasonable endeavor that will prevent disease, treat illness effectively and deliver comfort.  If persuasive scientific information informs us that a medical treatment or test is not effective or is harmful, our reaction should not be to attack the test as flawed.

We should also note if the criticizers have a personal stake in the test’s survival.   When colonoscopy is supplanted by a better test — which it will be — gastroenterologists will need to separate our own interest from the public interest, in accordance with our professional ethical standards and the oath that we all took.

This new view on mammography emerged from a randomized trial, which is a rigorous method of scientific study.  Ninety thousand women participated.  When there are a large number of subjects in a medical study, it strengthens the conclusions for mathematical reasons. This is why investigators strive to recruit a large number of patients in their studies.

The BMJ study concluded that women who underwent mammograms had the same death rate from breast cancer as women who only underwent breast examinations.   Additionally, “non-invasive” mammography led to unnecessary invasion on many women.  Twenty percent of cancers found were felt not to be a medical threat and yet led to surgery and other unpleasant treatments.

Even when prior mammography data is viewed in its most optimistic light, the benefit to an individual woman is extremely modest.  This point is so often misunderstood by even an informed public.  When a study performed on a large population shows a 10% benefit, for example, the benefit to an individual participant may be trivial.  This is why headlines such as, “New Drug Strengthens Bone Density by 20%,” are so deceptive.  Patients need to know what the benefit of a particular treatment is for them, not for a large study group.

Get ready for the mammography zealots to mobilize for their three pronged approach: pitchforks, placards and protests.

My question for them is do they want to save mammography or save women?

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower

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  • John C. Key MD

    Lies, damned lies, and statistics. Is “death rate” a meaningful yardstick for evaluating all of mammography? I think not–such a conclusion oversimplifies. Breast cancer causes much worse outcomes than death–ever see anyone with extensive local disease?

    In your own field, gastroenterology–back in the 70′s we struggled to get GI bleeders scoped to tell where the bleeding was coming from. “You don’t need it” we were told; “it doesn’t affect mortality.” It sure helped the operating surgeon find the bleeder, though. Would anyone operate on an upper GI bleeder today without endoscopy?

    Call me a mammography zealot if you wish, but just because having a big statistical study doesn’t make it “settled science”.

    • Gibbon1

      I think the two options in the study were, lets not forget, mammogram + manual exam _or_ manual exam alone. Not no surveillance. What it says to me is mammograms add little or no value over a simple manual exam.

      If that’s true it’s depressing because less progress has been made than assumed. Although progress has been made, just not from x-raying boobs. Yet good because seriously it’s a whole bunch of expense, lost productivity, and annoyance that we can avoid.

    • querywoman

      I maintain better treatments, not more mammograms, have increased breast cancer survival. So does Dr. H. Gilber Welch.
      In my experience, the medical profession/establishment does not like to be questioned. That’s unlike other schools or learning.
      Why, just because I am a woman, am I expected to regularly squeeze my breasts between plates and get intense, potentially damaging, lights shot at them?

  • SpringTexan

    I love this column and hate Dr. Key’s reply. He is right about extensive local disease; but as long as local disease is treated when it first manifests and people don’t ignore lumps, puckering or symptoms, we will still not see extensive local disease.

    I remember watching the Lifetime TV show Women Docs years ago and blithely seeing double mastectomy recommended — and done — for DCIS. I’ve seen how surgery, reconstruction, radiation and chemo affect people. Not to deny their usefulness — but mammography outcomes of a small death benefit and tons of overtreatment is not on balance kind.

    Overtreatment in breast cancer has been a curse from the days of the radical mastectomy and its bad effects are as genuine as bad effects from disease.

    We have good breast cancer treatments but both too much and too little are a problem — and mammography by and large leads to TOO MUCH treatment.

    • Kristy Sokoloski

      I remember that show Women Docs and loved it. Hard to believe that a lot has changed in the nearly 15 years since that program first aired.

  • Markus

    Dr. Key:
    Please recommend some studies on mammography that I should be reading. I am interested in some objective assessment of the benefits. From your note, I gather that mortality is not one of those benefits. Do screened populations have benefits in terms of less surgery, less other treatments, or fewer costs?

  • NormRx

    I have a 79 yo female friend. She hasn’t been to a doctor since the birth of her second son. This is over 40 years ago. No mammography, pap smears, cholesterol levels, blood glucose or blood pressure measures for her. I think fear of finding out that something is wrong is driving this decision. This woman loves to go to the casino, attends all of the neighborhood parties and is just a wonderful person to be around.

    • querywoman

      She sounds much healthier than my deceased brother, who was a noncompliant diabetic, who died after struggling for years with three amputations, and stroke/heart attacks. My mother and I speculated he was afraid something would be wrong with him.

      Some people don’t need health care.

  • EmilyAnon

    Confused lay person here. When I read “Twenty percent of cancers found were felt not to be a medical threat and yet led to surgery and other unpleasant treatments.”, doesn’t it then follow that the other 80%, or majority of cancers found, were a medical threat, therefore a good thing they were discovered?

    • Gibbon1

      I think the argument is what is the difference based on when they are discovered. And does a screening mammogram give you any edge.

      I think if you schedule mammograms far apart you miss most of the seriously malign cancers. Thus mostly catch benign tumors and low grade cancers early. Catching benign tumors early is counter productive. Catching low grade cancers early maybe buys you nothing.

  • Shirie Leng, MD

    Thanks Michael, I agree, but you can’t win on this one. People are not swayed by “data”, unfortunately.

    • MKirschMD

      Appreciate it, Shirie. Not only is there a fair amount of zealotry out there on this issue, but there are also huge economic forces that are in play here.

      • Patient Kit

        I get that this is a very controversial issue. But are you saying that people who believe in cancer screening for early detection are zealots and those who don’t are sensible? Are you saying that the whole concept of cancer screening and early detection is a scam? As a woman who was diagnosed with early stage ovarian cancer this year, are you saying that I should not have had surgery? That we should have waited to see if my cancer spread before doing anything? Really, my head is spinning trying to understand.

        • EmilyAnon

          I seem to be hearing from comments here that if the patient didn’t detect early symptoms they were lucky, and doctors that dismissed early symptoms were wise, even though cancer was discovered later at an advanced stage the end result would be the same. I also have ovarian cancer, stage 3C, and am totally confused. If I wasn’t a 10 year survivor, I could easily feel like a sap right now for suffering through all those scans, surgeries and chemos.

  • betsynicoletti

    As a consumer, if the survival rates are the same for mammography and breast exam by a health care professional, the choice is pretty easy.
    In a recent discussion on this topic, one physician noted that his quality scores would decrease, because a lower percentage of his patients would be meeting the standard of having a mammogram. My own insurance company has sent me two letters in the past five years, admonishing me to get a pap smear. Hmmm. They forgot they paid for my hysterectomy (sorry for TMI) twenty years ago. Now, my primary care doctor doesn’t “forget” that I don’t need a pap smear when he sees me. Both times, I replied with a snarky letter, copied my PCP and told the “quality nurse” that my health care decisions were best left between me and my doctor.

    Dr, Kirsch, how soon for colonoscopy alternatives, we’d all like to know.

  • Lisa

    I agree with you 100% about the down playing of over diagnosis. Surgery, radiation, and anti hormonal drugs are the most likely treatment for in situ cancers and non-agressive cancers. They can have serious side effects. Five years after a mastectomy for I have issues with chonic pain. I also had serious side effects (cataracts, trigger fingers, joint pain) due to the aromatase inhibitors I took as part of my treatment. At least I can console myself that the mastectomy was medically necessary as I had multi-centric invasive ductal carcinoma.

    I see many women with DCIS having bilateral mastectomies and reconstruction. It is infurating, to me, as I know that many of these cases of DCIS would not become invasive. Until we have better way of determining which cases of DCIS are likely to progress and become invasive, I think the search for smaller and smaller lessions is harmful to women.

  • Kristy Sokoloski

    That is a matter of opinion that mammography saves lives, just like when someone says that other types of screening tests for other types of cancer saves lives. The family who lost a loved one to cancer will often have a different opinion. Because they will want to try to understand how it is that even though their loved one had gone through the routine screenings, got diagnosed early, went through the treatments (which don’t always work for some people) may have worked for a while and then the cancer became immune to them so then metastasized and then died had then died. As a result of this they are going to form a different opinion of the screening exams.

    It is also a matter of opinion that annual physicals and well women exams save lives. Nothing wrong if someone wants to have that opinion, but why is it that if someone has a different opinion about these kind of exams and routine screenings for cancer they are considered to be in the wrong? That if they don’t follow what society feels is necessary for good health that they don’t care? Same thing if someone diagnosed with cancer then makes the decision to refuse to treat because it is just too costly even with insurance covering a bulk of the cost. And then when the medical bills start piling up because they can’t afford to pay them then they end up being told by the healthcare system “I am sorry but we can no longer care for you now because you haven’t paid your portion of the bill aka coinsurance”.

    • Lisa

      There are enough studies out there that indicate screening women for breast cancer will reduce the number of women who die from the disease. Most of the arguing is about how much screening is appropriate, and how balance the benefits agaist the harm.

      The only way you can say that it is a matter of opinion that mamorams save live is when you are talking about an individual. I hate it when I hear woman, particularly those who have been diagnosed with in situ cancers, saying that their mammogram saved their lives. The odds are very, very high that the mammogram had nothing to do with saving their lives.

  • NormRx

    Jean, I never said there was anything wrong with that. I personally don’t care what others do regarding their health care. Her decision appears to be working well for her, but I can also give examples of people who never go to a doctor and died at 50. We have both extremes, people who live at a doctors office and those that never go, I am somewhat in the middle. As far as the comment about her fear of finding out something was wrong, this was a comment she jokingly voiced, so I think there was a little truth in it.

  • Lisa

    I don’t think ultrasound works that well as a screening method for large numbers of women, just because an ultrasound on both breasts is very time consuming. And I’ve seen studies that indicate thermograpy doesn’t work at all.

  • Lisa

    I don’t know who funded the studies on thermograms, but if they worked I think radiologists would be pushing them as much as they do mammograms.

    I can understand why concern over radiation can be a deal breaker when you are talking a bout mammograms.

  • Patient Kit

    I was diagnosed with early stage ovarian cancer a year ago (stage 1a, grade 2, epithelial) and my head is spinning trying to follow the current controversies about mammograms and pap smears and well woman visits and whether any of them are necessary and whether early detection of cancer is a good thing. I spent the last year feeling so lucky and so blessed that my OC was found at stage 1a, not stage 4. I’m having a hard time grasping why that’s not a good thing. Very very confused.

    • JR

      Cells go through a lot of different stages before they become invasive cancer. The early the stage, the more likely it is that your body will clear it out without the need for treatment, especially if it’s “pre-cancer”.

      Pap smears do not detect cancer – they detect cells that look odd. If you have odd cells, then they have to take a biopsy to find out what kind of odd cells are there. Most the time it’s a HPV infection that isn’t cancer, but might become cancer. The best treatment for the earliest stages are to watch and wait, but because of defensive medicine, we’ve been treating women with the earliest stages (not yet cancer). These treatments have a negative impact on the women’s overall health, and can cause future miscarriages. But they can’t stop doctors from treating women who don’t need it and women keep demanding to be treated not truly understanding the consequences.

      Mammograms are really good at detecting slow moving pre-cancers. Most of these small pre-cancers will never advance into full cancer. The woman will never have any symptoms. The woman doesn’t need treatment. But we treat almost 100% of woman with aggressive, difficult treatments. These women think their lives were saved when in reality, many of them would have died without ever having a symptom or a problem.

      I actually had two relatives donate their bodies to science. Because of this we got detailed autopsy reports. Both of them had small cancers. Neither had any symptoms. Neither died from their cancer. If their cancer had been discovered, they would have been treated unnecessarily.

      The conundrum: How do we determine who needs treatment and who doesn’t? We don’t know. That is why it’s so controversial, how do we balance saving lives without harming patients who would never need treatment?

      • Patient Kit

        I do understand that this is a complex issue with no simple answer. I understand that some dx results in treatment that could be worse than the disease. I understand that there are many different kinds of cancer. I even understand that ovarian cancer can recur even once a woman’s ovaries are removed. But are you saying that the whole concept of cancer screening and early detection is a scam?

        • JR

          I wouldn’t call it a scam. It’s just that we create treatments with certain assumptions, then they don’t hold up under close scrutiny.

          There are lot of things that seem good: Monitors that monitor brain functioning to make sure you don’t wake up during surgery. Oops – they don’t actually reduce the number of people waking up during surgery like we’d expect. Fetal heart monitors to tell if an infant is in stress during delivery so an emergency c-section can be performed. Oops – they don’t actually lead to better outcomes for women or babies and increase the number of c-sections, perhaps evening causing more harm then help.

          None of these things are done with malicious intent, it’s just that as we study them we begin to question “are they as good as we thought they would be?” However, once they get into place as a “standard of care” the belief that they are effective becomes entrenched.

          People tend to remember positive correlations better than negative ones. For example, if you go to get your palm read and get 5 predictions, and 2 come true, that’s a pretty lousy outcome. But people remember the 2 things that came true and forget that they predicted 3 things that didn’t (per research into this area). That’s why studies are so important to determine if logical sounding treatments really hold up under scrutiny.

    • MKirschMD

      I’m glad you’re ok. My point is that folks who undergo a screening test should be informed of the proven benefits and the potential drawbacks. In my experience, the benefits of many screening tests, including mammography, are exaggerated while the risks are diminished. Can’t give informed consent if you are not truly informed.

  • drjoekosterich

    Trust the mammography industry to do everything it can to save itself.

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