The benefits of screening mammography have been greatly exaggerated

When first introduced four decades ago, breast cancer screening with mammography was widely regarded as an important tool in the fight against this terrible disease.  It seemed obvious that the earlier it could be diagnosed the more lives could be saved. Aggressive treatment, it was thought, would prevent the cancer from spreading through the body.  A huge amount of research evidence since then has slowly and painfully led to a different conclusion.

It is now clear that the benefits of screening mammography have been greatly exaggerated and the serious adverse effects all but ignored in the enthusiasm to support breast screening programs.  It’s time for these programs to be reconsidered

It must be emphasized that this is the case for population screening of healthy women, not those with extra high risk factors.

This is a very unpleasant message for modern developed societies where three generations of women have been led to believe that regular mammograms will save their lives and where an enormous related industry has been built up, but it is time to face the facts.

Unscientific opinions and powerful vested interests abound on this subject, so it is essential to focus on well-conducted studies from independent sources to summarize the evidence. One of the most trusted of these, the Cochrane Collaboration, has been studying screening mammography intensively.  Their most recent bulletin states that the benefit of screening 2,000 women regularly for 10 years is that one woman may have her life prolonged. Of the other 1,999 women, at least 200 will have false positive mammograms leading to biopsies and surgery, and at least 10 women will be falsely diagnosed with breast cancer and consequently subjected to unnecessary surgery, radiotherapy and chemotherapy.

This problem, called over-diagnosis, occurs when a biopsy reveals microscopic cells that are currently labeled as “cancer” by the pathologist, but with uncertain potential to cause any significant problem for the patient in the future.  The “c” word inevitably causes fear and distress for the patient and an aggressive treatment plan from the doctors.  This is now widely recognized, even by the USA National Cancer Institute which has recently recommended that these uncertain “cancers” should instead be labeled “IDLE” (indolent lesions) until research can help us differentiate those that need treatment from those that do not.

Now we’ve more evidence.  The Canadian National Breast Cancer Screening Study published in the British Medical Journal, and widely reported in the international media, solidly confirms that there is no upside to breast screening healthy women in terms of mortality benefit in exchange for the downside of all the adverse consequences.  In this study, 90,000 women aged 40-59 were randomly allocated to the mammography screening program or to annual physical examination only, with follow up to 25 years.  The mortality was the same in both groups (500 in the first group and 505 in the second).

Adverse consequences from screening can include false negatives (a cancer is growing but missed by the mammogram), and potentially cancer-causing cumulative x-ray exposure.  Not to mention the anxiety, pain and discomfort that women experience with the procedure and the huge cost of these programs to the health care system.

This new study, along with the Cochrane analysis, represent the beginning of a growing consensus among scientists and clinical epidemiologists that the evidence no longer supports population screening of healthy women with mammography. Several prominent female UK doctors have gone public about choosing not to have breast cancer screening, including the editor of the BMJ, the past president of the Royal College of GPs, and the professor of obstetrics at King’s College London.

Nobody can be happy about all of this disappointing news with its serious public, professional and political implications, but surely we cannot ignore it. The hope that breast screening could cause a reduction in the mortality from this terrible disease was at first well placed 40 years ago, but it is no longer possible to advocate for an intervention that carries such a tiny (if any) likelihood of benefit along with such a huge burden of harmful consequences.

The very essence of science is about seeking truth through the constant cycle of evidence, analysis and revision. In response to a hostile question, John Maynard Keynes famously remarked “When the facts change, I change my mind. What do you do, sir?”  We should heed that lesson here.

It may take a long time to dispel the false hope that has been given to women with mammogram screening, but the very least and immediate response should be the development of a mandatory consent form for women to sign before screening that distinguishes the most recent and overwhelming evidence from the current inappropriate enthusiasm. Women would then be empowered to make an informed choice.

Public health agencies should also consider a comprehensive plan for public re-education about screening mammography, followed by the gradual dismantling of population breast screening programs across the country.

Charles Wright is a surgeon and former chair, Ontario Health Technology Advisory Committee.  This article originally appeared in Evidence Network.

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  • JPedersenB

    Well said! It is going to take a long time and a lot of discussion to change anything in the screening industry as there is simply too much money involved…

    • Kristy Sokoloski

      Yes, I believe that money is a big factor for why the push to have routine screenings and annual physicals and wellness visits. There was a blog entry that got posted here about a year ago discussing whether or not annual physical exams should be devalued. It caused a rather interesting discussion.

    • Patient Kit

      It’s a given that I don’t much trust my health insurance company to have my best interest in mind. However, I do trust my doctors. But if you’re saying that the doctor/hospital side of things is pushing screening primarily because there is a lot of money in it, then are patients idiots to trust our doctors? I realize that we should, and do, think for ourselves. But we also go to doctors because they are well trained in medicine and we are not. I’m all for good patient-doctor communication and making big decisions together. But this whole thing makes it sound like patients should beware of trusting their doctors. I’m not one to blindly trust but can’t we trust anyone at all when facing serious medical issues? Sigh.

      • Lisa

        I think it is foolish to blindly trust doctor’s recommendations, especially when it comes to serious medical issues. I am the one who has to live with the consequences, so I will do enough research to determine if my doctor’s recommendations are good ones or not.

        • Patient Kit

          Oh, believe me, I do a lot of research so I can ask my doctors informed questions and understand what they are telling me. I’m a professional research analyst (though not a medical researcher) so I also take studies with a grain of salt. The first thing I always want to know is who funded the research. I’m also careful about the reliability and agendas of the sources of any info. I do understand that things change and evolve as we gain new info. But I also know that only things that are measurable can be measured. Medicine isn’t all pure evidence-based science. I don’t feel like I’m approaching my medical care from an ignorant, blindly trusting, uninformed place.

          That said, many patients get a serious and scary dx and have to make big decisions under a lot of stress. I will admit that it’s been an emotional year for me because, well, I was diagnosed with ovarian cancer.

          I agree that being an informed patient and a full partner in your healthcare is important. But am I supposed to start from the assumption that everyone in medicine can be expected to put their own self interest before their patients best interests? I guess I just don’t want to believe tha. I want to be able to trust my doctors.

          • Lisa

            I tend to believe that my doctors are looking out after their self interest before mine. But as our interests coincide most of the time, that doesn’t bother me a bit and I am comfortable with it.

            I know what it is like to make big decisions under a lot of stress. The only way I could handle the stress is by doing a lot of research. It made me feel less like I was drowning.

          • Patient Kit

            Sigh. Well, if that’s true — that our doctors look after their own self interests before their patients’best interests — then our healthcare system is in even worse shape than I thought. That is truly depressing. And it is not acceptable to me. And, honestly, I don’t think I’m that cynical at heart. I don’t think I could see a doctor who I didn’t basically trust to put his/her patients’ best interests first. I realize doctors are human. But really? Surely, there is something between ignorant blind trust of doctors and hardcore cynicism about them. Something like an imperfect but good human relationship that we both bring something to in order to build mutual trust? I may not be very cynical but I never thought of myself as particularly naive either. But trust is clearly important to me.

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            Ma’am,

            I can’t speak for most doctors, I’m still only a medical student.

            But from my observations, very few people go into medicine solely for their self interest. We see our peers in college who went into business or the law make far more money working far fewer hours 1 year out of college, while we still have 8 minimum (more like 10 typically) to go before we hit our earning potential. (Yes, not all people going into business or the law have our incomes, but study after study has confirmed what most of us know: the students with the GPAs and drive necessary to get into medical school typically could have done better financially for far less work in other fields) We chose to turn that down and instead work like dogs for 8 years to learn, and then from then on spend sleepless nights worrying if we missed something with our patient, or if we made a mistake- because we want to live our lives knowing we are improving and extending the lives of other people.

            Are doctors biased? Certainly. It is easy to fool oneself into believing that the treatments we offer to our patients help them. Radiologists do not recommend mammograms solely because they want to make oodles of money. They do it because they know the patients whose lives they save- the surgeon or family doctor may well call them up and congratulate them on a good catch. The patients whose lives are harmed, they don’t see as much. This is why we do research to avoid human biases- but that research is incredibly difficult and opaque.

            How much is piece of mind worth? If 1 women’s life is saved (or at least pro-longed for an additional 10 years before recurrence), is that worth 10 women who have to undergo the pain and fear associated with biopsies? How much is our research affected by the fact that the women we are studying had their mammograms and treatment 20 years ago, when technology was worse and when we don’t have the drugs that we do today? There are all judgments that must be made in these studies, and they are inherently incredibly difficult decisions. They are made by guideline committees, and your doctor uses those guidelines along with your wishes and desires to help you decide on a choice that’s best for you.

            And besides- the doctors who are (or are not) recommending a mammogram to you generally do not have any financial interest. Family Practitioners and General Internists who make the decision with you do not make money from the scans- the radiologists they refer you to do, and kickbacks from those radiologists are generally illegal.

            The medical profession certainly isn’t perfect- it is filled with influences. Every day doctors are bombarded by guideline committees, pharma company saleswomen, advertisements, and inducements. But all the same, I think most every doctor is driven on by the trust that is placed in them by patients such as yourself. I encourage you to research and educate yourself on your condition. But I also ask on behalf of my profession for your trust. I certainly hope to earn it.

            Respectfully,
            A medical student

          • Lisa

            I think you’re very good at reciting the ‘company line.’

            The radiologists are the ones who scream the loudest when studies indicate that screening mammograms are overused. They are the ones who screamed the loudest at the US Preventative Services Task Force recommendations. And I think in protecting the status quo, they are protecting their interests and their income.

            Another point, I think the harm of screening goes way beyond the pain and fear of biopsies. I think the major harm is women who undergo treatment for in situ cancers that will never become invasive, will never be life threatening. Until medical science can determine which cases of in situ cancers can be monitored and which require treatment. many women are having lumpectomies and radiation that may not be required. Don’t underestimate the harm caused by the current screening practices in this country.

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            I am not a part of any company, not yet anyway. I am only a medical student and a proud member of an ancient profession, following in the footsteps of many of my family members. And for the record, I will not be going into radiology.

            The radiologists certainly screamed the loudest- and yes their incomes were being threatened, but so was patient access to their care. If the USPTF guidelines changed, insurance companies may have stopped paying for mammograms, meaning that women who wanted them would be unable to get it. You’ll notice who wasn’t screaming for the most part? The ACP and the AAFP, who represent the Family Practitioners and the Internists who would be the ones actually ordering mammograms or not. Do the radiologists have a conflict of interest here? Certainly. But, they also have a purer motive- making sure their patients do not pay excessive amounts for the care they need.

            Let’s be clear: when the USPTF guidelines recommended mammograms, women who decided to get one could do so, usually free of charge. Women who didn’t want to have it done, didn’t have to.

            With the change in guidelines, women who want and who didn’t want mammograms were at risk of being told that they couldn’t have one regardless unless they paid $1000 or more out of pocket themselves (even if the doctor ordered it).

            I certainly agree that treatment for in situ cancers which would never threaten a life is harmful. At the same time, back in 2003, the 5 year survival rate for DCIS was 85%- meaning 15% of patients with it died. You may be comfortable taking that risk, but not all women may share your views. A women with the same risk as you may decide that screening mammograms are the right choice for her- she’d be okay with an large chance of an unnecessary lumpectomy in exchange for a reduced chance of dying- or just greater peace of mind.

            As I said, more than ever we know that this is a personal decision to be made with a trusted adviser- your doctor. I apologize for how my colleagues have apparently failed you in the past. I hope you can find someone you can trust to help you make decisions like these if you want to.

            Respectfully,
            A Medical Student

          • Lisa

            Five year survival rate for DCIS was 85% in 2003? That is not correct. I think the survival rate was almost 99.9%, even in 2003.

            If you are going to argue, get it right.

          • goonerdoc

            Can you be respectful? The medical student is doing so. I would hope you would be able to reciprocate.

          • Lisa

            I think you are wrong when you say that the five year survival rate for DCIS was 85% in 2003. I think the correct stat was around 99.9%.

            If you’re going to argue at least use the right facts.

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            Of course the 5 year survival rate of DCIS was 99.9%- if it was treated with mastectomy or lumpectomy. Any patient in the US who presents with a DCIS is treated. With no mammograms however, we wouldn’t catch such DCIS lesions until they’ve transformed and metastasized. Granted, many wouldn’t.

            I’m trying to find the paper I remember reading with the 85% statistic, and I’m having no luck.

            What I have found however is this- one paper that reports an 84% survival rate for Infiltrating Ductal Carcinoma in the mid 2000s. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC400666/).

            Another source states that low grade DCIS transforms into invasive ductal carcinoma 60% of the time if untreated, while high grade almost always transforms (http://breast-cancer-research.com/content/6/S1/P23). However, this uses old data, where screening techniques were less effective- it would be unethical these days to not at least offer treatment for DCIS, and the overwhelming majority of women would accept that treatment (a lumpectomy generally). I have to get to class, but I’ll see if I can’t take another crack at finding that paper later.

            Again, while I remember the survival being lower, don’t you believe that whatever the risk is that a women should have the choice to have such a scan covered? DCIS is not the most common lesion found on mammograms- they are actually less likely to be detected because they are generally small. The liklihood of finding a lesion on mammogram increases with tumor size- which is also correlated with the lethality of that lesion.

            (http://www.ncbi.nlm.nih.gov/pubmed/2910416)

            Ultimately, do you support dropping the requirement for insurance to cover screening mammograms if the individual woman desires it?

            Respectfully,
            A medical student

          • Lisa

            I agree that given the current state of knowledge, DCIS has to be treated once it is detected.

            I do not believe that our medical system should offer screening mammograms to all woman just because they want one. From a public health view point, it is very hard to justify that as the harms outweigh the benefit of screening younger women.

            I think the US preventative service guidelines are about right: that women of average risk begin getting screening mammograms at 50 (if they want to). Younger women, particularly women who are at higher risk,should reach a decision through consulatation with the doctors. To me, this means that doctors need to accurately present the risks versus harms inherent in starting a program of screening.

            One of the problems I have is that the information that is presented to women is often inaccurate. Many women do not understand that finding and treating breast cancer early does not gaurantee it is cured. They believe that early detection = cure. Also many women do not understand the limitations of mammograms. I think up to 20% of tumors are not seen on mammograms and that number is higher in younger women.

          • Anne-Marie

            Oh yes, I think it comes down to how each of us perceives risk and what level of uncertainty we’re willing to live with. But my sense of the American culture surrounding health care is that many people have a hard time tolerating ambiguity. We want black and white but what we have is gray.

            BTW, you are not “only” a medical student. Stand tall! Best wishes on your educational journey.

          • querywoman

            Ha! Ha! Typical medical talk about saving ONE life through mammography. Indeed, women die of all kinds of other things all the time, and doctors often ridicule any kind of symptoms in a woman.
            They’d rather do a cancer hunt on a healthy woman than pay attention to her illnesses with symptoms.

          • Patient Kit

            What happened to Lisa’s post that I responded to? The exact wording of that post and the cynical view of doctors’ motives was what prompted my response. But now that post has been deleted? Not a good way to have a discussion.

          • Lisa

            Kit, I deleted it because it was a duplicate – sort of. I typed the response that is now a Guest post first. It didn’t post, so I re-typed a response – the one you responded to. This morning my first post showed up. I deleted it, but the system converted it to the Guest post. So I edited my second post to indicate that it was a duplicate – sort of. I mishandled it. I am sorry.

          • Patient Kit

            Thanks, Lisa, for unconfusing me (about what happened with your post if not the subject we’re discussing). Weird how it converted “Lisa” to “Guest”, who I think of as a different poster. Also, I think the wording of the version of your post that I responded to was a bit more cynical sounding about doctors than your original that is now here. Obviously, this subject is a controversial and emotional one, especially for those of us who have been diagnosed with and treated for cancer. But the hard discussions are also the most important and interesting ones.

          • Lisa

            I agree with you 100% about of the hard discussions being the most important and interesting.

            Re the post you responded to being cynical – that is my nature – and I often find it hard to strike the tone I want to. Um cynical, but not too cynical?

          • Patient Kit

            LOL! Well, one thing I found out about myself over the last couple of very difficult years is that I am a hopelessly positive eternally optimistic person. So, together we represent two very different perspectives — CynicalLisa and OptimisticKit. I’m sure it’s good for both of us to hear the opposite view sometimes.

  • Lisa

    You will never convince US radiologists to change their recommendation that women begin getting screening mammograms at 40. Add that to the large numbers of women who are convinced that the mammogram that found their in situ cancer or early stage cancer saved their lives and you have an unstoppable pro-mammogram lobby.

    • Patient Kit

      I’m beginning to grasp the issues of the risks of false negatives and false positives. But are these studies saying that early stage cancer doesn’t ever need to be treated? And therefore we’re better off not even knowing it’s there? Are we saying that cancer only needs to be treated once is has begun to spread? And how does this view about early stage breast cancer translate to other early stage cancers ? Like my early stage ovarian cancer? Or does it not mean anything re other cancers like colon or cervical? Are we on the verge of scrapping the whole idea of screening for and treating early stage cancers? If so, this really will be a hard sell.

      • Lisa

        The problem with wide spread screen for breast cancer is that we don’t know for certain which early stage lesions will become life threatening and which won’t. Only the ones which could become life threatening need to be treated.

        The estimates I have read is that 20% to 30% of in situ cancers will become invasive, if not treated. At this time we can’t tell which ones will become invasive so the standard is to treat all in situ breast cancers. The treatments (surgery and radiation) have definite harms. Things are less clear for early stage invasive cancers – some are not aggressive, others are aggressive. Treating the aggressive early cancers does reduce mortality. However, even if you detect and treat aggressive breast cancer ‘early,’ before it has spread to the nodes, it may still recur. I am not sure if treating non aggressive early invasive cancers, beyond surgery and anti-hormonal drugs, is of that much benefit.

        I am not sure how this translates to other early stage cancers. I think the the arguments for screening and treating prostrate cancer are similar to the arguments for screening and treating breast cancer. And screening for prostrate cancer is of questionable value, for the same reasons.

        The current recommendations for screening for cervical cancer have changed (without much argument) from a yearly pap smear to one every three years under certain conditions, with screening stopping at 65. I don’t remember much fighting about the new recommendations – I do lot of fighting about the HPV vaccines. I don’t remember much controversy about colonscopies. We screen for skin cancers. We don’t screen for ovarian cancers because there aren’t any good screening tests. I don’t think the whole idea of screening and treating early stage cancers is invalid. This is just arguing about who should be screened for breast cancers -how often, and at what age.

    • elizabeth52

      Most of women’s “healthcare”, in my opinion, is actually harmful for most women. I don’t trust a word coming from official sources, most have a vested or political interest in screening and don’t have my best interests at heart.
      Almost all information provided to women is misleading, incomplete/conveniently omits important evidence, it’s important to keep women in the dark.
      Both breast and cervical screening are largely about profits at our expense. I’ve rejected both, but for those women interested in testing, take a look at the Nordic Cochrane Institute’s summary on the risks and benefits of mammograms, it’s at their website. At least you can then make an informed decision.
      For too long women have been cut out of the decision-making process and have been coerced, misled or pressured into screening, screening is a choice, to accept or decline as we see fit.

      Also, most women are not at risk of cervix cancer and cannot benefit from pap tests, but can be harmed. The new Dutch evidence-based program will scrap population pap testing and offer instead 5 HPV primary tests, or women can self-test using the Delphi Screener, at ages 30,35,40,50 and 60 and ONLY the roughly 5% of women who are HPV+ will be offered a 5 yearly pap test.
      Instead women in the States and Australia are pap tested to death generating huge excess biopsy and over-treatment rates with poorer outcomes, great for medical profits but bad medicine. I think our doctors will always have a “problem” with evidence based screening and informed consent, it get in the way of fabulous profits. It’s far more profitable to screen and “treat” most of the 95% of women who are not even at risk rather than focus on the 5% who have a small chance of benefiting from pap testing.

  • doc99

    Screening mammography saved my sister’s life. ‘Nuff said.

    • Lisa

      This is the reason there will never be a intelligent discussion on the benefits versus harms of screeming mammography. You and your sister are now part of the poro-mammogram lobby.

      • Kristy Sokoloski

        Very well said Lisa. This goes to my thought about Medicine and the majority of it being opinion based. You will have those that will say that because a screening …. saved someone’s life that they are going to be for the side that says it saves lives. However, if someone has a relative that goes through the screening… or the annual physical that showed a problem that was cancerous that was caught early but still died even after doing the recommended screenings and treatments then they are going to say ‘well, this is not worth it’.

        Some of us are basing our own opinions about making changes as to what we will continue to do for the benefit of our health because of observing our own health situation. And because of those observations realizing that screening tests, and annual physicals and wellness visits are not to our benefit.

        As some have said there are doctors that are afraid of being sued if they don’t push these things. Well, as for me, myself and I because of the choice I made it’s mine to make but that is not the doctor’s fault if I choose to not do these things. I am the one that must live with the consequences of that choice if such a consequence exists.

        • Lisa

          I really doubt if primary care doctors push screening mammograms and other tests because of fears of being sued. I think it is much more likely they push suçh testing because it is one of the metrics their performance is judged on.

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            In general, most of those metrics can be satisfied if the doctor “counsels the patient” regarding getting a mammogram. A performance metric based on their patients actually getting mammograms would not be a very safe or sound metric. But, that is not to say it hasn’t happened. Thankfully, most of health care still isn’t judged on the harder metrics.

            That said, every doctor has heard of stories like these:

            http://www.myfoxatlanta.com/story/18680466/widow-awarded-5m-in-malpractice-suit-after-m#axzz2v4yT5gL1

            And it certainly influences our counseling to some extent.

          • Lisa

            If doctors are so afraid of malpractice, how come so many young women (under 40) are denied diagnostic mammograms or ultrasounds when they present with a lump? They are told the lump is just a cyst, without imaging, because they are ‘too young’ to have breast cancer. And of course, some of these young women actually have cancer and diagnosis is delayed.

            I have never been counseled regarding having a mammogram. No one has every discussed the benefits versus risks of screening with me. I was just told I should get one. For a period of time, I received several calls from my primary care doctor’s office, because they noticed I was overdue for a mammogram and urging me to get one. The only problem is that I had a bilateral mastectomy after a breast cancer diagnosis. I had to throw a minor fit and ask them to make a notation on my chart to get the calls to stop.

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            It seems you’ve fallen a victim to one of those healthcare systems that has gone over to the dark side of managed care/hard performance metrics. As I said, just because standards are unsafe doesn’t mean they aren’t used.

            Frequently, a doctor will try to unload these performance standards to their staff in an attempt to meet them while still seeing patients each day. It sounds like you were called by an office staffer who probably didn’t know what ‘mastectomy’ meant when they read it on your chart before calling you.

            This is a consequence of health care reform done badly. Using hard metrics in ways which aren’t well thought out, and imposing them top down upon doctors to force improvement.

            My apologies for your experience- no woman should have to go through reminders like that. It is a consequence of the bureaucracy that has overtaken medicine.

            With regards to the young women who are denied mammograms, perhaps as you mention above that is an attempt to reduce the number of unnecessary breast biopsies/lumpectomies. If a lump in the breast is found, at any age it is more likely than anything else to be simple fibrocystic change (over 50% of women develop such benign lumps at some point). Especially if the changes in the lumps are cyclical with menstrual cycles, it may make sense to avoid further testing and mammograms. A common strategy is to follow the lump closely- the patient is advised to return to the clinical quickly, so that any changes in the breast can be assessed (static lumps indicate benign disease). Still, I think most doctors would order a mammogram if the patient was insistent- unless they are part of a managed care system, in which case all bets are off.

            Respectfully,
            A Medical Student

          • Lisa

            I know the reasoning behind not ordering testing for young women who present with a lump. My question was if doctors are so afraid of malpractice suits, why do they not order mammograms when young women present with a lump? Perhaps you are overstating the fear of malpractice as a way a justifying doctors continuing to adhere to the current screening guidelines for mammograms, ie beginning at age 40, rather than admitting that some of the reluctance to accept guidelines that call for less intensive screening is due to the fact that radiologists are protecting income streams.

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            Ma’am,

            What you are saying does not make sense. The risk of a malpractice lawsuit is something faced by primary care physicians for failing to order a scan. These PCPs generally do not benefit financially in any way from ordering a scan.

            The financial benefit from screening goes to radiologists. They do not control screening rates- they merely have an advisory role on the guidelines. As I said above- I acknowledge that radiologists are not unbiased. But, while they benefit financially from the guidelines, patients are protected as well. Those guidelines mean that women do not have to pay $1000 or more out of pocket for a mammogram if they want one. All I’m saying is that it’s a more complicated picture than greedy doctors lining their pockets.

            The fear of a malpractice lawsuit influences the decision made by individual PCPs- it is not the sole determinant. I don’t know the rate of mammograms ordered when young women present with a lump. Do you? I can’t find a paper at the moment, though again I am pressed for time. In general, a physician who has recently lost a lawsuit or whose friend has recently lost a lawsuit will be far more likely to order a test than one who hasn’t.

            Respectfully,
            A medical student

          • Lisa

            I don’t know the rate of mammograms ordered when young women present with a lump. What I said is that I have heard many stories of missed diagnosis in younger woman who present with a lump because they have trouble getting a mammogram. If the fear of malpractice is that great, then it seems to me that these women would have no problem getting a diagnostic mammogram.

            I think it is unlikely that primary care doctors order mammograms because of malpractice fears. I think other factors dirve primary care doctors to order screening mammograms. As I suggested, I do think screening mammograms pay a part in the metrics used in evaluating primary care doctors.

  • Patient Kit

    I think another core issue is a huge general lack of trust in our healthcare system. Many women remember the fight to get insurance to cover mammograms. Now, in a climate of finding ways to cut costs, women are suspicious that this revelation that mammograms are “suddenly” useless and/or harmful is all about insurance companies not wanting to pay for it. If it is, in fact, true that mammograms for the general population are useless and/or harmful, the message will only get through if it comes from those we trust.

  • Lisa

    I haven’t read “The Mammogram Myth,” but have read quite a bit about mammograms and the breast cancer industry. As someone who has been diagnosed with breast cancer, it is of extreme interest to me.

    A good book on the breast cancer industry, from a sociological point of view, is “Pink Ribbon Blues,” by Gail Sulik.

  • EmilyAnon

    That’s the problem with all the “maybes” and “mights” in a partisan argument. Maybe the mamo didn’t make a difference, but then gain maybe it did. Valid on one side, uncertainty on the other. Total confusion for the patient when the medical experts aren’t of one mind over this.

  • Lisa

    I think some people can’t deal with uncertainties. They want things to be black and white. Perhaps that is a hold over from the days of what I will call ‘paternalistic’ medicine – when doctors didn’t always tell patients they had cancer or women went in for a bioposy of a breast lump and woke up in recovery to discover the doctors had performed a mastectomy. I don’t know.

    Personally, I’d rather have the scientific evidence laid out for me; I understand the concept of risk & I am quite capable of figuring out what I am comfortable with.

  • doc99

    Mammography saved my sister. Nuff said.

    • Lisa

      Repeating yourself does not make it so.