Mammograms for some, miniature American flags for others!

November 17, 2009 11:21 AM

Yesterday, the little-noticed U.S. Preventive Services Task Force caused a stir by releasing new guidelines discouraging routine mammography for women under age 50 and breast self-examinations at any age. (Comparison chart of new and old guidelines here.) The American Cancer Society immediately registered its strong disagreement; meanwhile, the National Breast Cancer Coalition came out in strong support of the new guidelines, saying:

The over-emphasis on the importance of screening, despite a lack of strong evidence, has been elevated to such a degree that some even equate screening with prevention of breast cancer. The National Breast Cancer Coalition hopes that today’s release of the US Preventive Services Task Force (USPSTF) revised recommendations will put the brakes on this run-away train and will put screening and its limitations into proper perspective.

The release of the recommendations in the middle of the health care debate has led some to fear that the new guidelines are motivated by cost concerns rather than women's health. However, there was a debate over the benefits and costs of mammography in England earlier this year (little-noticed by Americans), where some doctors and researchers criticized NHS for being overly-enthusiastic in pushing screening mammography.

Those interested in the research that kicked the entire controversy off can browse the publications of the Nordic Cochrane Centre:

Review of the evidence for screening mammography (pdf)
Review of the evidence for regular breast self-exams (pdf)

posted by iminurmefi (64 comments total)

Told you so.
posted by The White Hat at 11:27 AM on November 17, 2009 [2 favorites]

Also, I wonder what's going to become of feelyourboobies.com.
posted by The White Hat at 11:29 AM on November 17, 2009

It's weird how I always see this sort of quote-controversy-unquote stuff around women's health issues, but never around comparable men's issues. I imagine they still recommend prostate exams?

It's been getting better a bit at a time, but so slowly. I honestly kind of expect to hear "the surgeon general strongly recommend all Americans not bleed for five days without dying" now and then.
posted by mhoye at 11:33 AM on November 17, 2009 [1 favorite]

On the one hand -- someone on the radio this morning made the very good point that the exceptions still stand for people who have a family history of breast cancer (i.e., if your mom had it, you may want to start screening sooner), and this new ruling may make it harder for women under 50 to have their insurance cover regular screenings. So that's a disadvantage.

On the other hand -- I've already HAD two mammograms (one when I was only 30, and god knows why they thought that was a good idea) and any excuse I can use to put off going through that again a bit longer is something I will embrace.
posted by EmpressCallipygos at 11:34 AM on November 17, 2009

I imagine they still recommend prostate exams?

I actually recall hearing a similar argument about prostate exams.
posted by clorox at 11:40 AM on November 17, 2009 [3 favorites]

I imagine they still recommend prostate exams?

Actually... there's a fair bit of controversy around PSA tests and prostate exams as well, and it's all the same issues as for breast cancer screening--the evidence about its effects on reducing mortality is mixed or nonexistent, and there are negative consequences in terms of biopsies and unnecessary treatment. That's why the USPSTF has recommended against prostate cancer screenings for men over 75, and says there is insufficient evidence for men under 75. (Link)
posted by iminurmefi at 11:41 AM on November 17, 2009 [4 favorites]

They interviewed someone from this task force on All Things Considered last night. He made the point that:

(a) If you have the breast cancer gene or a family history of breast cancer, then ignore these new guideline changes and get regular mammograms starting as early as your doctor thinks is necessary.
(b) If you find a lump in your breast, report it to your doctor.
(c) The decision as to whether or not to do regular breast exams/mammograms should be a decision made by the woman and her doctor.

Of course, (c) ignores the fact that many insurance companies are looking for any excuse to "bring down" the cost of health care for women - i.e. deny coverage of medical procedures determined to be necessary by the doctor and her patient.
posted by muddgirl at 11:44 AM on November 17, 2009

It's weird how I always see this sort of quote-controversy-unquote stuff around women's health issues, but never around comparable men's issues.

You're not paying attention. This (the applicability appropriate timing of screening tests) is a huge, huge issue in the prostate cancer field right now.
posted by mr_roboto at 11:52 AM on November 17, 2009 [1 favorite]

A useful book that helped me make the decision against annual mammograms in my forties was Should I Get Tested for Cancer? by Gilbert Welch (Amazon link). It seemed to me like a useful overview of the strengths and limitations of screening tests. I remember some statistic like my risk of developing breast cancer during my 40s was about 1%, but the chance of a false positive if I had a mammogram every year approached 60%; my numbers are probably wrong but it was something very disproportionate like that.

I stopped doing self-exams after a big study in China found that women who did the exams had no better survival rates than those who didn't; they did, however, have much higher anxiety about cancer. That was a decade or so ago.
posted by not that girl at 11:52 AM on November 17, 2009

I think the reason there is so much controversy about this screening, specifically, is that there's been a HUUUUGE push for early detection of breast cancer, and an associated backlash from some advocacy groups who want to put more emphasis on treatment and other angles of attack. This is just the newest skirmish in a much larger battle.
posted by muddgirl at 11:55 AM on November 17, 2009

I imagine they still recommend prostate exams?

I think self-exams are not recommended.
posted by betaray at 11:55 AM on November 17, 2009 [3 favorites]

If you actually work the numbers, you'll find that when the actual incidence is low (such as breast cancer in women under 50), then you get a lot of false positives. Like, 99% of the positives you get are false. These false positives are doubly expensive (because you have to retest) AND emotionally alarming, not to mention the fact that doing unnecessary (re)tests on younger women means some older women get excluded.
posted by DU at 11:56 AM on November 17, 2009

I'm curious - why are mammograms the standard? [any radiology techs or docs in the house who can explain?] is it a cost-effectiveness issue? It seems like they've got problems with false-positives .. so .. why mammograms, and not other technology?

I feel a little bitter about the subject, I guess - my mother had a routine mammogram, which didn't catch (metastatic) breast cancer (!). She pushed, got a sonogram later, which did show the tumor, and got her started on the cancer treatment rollercoaster, and I admit, I wonder if treatment had started a couple of months in advance, if she'd still be here.
posted by circle_b at 12:00 PM on November 17, 2009

It seems like they've got problems with false-positives...

No test is perfect. Even if it's 99% accurate, that means that you get 1 wrong answer for every 99 right answers. Now test 100,000 women, only 5 of whom have cancer. You are going to get roughly 1005 positives. The 5 cancer victims, plus 1000 false positives. If you are in the group that tested positive, then, your chance of actually having cancer is like .5%. So now you have to alarm and retest all those people on the extremely minor chance that they actually have something wrong.

If instead you limit your testing population to the higher risk group, you might have 100,000 women 1000 of whom really have cancer. Now a positive test is a lot more indicative of actually having the disease, more like 50/50.
posted by DU at 12:09 PM on November 17, 2009 [2 favorites]

I imagine they still recommend prostate exams?

I think self-exams are not recommended.

And yet, you'd be surprised how many guys dispense with the digital and go around all day with the full cranial.
posted by The Bellman at 12:12 PM on November 17, 2009 [7 favorites]

In the review of the evidence on the benefits of screening mammography (second to last link), there's one statistic that surprised me quite a bit, despite the fact that I've been following the literature around this issue for a while:

This means that for every 2000 women invited for screening throughout 10 years, one will have her life prolonged. In addition, 10 healthy women, who would not have been diagnosed if there had not been screening, will be diagnosed as breast cancer patients and will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress for many months because of false positive findings.

It's one thing to know that there is a risk of false positives in the abstract; it's another to see the numbers are quite that stark in terms of number of women undergoing unnecessary treatment for every life saved.
posted by iminurmefi at 12:13 PM on November 17, 2009

The prostate exam issue is fairly straight forward:
get an exam from age 50 yearly
the bloodwork exam, thought to be a breakthrough, is no longer believed as such and has too many false positives, but some urologists still tell patients to get both exams at the same time, and yearly after 50.
posted by Postroad at 12:17 PM on November 17, 2009

There are a lot of things wrong with this new set of guidelines, in my view. Just one of the limited assumptions on which this study is based is the number of deaths attributed to breast cancer.

My wife checks her breasts now and then. She found an unexpected lump, went to the doctor, and found out she had a small cancerous growth. Small: meaning she only had to have a lumpectomy (just what it sounds like) instead of a masectomy, which she might have had to have if she had not caught the lump in time. So why do they recommend that women not examine their own breasts?


Call me paranoid, but I wonder if the insurance industry might have had some influence on this government panel.
posted by kozad at 12:22 PM on November 17, 2009 [1 favorite]

If people won't listen to scientific evidence about vaccinations, there is no way they're going to get their head around the fact that a screening test for a disease could be harmful or a bad idea.

"I had a PSA and it SAVED MY LIFE! -- (because, uh...we used this alternate universe viewer to see that I definitely would have died if, well...nevermind, IT JUST SAVED MY LIFE, OK?!?) SO EVERYONE SHOULD HAVE A PSA!! NOW!!"
posted by straight at 12:22 PM on November 17, 2009 [1 favorite]

After reading the two abstracts from the Cochrane Centre about breast self-exams: they say that there is no statistical advantage in studies they have performed, however, they also say that women who detect changes in their breasts should see their doctor to check for cancer. Hmmm. I guess one could conclude by saying that it is up to the individual to trust her common sense or make decisions on the basis of statistics.
posted by kozad at 12:29 PM on November 17, 2009

straight - the recommendation is against teaching breast self-examination. That means the whole rigmarole that goes along with the teaching: The shower sticker that can be marked off for every month, the frequent warnings about the horrors of breast cancer, etc. etc. etc.

* It does not recommend that women completely stop BSE.
* It does not recommend that women refuse the breast exam regularly performed by doctors and gynecologists at yearly visits (aka clinical breast exams).
* It does not recommend that women ignore any lumps they or their partner may discover.
posted by muddgirl at 12:36 PM on November 17, 2009

On a personal note, I perform self-examinations on a completely irregular basis and have absolutely no idea what "a lump" feels like - my boobs are pretty lumpy which seems to be a family trait that goes along with having a big cup size. Hopefully my gynecologist has a lot more experience and training than I do, which is why I trust her to perform more thorough exams than I do.

Perhaps a better BSE training program would include hands-on mock-ups of what sorts of lumps should be causes for concern? Would this potentially lower the incident of biopsies for slow-growing or benign tumors, or do all growths feel the same?
posted by muddgirl at 12:41 PM on November 17, 2009

There's another risk my prof mentioned during a recent "genetics of cancer" lecture. Women who have high risk of breast cancer because of a mutant BRCA1/2 gene should probably NOT be getting mammograms. Why? Because they only need one tiny little mutation in the wrong gene to develop cancer, and X-rays are one of the best ways to induce DNA mutations.

This journal article goes over what kind of treatment most BRCA1/2- women go through, and it seems that most of those who don't get double masectomies go for regular mammograms. My prof, who is a cancer research and oncologist, did say that his opinion is not mainstream, but I have to admit that it makes a lot of sense from a scientific point of view. I have no idea how it could translate to a public health setting.
posted by snoogles at 12:47 PM on November 17, 2009

muddgirl, that is true, but it's also true that a lot of those women will have false positives from BSE and CBE and that some of those women will receive a net harm from such screening.

And if you just talk about younger women, more of them will be harmed than helped by doing BSE (although the magnitude of harm is mostly smaller than the magnitude of help).

Ultimately, it's up to you whether a 0.05% chance that a screening test will save you from breast cancer is worth a 0.1% chance of complications from an unnecessary biopsy (those are rough numbers that vary depending on your age and risk factors). But most people aren't really equipped to understand that choice.
posted by straight at 12:48 PM on November 17, 2009

So... you agree with the recommendations? I guess I'm confused. There's no conclusive evidence either way as to whether CBE are net harmful or net helpful, which is why I will continue to request them.

I think the real choice that women have to make is whether the small chance that a screening test will save you from a masectomy is worth the much greater chance of having unnecessary biopsies and lumpectomies. It's pretty clear that screening tests will not increase the chance of "saving you from breast cancer".
posted by muddgirl at 12:55 PM on November 17, 2009

So why do they recommend that women not examine their own breasts?

They did for a while -- but that faced a similar problem, in that there was no way to prove that regular monthly BSEs made a statistical impact. Doing BSE's in general was better than NOT doing them, but there was no way to prove that doing them MONTHLY was any better than doing them "when you remember to", so that took a lot of the wind out of their sails, unfortunately.

But, a lot of the controversy was because of situations precisely like mudgirl's -- some breasts are just lumpy normally. The idea behind the regular BSEs wasn't so much that "monthly BSEs = automatic cancer-catching", it was more about "if you feel yourself up on a regular basis you'll become more familiar with what you normally feel like, so you'll be better able to see if something's wrong and can go to your doctor." (I have a similar situation -- I'm prone to cysts, and it took two instances of false-alarms from finding lumps to discover that, so in my case doing a BSE serves only to check, "is THAT lump still there, or did it go away? Oh, it went away, good, probably just another cyst."

But "BSEs promote better body awareness so you can then go to your doctor and have a discussion" isn't as sexy as "BSEs stop cancer," so the message got a bit garbled.
posted by EmpressCallipygos at 12:59 PM on November 17, 2009 [2 favorites]

Oh, and mudgirl -- my own doctor gave me some good advice for knowing what to look for -- "imagine someone stuck a Tic-tac inside your breast and you're trying to find it."
posted by EmpressCallipygos at 1:01 PM on November 17, 2009 [5 favorites]

circle_b makes a good point about false negatives. I'll add that I read a blog written by a woman who is a survivor of Inflammatory Breast Cancer, which is typically not caught by Mammograms. As you can imagine, her blog entry today has some sharp words (and stats - she's a former NASA scientist) about this recommendation.
posted by anastasiav at 1:16 PM on November 17, 2009

Is there any value in having a baseline mammogram on file? Even if there is, I suppose images wouldn't be stored very long, just results and notations? I'd also be interested to hear from any radiologist or radiology tech. What do the front lines think?
posted by rainbaby at 1:21 PM on November 17, 2009

There's no conclusive evidence either way as to whether CBE are net harmful or net helpful, which is why I will continue to request them.

But remember we're talking about statistically net harmful/helpful. For you, it will either be helpful, harmful, or harmless. And there's an x%, y%, and z% chance of each of those outcomes, and we don't quite know what x, y, and z are (either for the population at large or for you in particular), although we are pretty sure that x gets bigger as you get older and y gets smaller as you get older.
posted by straight at 1:26 PM on November 17, 2009

I dunno. My doctor believed in baseline mammograms done when a woman turned 40. My cancer was discovered on that very first screening mammogram, less than 1 cm in size. By the time it was removed a couple of months later, it had more than doubled in size. I admit that I'm using confirmation bias to support screeening mammograms, and if my cancer had been left until I might have found it, perhaps I would still have survived. But I still feel better knowing that it was caught fairly early on. But that's not a validation for public policy, though.
posted by angiep at 1:35 PM on November 17, 2009 [1 favorite]

I'll add that I read a blog written by a woman who is a survivor of Inflammatory Breast Cancer, which is typically not caught by Mammograms. As you can imagine, her blog entry today has some sharp words (and stats - she's a former NASA scientist) about this recommendation.

Like so many people, she only looks at the benefits of screening and completely ignores the harm. She claims the USPSTF is saying "Mammograms help save lives. Just not enough lives." When what they're actually saying is that "For younger women, mammograms save lives, but they harm far more of them."

Since USPSTF is really addressing more the public policy questions, maybe a better way of looking at this would be: "Women? Do you think 100 unnecessary biopsies are worth averting 1 mastectomy? Are 1000 unnecessary biopsies worth saving 1 life? What about 10,000 unnecessary biopsies vs. averting 1 mastectomy?"

Because really, what USPSTF is trying to do here is draw a line. How many unnecessary biopsies is one averted mastectomy worth? How many unnecessary biopsies is one life worth?
posted by straight at 1:37 PM on November 17, 2009 [3 favorites]

I think I'm personalizing this issue a little bit, because mother and aunts have a long history of really troublesome mammogram results that lead to the exact kind of anxiety and false negatives that these recommendations are trying to prevent (like I said, really really lumpy breasts). If I came from a different family or had a history of breast cancer myself, I'd probably have a completely different bias.

Hopefully we can take these guidelines as an opportunity to be more nuanced about this issue on a national level - less polarized - but it's sort of a pollyanna-ish desire.
posted by muddgirl at 1:38 PM on November 17, 2009

During a period of 22 years the wife had 31 mammographies.
In Dec of 2007 she was tested. Again as per her schedule of later years she had one in June 08 six mos later. Three weeks later she underwent a radical mastectomy. An extreme procedure at best.
An obvious outlier. (I assume) But were some of the earlier mams justifiable? Who (lay persons) knows. I have never broached the subject at home. I don't want to foster any self doubt, recrimination etc. But I wonder.
posted by notreally at 1:54 PM on November 17, 2009

OK, here's one question I have after a lot of statistical clarification (for the most part) in our posts here: what is the harm done in having unnecessary biopsies performed? Psychological distress, check. Physical harm? I don't think so. Is there a way to quantify this harm? If so, you could then compare it to the number of cancerous growths detected (because of mammograms or self-exams). Again, don't compare it to deaths. That muddies the waters even more.
posted by kozad at 2:06 PM on November 17, 2009

Like I said above, a lot of lip service is paid to "distress", and I know it's a real phenomenon in my family, but I wouldn't be surprised if the real issue was plain old "cost of coverage". Women are over their lifetimes more expensive for insurance companies to cover. Yearly mammograms and exploratory biopsies are part of this.

Of course, no one's going to come out and say that it costs more to detect (say) 3 more cases of breast cancer out of 1000, but it's a factor.
posted by muddgirl at 2:10 PM on November 17, 2009

If we can't even stop doing unnecessary and essentially unhelpful medical testing, lord only knows how we will keep costs in check as we simultaneously develop more treatments and diagnostics that do work.

For some of the people hating on these new guidelines, think about it this way: what would you recommend for a poor, developing country where there were very limited healthcare resources? Would you take $ from vaccinations or education that have been shown to prevent sickness and death and spend it on something that has been shown to be ineffective? Of course not.

Now imagine you are in a pretty wealthy country, like the US. We can't keep up with healthcare costs, either, so it really isn't any different.
posted by snofoam at 2:17 PM on November 17, 2009 [2 favorites]

One other thing. Often I hear people saying stuff like, "I don't want to pay to treat smokers when they get cancer" or "I don't want to pay the hospital bill when those potheads crash their car" etc.

I don't usually hear "I don't want to pay for that hypochondriac to get endless tests" or "I don't want to pay for treatments that have not been shown to be effective."

I think this kind of needs to change if we are to have some kind of sanity around healthcare.
posted by snofoam at 2:26 PM on November 17, 2009 [1 favorite]

I can think of several times when my mother called me, in tears and nearly hysterical, because they'd found something on her annual mammogram. Each time, it turned out to be nothing.

This year, I got a call from my healthcare provider telling me to get a mammogram, which I do not plan to do. I'm more concerned about avoiding my family's history of diabetes and heart disease than breast cancer.
posted by mogget at 2:29 PM on November 17, 2009

OK, here's one question I have after a lot of statistical clarification (for the most part) in our posts here: what is the harm done in having unnecessary biopsies performed? Psychological distress, check. Physical harm? I don't think so.

From page 96 of this PDF:

"Although risk is low, there are complications associated with biopsies, such as hematomas, infection, and scarring; from wire localization itself, complications include vasovagal reactions (7 percent) and, rarely, prolonged bleeding (1 percent) and extreme pain (1 percent)."
posted by mr_roboto at 2:48 PM on November 17, 2009 [1 favorite]

I dunno. My doctor believed in baseline mammograms done when a woman turned 40.

Sure, but physicians still aren't necessarily very good at assessing risk. One study I have lying around somewhere gave physicians some actual numbers about the incidence of breast cancer, the incidence of true and false positives and negatives for mammography, and asked them "Suppose we give everyone a mammogram. If a woman has a positive mammogram, what is the probability she has breast cancer?" The true answer is about 8%, the average answer given by the physicians was 70%.

what is the harm done in having unnecessary biopsies performed? Psychological distress, check. Physical harm? I don't think so.

There was a quote above that deals with this. For every one woman who is saved because her cancer is found early, ten women without cancer will be misdiagnosed as having cancer and will receive actual, real, no-shit cancer treatment.

Not ten women will be scared for a bit. Ten women will undergo a lumpectomy or radical mastectomy as well as followup chemotherapy or radiation.
posted by ROU_Xenophobe at 2:50 PM on November 17, 2009 [5 favorites]

kozad: "what is the harm done in having unnecessary biopsies performed? Psychological distress, check. Physical harm? I don't think so. Is there a way to quantify this harm? If so, you could then compare it to the number of cancerous growths detected (because of mammograms or self-exams). Again, don't compare it to deaths. That muddies the waters even more."

I sort of addressed the physical harm issue in a post on this same subject almost two months ago:

The White Hat: "Let's talk about that unnecessary burden for a bit. An abnormal BSE will likely result in a clinic visit, which may then lead to a clinical breast exam (CBE), a mammogram, or a needle-biopsy. All of these procedures require time and money, and may also cause a certain amount of anxiety. Let's forget those for the moment and talk instead about actual physical harm caused by an unnecessary test. CBE is mostly harmless, as are mammograms if you factor out the low dose of radiation. Needle biopsies, however, can cause "hematomas, infection, and scarring; from wire localization itself, complications include vasovagal reactions (7 percent) and, rarely, prolonged bleeding (1 percent) and extreme pain (1 percent)"

These numbers were pulled from a packet (pdf) given at a 1997 NIH Symposium. So yes, you can quantify the physical harm. As for the psychological distress, RTFA-- the Cochran report cites eight studies (Brewer, Bulow, Brodersen 2006 & '7, Barton, Brett, Lerman, and Gram) that all found some amount of psychological distress associated with false positive results. If you want a quantifiable number, you might look at it from a financial perspective-- Barton ('01) found that women who have had false positive see their doctors more often, which means that they're paying for excess treatment based on unsound reasoning brought about by a false positive.
posted by The White Hat at 2:53 PM on November 17, 2009

Like I said above, a lot of lip service is paid to "distress", and I know it's a real phenomenon in my family, but I wouldn't be surprised if the real issue was plain old "cost of coverage".

Just to be really clear, because this is a common misperception that makes people discount this sort of effectiveness research for the wrong reasons: the USPSTF is tasked with looking at the strength of the clinical evidence around benefits and harms to patients for different preventive care (screening tests, annual physicals, etc), and making a recommendation to physicians about which populations should get the preventive care. The USPSTF isn't tasked with saving Medicare money, nor telling insurance companies what to cover and what not to cover, nor evaluating the cost-effectiveness of different medical treatments. All of that is valuable research we *should* be doing because our health care system is wildly inefficient, but it's definitely not the sort of review that USPSTF is doing. They're focusing only on whether a specific preventive service is more beneficial than not for the patient, separate from the question of systems costs.

The narrative that is emerging in certain partisan media outlets and on some blogs about how this is really secret cost-cutting that the socialist Obama administration (left wing alternative: evil capitalistic insurance companies) is trying to push on the American people as a first step towards killing grannie is just totally flat-out wrong. It's a bit distressing to see that gain traction.

The evidence does seem to show that there is a small but non-zero probability of harm for women undergoing mammograms, which includes not only mental distress and biopsies but also undergoing unnecessary (and potentially disfiguring) surgery or radiation treatment for cancers that never would have been life-threatening. That has to be weighed against the small probability of benefit from identifying and treating a cancer that would have been fatal; the evidence shows that the probabililty of harm doesn't change over a woman's life but the probability of benefit does, with older women more likely to benefit than younger women. There's a point (around 50) where the balance tips enough that they are comfortable saying "you should encourage your patients to get this routine screening done," but before that they are saying that women should really be ones making the choice, since it involves weighing small but important harms and benefits.
posted by iminurmefi at 2:59 PM on November 17, 2009 [4 favorites]

My point was that the result of this likely won't be that doctors and patients will be making more informed decisions. The result will be that insurance companies refuse to pay for mammograms for any women under 50, without a huge hassle. I didn't mean to imply that the USPSTF was taking cost of care into account but I can see how it looked that way.
posted by muddgirl at 3:19 PM on November 17, 2009 [1 favorite]

Well, if you don't get screened, and then you do get breast cancer. You obviously haven't saved any money. The problem is that by the time you actually get cancer there's a good chance your insurance company will have been able to dump you, or you'll have gotten another job or lost it or whatever. In that case, the insurance company will have saved money.

On the other hand, mammograms use ionizing radiation, so getting one every year would actually increase your chances of getting cancer, right? That ought to be taken into account.
posted by delmoi at 3:43 PM on November 17, 2009

And let's not forget, every test you take, the doctor gets paid. This is essentially a zero-sum issue here between people who do mammograms and people who pay for them.
posted by delmoi at 3:46 PM on November 17, 2009

Not ten women will be scared for a bit. Ten women will undergo a lumpectomy or radical mastectomy as well as followup chemotherapy or radiation.

Do they really do all that without getting a positive biopsy though? And then if they don't really have cancer you can blame the biopsy, particularly the pathologist's reading of the results. And I doubt they'd foist chemo or radiation on someone if the tissue surgically removed from their breast showed they didn't have cancer after all.

I guess I'm confused because the way some of this has been presented it sounds like boobs are being butchered unnecessarily left and right just based on a mammogram. I thought they check carefully before they go in cutting.

I had a thing on my mammogram about 18 months ago. Had a needle biopsy which was painless and no big deal at all, and my lump is thankfully benign. I'm still glad to have gone through the process. I also don't really mind mammograms in general, and I didn't mind the six month followup one they gave me.

My mother has had breast cancer twice. I feel, for me, screening (and biopsies when warranted) is worth the risk, as long as my insurance company is willing to pay for it. I'd much rather have a scare over something benign than miss the cancer.

I understand other people may choose differently. I just hope extra cautiousness is still going to be funded.
posted by marble at 4:09 PM on November 17, 2009

Anything that requires the general public to grasp basic statistics is doomed to failure.
posted by mattholomew at 5:16 PM on November 17, 2009 [5 favorites]

This is so creepy. This story was posted twenty minutes after I just heard it from my Machines professor.

...Because I asked him if he thought it was safe to drink from #1 PET bottles.

Either he's really good at tangents or I'm really good at triggering them (the last time I asked something, it lasted for 45 minutes and was supremely engrossing)

He said something...
"that's the argument that the people who oppose the people who oppose the opposition to mammography used"

but after hearing that sentence, I immediately forgot what the argument was. Something about cost of running lab equipment.
posted by rubah at 6:06 PM on November 17, 2009

that's the argument that the people who oppose the people who oppose the opposition to mammography used

That is, people who oppose mammography, but mainly because they disagree with people who are against who are opponents of mammography?

In other words:
Group A says everyone should get a mammograms,
Group B says people should not get mammograms because they are unnessisary and wasteful
Group C is a union of group A and people who think people should get them if they want to, it's no big deal, whatever.
Group D Disagrees with group C and thinks their wishy-washy idiots.

and Group E is your professor, who thinks group D used the same argument you did about PET #1 bottles?
posted by delmoi at 6:49 PM on November 17, 2009

I can't believe that no one is touching on the marketing aspect of this: Think Pink!

From a public relations point of view: our "Pink" product is under attack by scientists. I think if there is a basis for outrage in the media, this is part of it..
posted by kuatto at 6:55 PM on November 17, 2009

Do they really do all that without getting a positive biopsy though? And then if they don't really have cancer you can blame the biopsy, particularly the pathologist's reading of the results.

No. If they hadn't had a false-positive mammogram, they would not have had the biopsy (or other post-mammogram checking?) that gave the false positive that caused them to have surgery or other cancer treatment.

I guess I'm confused because the way some of this has been presented it sounds like boobs are being butchered unnecessarily left and right just based on a mammogram. I thought they check carefully before they go in cutting.

No matter how carefully you check, no matter what you're checking, you're virtually certain to have some type 1 and type 2 errors.
posted by ROU_Xenophobe at 7:16 PM on November 17, 2009

I guess I'm confused because the way some of this has been presented it sounds like boobs are being butchered unnecessarily left and right just based on a mammogram. I thought they check carefully before they go in cutting.

Here's the thing: there's a non-trivial number of breast cancers that would never, ever cause problems to the women who have them, because they never become invasive. Unfortunately, there's no way to tell right now which tumors are the "never become invasive, let's leave it alone" from the ones that will progress and kill you if untreated.

When you drastically expand screening for all women, you're going to start catching a lot of those cancers that could have safely been left untreated. So, just to throw some made-up numbers out there, maybe a certain screening procedure means we diagnose 10% more cancers, but we know from population data that successfully treating those cancers has only improved mortality rates from breast cancer by 1%. That means that for every one person whose life we've saved, we've also treated 10 women "successfully" with surgery, radiation, chemo--but all of it was unnecessary in the sense that if those women had never been diagnosed, they would have gone about their lives and been fine.

There are probably a lot of women who think, well, even if I have to take the risk of undergoing painful cancer treatment unnecessarily, I'd prefer to err on the side of being overly cautious. I don't think that would be an unreasonable position to take. However, women should be given the right to make that choice themselves, fully informed of the potential benefits (very low probability you'll catch a deadly cancer and save your life) and potential costs (a less low probability you'll have a false positive, or worse, you'll undergo months of painful treatment for something that would have been fine if left alone). The study linked to above put numbers on those risks: for every one life saved, 10 women undergo unnecessary [non-life-saving] treatment, and 200 women will undergo biopsies because of false positives.

It's kind of a non-intuitive thing, because we generally think of cancer as always being deadly, but that's not the case for all breast cancer (nor the case for all prostate cancer).
posted by iminurmefi at 7:29 PM on November 17, 2009

Often I hear people saying stuff like, "I don't want to pay to treat smokers when they get cancer" or "I don't want to pay the hospital bill when those potheads crash their car" etc.

I don't usually hear "I don't want to pay for that hypochondriac to get endless tests" or "I don't want to pay for treatments that have not been shown to be effective."

If this is a dichotomy, then I think it's a false one. There need to be some incentives to avoid behaviors that are proven likely to be a burden on the system, whether they're hypochondria, ineffective treatments, or smoking. Or where they can't be avoided, the system will need additional funds to cover the consequently increased costs.

(I don't know anything statistics relating marijuana use and car accidents, so I'm leaving that out, but even assuming there is a link, the incentive angle might be covered by typical DUI penalties.)
posted by weston at 9:12 PM on November 17, 2009

Hypochondriacs don't need incentives, they need mental health treatment. Which they rarely get. It's amazing how little money is put towards hypochondria and somatic illness research, considering how much money is wasted by unnecessary tests, treatments, etc.

There is a research program for people with heightened disease concern (I think that's what they call it) at Columbia University.
posted by kathrineg at 9:29 PM on November 17, 2009

What we need to do is pair up people who like breasts with women who need breast exams and people who like to engage in ass-play with men who need prostate exams. That way, everybody's happy and cancer-free!
posted by Saxon Kane at 11:48 PM on November 17, 2009 [1 favorite]

Another relevant book that I coincedentally read a few weeks ago is Reckoning with Risk by Gerd Gigerenzer (Amazon link.)

It explains a lot of the issues with screening for breast cancer and for other things; also for those above that think women should be given the information to decide for themselves it suggests how this information can be given in a way that people actually understand.
posted by Sinadoxa at 4:31 AM on November 18, 2009

I just hope extra cautiousness is still going to be funded.

Me too. I've been brushed off for asking to have a baseline mammogram done because "I'm too young" (early 20s). My mother died of breast cancer at age 38 and my maternal aunt had a tumor removed from her breast when she was in her early 30s that was detected by the mammogram she got after my mother was diagnosed.

Apparently, my time to get begin mammograms is two years after my mother's age when she died. Do people flipping out over "hypochondriacs" want to pay for my cautiousness now, or my cancer later?
posted by autoclavicle at 5:30 AM on November 18, 2009

autoclavicle, the new guidelines (which are not rules or laws or regulations or funding decisions, just guidelines) are specifically and clearly about routine (ie suspicion-less) screening as opposed to screening because of heightened risk from family history.
posted by ROU_Xenophobe at 6:58 AM on November 18, 2009

It's weird how I always see this sort of quote-controversy-unquote stuff around women's health issues, but never around comparable men's issues. I imagine they still recommend prostate exams?

I'm not sure what point is being made here. Is it that health care is somehow anti-women? Because nothing could be further from the truth. The scandelous gap between men and women's longevity (currently women live around 5-6 years longer than men -- and it's growing) is pretty strong evidence for this.
posted by bobbyelliott at 11:34 AM on November 18, 2009

I think perhaps it was a mistake to ever endorse self-exams as a means of reducing the incidence of cancer in a statistically significant way. But women get handed enough squeamishness about their bodies without discouraging BSEs on the grounds of strictly diagnosis/survivorship data. How are women supposed to report any unusual lumps to their doctors if they don't know where the usual lumps are?

Between this and the more recent guidelines on pap smears, I feel like all of these recommendations are being made in a huge vacuum of literalness, far from any comprehension of how people actually get health care.

(As for mammograms, I wish there was a stronger drive for alternative screening methods for breast cancer, given how ludicrously difficult it is to consistently and accurately read mammograms.)
posted by desuetude at 12:04 PM on November 18, 2009

Autoclavicle, you seem to clearly fall into the high risk category and the recommendation is to start CBE every six months to a year starting around 25 or if you have BRCA1/2, then MRI and mammography every six months starting at 25.

My sister married a man whose first wife died of breast cancer. Now his two daughters have it, both are in their early 30's.

I do SBE but haven't had a mammogram yet. I was glad of the new guidelines especially since I've been such a slacker about getting my first one. My mother was outraged that I hadn't done it but now I can tell her I'm following the most recent guidelines.
posted by shoesietart at 12:20 PM on November 18, 2009

I wish there was a stronger drive for alternative screening methods for breast cancer, given how ludicrously difficult it is to consistently and accurately read mammograms.

Amen. I am 39, and I have already had two mammograms -- both of them precipitated by my finding a lump in a breast during a routine BSE. The first time, I was about 30, the second I was about 33.

The first time, my doctor was just really damn paranoid, and recommended that I get a mammogram in addition to the sonogram. When I asked her, puzzled, whether they'd be able to tell anything because "I thought mammograms didn't really work too well if you were under 40?" my doctor just said she knew that, but she was paranoid. As we anticipated, the mammogram told us nothing -- the breast tissue was too dense for them to get a read on anything - and it was the sonogram that revealed that the lump was nothing but a cyst.

The second time, a different doctor this time, requested a sonogram only. But - the hospital I went to had the policy of automatically giving a mammogram as well as a sonogram to all women over 30. "But...I'm 33, and you're not going to see anything," I argued. They shrugged and said it was policy. I was over 30, I was a woman who had found a lump, I was getting a mammogram with my sonogram. QED. Again, the mammogram was pointless -- and it was the sonogram that told the story (another cyst).

In both cases, the mammogram was completely pointless, but in one instance the hospital was just routinely giving it out even though I hadn't asked. The sonogram was much more accurate, and didn't have that additional pain factor to deal with; the discomfort of mammograms probably puts a lot of people off right there.
posted by EmpressCallipygos at 1:02 PM on November 18, 2009

the discomfort of mammograms probably puts a lot of people off right there.

Amen to THAT. I dread it. It's going to hurt like hell for me and they're not going to see a damn thing because of density. Am I procrastinating on my routine appt with my gyn because she's going to recommend that I get a mammogram this year? (35, family history of breast and ovarian cancer.) Yep, I probably am.
posted by desuetude at 1:53 PM on November 18, 2009