government healthcare in action, but don't worry sweeties, it's your body, isn't it? [rquoter]Breast exam guidelines now call for less testing Change debated Potential harm of frequent mammograms outweighs benefit, task force says By Rob Stein Washington Post Staff Writer Tuesday, November 17, 2009 Women in their 40s should stop routinely having annual mammograms and older women should cut back to one scheduled exam every other year, an influential federal task force has concluded, challenging the use of one of the most common medical tests. In its first reevaluation of breast cancer screening since 2002, the independent government-appointed panel recommended the changes, citing evidence that the potential harm to women having annual exams beginning at age 40 outweighs the benefit. Coming amid a highly charged national debate over health-care reform and simmering suspicions about the possibility of rationing medical services, the recommendations immediately became enveloped in controversy. "We're not saying women shouldn't get screened. Screening does saves lives," said Diana B. Petitti, vice chairman of the U.S. Preventive Services Task Force, which released the recommendations Monday in a paper being published in Tuesday's Annals of Internal Medicine. "But we are recommending against routine screening. There are important and serious negatives or harms that need to be considered carefully." Several patient advocacy groups and many breast cancer experts welcomed the new guidelines, saying they represent a growing recognition that more testing, exams and treatment are not always beneficial and, in fact, can harm patients. Mammograms produce false-positive results in about 10 percent of cases, causing anxiety and often prompting women to undergo unnecessary follow-up tests, sometimes-disfiguring biopsies and unneeded treatment, including surgery, radiation and chemotherapy. But the American Cancer Society, the American College of Radiology and other experts condemned the change, saying the benefits of routine mammography have been clearly demonstrated and play a key role in reducing the number of mastectomies and the death toll from one of the most common cancers. "Tens of thousands of lives are being saved by mammography screening, and these idiots want to do away with it," said Daniel B. Kopans, a radiology professor at Harvard Medical School. "It's crazy -- unethical, really." The new guidelines also recommend against teaching women to do regular self-exams and concluded that there is insufficient evidence to recommend that doctors do the exams or to continue routine mammograms beyond age 74. Cost concerns Some questioned whether the new guidelines were designed more to control spending than to improve health. In addition to prompting fewer doctors to recommend mammograms to their patients, they worried that the move would prompt insurers to deny coverage for many mammograms. The new recommendations took on added significance because under health-care reform legislation pending in Congress, the conclusions of the 16-member task force would set standards for what preventive services insurance plans would be required to cover at little or no cost. About 39 million women undergo mammograms each year in the United States, costing the health-care system more than $5 billion. Petitti said the panel was not influenced by the reform debate or cost issues. A spectrum of women's health advocates, breast cancer experts and public health researchers praised the new guidelines. "It's about time," said Fran Visco, president of the National Breast Cancer Coalition, a Washington-based patient advocacy group. "Women deserve the truth -- and the truth is the evidence says this is not always helpful and can be harmful." While the American Cancer Society said it has no plans to change its guidelines, the National Cancer Institute said it will reevaluate its recommendations in light of the task force's conclusions. Long controversy The change is the latest development in a long controversy about mammography. The American Cancer Society and other groups have recommended that women regularly undergo the tests every one or two years beginning at age 40 to catch tumors early. Many experts have begun to raise questions about routine screening methods, including the PSA blood test for prostate cancer and mammography, because they often trigger false alarms and catch precancerous growths and tiny tumors that would never become life-threatening but nonetheless prompt treatment. The new guidelines were based on a comprehensive analysis of medical literature that included an update of a Swedish study involving about 70,000 women, new results from a British trial involving more than 160,000 women and data from the Breast Cancer Surveillance Consortium about more than 600,000 women. In addition, the task force commissioned an unusual study funded by the National Cancer Institute that involved six independent teams of researchers conducting separate mathematical modeling studies of the risks and benefits of 20 screening strategies. While annual mammography for all women beginning at age 40 reduced the death rate from breast cancer by at least 15 percent, the modeling studies indicated that the added benefit of starting before age 50 was modest, the researchers concluded. For every 1,000 women screened beginning at age 40, the modeling suggested that just about 0.7 deaths from breast cancer would be prevented, while about 470 additional women would receive a false-positive result and about 33 more would undergo unnecessary biopsies. "What isn't in the model but is an issue is how many extra imaging tests are done to follow up on things that turn out to be falsely positive and the harm of the anxiety that goes along with that," Petitti said. "Then there's the whole other line of problems that come into play, which is where there are some breast cancers detected that grow very slowly and would never have killed you." For women age 50 and older, cutting back to screening every two years would maintain 81 percent of the benefits of testing annually while reducing by half the number of false-positives, the computer modeling study estimated. Petitti stressed that the task force is not recommending against mammography, but that it hopes the new guidelines will lead more women to make their decisions based on their personal circumstances. Those at high risk because of a family history of breast cancer, for example, or those who are simply more worried about the disease might still opt to have annual screenings, she said. While the task force recommended against doctors teaching women how to perform regular breast self-exams and concluded that there was insufficient evidence to determine whether doctor exams were beneficial, several experts stressed that women should seek medical attention if they come across any unusual lumps. Others worried that the conflicting advice would prompt women to delay or avoid the exams completely. "People will end up not getting mammograms -- they'll just kiss them off," said Judith A. Luce, who treats breast cancer patients at San Francisco General Hospital. "I'm concerned the sense of urgency about getting them done will fade."[/rquoter]
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This has nothing to do with government healtcare, there have been researchers challenging this for years and their viewpoint has just come to light. per the article you posted
I was wondering when this article would come up. You were a little slow to the punch on this one, basso. Personally, I think the "findings" are r****ded. Mammograms should be done just as frequently as they are today. Tons of people get breast cancer before 50, and tons of people's lives are saved because they screened earlier. Leveraging human lives with cost is a dangerous thing to do, and while it has to be done relating to health care, I don't really think breast cancer prevention is the right thing to attack when trying to reduce cost. Wow, really? 10%? That seems awfully high.
yes, my sister-in-law just had a double mastectomy, at the age of 46. she'd likely die before her first mammogram if these rules were in place. my sister, who is a breast surgeon, thinks the recommendations are a crock.
There are a number of medical tests that give extremely high false positive rates. The "triple screen" test given to pregnant women to check for various birth defects has a false positive rate of 20% or more... http://www.aafp.org/afp/20020301/915.html
My girlfriend, who is getting her PhD in cancer biology (specifically breast cancer) and whose mother had breast cancer also thinks these recommendations are a croc. What it boils down to is: who are you going to listen to? Medical professionals and scientists or the federal government? Fortunately, you have a choice. Relating to health care reform, I don't think the government will enforce anything that will prevent someone from having regular mammogram screenings at any age with any frequency; at least not any more restriction that what a private insurer would impose. If they do, my opinion just may begin to change.
Do not fall into the basso trap please, this is actually an interesting topic and it has nothing to do with trying to reducte healthcare costs. I know the article mentions costs but from the article
Okay, let me rephrase. Are you going to listen to medical professionals employed by the federal government, or the American Cancer Society and American College of Radiology?
I'm going to listen to the ones making the most sense. What does "government" have to do with their ability to give good recommendations? In this case I'd say that the task force recommendations make the most sense. In the articles I've read, their positions are reasoned, balanced and well thought out. The reactions to the recommendations, on the other hand, seem to stem from people jumping to conclusions or not paying full attention to what was proposed.
From the article: [rquoter]Several patient advocacy groups and many breast cancer experts welcomed the new guidelines, saying they represent a growing recognition that more testing, exams and treatment are not always beneficial and, in fact, can harm patients. Mammograms produce false-positive results in about 10 percent of cases, causing anxiety and often prompting women to undergo unnecessary follow-up tests, sometimes-disfiguring biopsies and unneeded treatment, including surgery, radiation and chemotherapy. ... A spectrum of women's health advocates, breast cancer experts and public health researchers praised the new guidelines. "It's about time," said Fran Visco, president of the National Breast Cancer Coalition, a Washington-based patient advocacy group. "Women deserve the truth -- and the truth is the evidence says this is not always helpful and can be harmful." ... The new guidelines were based on a comprehensive analysis of medical literature that included an update of a Swedish study involving about 70,000 women, new results from a British trial involving more than 160,000 women and data from the Breast Cancer Surveillance Consortium about more than 600,000 women. In addition, the task force commissioned an unusual study funded by the National Cancer Institute that involved six independent teams of researchers conducting separate mathematical modeling studies of the risks and benefits of 20 screening strategies. [/rquoter] It sounds like a lot of the people in support of this change in guidelines aren't working for the Fed. Anyway before some of y'all get apoplectic about Death Panels the article also says: [rquoter]Petitti stressed that the task force is not recommending against mammography, but that it hopes the new guidelines will lead more women to make their decisions based on their personal circumstances. Those at high risk because of a family history of breast cancer, for example, or those who are simply more worried about the disease might still opt to have annual screenings, she said. [/rquoter] These are guidelines not laws and those who have concerns about breast cancer should still consider doing regular mammograms before 50.
It's basically an optimization problem, no? Leaving cost out of it (which is mentioned in the article anyway), you're leveraging false-positive induced procedures versus cancer prevention. In other words, unnecessary invasive surgeries versus life. As stated in the article, 0.7 deaths versus 33 unnecessary biopsies (which, as you should note, are not even major surgeries). Personally, I value 0.7 lives (per 1000) more than 33 unnecessary biopsies.
I think this is the real interesting conversation to have, actually. (It's too bad the anti-government fear-mongering overshadows the blander but more honest discussion topics.) Apparently, the American Cancer Society agrees with you. It's a valid position to take. But there has to be some point where the drawbacks outweigh the benefits, right? I mean, why stop at 40? Why stop at women (men can have breast cancer, too)? If we recommend that all people with a breast big enough to fit in the machine should get yearly mammograms, I'm guessing another 0.01 life will be saved (per 1000) or something like that. Is that really worth it though? I would hope you'd say no. So the question is, where is that balance?
That is the key point. In the case of breast cancer we have to consider not just the costs of invasive biopsis and other procedures in regard to false positives but also potential health side affects from those, not forgetting the radiation dose you are getting everytime you have a mammogram. I don't know enough about cancer to give a definate opinion on these guidelines but they do seem pretty well thought out. Anyway the most important message that I take away from this topic is if you have a reason to be worried about breast cancer, such as family history, you should get screened no matter what your age.
While an interesting argument, I don't think there could ever be a consensus that could ever be agreed upon. It's similar to the whole abortion argument. Some folks feel life is always more important regardless, so 0.00001 lives is still more important that 10000 unnecessary biospies to some (I'm not in the camp). That doesn't mean it cannot be discussed, however. Of course, I can't exactly put my finger on an exact ratio, either, but 0.7:33 just feels too small. Now, if it was 33 unnecessary mastectomies, then I may feel different, but it's just biopsies. To add to that, I couldn't figure out if they included the prevented mastectomies that early screening can provide either -- they mention it, but I'm not sure if they quantified it to go along with the 0.7 deaths. Could you quantify the unnecessary radiation into a numerical death toll as well (shortened lifespan due to the radiation, perhaps)? There are just too many variables to consider, so quantifying them and putting it in a report just seems... misguided to me. But what else can you do?
