Denise Grady frames the recent debate on mammogram screening in today’s New York Times. The article tag teams and improves upon Gina Kolata’s recent story on the topic.
These articles highlight what we health professionals have known for some time about mammograms – they are not perfect.
About 10% of cancers will be missed by mammography alone. About 65% of so-called “positive mammograms” end up being benign on biopsy. We really don’t know what we are supposed to be doing with DCIS – is it precancerous, and should we be treating it? And finally, some cancers are faster-growing and more likely to kill you than others, and mammography is not so good at figuring out which is which.
If you’ve never really heard all this before, it’s not surprising. The debate now being played out on the pages of the Times has until now been held pretty exclusively among health care experts, with the results of that debate becoming the recommendations we all know and love – mammograms every 1 to 2 yrs from ages 40 to 50, then annually thereafter, till an as yet not defined upper age, when one weighs the need for mammograms against the overall health and projected longevity of the individual.
If it sounds complicated, well, that’s because it is. And until now, the approach doctors and patients took to complex issues like this was simply – we docs know more than you do. Allow us to weigh and measure the risks and benefits for you, consider costs while we’re are at it, and then we’ll tell you what we think is best and you’ll do it.
The price we are now paying for this simplistic approach to screening is a loss of faith on the part of the public, who have taken our endorsement of mammograms to be a guarantee of infallibility and a promise to lower breast cancer mortality across the board. We’ve struck out on both counts.
So now, like a parent whose child one day sees us as the imperfect humans we are, we docs are having a bit of a mid-life crisis. Do we stick to our guns and keep the same old recommendations, imperfect as they are? Or do we arm our patients with the facts and let them begin to make their own decisions about mammography?
One thing I think we do need to be careful about is allowing the pendulum to swing too far in the other direction – making the decision to advise women to forgo mammography due to a risk of over-diagnosis and over-treatment. This approach, framed in terms of prevention of anxiety and morbidity, but with an underpinning of financial cost savings, uses the same simplistic thinking we’ve used in the past to aim patients in the opposite direction, away from screening.
While there is much talk about how screening may not benefit more indolent cancers, the fact remains that we don’t have reliable non-invasive testing to identify which cancers are slower growing and which are not. Nor do we know how to stratify women into high and low risk groups for these cancers, other than genetic testing and imperfect modeling, which only identify a subset of at-risk women. To substitue another imperfect screening methodology for current guidelines just trades one set of problems for another.
I am more than happy to entertain the mammography debate with my patients, some of whom may want to forgo annual screening when they learn what I know. If I know my patients, I predict that most will continue to accept a chance of a false positives in return for a potentially reduced mortality from breast cancer.
But stay tuned – this discussion is likely to go one for some time.
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Orac takes on the topic. Nice discussion of the issues.
Having read a good bit about this over the past few years, and having (anecdotally, I know) had two friends who had false positives that led to painful biopsies and lots of anxiety, and having never personally known anyone who was diagnosed with early-stage cancer because of a screening mammogram, I decided this year to begin having mammograms every two years rather than annually. I can't help but think the reduction in radiation exposure (2 views x 2 breasts) will cancel out the minuscule increase in risk.
Glad to see you're blogging regularly again. Hope that means your personal life is more cheerful than it was this summer.
All I know is, I'm mighty jumpy until the mammogram results come back.
Sometimes I feel that there is a degree of superstition involved.
It would really help me a lot if I felt there was better risk projection. Let's face it–just because my female elders died of other causes, does not mean they didn't also have undetected breast cancer. Just checking off "no family history" doesn't really mean so much to a middle aged person now–mammograms haven't been around all that long.
What a good discussion! It's hard to know how to make a good decision regarding these sorts of things, isn't it. It's especially hard when the media plays on emotions (fear, especially) rather than on logic or reasoning.
My first mammogram at 50 resulted in a false positive and 48 hours of extreme worry. I really think that sort of stress is very bad for your health.
I've known for some time that doctors tend to exaggerate the benefits of all cancer screening and conceal any negatives. I usually do my own research, but on this occasion, a friend's diagnosis of breast cancer made me drop my guard.
The biopsies came back benign, but I still felt like a cancer survivor.
I then spent 12 months reading everything I could get my hands on and came away unconvinced and worried. I'd really recommend the Nordic Cochrane Institute's information sheet on mammograms – the facts, good and bad. This world renowned Institute has criticized governments around the world for failing to be honest with women – for inflating the benefits and washing over the risks.
Anyone considering mammograms at any age, might care to check this information.
I've chosen not to have mammograms at all. Not a decision I took lightly.
My Dr told me self-examination was out years ago and instead I've adopted a "breast aware" approach instead…
The value of CBE's is unclear – our doctors don't recommend them or rather they say there is no evidence that they really help and may just lead to more biopsies.
I'm now looking at thermal imaging although I understand false positives are a problem there as well.
It's strange, but we're all now conditioned to "do something" to protect ourselves from cancer.
I think sometimes the only and best protection is to be watchful and respond quickly to symptoms.
Looking after our health generally and shaving off the excesses is likely to be more helpful overall than some screening tests. (losing weight, giving up cigarettes, a leaner diet, regular exercise etc)
I've always believed screening is my decision and not my doctor's…after all, it's my life on the line. It took a while, but I found a doctor who respects my right to choose.
http://medconsumers.files.wordpress.com/2009/05
/cochrane_screening_mammography_
leaflet.pdf
By the way, the Swedish meatballs are delicious!
Francis