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I have worn many labels (Not in any particular order): Catholic, Wife, Mom,Gramma, Doctor, Major, Soccer Mom, Military Wife, Professor, Fellow.

All of these filter my views of the world. I hope that like St. Monica, I can through prayer, words and example, lead my children and others to Faith.
"The important thing is that we do not let a single day go by in vain without putting it to good use for eternity"--Blessed Franz J├Ągerst├Ątter

Tuesday, November 17, 2009

New mammogram recommendations are actually a victory of science over politics

Before you read this post, take the time to read the response I wrote to RAnn's comment on the last post. The reason for this is that I mentioned the U.S. Preventive Services Task Force (USPSTF) there as well. This is an old entity that is doing what politicians have neither the spine nor the competence to do--defining what is medically necessary or prudent to do. If you read through the USPSTF recommendations, you will be surprised to see how little the recommendations entail. A lot of the preventive testing we do is based on giving the patient peace of mind. It is a luxury, not a necessity.

The USPSTF analysis of the benefits of various breast cancer screening modalities just hit the airwaves. It would be a mistake to lump this analysis in with the Obamacare rationing arguments. The lack of efficacy in breast self-exams and the questionable benefit of mammograms for women in their forties is not new information. This has been known for at least a decade. Ten years ago I got dirty looks at a coffee klatch when a woman was lamenting the death of one of our neighbors from breast cancer and exhorting us to make sure we were doing our breast exams. I probably should have kept my mouth shut, but the scientist in me had to mention that the evidence did not back up the efficacy of regular breast self-exams.

It is important to understand that the new mammogram recommendations pertain to women who have no increased risk factors like a family history or known genetic mutations. The USPSTF now says that women should not begin mammogram testing until age 50. Women in their forties face a higher risk from the testing than they do from breast cancer. Most screening tests are going to be negative. A significant number of the positive tests are false positives. A positive test requires follow-up testing. This follow up testing is much more invasive than the screening test and has risks. Biopsies are surgical procedures. Surgery is never risk free.

Understand as well that the previous recommendations were not based on science. They were the result of medical politics. Breast cancer before age fifty and breast cancer after age fifty are two different diseases. Actually, there is nothing magical about age fifty, but that is just a convenient age to distinguish between pre-menopausal and post-menopausal women. For screening to be effective the screening test must be specific enough to minimize the false positives and sensitive enough to minimize the false negatives. The screening must catch the disease early enough to do something about it. The more aggressive the disease, the more frequently the screening needs to be done in order to affect the outcome of the disease process. Breast cancer in the woman under age fifty or pre-menopausal tends to be much more aggressive than breast cancer in the post-menopausal woman. Therefore, based on the sound principles of preventive screening pre-menopausal women should be screened more frequently than post-menopausal women. But that is not what was recommended. Women in their forties were encouraged to be screened every two years while women over the age of fifty were screened yearly.

The truth is that screening asymptomatic women in their forties has never demonstrated a significant increase in their survival from breast cancer. The advances in survivability are the result in advances of therapy not detection. But radiologist make money from mammograms. They want everyone screened. Surgeons make money doing biopsies. They like the revenue generated by positive mammograms. The American Cancer Society needs the backing of these two medical specialties to get breast cancer prevention going. Therefore, the resultant standards were a matter of compromise. Screening was extended to women in their forties but only every two years because they really don't need it at all. Post-menopausal women who really do benefit from mammograms are screened yearly. Once these recommendations are uttered, no doctor dares to practice according to science because failing to follow these guidelines leads to gross malpractice liability.

What caused the USPSTF to finally stand up for science is they now have the evidence that the incidence of bad outcomes from screening and follow-up testing are worse than the bad outcomes from the disease (breast cancer) for which the screening is being done. Let me tell you a tale about the hazards of medical testing. When I was a medical student, a gentleman came into the emergency room complaining of crushing substernal chest pain radiating to his left arm and shortness of breath. This is the classic description of a heart attack. This man was admitted for a cardiac work-up. Amazingly, his EKG and cardiac enzymes were normal. However, with such a classic history we had to investigate further. A stress test was inconclusive. He had to undergo a cardiac catheterization. The catheterization procedure triggered an arrhythmia that caused him to go into cardiac arrest. This is a known risk of cardiac catheterization. He was revived with electric shocks. His cardiac arteries, however, were clear. The complication of his cardiac arrest, however, lead to some kidney damage. He required dialysis until his kidneys recovered. After two months in the hospital it was revealed that he had never really had chest pain in the first place. He had been caught in an embezzlement scheme and in order to delay judicial proceeding he came into the emergency room with symptoms that would guarantee his admission and delay his having to testify. His little ruse nearly killed him. Invasive medical testing is not something to be taken lightly.

So how should such a finding play out in the health care system? Taxpayer funded health care should not have to provide screening mammograms to asymptomatic women in their forties. If a woman in her forties wants to buy a screening mammogram, she should be able to choose to do so. She should be fully informed about the risks this entails and the lack of evidence that such a mammogram will improve her survival of breast cancer. Her priority in the queue of women waiting to get a screening mammogram should be below those women over age fifty for whom mammograms have been shown to provide a benefit.

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