There has been a lot of brouhaha over the new mammography recommendations by the United States Preventative Services Task Force (USPSTF). Rachel at Women’s Health News has an excellent round up of posts on the issue, if you feel like you need to do some background reading.
I am also a big fan of Barbara Ehrenreich’s take on it.
Take your time if you need to check out those links, since I highly recommend it. Back? Good.
I have many thoughts on this issue. First of all, I am completely in support of the new recommendations. If you have been reading my blog for long, this may come as no surprise, since I tend to prefer using interventions only when absolutely necessary, and am a big fan of evidence based medicine.
Secondly, I don’t think it is anti-feminist to discuss the anxiety caused by false positive diagnoses, whether it be false positive mammography results or false positive prenatal genetic screening results. Not only is the anxiety potentially substantial to many, but, the false positives also lead to more invasive tests. My mother, who is as low risk as I am for breast cancer (white, has had children and has breastfed, non-smoker, not a heavy drinker, no first degree relatives who have had breast cancer, etc.) is also endowed with huge breasts, as I am. She had at least three biopsies and lots of ultrasounds in her 40′s. None of these came up with anything of concern, but there was plenty of anxiety leading into them. And, a biopsy is not comfortable or risk free. Come to think of it, neither is a mammogram. In fact, the radiation from repeated mammograms may actually cause breast cancer in some women. I know this is an anecdotal story, but my mother is the primo example of who this consensus opinion is talking about. These mammograms are not improving outcomes in typical low risk women in their 40′s, like my mom was when she started getting mammograms and subsequent biopsies.
Third, I had an argument with a fellow student today. He said that the public wants the extra mammograms, and they are too stupid to understand the nuance to the issue. He also said all they want is “the best care.” I said the best care is evidence based care, and that I plan on educating my patients. I do not believe in the can-I-have-fries-with-that-have-it-your-way approach to medicine. I do believe that patients’ values and opinions definitely matter. But, in the end, if a patient insists on a procedure I think will cause more harm than good, I will politely refuse and refer them to a practitioner that will accommodate them, if I know of one.
Fourth, and possibly coolest, I heard a discussion on Doctor Radio that made my nerdy day. The oncologist, Dr. Silvia Formenti, is fully supportive of the new recommendations. She also explained why there is an apparent discrepancy in breast cancer survival rates between the United States and United Kingdom, which is one of the few if only outcomes that appear better in the United States. She explained that this is a false comparison, since the denominator is different. My public health instructor has always harped about the denominator of any rate being key, but I thought it was just a nitpicky instructor thing – sure, you only include women of childbearing age in maternity rate stats, got it – but it’s more important than that. Dr. Formenti said that the reason our rates seem better is that we are currently overscreening younger women, and overtreating in situ cancers. So, our denominator is stacked with low risk women who are not really that sick. In fact, I spent too much time looking over the ACOG site for the article, but I read something recently in one of their publications that showed that a wait-and-see protocol for such cancers led to a shocking remission rate. I remember it being over 20%, but since I cannot find the article, please don’t quote me on it.
So, the denominator matters, and not just in a nit-picky way. Also, I was happy to see that the National Health Service, of which I am a fan, is not failing women with breast cancer, which was bugging me a little. What especially impressed me with her commentary was that not only is she a renowned oncologist and an attending at NYU Langone, but she practices in the United States. She could have easily said “Hooray for my team, hooray for my field, we’re kicking butt.” It’s really refreshing to hear someone value truth over seeming to be the best.
And, finally, I am a little chagrined by how many people are saying that these USPSTF recommendations are going to change the way the insurance companies reimburse mammography, and change medicine in the United States dramatically. I am still waiting for that to happen due to their recommendations of labor and delivery from November of 2008, in which many interventions are panned as inconclusively supported by evidence or detrimental to patients (such as third trimester estimation of fetal weight, denying nutrition p.o. to laboring patients, and episiotomy) and others are highlighted as extremely effective and highly recommended (e.g. upright positioning for pushing and the continuous support of a doula during labor.) I wish there was an uproar following those dramatic recommendations, but there was barely a peep. Hello, sweeping changes? Helloooooooo?