Mammograms and the USPSTF: it’s the denominator, stupid

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?

18 Comments

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18 responses to “Mammograms and the USPSTF: it’s the denominator, stupid

  1. I was happy about the recommendations, and rather dismayed by the reaction to them. People complain about high health care costs and then demand unfettered access to health care that is not effective.

    I’m 45 and I’ve had two rounds of stereotactic breast biopsies to pluck out microscopic calcifications that proved benign. The procedure is ghastly (dangle breast through hole in elevated table while docs mash and poke breasts from underneath) and the fear while waiting for the results is awful. I made the decision after the second round that it was not worth it…the data doesn’t support it. I realize I could pay for this with my life, but it’s unlikely. In the meantime, I will be able to walk around not feeling like my breasts are grenades strapped to my chest. When I informed my PCP 2 years ago of my decision to do no more mammograms till I’m postmenopausal, she had a hissy fit at me. How can we expect the public to understand cost-benefit equations of the docs themselves can’t?

    Oh, and as a side note…my theory is that my breasts sparkle with calcifications because I spent so many years breastfeeding. I have no scientific basis for that belief…it just sounds right!

    • MomTFH

      Sparkle with calcifications – love it!

      Thanks for the post. How true. There are many in the medical profession that are reacting quite negatively to the recommendations. It’s not that anyone is stupid, like my fellow med student said, but some people, even physicians, don’t understand risk and tend to react in fear.

  2. IndianaFran

    Is this what you’re looking for?

    http://archinte.ama-assn.org/cgi/content/full/168/21/2311

    Conclusions Because the cumulative incidence among controls never reached that of the screened group, it appears that some breast cancers detected by repeated mammographic screening would not persist to be detectable by a single mammogram at the end of 6 years. This raises the possibility that the natural course of some screen-detected invasive breast cancers is to spontaneously regress.

    see also

    http://www.sciencebasedmedicine.org/?p=300

    http://www.sciencebasedmedicine.org/?p=116

  3. IndianaFran

    Am I in moderation?

  4. IndianaFran

    Is this what you are looking for?

    http://archinte.ama-assn.org/cgi/content/full/168/21/2311

    The Natural History of Invasive Breast Cancers Detected by Screening Mammography

    Per-Henrik Zahl, MD, PhD; Jan Mæhlen, MD, PhD; H. Gilbert Welch, MD, MPH

    Arch Intern Med. 2008;168(21):2311-2316.

    Conclusions Because the cumulative incidence among controls never reached that of the screened group, it appears that some breast cancers detected by repeated mammographic screening would not persist to be detectable by a single mammogram at the end of 6 years. This raises the possibility that the natural course of some screen-detected invasive breast cancers is to spontaneously regress.

  5. IndianaFran

    or maybe this one:

    http://www.bmj.com/cgi/content/full/339/jul09_1/b2587

    Cite this as: BMJ 2009;339:b2587
    Research
    Overdiagnosis in publicly organised mammography screening programmes: systematic review of incidence trends

    Karsten Juhl Jørgensen, researcher, Peter C Gøtzsche, director

    Conclusions The increase in incidence of breast cancer was closely related to the introduction of screening and little of this increase was compensated for by a drop in incidence of breast cancer in previously screened women. One in three breast cancers detected in a population offered organised screening is overdiagnosed.

  6. infamousqbert

    excellent post, and thanks for the links. i’m in a quandary here, mostly emotionally, because my mother was NOT a survivor. the race for the cure has been a healing experience for me, seeing all of those women, of all ages, coming together to say that we can beat this thing. and, for the women who are in the midst of their battle, i know that it can give them spiritual/mental strength, which is a critical aspect of fighting any illness. but, the “A+ in logic” student in me knows that it all means jack if the numbers don’t support it.

    • MomTFH

      Thanks for this post, and I am sorry about your mother.

      I can easily see why people can easily be swayed to rally behind the current screening guidelines, and that is why it angered me so much when my fellow med student said the public was “stupid” and “thinking on a second grade level” when they responded in fear or increased risk. Here is a good article about how, in general, risk is really hard to understand and then explain, even to physicians.

      When it comes to something as common and potentially devastating as breast cancer, we need to be extra careful not to discount the real risks and real concerns on all sides of the screening and treatment debate.

      • MomTFH

        Oh, and I hear what you are saying about being involved in the mainstream advocacy and awareness groups. I don’t mean to discount Race for the Cure and never would.

        I know Barbara Ehrenreich has some opinions on some of the breast cancer advocacy groups. I think it is her right as a survivor herself to say how she feels supported or not, but I definitely agree that these groups have been an important inspiration and healing agents (emotionally and spiritually) for many people and their families.

  7. This is a great post.

    Even before the new recommendations came out, I was wondering about whether DCIS is overtreated. I’ve heard of people getting double mastectomies due to DCIS. If it never becomes invasive in some women, a double mastectomy would definitely count as overtreatment.

    The NBCC had a great statement recently along the lines of, we need to trust that women are smart enough to deal with some complexity. And I agree. In order for that to happen, though, doctors have to trust them, too, and be able to handle complexity themselves. I’m glad you’re talking about this with your colleagues because obviously there’s a need for a lot more education on every level. For a country that’s been “raising awareness” of breast cancer for years, we’re appallingly *uneducated* about it!

    Oh, and I loved that Barbara Ehrenreich essay, too. It’s ironic that breast cancer has gone from being taboo in the early 1970s to less stigmatized than feminism today.

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  9. desifeminists

    amen. i was really surprised by how many women, even on feministing.com were shocked or mad about it! i had read somewhere about how to make public health decisions and the example they had was comparing the benefits of screening with mammogram induced breast cancer, and since then i’ve been more concerned about the rule of yearly mammograms than screening less! i was bothered by how many low risk women had to get a rather invasive screening every year. add to that the costs and troubles of getting biopsies.
    when will labor and childbirth guidelines get this much attention?

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