Respectful Insolence

How not to protect your medical turf

When the USPSTF issued new guidelines for who should undergo screening mammography, at what ages, and how often, it set off a firestorm of negative reactions. Some of this is not surprising, given that the reevaluation of the evidence for screening mammography led the USPSTF to recommend against its routine use in women between the ages of 40 and 50 who lack strong risk factors for breast cancer; i.e., who are at “average” risk. Add to that the recommendation that screening for women age 50 and older should only be every two years instead of every year plus the recommendation that women should not be encouraged to do routine breast self-examination, and women, who had been told for years of the importance of these modalities, were justifiably confused and felt betrayed. After all, most women had no way of knowing that whether or not to do routine screening mammography between the ages of 40 and 50 has long been controversial, given the relatively limited benefits and the downsides of false positives leading to biopsies, overdiagnosis, and overtreatment for breast cancers that might never have threatened life. Meanwhile, they had heard for the last decade or more an insistent drumbeat of how important mammography beginning at age 40 was to detect cancer early and save lives.

While there is no doubt that screening mammography does decrease mortality from breast cancer, particularly for women between the ages of 50 and 70, the effect is not as great as intuitively we think it should be. Indeed, the whole issue of screening mammography and how much impact early detection has on cancer mortality is a lot more complicated than most people, including–alas!–most doctors, understand, which is why, over the last five or ten years or so, in response to new evidence there has begun a major rethinking of the benefits versus the risks of screening. In essence, it has been questioned whether screening as intensively for breast cancer as we do in actuality saves enough lives to justify the numerous downsides and whether we should back off a bit in order to concentrate on populations for which the evidence of a benefit in terms of reducing cancer mortality is the strongest.

What also no doubt contributed to this firestorm of controversy over the last month or so was the manner in which the USPSTF announced its results and new recommendations, as Val Jones pointed out in her “post-mortem” of the issue of how badly botched the communication of these recommendations was. Suffice it to say, I have a hard time recalling an announcement of medical findings that was more incompetently handled, at least from a science communication standpoint. For instance, no groundwork was laid beforehand, which meant that to the public the announcement seemed to come out of nowhere. Also, the issue was framed about as poorly as I can imagine. Instead of emphasizing that the reason for recommending backing off on mammography in women in their 40s is because of the risk of overdiagnosis and overtreatment, somehow the concept that it was fear and anxiety due to false positive test results that were the main negative consequences of screening that were driving the USPSTF’s recommendations. That may have been part of it, and we shouldn’t denigrate the very real fear women with an abnormal mammogram feel until the issue is resolved, but what ended up being communicated, more than anything else, was a paternalistic idea that somehow women couldn’t emotionally handle false positives and needed to be protected from them, even if it increased their risk of dying of breast cancer between the ages of 40 and 50. This perception led to misguided and in some cases disingenuous attacks on the guidelines as “misogynistic.” Even worse, the results were communicated at what was arguably, politically at least, the worst possible time. President Obama’s massive health care reform bill was approaching a vote in the House, and opponents of this bill seized upon the USPSTF guidelines as evidence that this bill would lead to “rationing” (as if care weren’t already being rationed on the basis of income and insurance). Some even resurrected the brain dead idiocy of “death panels” in response. Meanwhile, when members of the USPSTF tried to defend their guidelines in the press and on TV, they came across as tone-deaf bureaucrats, even like the proverbial deer in the headlights. This unpreparedness allowed certain physicians protecting their turf to eat their lunch, so to speak.

Yes, unfortunately, one of the more depressing aspects of this whole kerfuffle is how some medical organizations, instead of calmly discussing the guidelines and saying why they disagreed, decided to engage in a bit of demagoguery that, to me at least, appeared to be some of the most blatant turf protection I’ve ever seen. Some, fortunately, did not. For example, ASCO issued a press release that engaged the USPSTF’s recommendations and, while arguing against the new guidelines, did so without hyperbole, addressing the real issues involved. I wish I could say the same thing about the American Society of Breast Surgeons, whose press release characterized the new recommendations as “effectively turning back the clock to pre-mammography days by making the diagnosis of breast cancer occur only when the tumor is large enough to be felt on a physical exam,” a charge I termed utterly ridiculous. So incensed was I that I whipped off a strongly-worded complaint. Some oncologists even expressed the highly exaggerated (at least) fear that their practice would be transformed to that of a Third World country, where they would suddenly be buried in an onslaught of patients with advanced cancers that wouldn’t have been detected by mammography, you know, just like Canada, the U.K., Australia, and much of Europe, whose mammography screening guidelines closely resemble the new USPSTF guidelines.

The worst of all of these embarrassingly knee-jerk reactions by professional societies to these guidelines came from the American College of Radiology, whose first press release was entitled USPSTF Mammography Recommendations Will Result in Countless Unnecessary Breast Cancer Deaths Each Year. (How’s that for nuance?) The ACR rapidly followed up with a press release entitled Detailed ACR Statement on Ill Advised and Dangerous USPSTF Mammography Recommendations, playing politics and turf protection with these guidelines, using purposefully inflammatory language to frighten women and raise the very same specter of “death panels” that political opponents of health care reform raised. True, the ACR didn’t use the word “death panels,” but it did raise the specter of rationing. One wonders what radiological societies from other countries think of this hyperbole, given that the mammographic screening guidelines recommended by the USPSTF strongly resemble those of Canada, many nations in Europe, and Australia. As I’ve said before, there are reasons to criticize the new guidelines, not the least of which is how they don’t adequately account for high risk populations, but the ACR’s response to them smacked far more of polemics and turf protection than it did of sober scientific objections.

Unfortunately, the ACR is not alone among radiology associations in appearing more interested in protecting its turf than in debating the guidelines based on science. For example, the Radiological Society of North America used its annual conference to go on the offensive, even getting another inflammatory headline, namely Top Mammography Experts Voice Outrage Over New Breast Cancer Screening Recommendations.. Now that gets your attention, doesn’t it? Here’s the problem. What a lot of these mammography experts say in this article make me wonder if they’ve been paying attention to the data over the last few years. As I’ve said before, if you had shown me the USPSTF guidelines two or three years ago, I’d have been disturbed by them and probably would have strongly opposed them. However, over the last two or three years, the weight of studies has started to change my mind, and even though I think the USPSTF probably went too far too fast my thinking with regard to screening mammography has become less gung ho. That’s not to say that I think moving towards starting screening at age 50 should be immediate or even at all. I do think that a more nuanced approach to women under 40 is required based on the evidence. As I said before, I rather like Australia’s approach, where routine screening is not recommended for every single woman before the age of 50. However, if physician and patient come to a joint decision based on the known risks and benefits to begin screening with mammography at age 40 it will be paid for. In other words, the decision whether or not to screen and how often between the ages of 40 and 50 should be more individualized. Even as currently I still tend to recommend that screening begin at age 40, the data over the last few years have made me less dogmatic about it than I once was.

Not for Dr. Kopans and the radiologists participating in this panel is anything resembling even a hint of nuance, however:

Speaking to reporters, panelist Daniel B. Kopans, MD, senior radiologist at the Massachusetts General Hospital and professor of radiology at Harvard Medical School in Boston, told reporters that the USPSTF guidelines ignore the scientific evidence that annual screening with mammography starting at age 40 saves women’s lives.

“The US Preventive Services Task Force says no to routine clinical breast exams, breast self-exams, and mammography in women under the age of 50. The implications are that women aged 40 to 49 must wait until they can no longer ignore a lump in their breast before they can seek medical attention,” he said. “The USPSTF admits that screening women aged 50 to 74 every 2 years, instead of every year, will mean that a large number of women will die from breast cancer whose lives could have been saved by annual screening,” Dr. Kopans asserted during the press briefing.

The task force has said it believes that annual screening actually harms women because it is a source of stress and anxiety, especially when false-positive results force the women to undergo unnecessary biopsies.

Dr. Kopans is one of the worst offenders. He’s definitely a pit bull protecting his turf, and he’s one of the ones who’s been eating the USPSTF members’ lunch from a strictly PR perspective. On the one hand, I have to admire his purity of message, which derives from his apparently having zero concern for nuance. On the other hand, his knee-jerk attacks on the USPSTF represent the sort of attitude we physicians will have to overcome in our own profession if we are ever to move our practices to being truly science-based. When new data arrive, we have to be able to adjust our practices accordingly; Dr. Kopans is a throwback arguing for dogma-based, rather than science-based, medicine.

In any case, the implication is not, as Dr. Kopans claimed that women must wait until the can “no longer ignore a lump in their breast” before seeking medical attention. That’s, as I like to say, a load of fetid dingo’s kidneys, as I’ve pointed out before in my other posts on the topic. Dr. Kopans seems not to have noted the literature of the last three or four years that have called into question the magnitude of the benefit of screening mammography and pointed out the downsides of overdiagnosis and overtreatment and more recent evidence that, while detecting a tumor by mammography does improve survival compared to detecting the same tumor by other means, the benefit is not as large as one might think. If he has scientific reasons for rejecting this data, it doesn’t show in his statements to the press. Indeed, it’s as if the ACR has never heard of lead time bias, length bias, the Will Rogers effect, overdiagnosis, overtreatment, and the likelihood that a percentage of mammographically detected tumors spontaneously regress. Or so it seems from the pronouncements of the ACR.

One also has to wonder if there’s a wee bit of ego involved, too:

Dr. Kopans told Medscape Radiology that the task force spurned his offer to provide scientific data from randomized trials that would help them make informed decisions.

“I’m one of the world’s experts on breast imaging and mammography screening. I’m also chair of the subcommittee of the American College of Radiology for Mammography Screening. I had heard rumors that the task force was working on new screening guidelines, so I emailed them and offered to work with them. I didn’t even get a thank you. Not even a response. Clearly they didn’t want input from experts.”

Asked for a possible reason why the task force would ignore expert opinion, Dr. Kopans told Medscape Radiology that there is a nucleus of people who have long been opposed to mammography.

“I just got some updated information that they were involved with the task force. I hate to say it, it’s an ego thing. These people are willing to let women die based on the fact that they don’t think there’s a benefit.”

Project much, Dr. Kopans? Perhaps the reason the USPSTF didn’t include Dr. Kopans is because of his obvious bias towards screening? Could that be the reason? Given Dr. Kopans’ recent behavior, I really do have to wonder. It might be that the USPSTF was as clueless as Dr. Kopans claims, but he really hasn’t shown that, other than to whine that he wasn’t included in its deliberations.

Another rather obvious tactic on the part of those attacking the USPSTF is to paint those who are not as gung ho about mammography as Dr. Kopans is not as physicians or investigators who have looked at the science, weighed the evidence and come to a different conclusion than the ACR or the radiologists at the RSNA conference. Oh, no. That would be far too reasonable. Instead, they are “unbelievers”–infidels, even:

John Lewin, MD, a breast imaging specialist from Diversified Radiology of Colorado and medical director of the Rose Breast Center in Denver, agreed that the task force’s position reflects a bias against mammography among its members.

“Just the way there are democrats and republicans, there are people who are against mammography. They aren’t evil people. They really believe that mammography is not as important,” Dr. Lewin, who was not part of the expert panel, told Medscape Radiology in an interview.

This quote particularly irritated me, because it likens the debate to a a religious or political disagreement. It’s not. It’s a scientific disagreement. I’d also point out that Dr. Lewin just undermined the ACR’s position by painting the debate more as a political debate. How so? If this is a political debate, then there’s no real objective reason (or at least there is much less of one) to view Dr. Lewin’s objections to the USPSTF guidelines as being any more scientifically valid than the guidelines, now, is there? Radiologists, particularly the ACR, really should be careful making specious arguments like this, because they undermine its own scientific objections to the USPSTF’s findings, casting them as an issue of belief rather than science. Also, I particularly detest the disclaimer that “they aren’t evil people.” Oh, really? After a lot of heated rhetoric being thrown around by his good friend Dr. Kopans about how the USPSTF is content to let “many women” die of breast cancer by taking screening away from 40 to 49 year old women and letting them develop tumors that are too big to ignore, much more difficult to treat, and far more likely to kill them, it’s nice to know that Dr. Lewin doesn’t think those who doubt whether the benefits of mammography outweigh the harms for that age range are evil people. How very magnanimous of him!.

Determining who should undergo screening, when, and how often is not a matter of “belief” akin to politics or religion (although all too frequently it can seem so). Indeed, framing the issue thusly is an insult to the science behind the issue. In reality, this debate should be a matter of looking at the evidence, weighing the risks and the benefits, and then deriving rational recommendations based on them. As I’ve pointed out before, there is inevitably a value judgment involved. How many women, for instance, need to be screened to save one life? How many false positives are acceptable? The ACR’s “many dead women” gambit almost seems to imply that there is no such point beyond which more screening is counterproductive or even harmful, but obviously there is. After all, we could screen women every 3 months beginning at age 21 and probably save a few more lives, but not even the biggest boosters of mammography propose this. Why not? I mean, come on! They’re condemning women in their 20s to die of breast cancer!

The point, of course, is that there is a limit beyond which ever more intensive screening just doesn’t make sense. The very fact that even Dr. Kopans wouldn’t propose such a screening regimen tells us this point exists. However, where that point is is a value judgment that should be informed by the best science possible. Where that point is is an issue about which reasonable people can disagree. Yet, instead of simply voicing its disagreement in scientific and policy terms, which could have been the starting point for a rational debate over evidence, the RSNA and in particular the ACR have chosen to demonize the USPSTF, with weak disclaimers that they “aren’t evil people.” How very generous of them. I’ll be equally generous and provide my disclaimer that Dr. Kopans, the ACR, and the panelists at the RSNA aren’t evil people either. They do, however, appear to me to be more about turf protection and demagoguery than they are about sober discussions of science and policy, and that makes me sad.

Comments

  1. #1 skeptyk
    December 14, 2009

    Thanks for all the time you’ve been taking on this one, Orac. I have tried to have reasonable discussions with a few people on this and have run up against the wall of soundbite hyperbole. When I suggest “I think you’ll find it’s a bit more complicated than that” no one has time for that.

    Ah, the false empowerment of a little knowledge delivered in a context of emotion (rather than an architecture of the much larger knowledge that is its real context).

  2. #2 History Punk
    December 14, 2009

    Words and labels misogynistic, misogyny, and misogynist get tossed about so often and such in a blatantly incorrect fashion that they are at risk of losing all meaning and impact as an insult or as a description.

  3. #3 LibraryGryffon
    December 14, 2009

    When I read the actualy guidelines they were not as bad as the initial reporting on them, including the USPSTF’s description. However…. they seemed to rather dogmatically state “no mammography till 50″, and then only in the small print mention that the decision should actually be made by a woman and her doctor after discussing her risk factors. Shouldn’t it have been the latter statement first, followed by “if no specific risk factors, we recommned no mammograms till 50″?

    It didn’t help that this came out shortly after we learned about the women in the UK dying of cervical cancer because the NHS, due to lack of money, decreed no pap smears ’til age 25. Since one of the things the current administration has been harping on is how we spend too much on medical care, it is hard not to view this as a cost-cutting measure, rather than a medical one.

    Add in the bit about no self-exams, and that the USPSTF didn’t even seem to see any benefit to manual exams by physicians at a woman’s annual exam, how were we supposed to take it?

  4. #4 neuromofo
    December 14, 2009

    Not a bad argument against the fee-for-service model, in general. I suppose we can expect to see more demagoguery from specialty organizations, as cost controls are imposed.

  5. #5 d.hughes
    December 14, 2009

    Not sure it’s entirely accurate to describe the English NHS decision not to screen until age 25 as cost-cutting – the advisory committee spoke in terms of the consequences of overdiagnosis\overtreatment including premature birth. Note that the Welsh and Scottish NHSes have retained the lower limit of 20 pending further evidence. France also don’t start screening until 25.

  6. #6 antipodean
    December 14, 2009

    LibraryGryffon

    You might also view it as public health protecting you from the avaricious screening industry. Fee-for-service love self exams because they throw up so many needlessly panicked women who want expensive screening.

    Screening is not necessarily a good thing. It causes harm- just like Orac just described. Rational healthcare systems around the world don’t bother screening for cervical cancer before age 25 because it’s too rare and there are far far too many false-positives in women this young. Furthermore it’s possible that my daughter’s generation won’t need cervical screening anymore or will need it much later because of HPV vaccination.

    The US fee-for-service model provides the worst healthcare in the world dollar for dollar.

  7. #7 Pablo
    December 14, 2009

    I think the best point Orac makes in this point is about how everyone agrees there is a limit to where screening is beneficial. As he says, if more screening were always better, then why not every three months starting at 21? Because even those in opposition to the new guidelines know there is a point where the extra lives saved isn’t worth the effort it takes to find them. After that, it is just a question of where you draw the line.

    I’d like to hear those opposed to these guidelines provide a justification for setting their bar at 40 as opposed to, say, 35, or 30.

    “Starting screening at 40 saves lives”
    “But wouldn’t starting at 35 also save lives? Would you support new guidelines recommending screening at 35 instead?”

    But the burden on the to justify why 40 is best.

  8. #8 DLC
    December 14, 2009

    It’s guidelines. not necessarily carved in stone, is it ?

  9. #9 Kristen
    December 14, 2009

    I think it is different for everyone and women should be educated on the risk factors.

    One of my adopted daughters is half African American, therefore I will probably encourage her to seek screening sooner than my daughters who are Caucasian. I probably won’t have a mammogram until I am 50 at least because I have breastfed three children and have no other known risk factors.

    This is, after all just a recommendation. Doctors do need to be aware of their patient’s risk factors and judge accordingly.

  10. #10 Tsu Dho Nimh
    December 14, 2009

    The worst of all of these embarrassingly knee-jerk reactions by professional societies to these guidelines came from the American College of Radiology,

    Whose members have probably “invested” heavily in diagnostic equipment? Who has payments to make on the state of the art machinery?

    Whose ox is bellowing loudly?

  11. #11 Rene Najera
    December 14, 2009

    It’s guidelines. not necessarily carved in stone, is it ?

    If you ask Glenn Beck, yes, they are carved in stone. And they’re the first step to sending us all off to the concentration camps, too.

  12. #12 grisbe
    December 15, 2009

    Why not do a baseline at 40, then if everything is normal about at 45, then begin regular screenings at 50? Wouldn’t that be a compromise everyone could live with?

  13. #13 The Perky Skeptic
    December 15, 2009

    @ grisbe– Not a compromise I want to live with. I am not getting my first mammogram until I’m 50, and yes, it is because I am afraid of the pain. Well… also because I have no family history and because I looked at the guidelines in other countries, so not just because I am afraid of pain. ;)

    Like the Pirate’s Code, it’s more guidelines than actual rules.

  14. #14 Paul Browne
    December 15, 2009

    An excellent post Orac, one I’ll definately return to when this subject comes up in discussion.

  15. #15 LibraryGryffon
    December 15, 2009

    I do understand that screening has it’s downside. I’m just saying that when I read the guidelines they seemed very much of the “NO mammograms till 50″ with the “YMMV based on personal risk factors” as a very, very tiny foot note. I prefer not having annual mammograms, but then I’m one of those with no risk factors. My daughters should start screening earlier because they have a paternal aunt who had breast cancer.

    As for the NHS, in at least one place I’ve seen it stated flat out that 25 was chosen to save money using science as the reason. And again, it probably depends on the woman’s risk factors. But I’ve seen an interview on the BBC with one girl who asked about a PAP smear and was given the “We don’t do them for women under 25 because it costs too much”.

    The problem with guidelines, especially government produced guidelines, is that they then tend to become the basis for what insurance will cover. And a woman who is 40 with risk factors may not be able to pay out of pocket.

  16. #16 Scott
    December 15, 2009

    As for the NHS, in at least one place I’ve seen it stated flat out that 25 was chosen to save money using science as the reason. And again, it probably depends on the woman’s risk factors. But I’ve seen an interview on the BBC with one girl who asked about a PAP smear and was given the “We don’t do them for women under 25 because it costs too much”.

    Not convincing at all. The individual may have misheard, misinterpreted, or misremembered. And even if that’s precisely what she was in fact told, a single doctor isn’t exactly firm evidence.

    That’s entirely without considering the possibility that one or both has an axe to grind, AND ignoring the fact that of course the BBC is going to seek out the most striking case to interview.

    It barely rises to the level of suggesting a question. Not even in the same ballpark as coming close to beginning to maybe someday thinking about justifying “the NHS, due to lack of money, decreed no pap smears ’til age 25″.

  17. #17 Texas Reader
    December 15, 2009

    Perky – it’s not painful. If you still menstruate don’t schedule it for right before the expected beginning of your period when you may have tenderness. I’ve had 4 of them done and no pain at all.

  18. #18 momkat
    December 15, 2009

    Perky, I second what TR said. Somehow women have gotten it into our heads that mammograms hurt unbearably. I’ve had three, and the first was before I was 40. I have large breasts with dense tissue so I was expecting major pain and dreaded the first one. All that anxiety over what turned out to be a little discomfort. Why is it that women love to tell horror stories like they are badges of honor? I acknowledge that sensitivities to pain are very individualized, but a lot of times you get what you expect, even if you have to make it up.

  19. #19 momkat
    December 15, 2009

    Orac, your posts on this issue have made me seriously reconsider what I thought I knew. My sister (a pulmonoligist) and I discussed this over Thanksgiving and her contention was that “saving even one woman from death is worth the cost”. I am in the women’s health field and know some things about the collateral issues of cancer sceeening that she has not considered. When I postulated earlier implementation of cancer screening for lung cancer among smokers/former smokers she back-peddled and said that evidence didn’t support that. When asked how that was different from advocating an earlier age for breast cancer screening when the evidence didn’t support that, she didn’t have a comeback. When what we think we know conflicts with what is supported by evidence, it takes time to work it all out.
    You so hit the nail on the head that the USPSTFs method of announcement of their findings deserves a monumental FAIL. No wonder the ARC is upset. This rocks their whole world and greatly affects their reason d’etre. Sure, mammograms aren’t the only thing they do, but they are a large income generator. This same sister stated “whatever Medicare does, insurance companies follow”, so starting screening later means fewer lifetime visits (and their associated payments). Anyone who thinks we have fully separate systems is delusional or deliberately obtuse, but that’s another rant for another day.

  20. #20 antipodean
    December 15, 2009

    Momkat

    “saving even one woman from death is worth the cost”- Of course Pulmonologists are not trained to make those kinds of decisions or pronouncements. I wonder what her ratio for the number of women we need to maim to save one other women would be? I could ask LibraryGryphon the same since she is confusing cost with direct dollar amounts. How many women are you willing to maim in order to give one other woman another 5 years of life (which is the actual definition of a saved life in many of these projections since we can’t all live forever)?

    This is the problem with physicians making public health pronouncements- They have a tendancy to ignore the true costs of their decisions and only consider the patient in front of them. Laudable when you are the chosen patient. Not so great if you’re at the back of the line.

  21. #21 OurSally
    December 16, 2009

    You are the expert so tell me, I am just curious:

    Men have breasts too, if just vestigial ones, so can men get breast cancer? Especially really fat men who do have a lot of bosom?

  22. #22 Joseph C.
    December 16, 2009

    Men have breasts too, if just vestigial ones, so can men get breast cancer?

    Yes.

    http://www.mayoclinic.com/health/male-breast-cancer/DS00661

  23. #23 Tracy W
    December 16, 2009

    LibraryGriffon, I once had a summer job at a research lab, for which we had to attend a Health and Safety induction (lots and lots of Health and Safety risks there). One of the people talking to us was the on-site nurse, who described the first aid kits and specifically said that there were no painkillers in the kits because if someone had a headache, even if they were dead sure it was a headache from a hangover, the nurse wanted to know about it just in case it was the start of some new hazard. Then she asked for questions. One of the other attendees immediately put her hand up and said that she’d been looking in the first aid kits the other day and there were no painkillers there, why not?
    Clear communication is *not* easy.

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