As I discussed in detail when I analyzed them, the new USPSTF recommendations for screening mammography for breast cancer have sparked a debate that has degenerated from a scientific and public policy debate into pure emotional rhetoric. When last I visited this topic, yesterday, I had intended it to be my last post for a while, perhaps ever. However, the amount of idiocy that I was dealing with became so overwhelming and the post grew to even huger than Orac-ian proportions. So I decided to split the post into two parts, because the particular argument I'm about to discuss deserves its very own takedown. It also cleverly allowed me to post a big "TO BE CONTINUED..." and thereby nefariously manipulate my audience to be curious over whom the target of today's Insolence would be and thus more likely to pay me a return visit. Or not. Who knows? Either way, it let me make two long posts out of one gargantuan post. How cool is that?
For those just joining the debate, I concluded yesterday's post by describing the claim that the USPSTF's recommendations were the equivalent of "death panels" and an example of the horrors that will come if the health insurance plan being debated in the Senate right now were to become law as the undead beast continuing to lumber on, using one of my favorite analogies, the brain-eating zombie, to describe how the whole "death panels" thing destroys any intelligent argument and renders its adherents stupid and/or ignorant, much the way certain varieties of brain-eating zombies do when they feast upon grey matter. In fact, as I said yesterday, the brain-eating death panel zombie even shows up in places where you wouldn't necessarily expect it. In this case, it appears to have eaten can eat the brains of bloggers that I used to consider fairly reasonable, creating new zombies. However, unlike the drooling "Hot Air"-type death panel zombie, though, the new "death panel" zombies are more like the speedy, running zombies in 28 Days Later, not the shambling, dripping, drooling zombies of Night of the Living Dead. They're the new, improved, cleverer zombie, like the ones in The Return of the Living Dead who, after feasting on the brains of paramedics, picked up the radio from their ambulance and asked the dispatcher to send more paramedics. But at the heart, the zombie lie continues on, eating brains and reducing the level of debate from the merits of the recommendations as a matter of science and public to raw emotions manipulated by fear of government.
Most disturbing to me all was that a blogger who really should know better than to use such brain-chomped terms to describe a complex issue, Dr. Rich, has fallen victim to the zombie, likening the USPSTF's recommendations to "soft death panels":
It is this image of a death panel that allowed Ms. Palin's many critics to ridicule her backward ways, and dismiss both her and her unruly supporters (mindless rabble, angry mobs, and teabaggers one and all) as complete buffoons, unworthy of any response save disdain. For, this sort of death panel truly is patently absurd.
It would be far too inefficient (and far too personal) to set up your death panels in this way.To get a glimpse of what death panels will really look like, let us consider the new "Recommendation Statement on Screening for Breast Cancer," released just yesterday by the United States Preventive Service Task Force (USPSTF).
These new recommendations will seem stunning to many, because they constitute a significant about-face for the USPSTF. The new document, for the first time, emphasizes the risks of cancer screening, and greatly reduces the type, frequency, and duration of recommended breast cancer screening, compared with the same agency's recommendations of just a few years ago.
These changes, DrRich humbly submits, reflect just what one would expect to see from an actual death panel - if there were such a thing as death panels. It is not the "hard" death panel that Ms. Palin's critics accuse her of raving about; rather, it is a "soft" death panel (and more likely what she actually meant).
Noooo! Not you, too, Dr. Rich! This is not a "death panel"! And I can't believe you gave the ever-ignorant Sarah Palin the benefit of the doubt on this issue, because she clearly didn't mean this when she first pushed the "death panel" nonsense! (Yes, I know she did have someone write something for her on Facebook later that backpedaled a bit and sounded more in line with Dr. Rich's speculations. Probably someone affiliated with her told her how utterly idiotic her first spew was.) Remember, that was all a ploy to demonize quite reasonable provisions in the health insurance reform bill to reimburse for end-of-life counseling.
Be that as it may, only someone nearly completely ignorant of the issues and difficulties with cancer screening and its pitfalls would be the least bit surprised that an advisory panel would recommend scaling back screening for cancer. The "surprise" only comes from people who haven't been paying attention to the literature on screening over the last decade. Sadly, that includes even some oncologists and breast cancer specialists. Suffice it to say that screening women under 50 by mammography has been controversial for a long time, and the USPSTF's latest revision of its screening mammography recommendations is only the latest zig-zag on this issue. Moreover, Dr. Rich is easily demonstrably wrong when he claims that this is the first time the USPSTF has emphasized the risks of cancer screening. Again, only someone ignorant of the issues involved in screening a healthy population for cancer could say something so monumentally ignorant of the literature. Heck, it's not even the first time that the USPSTF recommended against screening, as Dr. Rich would know if he had just bothered, oh, to peruse at the USPSTF website. Let's see, there's its recommendations from 2008 for prostate cancer screening:
Summary of Recommendations
- The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years. Grade: I Statement.
- The USPSTF recommends against screening for prostate cancer in men age 75 years or older. Grade: D Recommendation.
D'oh! And that was under the Bush Administration, too! In fact, several advisory bodies, such as the American Cancer Society) concluded over the last few years that routine screening for prostate cancer for men under 75 probably causes more harm than good, and, except for high risk populations, routine prostate cancer screening with PSA testing is no longer recommended in general. None of this is anything new. A major rethinking of the benefits versus risks of cancer screening has been going on for at least five years now. It happened first for prostate cancer, where it was far more obvious that screening was finding a lot of cancers that would never threaten the life of the men in which they were diagnosed but subjected these men to overtreatment, including major surgery and radiation. It's happening now for breast cancer, where the problem of overdiagnosis is not nearly as great as it is for prostate cancer, but nonetheless significant. Moreover, the USPSTF did discuss potential harms of breast screening in its 2002 recommendations. Here are selected examples:
- The precise age at which the benefits from screening mammography justify the potential harms is a subjective judgment and should take into account patient preferences. Clinicians should inform women about the potential benefits (reduced chance of dying from breast cancer), potential harms (e.g., false-positive results, unnecessary biopsies), and limitations of the test that apply to women their age. Clinicians should tell women that the balance of benefits and potential harms of mammography improves with increasing age for women between the ages of 40 and 70.
- Women who are at increased risk for breast cancer (e.g., those with a family history of breast cancer in a mother or sister, a previous breast biopsy revealing atypical hyperplasia, or first childbirth after age 30) are more likely to benefit from regular mammography than women at lower risk. The recommendation for women to begin routine screening in their 40s is strengthened by a family history of breast cancer having been diagnosed before menopause.
- In the trials that demonstrated the effectiveness of mammography in lowering breast cancer mortality, screening was performed every 12-33 months. For women aged 50 and older, there is little evidence to suggest that annual mammography is more effective than mammography done every other year. For women aged 40-49, available trials also have not reported a clear advantage of annual mammography over biennial mammography. Nevertheless, some experts recommend annual mammography based on the lower sensitivity of the test and on evidence that tumors grow more rapidly in this age group.
- The precise age at which to discontinue screening mammography is uncertain. Only 2 randomized controlled trials enrolled women older than 69 and no trials enrolled women older than 74. Older women face a higher probability of developing and dying from breast cancer but also have a greater chance of dying from other causes. Women with comorbid conditions that limit their life expectancy are unlikely to benefit from screening.
Read, Dr. Rich. Read. Or ask an oncologist or breast surgeon familiar with the issues involved. Similarly, as is described by the New York Times, the American College of Obstetricians and Gynecologists is revising its recommendations for Pap smears to decrease the frequency and increase the age at first screening. Again, none of this is anything new, and you really should learn about the issues involved--or at least the history of this whole issue--before you stick your foot in your mouth, blogophorically speaking. Indeed, medical history is littered with examples of overzealous screening that we had to back off from after scientific studies showed that they either didn't do much good or did as much or more harm than good. Screening asymptomatic patients for cancer (or other disease) is one of the hardest issues there are in medicine because it's so difficult to define how many benefit and at what cost. Not all that long ago there was a lot of enthusiasm for screening for lung cancer with either chest X-ray or spiral CT scans. It turns out that screening almost certainly doesn't decrease mortality from lung cancer and comes at a high cost and potential harm, which is why the USPSTF doesn't recommend screening for lung cancer, either.
Dr. Rich then characterizes independent panels such as the USPSTF as in essence stealth death panels:
DrRich must therefore remind his readers that bias is inevitable in clinical research, and those who control the process get to control the bias - and therefore control what turns out to be medically right and wrong. Further, clinical research of any kind only tells you about the average response within a large group of patients, and cannot tell you how specific individuals will respond, or which specific individuals are likely to respond differently from the average, or which individuals would - if given the opportunity - weigh the risks and benefits differently than a panel of experts thinks they should. In other words, what we are getting with such a system is group medicine, and not individualized medicine.
So, the hallmark of soft death panels will be to take clinical evidence collected in groups of patients - interpreted with an overwhelming bias toward reducing costs - and to institutionalize and enforce the application of that evidence to individual patients. Soft death panels will be in the business of interpreting clinical evidence in the service of covert rationing, and the results will be packaged and sold as science - pure, sweet, clear, and unassailable science.
Is Dr. Rich for real here? Because there might be bias in clinical research, these panels will control the bias and research and therefore control what medically is "right" and "wrong"? Dr. Rich takes a tiny germ of a reasonable concern and drives right off the cliff with it. Worse, his observations about clinical research are trivial and obvious to anyone who knows anything about clinical research. They've always been true. Clinical research of almost any kind always involves deriving conclusions from studying populations because statistically valid conclusions can't really be drawn for individuals. Much of the challenge of science-based medicine is the application of data taken from groups to individual patients. That's been true for decades now. In fact, if anything, with the advent of genomic medicine, for the first time we have the possibility of truly personalized medicine. Dr. Rich is in essence making a "well, duh!" observation and yoking it to his special "covert rationing" agenda. Thus, his observation not in the least bit insightful, nor is it particularly useful. Like so much of what I've described before, it's heat but no light. In fact, more than anything, it reminds me of the same sorts of criticisms CAM advocates use to justify ignoring the standard of care in favor of woo: EBM doesn't apply to my patient; I provide individualized care; EBM is hopelessly biased; only randomized clinical trials count. How many times have I addressed such "concerns" on this blog when they came from woo-meisters or political cranks. The Association of American Physicians and Surgeons couldn't have said it better.
Dr. Rich then goes on to make statements that exhibit, frankly, an amazing collection of ignorance about breast cancer and misrepresentation of the USPSTF's recommendations. Some examples:
The bottom line is that breast cancer screening is just as effective for women aged 40 - 49 as it is for women aged 50 - 59; the reduction in mortality is the same. But because there are more false-positives among the younger women, and so it is more expensive to save those lives, the USPSTF has stopped recommending breast cancer screening for the younger women.
If this is something other than a pure cost play, DrRich does not see it.
Dr. Rich only sees what he wants to see, actually. More precisely, he doesn't see what he doesn't want to see, which is why he can't see that this is not a "pure cost play." It's also why I refer Dr. Rich to the following, that he may begin his education on the issues involved in cancer screening, be it for breast or other cancers:
- Early detection of cancer, part 1: More complex than you think
- The spontaneous regression of breast cancer?
- Overdiagnosis of breast cancer due to mammography
- Rethinking cancer screening?
- Really rethinking breast cancer screening
No need to thank me. It's my pleasure.
Suffice it to say that there were far more elements than just cost involved in the decision. Indeed, not only was cost not mentioned in the modeling studies used to formalize the recommendations, but the panel explicitly denies that costs were a consideration:
But Ned Calonge, who chairs the 16-member panel, defended the recommendations and denied that cost or the debate over health-care reform played any role in the decision. "Cost just isn't a consideration when the task force deliberates," said Calonge, who is also the chief medical officer for the Colorado Department of Public Health and Environment. Twelve of the task force members were seated during the Bush administration, and the remaining four were chosen before President George W. Bush left office, he said.
Worse, Dr. Rich's suspicion of evidence- and science-based medicine reminds me, more than anything else, of alternative medicine practitioners. I've seen exactly the same sort of rhetoric on various woo-friendly forums. Not company one wants to emulate.
Next, Dr. Rich's discussion of breast self-exam is, quite frankly, embarrassing. He points out that the populations of the two largest trials that drive the consensus that breast self-examination does not save lives, making speculation after speculation that the results would have been different in the U.S. Here's the problem: There's no counterevidence compelling enough to cast sufficient doubt on the results of these studies to reject them out of hand. Because Dr. Rich doesn't like the results of the trials and (more importantly, I suspect) the body using them to make recommendations, he decides that he'd rather recommend an intervention that has no better evidence in the context he likes to support it. (One wonders if he'd do the same thing about a cardiology intervention, where he understands the issues involved.) Indeed, even advocate groups, such as the Susan J. Komen Foundation, have backed off on recommending routine breast self-exam, except as a tool to become aware of what is and is not normal for the individual woman and admitting that the evidence that it saves lives is lacking. Even the Young Survival Coalition, a patient advocacy group that I much admire dedicated to younger women who have or have had breast cancer, wrote this position statement back in 2002:
Currently, women under 40 have no other existing methodology for detecting breast cancer other than monthly breast self-examination and annual clinical examination. These methods have not been proven to save lives, however a woman should be educated about how to be her own best health advocate and make a very personal choice about whether or not to perform BSE.
In essence, the YSC recommended BSE with caveats and the understanding that it probably doesn't decrease mortality from breast cancer. Its justification is that for young women there is no other tool, which seems like a fairly reasonable position, based on the lack of evidence and other options. It's also not that all far out line with what the USPSTF recommended on Monday. And the YSC wrote it seven years ago.
Dr. Rich's speculation that women in America would get a mammogram if they felt a lump, while seemingly reasonable, neglects that many, if not most, such women ultimately end up with a biopsy unless the mammography and ultrasound show a cyst or is stone cold normal. In the latter case they'd have a high probably of either getting an MRI or having to come back for multiple followup visits and exams. In other words, it's impossible to tell whether there would be a huge difference in the U.S. A case could equally be made that American women would suffer more harm and more biopsies. No one can tell, and, true to science- and evidence-based medicine we can only use the best evidence available. That evidence does not support the contention that teaching routine monthly breast self-examination saves lives. As I said before, I really, really wish it did, but the evidence just isn't there to show that it does. Indeed, most breast surgeons, primary care doctors, and oncologists no longer promote BSE routinely, although most do consider it reasonable to teach women to be aware of how their breasts normally look and feel and to bring to a physician's attention any changes that concern them. We still do that at our clinic. That is not the same thing as teaching BSE.
In any case, Dr. Rich's claim that the USPSTF was abusing EBM, who's abusing EBM, the person who takes imperfect data and makes the best recommendation he can with it or the person who simply urges wholesale discounting of existing evidence from randomized trials based on speculative objections without other evidence to suggest that evidence is in error or not applicable, all to promote a political agenda?
Finally, Dr. Rich demonstrates further his ignorance of breast cancer:
The USPTSF, in defending this unusual recommendation, says "the benefits of screening occur only several years after the actual screening test, whereas the percentage of women who survive long enough to benefit decreases with age." In case that didn't sink in, they go on to say that, "women of this age are at much greater risk for dying of other conditions that would not be affected by breast cancer screening."
In other words, it is not particularly valuable to identify early, treatable breast cancer in these old coots, since they are fixing to die anyway. In fact (one can almost hear them say), you've had a nice long life already - what the hell do you expect from us?
This is as close as the "soft" death panel gets, within this remarkable set of recommendations, to behaving like the "hard" death panels Sarah Palin and her unsophisticated followers like to complain about.
The ignorance, it burns us, preccciooousss! Dr. Rich, that's just despicable. Pure nastiness mixed with ignorance. I'm so disappointed.
Once again, Dr. Rich, consider the case of prostate cancer, where 75% of men over 80 have foci of cancer in their prostate glands, yet relatively few of them as a fraction of total men ever exhibit clinical cancer or die from the disease. Most die from something else, and their cancer never bothers them. However, we have in the past probably done harm to a great many men who did not require treatment, through screening too aggressively, detecting a lot of disease that didn't need treatment, and then removing or radiating a lot of prostates. We're now starting to recognize that for men with low volume, low Gleason score disease, watchful waiting is very likely a better approach. Under Dr. Rich's logic, such a decision would be exercising a "death panel."
We are also increasingly learning that the same biological behavior is true of breast cancer, albeit to a lesser extent. There appear to be a proportion of breast cancers that never advance. There are breast cancers that even regress. There are cancers that grow so slowly that it would take 20 years or more for them to become a problem. But we treat virtually all breast cancers because we can't identify the ones that are safe to watch; i.e., the ones that will not progress or may even regress over the course of the woman's remaining lifetime. Moroever, it tends to be older women who have more indolent disease, which is why we're less likely to recommend chemotherapy for women over a certain age, particularly if they have comorbidities. There are even trials asking if radiation is always necessary for small breast cancers in older women. (OMG! Death panels!) In any case, calculations of remaining life expectancy can't be separated from calculating the benefits of any intervention, be it screening, radiation, or chemotherapy, because it takes several years for the survival curves to separate. If that separation is not likely to occur until after a reasonable estimation of life expectancy, it just doesn't make a lot of sense to do it. It's not a plot; it's not "death panels"; it's just a reasonable weighing of the risks and benefits. True, it would have been better if the USPSTF had pointed out that whether screening should continue probably depends upon how much additional life expectancy a woman over 75 has, based on her medical history, but it is true that there really is a paucity of data for women over 75. Could the recommendations be turned into "rationing"? Possibly, but these recommendations, whatever their shortcomings from a scientific standpoint are not it.
For example, Dr. Rich scoffs at "nonmalignant" risks from screening, but such a complaint clearly shows that he has no concept of what overdiagnosis and overtreatment are with respect to cancer. For example, ductal carcinoma in situ (DCIS) is often viewed as a precursor lesion to breast cancer, but we don't know what percentage of DCIS lesions will advance into breast cancer that will threaten a woman's life. So we treat them all with surgical excision, be it lumpectomy or mastectomy, with radiation for women who undergo lumpectomy, often all followed by five years of tamoxifen therapy. There are complications from this, and even occasional deaths (for instance, from a pulmonary embolus due to tamoxifen's tendency to increase blood clotting). And guess what kind of cancer mammography is particularly good at detecting? DCIS. As Dr. H. Gilbert Welch put it:
"This represents a broader understanding that the efforts to detect cancer early can be a two-edged sword," said Dr. H. Gilbert Welch, a professor of medicine at Dartmouth who is among the pioneers of research into the negative effects of early detection. "Yes, it helps some people, but it harms others."
Dr. Welch said this week's recommendations could mark a turning point in public acceptance of that notion. "Now we're trying to negotiate that balance," he said. "There's no right answer, but I can tell you that the right answer is not always to start earlier, look harder and look more frequently."
Exactly. If you screen more, you will find more disease. But you will also cause some harm in the process and find subclinical disease that may never have required treatment, the treatment of which will not save lives. As I pointed out before, the balancing of these risks and benefits is less a matter of science than a matter of making a value judgment, and different patients and doctors may come down on different sides of the issue. As I said before, I was surprised that these recommendations came out now and just how far they went, but I was not at all surprised that recommendations had been made to scale back screening for breast cancer somewhat. The evidence has been trending that way for quite some time. I do understand, however, why some are so suspicious of these recommendations:
"It's going to take time, there's no doubt about it," said Louise B. Russell, a research professor at the Rutgers University Institute of Health who has studied whether prevention necessarily saves money (and found it does not always do so). "It's going to take time in part because too many people in this country have had a health insurer say no, and it's not for a good reason. So they're not used to having a group come out and say we ought to do less, and it's because it's best for you."
As hard as it is to believe, sometimes less is more. I'm not sure I'm entirely convinced that this is the case for the USPSTF recommendations, but I am sure that they are not an attempt to set up "soft death panels" and deny your grandma life-saving screening for breast cancer. In fact, this debate has been going on for decades, with most evidence leading to recommendations that routine screening of women under 40 with mammography should not be recommended. Here's just one example in the long-running war:
Seeking to clear up uncertainty about the benefits of breast cancer screening in younger women, NCI held a consensus conference in early 1997. Many of the key players in the controversy from 1969 to the present participated in the conference, either as a panelist or speaker. Presentations and discussions focused only on the 40-to-49 age group.
Initially, the 13-member consensus panel reached a unanimous agreement about the conclusions and wording. After reading the draft consensus statement, two panelists disagreed with the document's language. When the panel could not reach a unanimous consensus, the final document included majority and minority opinions (NIH Consensus Statement 1997 Jan. 21-23; 15(1): 1-35).
The majority opinion stated that "the data currently available do not warrant a universal recommendation for mammography for all women in their forties. Each woman should decide for herself whether to undergo mammography."
Then Congress got involved:
For example, when a National Institutes of Health panel declared in 1997 that routine mammograms for women in their 40s may not be worth the risks, the Senate convened hearings and voted 98 to 0 to urge the National Cancer Advisory Board to endorse routine screenings for that age group, a recommendation that was eventually adopted.
Here's what Dr. Robert Aronowitz, author of Unnatural History: Breast Cancer and American Society, has to say:
Nor is the controversy that has flared since the announcement something new. It's the same debate that's gone on in medicine since 1971, when the very first large-scale, randomized trial of screening mammography found that it saved the lives only of women aged 50 or older. Despite the evidence, doctors continued to screen women in their 40s.
Again in 1977, after an official of the National Cancer Institute voiced concern that women in their 40s were getting too much radiation from unnecessary screening, the National Institutes of Health held a consensus conference on mammography, which concluded that most women should wait until they're 50 to have regular screenings.
I don't agree with Dr. Aronowitz's apparent nihilism about therapy for breast cancer that he expresses elsewhere in his article, but I do like how he laid out the decades-long history of this debate. As I said. Dr. Rich should learn a little history, or at least demonstrate that he knows the history. His characterization of the USPSTF and its recommendations as being akin to a "soft death panel" is ignorant and offensive, regardless of whether one agrees with the USPSTF's recommendations. You may think I was too harsh on Dr. Rich. Maybe I was. On the other hand, hijacking recommendations like this and demonstrating such monumental ignorance of the history of mammographic screening and the science and clinical trials behind it makes me angry. Real angry. Over the last couple of days I've become very disappointed at the tenor this debate has taken and in particular disappointed at the level of understanding I've seen in fellow physicians and their willingness to engage in cheap rhetorical gambits designed to exaggerate and demonize rather than illuminate. Indeed, sometimes I wonder if the panel released its findings now in order to sabotage the health insurance reform bill now being debated by the Senate. Probably not. The best time to have released these results to accomplish that would probably have been back when Sarah Palin was mindlessly suggesting that end of life counseling recommendations were the equivalent of setting up "death panels."
There are real issues in these recommendations that need debate and a couple of the recommendations are not as strongly grounded in evidence and science as I would like. I even tend to think that the panel struck too dogmatic a pose when it comes to discouraging BSE. (I would have probably recommended not promoting it but suggesting it as a tool for a woman to know what is and is not normal for her, which is what I do now.) My disagreements aside, the USPSTF recommendations are probably, although not certainly, more strongly grounded in science than earlier recommendations. They are also a first word, not a last word, in deciding how the standard of care will change when it comes to breast cancer screening.
I realize that emotions run high when it comes to breast cancer, particularly among survivors and relatives of survivors. Unfortunately, the "misogyny" gambit, the "Third World" gambit, and the "Obama death panel" gambits do not contribute to this debate or provide an effective refutation of these guidelines. They're all heat, no light.
ADDENDUM: Here's a reasonable take on the issue at Our Bodies Our Blog.
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I stopped reading Dr Rich when he seemed to give credence to global warming denialism.
Here's another blogger's take on this:
http://www.evidenceinmedicine.org/2009/11/uspstf-mammography-and-gradin…
What I don't get about these health care debates in America is that we're already talking about more people getting more health care than they were getting before. How does that become a plot to kill them by restricting their options for health care? Since when is it more acceptable to let people die because they're extremely poor than because the state is not infinitely rich? And that's even if these recommendations were cost-driven which I know you say they are not.
One thing I've noticed is that many critics focus on the "stress" issue that the USPSTF brought up as a risk associated with false positives. The critics take that to mean the authorities think women are too wussy to handle being told they might have cancer, or too wussy to put up with the mammogram itself. But they overlook what a biopsy actually is: a surgical procedure involving a fairly tender and certainly personal bit of anatomy. It is definitely stressful, and not just in the "I need a hug" kind of way. It is *physically* stressful.
I have a friend who had a lump biopsied recently. She's in her 30s. The lump was detected on BSE, if I recall correctly, and the mammogram wasn't conclusive, so they did a biopsy. It was normal. But the biopsy caused her considerable pain. She was taking Vicodin for a couple of days. I would say that's a legitimate kind of stress to worry about; if the surgical site hurts that much in some cases, it's obviously stressful to the body, and that's not a trivial risk. She lost time at work too, of course, while she recovered. And her biopsy went very well; what about the risks of things going wrong? Any surgical procedure can be bungled, and even the best surgical procedure carries a risk of infection. If a mammogram finds a suspicious spot, it get biopsied and proven benign, but the woman ends up with gangrene ultimately requiring the removal of part or all of the breast anyway, it really hasn't done a lot of good. They definitely underestimate the risk of false positives.
So are new guidelines going to be forthcoming for colon cancer screening? Because I for one would love to be told not to worry about getting a colonoscopy.
I was watching C-Span as the Senate legislation was introduced. All the Repubs were ranting about "rationing", "this is how it starts", "women don't matter under Obamacare", "government panel". Then came the testimonials: "My mother found a lump at age 45, and her life was saved", and so on. They mangled even the most basic tenets of science and research that I really could not keep up with it! They were all acting like Glenn Beck (fakey crying) and "pleading" with the President to spare the women aged 40 to 50 who will DIE now this government panel will be taking over our health care, blah, blah, blah. It was truly too hard to watch after awhile.
Personally, being at very low risk and now 60, I skipped a few mammos along the way and didn't start at exactly 40. I never did BSE's even though the tech's always pleaded with me. As to the "stress", I was called back after one of my mammos for a "second look" and those three days were just truly terrifying. It turned out to be nothing, they didn't even take another x-ray. The thing is, personal experiences are all over the map (and isn't proof of anything) on this and NOONE is going to prevent you doing BSE if you want to, so I wish people would just calm down and talk to their own doctors and read credible stuff! Fat chance!
This panel of "experts" is severely deficient in people who actually take care of women with breast cancers. The people who live with this problem and understand it best are medical oncologists, surgeons and patients. The people on the panel are predominantly public health/epidemiology types. Therefore the panel is making its recommendations based on numerical analysis of outcomes and has VERY little real world experience with the issues involved. I would have a whole lot more respect for the panel's recommendation if it had been more appropriately staffed.
One can't help but note that you haven't argued against the panel's recommendations based on--oh, you know--any actual data or flaws in the panel's interpretation of the data. I've pointed out how this is an example of how different scientists and clinicians can look at the same data and come to different conclusions based more on their relative weighing of risks and benefits.
Remember, the purpose of this post is not so much as to defend the recommendations but rather to point out how so many have taken the panel's recommendations and used demonization and exaggerated rhetoric to attack them rather than debate them on their merits or lack thereof.
Why doesn't that surprise me. An example of crank magnetism?
Thanks for these posts, Orac. I've been minorly involved in some debates on this issue lately. So far, no-one has demonstrated any stupidity, no trolls have shown up, and we're having an informative discussion. Your posts are helpful in navigating, and in seeing some of the history of this debate. It puts things in perspective.
@Anthro
"so I wish people would just calm down and talk to their own doctors and read credible stuff!"
Exactly! I'm in a similar situation as you, but in my late 40s with one re-look at the left tata a few years ago. It was a scary few days until I could go in for a re-test.
The constant need of everyone for more and more testing regardless of what the data tells us is worthwhile is part of the reason our health care costs are going up astronomically.
Orac: An Actual Oncologist does not appear to have read your first post on the recommendations. Since you ARE an expert in women with breast cancers, I'd be a lot more concerned about the recommendations if you had a lot of reservations about them. Since you don't, I have no quarrels with them.
I did download and read the recommendations...the new recommendations are close to what I first learned as a midwife, outside of not teaching BSE.
I will admit to being rather peeved that they upped the under 50 year old screening mammos to every year from every 2 years in 2002(?), since I LIKED only having to go every 2 years. I don't like making myself go every year, being in a low-risk group, but out of respect and liking for my GYN, and knowing that P4P is based on his scores for those metrics, I go.
Abnormal mammograms (my very first one was abnormal, due to localized breast fat necrosis) are very scary and stressful. I can sympathize with those who have abnormal ones, and feel for the women diagnosed with breast cancer (3 of my women friends, within the past 4 years). But I don't think the guidelines are bad.
It strikes me as odd that people would be so surprised at this recommendation. As Anthro said, if people want to get a BSE (or any other kind of screening), they still can. More to the point, if they think they have a good reason to, their doctor will probably agree, despite their age. Lump = risk. Der. Why would it surprise anyone that smashing, probing and poking at your junk might actually make things worse? Granted, I don't have breasts, but if someone wanted to smash my balls in a clamp over and over again to look for hard lumpy bits, I might think that's time better served when I'm more likely to be at risk. Just because we don't have less traumatic screening methods doesn't mean they shouldn't be taken, but science is a growth process. If new data comes out in a few years that tends to indicate that screening is harmless compared to an elevated element of risk, then okay. If it zigs back again from some other data, okay. That's how it works, and it's how we learn from experience. This just seems to be politics getting in the way again. I'm sure it won't be the last time.
Since you reference the American Cancer Society, I'd like to quote Dr. Otis Brawley, the Socity's chif medical officer"
"The USPSTF says that screening 1,339 women in their 50s to save one life makes screening worthwhile in that age group. Yet USPSTF also says screening 1,904 women ages 40 to 49 in order to save one life is not worthwhile. The American Cancer Society feels that in both cases, the lifesaving benefits of screening outweigh any potential harms. Surveys of women show that they are aware of these limitations, and also place high value on detecting breast cancer early.
With its new recommendations, the USPSTF is essentially telling women that mammography at age 40 to 49 saves lives; just not enough of them".
I'm not concerned about "death panels" -- except maybe from my current health insurance company--but when professionals in the field hold such different opinions, it's hard to know, as a layperson, what the right course of action is. This is not hysteria, it's just confusion.
So I went and read the USPSTF. No help, due to my poor understanding of statistics. I did note, though, that they don't want us to bother doing breast exams either. Instead, we're to practice "breast awareness." I know that to pose this question is to invite every troll in the world, but seriously, what does that even mean?
I did note, though, that they don't want us to bother
doing breast exams either. Instead, we're to
practice "breast awareness." I know that to pose this
question is to invite every troll in the world, but
seriously, what does that even mean?
I am guessing it means to know how your own breasts "feel" during the month. If you have lumpy breasts, then your would know if they lumps change, if you don't have lumpy breasts, then you would know if you have a lump. Mine are very fibrocystic but there are changes that I am aware of during my cycle (and I do not do regular BSEs).
I don't get the big uproar though - is anyone really thinking that their insurance is not going to cover a mamo if they needed it? They cover them now when you are under 40. I've had diagnostic ones done to rule out cysts and now that my mother was just diagnosed with Stage II IDC and ILC, I don't think I will be denied one before I am 50. Geez, wait till all these people see the new PAP recommendations.
Re: breast awareness
Obligatory disclosure: my only expertise consists of having breasts and being concerned about what happens to them. ;-) I think by "breast awareness" as opposed to BSE is that it doesn't matter if you do the exam a particular way or on a particular schedule (like, it's not necessary to do it every month, with rotating motions starting at the nipple and spiraling outwards systematically). It's still a good idea to be familiar enough with your breasts that you know if they're changing. I think. That's my take on the recommendation, anyway, and how I intend to interpret it.
@Calli Arcale
Does that make you a Breast Warrior? At the very least, it makes you an expert on all things related to breast cancer, obviously, just like Jenny McCarthy is an expert on all things vaccines/autism.
If people get the government they deserve, than the public reaction to this recommendation demonstrates why our health care system is so horrible.
Why does is surprise anyone that as the government gets more involved with health care the decisions become more political? That's the way the government works. Period, full stop. You cannot name a program or branch that makes "rational" or scientific decisions insulated from politics. This is why I, personally want less government intervention pretty much everywhere. For those who believe the program (whatever program) will work if only "that side" wasn't involved -- tough.
DRK: from the explanation I heard from a doc on NPR yesterday (don't remember her name, I came in in the middle of the program) "If you found a lump on your calf, it wouldn't be because you were doing a monthly examination." She then went on to say that most lumps were found during washing/dressing, not structured examinations.
I think they could have worded it better to be "You all do such a good job finding your lumps on your own that we don't need to teach you how to feel yourself."
I also remember hearing somewhere that a non-negligible number of lumps are found by partners. Hence the t-shirts "save a life, feel up your wife".
orac, I have consistantly used the panels data (and other data to argue against their recomendations.
Ahh, another good argument for national medical program, it is the ability to determine true therapy, risks and benefits. The monetary stimulus of service based remuneration makes these therapies subject to bias and under-analysis. Too bad that thoughtful algorithms were not issued by the panel and yourself.
I had breast cancer in my right breast three years ago. I get a yearly MRI and Mammogram on my left breast. Should I just do the MRI and not the mammogram? Am I now supposed not to get a mammo until I'm 50 (I'm 42)? How do these guidelines effect me?
And I find my lumnp by accident. I had never had a mamo nor done BSE. I wish I had a mammo at 35 - maybe I would have a better chance at survival. Then again, maybe not.
Is the bottom line here that early detection doesn't really matter? That's what I'm taking away. Maybe the treatment doesn't help either. I'm feel very depressed about all this right now, as are all the women in my young BC group. We all feel very hopeless - like the truth that's just come out is that early detection doesn't matter, and that all the treatment we got is in vain.
Thanks.
I had breast cancer in my right breast three years ago. I get a yearly MRI and Mammogram on my left breast. Should I just do the MRI and not the mammogram? Am I now supposed not to get a mammo until I'm 50 (I'm 42)? How do these guidelines effect me?
And I find my lumnp by accident. I had never had a mamo nor done BSE. I wish I had a mammo at 35 - maybe I would have a better chance at survival. Then again, maybe not.
Is the bottom line here that early detection doesn't really matter? That's what I'm taking away. Maybe the treatment doesn't help either. I'm feel very depressed about all this right now, as are all the women in my young BC group. We all feel very hopeless - like the truth that's just come out is that early detection doesn't matter, and that all the treatment we got is in vain.
Thanks.
I don't undertand. Why are people overreacting? Don't the new recommendations make some sense? There might be some weaknesses, and pointing them out is good. But instead, people are demonizing the new recommendations without having the necessary knowledge. I wonder, what is driving this overreaction?
grisby
Since you are a breast cancer survivor, any recommendations for screening mammograms don't apply to you. Notice when your doctor writes the order for your mammograms and MRIs, he/she always writes "history of rt breast cancer," or words to that effect. I urge you to discuss your concerns with the doctors who are following you for breast cancer.
I am a BC survivor also, so I know it can be confusing and stressful at times.
Early detection does matter for *some* women, but not all. In some cases, a tumor discovered on a mammogram will have already spread, so discovering it "early" does not prolong life. In other cases, a tumor discovered on a mammogram would never have caused symptoms, so all the stress and harms of treatment are for nothing. In many cases, an individual woman cannot know whether early diagnosis made a difference in her particular case or not.
Feel free to email me privately if you want to: mannm@comcast.net.
BladeDoc @ # 17: You cannot name a program or branch that makes "rational" or scientific decisions insulated from politics. This is why I, personally want less government intervention pretty much everywhere.
Why, of course! Profit-driven institutions always make the best choices for all concerned, especially the "little guys"!
It's enough to make you wonder why we ever set up any other form of handling problems, isn't it?
Isn't it?
Personal anecdote: In the back room at my other job (the one where we sell homeopathy and other woo to suckers), my boss and another female employee were working together and talking about the Pap smear recommendations. It ended up with the "they just want women to get sicker" arguement. I pointed out that prostate cancer recommendations came out a while ago. They came back with the "if rape happened to men more often, it'd be eradicated by now" statement.
Then the other woman complained that she takes a thyroid medication and her doctor forces her to get a test every year. "Maybe he's concerned about your health," I replied. No, she said, he's concerned about making all that money.
Then I had to leave and take a long walk.
Either that or scream.
But I will say, after reading Orac's incredibly useful, informative, and entertaining posts on this matter, I know a whole heck of a lot more about it all. Thank you Orac. Thank you for your sanity.
Hm. The last people I would want doing screening recommendations are "actual oncologists."
A surgeon will tell a patient, I'm sorry, this surgery will not help you and might make you worse. An oncologist will give chemotherapy of some fashion to the last breath, and will never say that there really is nothing to help.
I suspect an oncologist would have us screened from birth. Not out of malice, but from the genuine wish to help, regardless of the evidence.
My favourite oncologist was a guy with Asperger's whose social skills were a bit iffy. He wanted to help, but made no bones about what he could and could not accomplish. His patients ADORED him, and the other oncologists sent their relatives to him.
Thanks for the response, Marilyn Mann.
What really complicates things is when your doctors disagree.
My plastic surgeon says there's no reason at all to do a mammo on my reconstructed breast. My radiologist says absolutely mammo it because she's caught recurrences that way. My onc says that either is reasonable.
When my insurance wouldn't cover my yearly MRIs (I'm young enough to have dense breasts, and to have had lobular as well as ductal cancer), my onc said no problem. Again, radiologists said MRI was absolutely necessary, and fought to get MRI covered.
So, since none of the specialists seem to agree on what screening is necessary for me, how am I supposed to know? Further, how is the government to make guidelines that anyone can follow?
I'm even more confused now that these guidelines have come out.
Today, I decided to forgo my AIs and go back to tamoxifen due to side effects. I can't even find data on which is really better and why.
grisbycat
The difference between AIs and tamoxifen is small. In early stage BC, the difference in overall survival was only 11% in a recent trial, and the difference wasn't statistically significant. If the AI is giving you problems, by all means go back to tamoxifen, IMO. The only issue would be if you are not a good metabolizer for tamoxifen. Have you been tested for that? They do it at Mayo, your doc can order it. Maybe other places as well by now, I had my test in 2007.
The other stuff does sound like a mess, but I am still not seeing what it has to do with the USPSTF guidelines. Your mammograms are not *screening* mammograms; they are *diagnostic* mammograms. The USPSTF is not even talking about followup for women who have had BC.
Marilyn, it's so kind of you to respond.
Yes, I'm going back to tamoxifen. I was tested and I'm a good metabolism. I had no side effects from it than I know if. My doc wanted me to switch based on the "switching studies." But like you say, there's little difference so why live in pain?
I guess what upset me about the new USPSTF guidelines is that it feels like they're saying that early detection doesn't matter. I can't understand why else they wouldn't want screening for my age group. That makes me wonder whether I really caught my 3cm and 2cm grade III tumors early enough, or whether it's just lead time bias that makes it seem like I'm cured.
Thanks again for your response. It's very kind of you to answer my silly questions.
Grisbycat:
You were diagnosed with 2 and 3 cm. Grade III tumors - These tumors would not be expected to lie dormant for years or spontaneously regress. I think the cancers that would do this would be small (less than 1 cm) low grade or in situ. A Grade III tumor tends to behave aggressively and grow fast, so I would say that it is good that you caught your tumors when you did. In fact, it's possible that a mammogram a year before you found your tumors would have been negative. That's how fast some of these tumors can grow. I have seen several cases where a tumor mass like yours has presented itself a few months after a negative mammogram.
Mammography, like any screening test so far, has its limitations.
I wish you success in getting your other questions answered. I'm sorry that they are outside my field of study.
Orac,
I have attempted to reply to some of your more substantive criticisms here:
http://covertrationingblog.com/general-rationing-issues/drrichs-last-wo…
I greatly appreciate the fact that, unlike some others, your comments were indeed substantive, and avoided the ad hominem variety.
Regards,
DrRich
Would be interested what people think of the following comment by Dr. Rich:
http://covertrationingblog.com/general-rationing-issues/drrichs-last-wo…
"Actually, I do not deny global warming. I believe, in fact, that itâs probably occurring. But I have an open mind, and view with interest some of the evidence that we may be starting to cool. What I object to is the notion that the science of global warming is settled, and that no evidence to the contrary is to be admitted. While political questions may be settled (by a consensus, or by force), science can never be truly 'settled.'"
I am not an expert on global warming, but I have my doubts about the idea that evidence is being suppressed because it is politically incorrect.
I also think the idea that "science can never be truly settled" ignores the fact that over time a scientific consensus may develop on a certain issue because of the evidence on that issue becomes overwhelming. To me, the fact that manmade global warming is occurring seems to be such an issue.
In other words, I think there is a spectrum along which different concepts in science can fall with respect to amount and quality of evidence for that concept, from "overwhelming" to "none." To simply say that "science is never settled" ignores the fact that the strength of the evidence can vary greatly depending on the issue.
I guess I resent the implication that people who are convinced on global warming are necessarily closed-minded and are even actively suppressing evidence. I just don't think that's accurate.
Wow. Dr. Rich sure sounds pretty AGW denialist to me, particularly the blather against "scientific consensus."
Actually, I am less and less impressed with Dr. Rich. He clearly has a political agenda, and he's let it color his interpretation of science. His posts on the USPSTF guidelines have been quite embarrassing, particularly his willingness to reject evidence-based medicine if it doesn't show what he thinks it should show or if it is convenient to his political "covert rationing" schtick to do so.
You need to read DrRich's latest entry. I suspect you've made your own ideological conclusionary jumps.
It isn't the science that is being questioned. It's the place where it transitions into policy. Orac, you need to do a better job of reading comprehension. I'm disappointed you spent so much time and effort addressing the wrong issues. I guess you have a political agenda and have allowed it to color your interpretations of science as well. Speaking of which, I sincerely suggest you remove yourself from the topic of global warming...it is clearly far outside your realm of expertise.
I know what Dr. Rich was trying to do, but he did it so ineptly and demonstrated such a profound and appalling ignorance of the issues involved in the issues involved with breast cancer screening--nay, all screening for cancer--that he richly deserved a blog beatdown. If anything, I went easy on him. His post on the USPSTF guidelines was absolutely pathetic. He clearly knew almost nothing about the history, science, or clinical issues behind mammography screening (and what he did know he mangled so horribly that he should have been embarrassed to post about it), and it showed.
Badly.
As for my removing myself from discussions of AGW, I have a very simple retort to you, taken from one of my all time favorite retorts. Naturally, it's from World War II, and it was what General Anthony McAuliffe said during the Battle of Bastogne in reply to the German commander's demand for his surrender:
Nuts! (Personally, I would have used a four letter word, but I try to keep this blog no worse than PG-13 whenever possible.)
It doesn't take a detailed mathematical knowledge of climate science to recognize denialist arguments and techniques in the AGW denialist camp.
Orac, this is not about the substance of this post, or your latest comment but I only learned of that event from the Battle of Bastogne last night while watching TV. Eerie feeling, well, it would be if I thought it meant anything beyond a coincidence that happens on occasion.
Then perhaps you should acquaint yourself with the recently uncovered perversions of the scientific method carried out by some of the primary AGW proponents...deleting data, "blackballing" journals that published authors they disagreed with, "blackballing" colleagues that raised contradicting or alternative explanations, collusion and conspiracy to hide methodologies. Some of these fellows may even face criminal charges, because of the willful failure to abide by FOIA-like laws. Try Googling "climategate."
The AGW theory has always been rather tenuous, to those of us with hard science and engineering backgrounds. Interesting, but highly speculative. There are so many weaknesses and unknowns in the modeling, problems with the temperature monitoring networks, and by necessity, reconstruction of older temperature histories (tree rings, ice cores, etc.) Problems with the magnitude of the predictions, as well as the margins of error, given the physical processes that were unknown or merely presupposed. The failures to predict future trends. And the proponents have always resisted, irrationally and in complete contradiction to accepted scientific methodologies it had seemed, disclosing the basis for their "temperature history." Now we know why. Because they "cheated" to get the results they wanted, and conspired to ridicule anyone who questioned them.
And there are so many alternative explanations that made better physical sense, or at the least added to the understanding. Read a bit of Prof. Richard Lindzen's work, from the MIT Department of Earth and Planetary Science. If you have any competence in science outside the medical fields, and have any intellectual honesty, you may be surprised.
My suspicion is that you are like many medical practitioners, competent within your narrow field, but gullible to the whims of the popular delusions when you step outside of it. (Speaking as a tax attorney, there's a reason so many medical doctors get mired in tax shelter frauds; Tax Court is full of them. It's called Ego and Inexperience.) Your AGW comments are what make me believe this to be true in your case. As one of my law professors once said, everyone has an opinion. The point is to make it an informed one, know the limits of your own knowledge, and when you are unjustifiably relying on someone else's.
That's why I don't question your medical explanation above...I certainly don't have any way of independently judging it. But I understand full well what happens when this kind of science runs smack into government, regulatory bodies, and Congressional sub-committees. Your criticism of DrRich, in my view, was off base. Way off base. Not in the medicine, but in its impact on healthcare regulation.
So frankly, you may not need detailed mathematical knowledge to understand "arguments and techniques", but you do need to understand how hard science is supposed to work, and a bit about physics, data collection and integrity, if you are going to hold an honest opinion about AGW. Or at least be willing to hold up the same mirror of criticism to your own "camp." Anything else is just an opinion, without any justifiable reliance. I expect a medical doctor to understand how these fads run their course through the media...lord knows there have been plenty of them in the field of medicine; vitamin C, homeopathic remedies, cholesterol being all "bad", etc.. There used to be a "consensus" about bleeding and the non-existance of "germs" in your area, once upon a time. All I ask is for a little honest scientific scepticism from someone who is supposed to be schooled in deductive reasoning and analysis. Labeling someone a "denialist" in a pejorative way just tells me you're a pompous know-nothing about the topic. By all means, have an opinion. But unless you're willing to invest in understanding the scientific arguments, you probably ought to keep it to yourself. Or at the very least, quit acting so defensive about it with folks that hold rational but different ones.
Of course, you're free to ignore my opinion, but since you chose to put your opinion out in a public forum such as this, expect to be called on it. And be glad the "denialists" aren't advocating criminal prosecution of the "warmists", which is more than can be said for the media-led crowd of ignorami who have turned AGW into a faith-based religion.
So, enjoy your "nuts." You have plenty of them keeping you company in the AGW theory and socialized healthcare debate.
Perhaps ruralcounsel will like my latest post:
http://scienceblogs.com/insolence/2009/11/the_vindication_of_all_kooks_…
:-)
Ruralcounsel:
It's funny that you should be lecturing Orac for stepping outside his field of expertise by commenting about AGW. I wasn't aware that tax lawyers dealt with global warming on aprofessional basis (apart from, perhaps, turning up the air conditioners in their offices)
T. Bruce
I also happen to hold a BS, MS and ScD in Chemical Engineering, and have actually taken courses in heat transfer, physics, reactor engineering, computational fluid mechanics and fluid mechanics of rotating systems, and done a fair amount of computer modeling.
I alluded to having a technical background, but wasn't specific, so your assumption, however mistaken, is understandable.
Orac,
Yes, I enjoyed that posting quite a bit, actually.
You'll note that I only spoke to the concept of AGW, not any of the other "theories" you wrote about. Interestingly enough, I would consider all of the "theories" you mentioned to be kooky as well, but for for the AGW "denial." And I'm sure you'll agree that the fact that the AGW community is reeling from the fraud revelation has no logical impact on the legitimacy of any of the other kooky theories...which I believe is the one sentence synopsis of your posting.
Frankly, I would consider the AGW theory itself to be a candidate for a "kooky" theory, but for the fact that there is some small scientific basis for the most simplistic parts of it. Unfortunately, it neither predicts the known climate data (without highly selective massaged data sets), nor even if it could, is not capable of establishing cause-and-effect between anthropogenic activity and climate trends. And, there are those pesky natural laws of physics and chemistry that provide many alternative, if not better explanations of the data.
There is probably another corallary that those that criticize one crazy theory have a tendency to try and lump everything they disagree with into the same general criticism. The risk in that of course, is that if one starts with a list of everything one believes to be "crazy" ab initio, one hasn't performed any rational processes.
One always runs a risk when you allow other experts to do your thinking for you. The first of which is that the experts are lying. Fortunately, this is relatively rare in the scientific community these days. Rare, not unknown. The second risk is that the experts are biased.
Bias is not always a bad thing. Like habit or routine, it avoids a lot of repetition and waste. I would prefer a medical practitioner that is biased to believe in germ theory. Or a bridge architect that believes in the concept of yield strength and stress-strain curves. Pilots who believe in aerodynamics. The trick is is knowing what to be biased about.
I happen to believe that the Earth's climate is changing. Being a dynamic system, it always has changed. We don't always understand why. We can only infer what it has been, since modern measurements span too short a time to provide meaningful climate trends. Complex non-linear systems with many cross interactions are difficult to analyze. especially if you don't know all the equation terms or the initial conditions. The AGW proponents took one tiny aspect (carbon dioxide's radiation absorbtion/emissivity) and extrapolated it to absurdity with a very small data set and huge error bars. They thought they had found the key to unlimited research grants. They also tapped in to massive financial flows, like ticks on a dog. Investments in such things as "green" industry, cap-and-trade, international treaties proposing large transfers of wealth from the developed nations. Nothing sells like apocalypse.
Like a tax attorney who writes a market opinion letter on a tax shelter, they found themselves in the powerful position of blessing various economic transactions and political manueverings. And just like the attorney, they had to make a lot of unreasonable assumptions and ignore a lot of facts to reach their conclusion. And they've been handsomely rewarded for it, either in professional success, fame, or fortune, and sometimes all three. The scientists weren't alone, of course. The hucksters (news media) and politicians, having their own economic or social engineering agendas, have piled on as well. Mr. Gore is now a very wealthy man. The public has been captivated by the concept, artfully touted by the media. Like investors caught in a bubble, they think the market can only go up. Only the cheerleaders in AGW are raking in lots of money. Try googling "carbon trading companies." Or better yet, "goldman sachs carbon trading." And the UN is positively salivating at the thought of controlling economic activity across the globe.
It's a simple concept, but one worth repeating. Follow the money.
Which is why the experts should provide the analysis of the risks, but individuals should be left as free as possible to make their own "policy" decisions. I have no issue with the analysis of mammogram risks...but no one should use that information to make sweeping decisions for all of the women of our country. That is something they should each decide for themselves.