Does mammography save lives? A new study shows that this is a harder question than you might think

Mammography is a topic that, as a breast surgeon, I can't get away from. It's a useful tool that those of us who treat breast cancer patients have used for over 30 years to detect breast cancer in asymptomatic women and thus (or so we hope) decrease their risk of dying of breast cancer through early intervention. We have always known, however, that mammography is an imperfect tool. Oddly enough, its imperfections come from two different directions. On the one hand, in women with dense breasts its sensitivity can be maddeningly low, leading it to miss breast cancers camouflaged by the surrounding dense breast tissue. On the other hand, it can be "too good" in that it can diagnose cancers at a very early stage.

Early detection isn't always better

While intuitively such early detection would seem to be an unalloyed Good Thing, it isn't always. Although screening for early cancers appears to improve survival, the phenomenon of lead time bias can mean that detecting a disease early only appears to improve survival even if earlier treatment has no impact whatsoever on the progression of the disease. Teasing out a true improvement in treatment outcomes from lead time bias is not trivial. Part of the reason why early detection might not always lead to improvements in outcome is because of a phenomenon called overdiagnosis. Basically, overdiagnosis is the diagnosis of disease (in this case breast cancer but it is also an issue for other cancers) that would, if left untreated, never endanger the health or life of a patient, either because it never progresses or because it progresses so slowly that the patient will die of something else (old age, even) before the disease ever becomes symptomatic. Estimates of overdiagnosis due to mammography have been reported to be as high as one in five or even one in three. (Remember, the patients in these studies are not patients with a lump or other symptoms, but women whose cancer was detected only through mammography!) Part of the evidence for overdiagnosis includes a 16-fold increase in incidence since 1975 of a breast cancer precursor known as ductal carcinoma in situ, which is almost certainly not due to biology but to the introduction of mass screening programs in the 1980s.

As a result of studies published over the last few years, the efficacy of screening mammography in decreasing breast cancer mortality has been called into question. For instance, in 2012 a study in the New England Journal of Medicine (NEJM) by Archie Bleyer and H. Gilbert Welch found that, while there had been a doubling in the number of cases of early stage breast cancer in the 30 years since mass mammographic screening programs had been instituted, this increase wasn't associated with a comparable decrease in diagnoses of late stage cancers, as one would expect if early detection was taking early stage cancers out of the "cancer pool" by preventing their progression. That's not to say that Bleyer and Welch didn't find that late stage cancer diagnoses decreased, only that they didn't decrease nearly as much as the diagnosis of early stage cancers increased, and they estimated the rate of overdiagnosis to be 31%. These results are in marked contrast to the promotion of mammography sometimes used by advocacy groups. Last year, the 25 year followup for the Canadian National Breast Screening Study (CNBSS) was published. The CNBSS is a large, randomized clinical trial started in the 1980s to examine the effect of mammographic screening on mortality. The conclusion thus far? That screening with mammography is not associated with a decrease in mortality from breast cancer. Naturally, there was pushback by radiology groups, but their arguments were, in general, not convincing. In any case, mammographic screening resulted in decreases in breast cancer mortality in randomized studies, but those studies were done decades ago, and treatments have improved markedly since, leaving open the question of whether it was the mammographic screening or better adjuvant treatments that caused the decrease in mortality from breast cancer that we have observed over the last 20 years.

Given that it's been a while since I've looked at the topic (other than a dissection of well-meaning but misguided mandatory breast density reporting laws a month ago), I thought now would be a good time to look at some newer evidence in light of the publication of a new study that's producing familiar headlines, such as "Mammograms may not reduce breast cancer deaths".

Here we go again.

An ecological study of mammography and breast cancer

The study that produced a brief flurry of the usual headlines last week was published in JAMA Internal Medicine a week ago by Harding et al, "Breast Cancer Screening, Incidence, and Mortality Across US Counties". It was a collaborative effort from doctors Seattle, Harvard University, and Dartmouth. One disclosure that I have to make here is that one of the authors is H. Gilbert Welch, whose studies I have discussed here before on multiple occasions. Back then, however, I had had little contact with him. Now, however, I must disclose that I am working on a brief commentary on cancer screening with him and another coauthor. However, I had nothing to do with the study under discussion. Thus endeth the disclosure.

So what did the study do? In concept, the study is very simple in design, although carrying out such a study is devilishly difficult. To boil down the concept of the study to a single question, the investigators asked whether differences in rates of screening mammography correlate with differences in breast cancer mortality. In other words, does a high frequency of screening correlate with lower breast cancer mortality and vice-versa? To accomplish this, the authors used the Surveillance, Epidemiology, and End Results (SEER) database to perform an ecological study of 16 million women aged 40 or older who resided in 547 counties reporting to the database. The study covered a period from January 1, 2000 to December 31, 2010 and included 16 million women, of which 53,207 were diagnosed with breast cancer and followed for the next ten years, a population that is drawn from approximately one quarter of the US population. The extent of screening in each county was assessed as the percentage of included women who underwent screening mammography within the last two years. The main outcomes were breast cancer incidence in 2000 and incidence-based breast cancer mortality during the ten year followup. These were calculated for each county and age-adjusted to the US population. Incidence-based mortality was chosen as the endpoint because it excludes cancers diagnosed before the study period and is insensitive to overdiagnosis.

Here is the schema for how subjects were chosen:

Study schema

The not-unexpected, and unexpected results

So what were the results? Not unexpectedly, there was a positive correlation between the extent of screening and breast cancer incidence. This is not in the least bit surprising, and, in fact, I would have been surprised if this result was not found. Basically, an absolute increase of 10 percentage points in the extent of screening was associated with 16% more breast cancer diagnoses. This increase in detection of breast cancer, unfortunately, was not associated with a decline in breast cancer incidence-based mortality. A picture is, as they say, worth 1,000 words, and here's the "money" figure, so to speak:

No correlation

Notice how there is a correlation between incidence and increasing percentage of women 40 and older who received mammography during the previous two years, but there is no correlation between the percent screened and 10-year incidence-based mortality from breast cancer. I realize that this looks like what we sometimes call a "star chart," but for population-level data like this the correlation between percent screened is striking; equally striking is the lack of correlation between percent screened and mortality.

Next, the authors stratified the data based on tumor size, to determine whether screening had more of an effect on small versus large tumors, the cutoff being 2 cm in diameter. The reason that cutoff was likely chosen is because tumors less than 2 cm in diameter are considered stage I (assuming negative axillary lymph nodes), while tumors greater than 2 cm are at least stage II. Consistent with the results reported in the 2012 NEJM study, the effect of mammography was more marked on smaller tumors, with a 10% increase in mammography screening associated with a 25% increase in the incidence of small tumors and only a 7% increase in the incidence of larger tumors. Of note, no decrease in the incidence of larger tumors was observed associated with screening mammography, again contrary to what one would predict based on the hypothesis that early detection prevents the presentation of disease at later stages because, or so it is presumed, early detection results in treatment of early stage tumors that decreases the number of tumors that make it to later stages before being detected.

Finally, the authors looked at disease stage and extent of surgery. The reason they did this is because one rationale for mammography is that, even if early detection doesn't have much of an effect on incidence-based mortality, at least treating such cancers earlier allows women to undergo less invasive, less aggressive therapy. Here the results are somewhat mixed. The authors reported that a 10 percentage point increase in screening is associated with an increased incidence of early disease (stages 0-II) but no change in the incidence of locally advanced and metastatic disease (stages III and IV). That's consistent with what they found in their first analysis and what Welch found in 2012. The authors also found that a 10 percentage point increase in screening is indeed associated with more breast-conserving surgical procedures (lumpectomy) but that there is no concomitant reduction in mastectomies. In other words, putting it all together, I'd describe this result as finding that all the additional breast-conserving surgery went towards the excess early stage cancer found by screening.

The authors conclude:

For the individual, screening mammography should ideally detect harmful breast cancers early, without prompting overdiagnosis. Therefore, screening mammography ideally results in increased diagnosis of small cancers, decreased diagnosis of larger cancers (such that the overall risk of diagnosis is unchanged), and reduced mortality from breast cancer. Across US counties, the data show that the extent of screening mammography is indeed associated with an increased incidence of small cancers but not with decreased incidence of larger cancers or significant differences in mortality. In addition, although it has been hoped that screening would allow breast-conserving surgical procedures to replace more extensive mastectomies, we saw no evidence supporting this change.

And ask:

What explains the observed data? The simplest explanation is widespread overdiagnosis, which increases the incidence of small cancers without changing mortality, and therefore matches every feature of the observed data. Indeed, our cross-sectional findings are supported by the prior longitudinal analyses of Esserman et al29 and others,30,31 in which excess incidences of early-stage breast cancer were attributed to overdiagnosis. However, four alternatives are also logically possible: lead time, reverse causality, confounding, and ecological bias.

The authors do a convincing job of arguing that three out of four of these are not a major factor. For instance, lead time bias can become an issue in counties where screening had recently increased as cancer diagnoses are advanced in time, as they describe in the supplement:

Tumors in screened women are diagnosed earlier than tumors in unscreened women. It is not known exactly how much advanced notice (lead time) is provided by mammography screening. If mammography screening results in long lead times, then breast cancer incidence should increase when more women are screened. For example, suppose a woman receives her first screening today, and the screening detects a breast tumor that otherwise would not have been detected for another two years. Accordingly, the incidence of breast cancer would be increased today, and would also be decreased two years from now.

By examining correlations between screening frequency in counties at different time points in counties that had recently increased their rates of screening, they failed to find an effect that could be attributed to lead time bias. Using additional analyses, they were able to counter criticisms that the results they observed were due to confounders, such as differing incidences of breast cancer in various counties that might lead to increased emphasis on screening (reverse causality) or because risk factors for breast cancer happen to be associated with screening.

Epidemiology and the "ecological fallacy"

But what about the ecological fallacy? In epidemiology, the word "ecological" has quite a different meaning than it does in biology or every day colloquial usage. Most medical studies are done at the level of the individual. In other words, data are gathered for each individual, such as risk factors, diagnosis, age and other demographic factors, treatment, and outcome; the individual is the unit of analysis. In contrast, in an ecological study, data are collected at the group level, and the group is the unit of analysis. In the current study, data were collected at the county level and the unit of analysis was the population of each county assessed. This can be a problem.

The term "ecological fallacy" was first coined by the sociologist H.C. Selvin in 1958, but the perils of imputing correlations found in groups to the individuals composing them have been known at least since 1938, when psychologist Edward Thorndike published a paper entitled, "On the fallacy of imputing the correlations found for groups to the individuals or smaller groups composing them". Basically, relative risks detected by ecological analyses can be magnified upwards by many-fold, the cause being a greater sensitivity to problems such as model misspecification; confounding; non-additivity of exposure and covariate effects (effect modification); exposure misclassification; and non-comparable standardization.

As the authors point out in their supplement, ecological biases arise because values that are identified for individuals are aggregated before analysis, resulting in a loss of information, particularly when the aggregation takes place at a larger scale. They also concede that ecological biases can't be completely ruled out without access to individual-level data, but they did their best, taking note that one warning sign of ecological bias is seen when the results of an analysis vary based on the population of each county analyzed. Counties with larger populations would be expected to show more ecological bias than counties with smaller populations, but this was not seen. As the authors point out, similar relationships between screening and incidence were found regardless of whether the counties included 5,000, 50,000, or 500,000 women, and there was no significant relationship between screening and 10-year mortality from breast cancer in any of them. While this analysis doesn't rule out ecological biases (again, only access to individual-level data can do that), it does reassure that there were no obvious warning signs that such a bias was creeping in. The authors also note that, in essence, you can't get away from ecological analyses when trying to estimate rates of overdiagnosis, because "overdiagnosis is currently not observable in individuals, only in populations," which is quite true, citing a recent comparison of methods for estimating overdiagnosis that concluded that "well conducted ecological and cohort studies in multiple settings are the most appropriate approach for quantifying and monitoring overdiagnosis in cancer screening programs."

A usual suspect chimes in

Not unexpectedly, a radiologist whom we've met before chimed in almost immediately in his usual inimitable fashion. I'm referring, of course, to Dr. Daniel Kopans, Director of Breast Imaging at Massachusetts General Hospital and outspoken—to say the least!—mammography advocate. Predictably, he didn't take long at all to come up with one of his bombast-filled criticisms that he is so well-known for in which he imputes dishonest motives to those with whom he has a scientific disagreement, a character trait that both amuses and annoys because he himself is so sensitive to criticism. In this case, his attack is even more off-base than usual. Indeed, I'm going to go straight to the paragraph in his response to Harding et al that shows that Dr. Kopans almost completely missed the point of Harding et al:

One also has to wonder what the authors have done with the data. Between 2000 and 2010 (10 years of follow-up), the SEER breast cancer death rate fell from 26.6 deaths per 100,000 women to 21.9 deaths per 100,000 women -- a decline of 18% (almost 2% per year), yet the authors claim there was no decline in deaths over the same period using SEER data. Something is wrong. This should have been recognized by the peer review and the fundamental discrepancy addressed.

Puzzled by this particular criticism, I actually looked through the paper again to find where the authors made the claim that breast cancer mortality had not decreased from 2000 to 2010. I failed to find it. In any event, what Dr. Kopans is criticizing is not the analysis the authors did. They did not look at whether the death rate from breast cancer fell over the ten years of the study. What they did was to look at one year! That year was 2000. They then analyzed the rates of mammography uptake in each county for that year and compared them with the ten year mortality. I mean, bloody hell! It's right there in the abstract:

Breast cancer incidence in 2000 and incidence-based breast cancer mortality during the 10-year follow-up. Incidence and mortality were calculated for each county and age adjusted to the US population.

The primary measure was not breast cancer mortality over time, so there was no reason to point out that breast cancer mortality declined between 2000 to 2010. But they did anyway. In the supplemental data, the authors did note that breast cancer mortality has been declining, observing, "As breast cancer mortality has been decreasing since 1990,4 there is no reason to suspect that breast cancer mortality in future years will exceed breast cancer mortality in 2000." In any case, in this study the primary measure was ten year mortality of a cohort from a single year, the year 2000, who were diagnosed with breast cancer in that year. That's why the SEER database had to be examined to 2010. Thus, this particular criticism by Dr. Kopans is irrelevant to the study and is so egregiously wrong that it is tempting to use it to invalidate everything else he wrote.

Hints, allegations, and things that should have been left unsaid

Also note how, here and throughout the article, Dr. Kopans insinuates that the authors did something dishonest. He's perhaps a little less blatant about insinuating scientific fraud than he used to be (perhaps he learned his lesson from his previous similar insinuations about the CBNSS), but to Dr. Kopans, the authors aren't just wrong, but dishonest or at least so ideologically motivated that they don't care. Don't believe me? Look at his very first paragraph:

The ploy used by Harding et al in their new study is classic. Explain why using your approach is scientifically unsupportable, and then go ahead and use it claiming there is no alternative.

Also note the part where he claims that studies like this are "being used to reduce access to screening," even going so far as to put the word "studies" in scare quotes. This is a common theme in Dr. Kopans' oeuvre with respect to mammography, as well as that of various radiology groups: That there is a coordinated attack by anti-mammography ideologues out there who want to take away women's access to mammography and don't care that (if you believe Kopans' claims) thousands will die unnecessarily as a result. Indeed, I frequently quote Dr. Kopan's famous statement about the 2012 Bleyer and Welch NEJM study:

This is simply malicious nonsense," said Dr. Daniel Kopans, a senior breast imager at Massachusetts General Hospital in Boston. "It is time to stop blaming mammography screening for over-diagnosis and over-treatment in an effort to deny women access to screening."

Here's what he said after the USPSTF task force recommended against routine mammographic screening of 40-49 year old women in 2009:

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."

One notes that if "they" don't think there's a benefit, then "they" don't think they're consigning thousands of women per year to die, as Dr. Kopans does. Consistent with these positions, Dr. Kopans goes on the attack again in his response to this most recent study:

The claim of massive overdiagnosis of invasive cancers has been manufactured. No one has ever seen an invasive breast cancer disappear on its own, yet it has been claimed there are tens of thousands each year. When we looked directly at patient data, we found that more than 70% of the women who died of breast cancer in major Harvard Medical School teaching hospitals were among the 20% of women who were not participating in screening.3

Note the word choice: "Manufactured." Once again, he is imputing dishonest—or at least ideologically biased—motives to those with whom he disagrees.

What Dr. Kopans won't admit is that the result of the study he cites has numerous weaknesses, in particular a bias towards younger women with more aggressive cancers (not unexpected in a tertiary care hospital) who, not surprisingly, would be less likely to have been screened, as well as the simple observation that, by definition, overdiagnosis can't occur in women who die of breast cancer. Be that as it may, Dr. Kopans concludes:

Enough is enough. The effort to reduce access to screening has been relentless by a small group that has continued to use specious arguments and scientifically flawed analyses to support their agenda. At some point, peer reviewers need to read more carefully and stop the publication of scientifically unsupportable and misleading material.

My retort is that, at some point, scientists need to call out Dr. Kopans for so frequently assuming that those who disagree with him do so out of less than honorable motives. I don't even make that assumption for most leaders of the antivaccine movement, who, though profoundly wrong, are motivated by what they mistakenly believe to be an evil that must be opposed. I realize that Dr. Kopans really does appear to believe that those who do studies that conclude that mammography might not be as effective at preventing deaths from breast cancer as he believes it to be are monsters willing to lie and twist science to deny women mammography, but such is not the case. For example, does Dr. Kopans really think that the authors of the CNBSS wanted their study to find that screening did not save lives? Of course they didn't! Scientists don't start large, expensive, multi-institutional studies hoping for a negative result! They just don't! They're too much work and require too many resources. Worse, any time Dr. Kopans is called out for assuming the worst about physicians and scientists with whom he disagrees, he disingenuously assumes an attitude of, "Who me? I never accused anyone of that."

One also can't help but notice that in their paper Harding et al bend over backwards to be clear and up front about the limitations of their study, particularly the ecological fallacy. That's just good science. It's also what Dr. Kopans turns into a weapon to try to discredit the entire study. Finally, the usual error that results from the ecological fallacy is the tendency to find associations that don't exist or to overestimate associations that do exist. Consequently, the most probable error in Harding et al is to have overestimated the association between screening and breast cancer diagnoses, which makes the negative finding with respect to mortality stand out all the more.

The bottom line: Breast cancer screening is not simple

It must be re-emphasized that Harding et al is just one study among many. Although it reinforces the growing consensus that mammographic screening leads to significant overdiagnosis, it is nowhere near the final word. Indeed, there is a much more measured commentary on the study published alongside it by Joann G. Elmore, MD, MPH and Ruth Etzioni, PhD at the Fred Hutchinson Cancer Research Center. Elmore and Etzioni express proper caution at interpreting the results of ecological studies, noting:

Most scientists now acknowledge that there is some level of overdiagnosis in breast cancer screening, but the frequency of overdiagnosis has not been conclusively established. Estimates in the literature cover a frustratingly broad range, from less than 10% to 50% or more of breast cancer diagnoses. Published studies of overdiagnosis vary widely not only in their results but also in their populations, methods, and measures.4 In practice, the frequency of overdiagnosis is likely quite different for DCIS and invasive tumors.

Sadly, we are left in a conundrum. Women will increasingly approach their physicians with questions and concerns about overdiagnosis, and we have no clear answers to provide. We do not know the actual percentage of overdiagnosed cases among women screened, and we are not able to identify which women with newly diagnosed DCIS or invasive cancer are overdiagnosed. Many screening guidelines now mandate shared and informed decision making in the patient-physician relationship, but this is not an easy task.

Indeed, it is not, particularly when data conflict. For example, just last month, the World Health Organization through its International Agency for Research on Cancer (IARC) published new recommendations on screening mammography. After considering older randomized clinical trials and voicing some skepticism over whether they are still relevant, the IARC examined evidence from 20 cohort and 20 case-control studies, all conducted in the developed world (Australia, Canada, Europe, or the United States) that they considered informative for evaluating the effectiveness of mammographic screening programs. Based on its analysis, the IARC notes that screening mammography could be associated with as much as a 40% reduction in the risk of dying from breast cancer and concluded:

After a careful evaluation of the balance between the benefits and adverse effects of mammographic screening, the working group concluded that there is a net benefit from inviting women 50 to 69 years of age to receive screening. A number of other imaging techniques have been developed for diagnosis, some of which are under investigation for screening. Tomosynthesis, magnetic resonance imaging (MRI) (with or without the administration of contrast material), ultrasonography (handheld or automated), positron-emission tomography, and positron-emission mammography have been or are being investigated for their value as supplementary methods for screening the general population or high-risk women in particular.

However, the IARC also cautioned about the risks of mammography, including overdiagnosis. Interestingly, its estimate of overdiagnosis, ranging from 4-11%, was lower than most I have seen.

Unfortunately, there remains a large contingent of radiologists who, like Dr. Kopans, believes that overdiagnosis either does not exist or is such a small problem as not to be worth the consideration it is currently receiving. Fortunately, that appears to be changing. For instance Academic Radiology's 2015 issue will center around the theme of overdiagnosis, and several of the articles have already been published electronically ahead of release of the issue, such as this one by Archie Bleyer updating Bleyer and Welch's 2012 NEJM article, a commentary by H. Gilbert Welch," Responding to the Challenge of Overdiagnosis", and an article by Saurabh Jha, an academic radiologist, "Barriers to Reducing Overdiagnosis", the last of whom notes that the first steps in reducing overdiagnosis are to admit that overdiagnosis occurs. I couldn't have said it better myself and I might very well be blogging about these in the future.

Implications for primary care and beyond

It's not just radiologists, either, who seem to have a problem with the concept of overdiagnosis. I'm frequently surprised at how few primary care physicians and even oncologists, both medical and surgical, "grok" the concepts of overdiagnosis, lead time bias, and length bias in screening for asymptomatic diseases, especially cancer. Examples of this misunderstanding sometimes even appear in the lay press; for example, this a doctor accusing the New York Times of "killing" his patient because it published news stories about studies questioning the value of PSA screening. It's also true that the lay public assumes that early diagnosis is always better, damn the consequences. How are they to be educated if we physicians do not adequately understand the complexities and tradeoffs involved in screening ourselves?

Although Dr. Kopans has more than implied that I belong to the evil cabal of anti-mammography ideologues against whom he regularly does battle, I actually still recommend screening mammography for my patients 50 and over. The reason is simple. I still believe it offers benefits in terms of reducing the risk of dying from cancer, albeit benefits more modest than I used to believe. However, I also point out the potential harms now. For women aged 40-49, I'm much less dogmatic than I used to be. If there's high risk due to family history or other factors, I will more strongly recommend screening, but if there isn't I will tell them about screening, explaining the potential benefits and risks, and then more or less leave it up to the patient. Of course, you need to realize that most of my patients already have breast cancer or have had breast cancer, which makes them high risk for developing another breast cancer, even if they are under 50; I don't see too many 40-something year old women just asking about screening.

We can overcome the problems of overdiagnosis and overtreatment due to cancer screening. Developing better screening tests will not be sufficient to achieve this end, however. What will be required is the development of predictive tests that tell us which lesions found on mammography or future screening tests are likely to progress within the patient's lifetime to cause death or serious harm and which are unlikely to do so. Such information would allow us to stratify cancers into those that need to be treated promptly and those that can safely undergo "watchful waiting." This will not be an easy task. In the meantime, we do the best we can with the data that we have—and its uncertainty.

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So why are the woo-heads into thermography? Presumably if it worked, it would suffer from the exact same problem of over-diagnosis.

Just as Nicholas "Black Swan" Taleb has calculated that most of the improvement in life expectancy over the past half century can be attributed to reduced smoking, it is a sure thing that some, if not most, of the cited 18% decline in U.S. breast cancer mortality between 2000 and 2010 is attributable to a greater proportion of postmenopausal women finding the backbone to tell abusive male MDs like Kopans where to shove their hormone 'replacement' 'therapy'. I'd like to see him forced to give a numerical estimate: What percentage of breast cancer deaths in the endless-HRT-for-all era were caused by HRT? Say none, and you are at best a laughingstock. Admit that there were some, and the decline in deaths correlated with reduced use of one mass intervention can't be attributed to increased use of another.

Age 44, maternal aunt with premenopausal (age 45) breast cancer, never had a mammogram, and won't until age 50, per my GP. His recommendations on the mammography front have changed in the past few years, and he pretty much echoed what Orac is saying with respect to overdiagnosis.

I’d like to see him forced to give a numerical estimate: What percentage of breast cancer deaths in the endless-HRT-for-all era were caused by HRT?

Rather than ranting about "abusive male doctors," you could always spend 30 seconds looking for yourself.

^ Although you're only going to get an limit on mortality there.

Are there any risks to getting a mammogram other than overdiagnosis? If not, than it would seem like the ideal approach (financial considerations aside) would be to continue screening but be more conservative about treatment rather than to stop or delay screening. But then, that's so obvious that I'm guessing there's actually some other factor(s) I'm not aware of that prevents it from being that simple.

And, of course, in real life we can't just say "financial considerations aside" and leave it at that. Every dollar we spend on mammograms is a dollar we don't spend somewhere else. Let's just say for the sake of argument that we decide to only cover mammograms every five years and invest the money saved in improved screening for some disease X for which early screening improves outcomes. Cutting back on mammograms may make overdiagnosis less frequent but also result in, say, 5,000 preventable deaths from breast cancer a year. If investing the money elsewhere results in saving, say, 10,000 lives per year that were previously lost to disease X, then obviously that's a better use of those funds. The problem is that if you cut funding for mammograms, people will start screaming about the 5,000 people you're "killing," whereas no one is screaming about the 10,000 people you're "killing" right now because you're using the money that could have saved them for something else - because those 10,000 deaths are currently part of the status quo.

Of course, in the case of breast cancer you have the fact that it's been politicized as a "women's issue" on top of all of the above (I'm assuming I can get away with pointing out the elephant in the room because my 'nym makes it obvious that I'm a woman. Right-thinking men are understandably reluctant to mention that whole aspect since it tends to smack of MRAs.) But then, I'm biased too: I study diseases of poverty, so of course I'm always p!ssing and moaning self-righteously about the disproportionate amount of funding the "sexy" diseases get.

Heh! Why, thank you, Narad. Your second link indicates that long-term HRT use - which many male doctors indeed aggressively coerced women into submitting to in the second half of the twentieth century - is associated with a nearly doubled risk of breast cancer death. Indeed, it sounds quite plausible that most or even all of the 21st-century mortality drop is attributable to a reduction in iatrogenic breast cancer. Also very informative for those of us who are middle-aged and estimating our personal cancer risks: the endless yammer of "1 in 10! 1 in 9!! Nooo, 1 in 8!! [if you live to be 120]" was always based on numbers derived from a population that was being systematically poisoned. Just say no to drugs, as good ol' Nancy Reagan used to say, and your risk should indeed be a lot lower.

"which many male doctors indeed aggressively coerced women into submitting to in the second half of the twentieth century"

Citation needed. Especially for evidence that the adjectives "male" and "aggressively", plus the verb "coerced" are accurate, and not just your opinion.

"Aggressively coerced women into submitting"

MD: You should take HRT.
Patient: No.
MD: DO IT! DO IT! DO ITTTTTTTTTTTTTTTTTTT!!!!!11!!11

@jane

I'm curious as to what you mean by "many male doctors indeed aggressively coerced women into submitting to [HRT]." How does that even work? Women were coming to doctors with sprained ankles, etc. and the doctors (only the male ones, presumably) were forcibly cramming HRT down their throats? Is the assumption of malice necessitated by some prima facie implausibility to the far more straightforward assumption that women were seeking relief from the symptoms of menopause and doctors were prescribing HRT in the sincere belief, consistent with the state of knowledge at the time, that symptoms (apparently) caused by a reduction in hormone levels could be alleviated by administering exogenous hormones?

Granting that you are simply using inflammatory language to make an otherwise valid point, are there even any studies showing that male doctors were any more likely to prescribe HRT than female doctors? The most recent, relevant study I was able to find was a survey of OB-GYNs' level of acceptance of the results of the Women's Health Initiative trials that showed less benefit and more risk (over-all) to HRT than had previously been thought. That survey showed that there was no difference between male and female doctors' level of acceptance or skepticism of the results after controlling for how recently they completed their residency. In other words, older doctors were more likely to be male and to be skeptical of the results, but skepticism was more closely correlated with how long a doctor had been in practice ("set in their ways," one might say) than their gender.

^ I should probably add that I don't know nearly enough about HRT or menopause in general to assess to what degree skepticism of the study was warranted, and to what degree it reflected simple resistance to change, confirmation bias, etc. The main point is that it wasn't split along gender lines, after accounting for the generally increasing proportion of female doctors.

Heh, "citation needed" - the scientistic way of invalidating inconvenient personal experiences. Older American women who went through menopause at a time when most doctors were male have detailed their experiences of pressure to take drugs. Whole books have been written about the HRT scam. A famous (male) opinion molder focused much lurid rhetoric on the senility, shrewishness, and physical repulsiveness that only women who submitted would be spared - but women were additionally threatened with heart disease and cancer if they refused the drugs. It could hardly be said that women thus given cancer made a free and informed choice, any more than a woman who gets her information on mammography from Daniel Kopans has made a free and informed choice.

But Dr. G has raised an extremely important and valuable larger point here - I give him significant credit for his intellectual honesty in this post - which his followers ought to be acknowledging and considering, and if the comment thread turns into a game of bash-the-small-s-skeptic, it will make it possible for everyone to ignore that crucial issue. So I shall bow out and say no more about the peripheral issue of HRT.

So, exactly how does that issue relate to the above article? And where is your criticism for Suzanne Somers who may still be pushing hormone replacement in her own way?

Translation: I can only provide emotive anecdotes, so I'm taking my Tinkertoys and going home because you guys are MEEN and fail to acknowledge my angry brilliance.

I just loved the blatant sexism. Only males are being accused, yet Suzanne Somers promoting the treatment even after issues about it were discovered is okay dokay.

She would have been fine if she had not used the word "male."

I’m curious as to what you mean by “many male doctors indeed aggressively coerced women into submitting to [HRT].” How does that even work?

Doctor enters examining room where Patient has been waiting for half an eternity
Doctor: Good afternoon, sir, how are you today.
Patient: It's "ma'am".
Doctor: No, certainly I can't be wrong about this. I am a doctor after all.
Patient: I've been female my entire life. You're a gynecologist, for Pete's sake. Why would a man waste half a day trying to see you for 15 minutes?
Doctor: No need to be upset, sir. Ma'am. Sorry, it won't happen again. Would you happen to be going through...the change?
Patient: You mean menopause?
Doctor: Well, if you don't feel comfortable with the medical term, yes. The change is a medical condition that happens to women of a certain age, making them undesirable, sexless beings who will never keep a life partner. And by the way, I'm going to have to double your co-pay unless you start hormone replacement therapy; I can't afford the cooling bills otherwise.
Patient: Will I get a credit in the winter for reducing your heating bills?

By Mephistopheles… (not verified) on 20 Jul 2015 #permalink

Sarah A @8: Given that there is some radiation involved in mammography, that would be a reason to use it judiciously.

You are right about the issue of "financial considerations". And even if money weren't limited, time is, so there are always trade-offs.

By JustaTech (not verified) on 20 Jul 2015 #permalink

Also, even if a woman doesn't pay anything for the screening, there are only so many mammogram appointments available outside most women's working hours, so the effective cost of a mammogram often includes lost income.

@Sarah A #12

in the sincere belief, consistent with the state of knowledge at the time,

This particular angle comes up all the time when dealing with the cranks and the crackpots. It is not enough, in the minds of those blessed with the benefit of hindsight, that the practitioner (of whatever art) be using the best possible information available at the time but that a Truly Competent Practitioner ought to reach forward through time and anticipate any possible issue that might become problematic at any point in the future.

The fact that this is a stupidly impossible standard is no object to the True Believer. "This bad thing that happened to me can not be an unfortunate draw in the lottery of life, it must be an act of malice or incompetence."

Regular people make the best decisions they can, including reasonable amounts of insurance, and live with the consequences.

By Robert L Bell (not verified) on 20 Jul 2015 #permalink

Just in case anybody hasn't heard it yet, I'm going to leave this Tim Minchin song here. It's appropriate to the topic.

Robert L Bell @ 23.

I'm cool with this as long as physicians are fine with letting me make the decisions. I anticipate an issue when the time comes for them to be rated on outcomes and there is pressure to make me conform. For example, statins are something I will not take. Genetics say I don't need them (tot chol b/t 118 -157 past 30 years) but there is talk of making a recommendation based upon age. Things will get interesting then but at least we are not there yet. And maybe by that time we will have better medications.

By Not a Troll (not verified) on 20 Jul 2015 #permalink

Heh! Why, thank you, Narad. Your second link indicates that long-term HRT use – which many male doctors indeed aggressively coerced women into submitting to in the second half of the twentieth century – is associated with a nearly doubled risk of breast cancer death.

You didn't read the whole thing, did you?

Indeed, it sounds quite plausible that most or even all of the 21st-century mortality drop is attributable to a reduction in iatrogenic breast cancer.

Perhaps you could "force yourself" to work the numbers.

^ Hint.

Extra hint: "second half of the twentieth century."

^^ Cripes, I might as well have started with the W—dia entry rather than trying to work from first principles.

^^^ Oh, and silly me, I missed the inevitable flounce. Should've started from the bottom.

Addressing jane's point about HRT, we know that estrogen promotes some breast cancers, and that earlier menarche and later menopause lead to increased risk of breast cancer (5% per year and 3% per year respectively), so it isn't surprising that the use of HRT increases the risk of breast cancer. If women really want to reduce breast cancer risk they can always have an oophorectomy before puberty, just as men can dramatically reduce prostate cancer risk by being castrated (I am not seriously suggesting this, obviously).

My point is that we tolerate the risks and enjoy the benefits of estrogens (and androgens) during our reproductive years, and HRT offers the opportunity to extend that period. I don't see why this choice between the advantages and disadvantages of estrogens and androgens is fine when presented to us by nature, but monstrous when presented by a physician. Is a reduction in menopausal symptoms and a reduced risk of cardiovascular disease (see below) and osteoporosis worth the increased risk of breast cancer? It is surely an individual's right to make an informed choice.

Also worth bearing in mind are subsequent studies and reanalyses of the WHI data:

It should also be appreciated that, in a surprising turnabout, subsequent publication of the full WHI results showed the apparent increased risk for breast cancer was only found in those who had been on HRT before entering the study. In addition, whereas the authors claimed initially that there was no difference in effects with age, further analyses from both the combined HRT and oestrogen alone WHI studies have shown no increase in heart disease in women starting HRT within 10 years of the menopause. This about turn and retraction of some of the previous findings has received little publicity in the media.
Furthermore, a large controlled trial from Denmark reported in 2012 has demonstrated that healthy women taking combined HRT for 10 years immediately after the menopause had a reduced risk of heart disease and of dying from heart disease. This report supports the concept of a ‘window of opportunity’ when HRT is started shortly after menopause, whereas the WHI study confirmed that starting HRT after the age of 60 years may increase the risk of heart disease.

By Krebiozen (not verified) on 21 Jul 2015 #permalink

we know that estrogen promotes some breast cancers

Does it? My understanding was that estrogen-only therapy led to either no or decreased risk of breast cancer. Hence the implicit question to Jane when progesterone was introduced, i.e., when ET was connected to endometrial cancer.

Narad,

we know that estrogen promotes some breast cancers

Does it?

You're quite right, I was sloppy in my use of language. Estrogen-only formulations are not associated with breast cancer, but they are associated with endometrial and (perhaps) ovarian cancer. Even mixed formulations only lead to a modestly increased risk:

To put the risk into numbers, if 10,000 women took EPT for a year, it would result in up to about 8 more cases of breast cancer per year than if they had not taken hormone therapy (HT).

My point is that the likes of jane seem quite happy when nature delivers a mixed bag, but horrified when medicine offers a similar mixture of risks and benefits. I suspect it's a variation on the appeal to nature.

By Krebiozen (not verified) on 21 Jul 2015 #permalink

Robert L Bell #23

" It is not enough, in the minds of those blessed with the benefit of hindsight, that the practitioner (of whatever art) be using the best possible information available at the time"

Which perhaps brings us back to the topic of the post, (which many seem quite content to avoid.)

The "best possible information at this time" is that some very common screening practices, and there I include "the yearly checkup", do not offer a net benefit.

And yet, doctors and patients both engage in them with a zeal and disregard for science reminiscent of the woomeisters and (as oft described here) overly self-regarding suburban housewives of the anti-vax cabal. And then there's homeopathy....

Perhaps what's needed is an (objective) discussion of human psychology, which seems to transcend the simple categorizations that human psychology likes to create.

Oh Lordy, zebra's back obsessing about yearly check-ups.

Show of hands, please: who here has ever had a yearly check-up?

I haven't. So far as I know no one in my family ever has. None of my friends and co-workers has ever mentioned having one. Those of us with chronic illnesses go in regularly to be sure the chronic illness isn't getting worse, and I know a cancer survivor who goes in regularly to check for recurrences, but that's the closest I've ever heard of to getting a "yearly check-up". Is that other people's experience?

LW #34,

And so we begin with the misinterpretations.

"The “best possible information at this time” is that some very common screening practices, and there I include “the yearly checkup”, do not offer a net benefit."

"and there I include"

Meaning, I am characterizing it as a screening, along with mammography. Get it?

This is a "screening" which is mandated to be covered by insurance. Do you think that there are not lots of individuals who are not symptomatic at the time (whether they have ever been diagnosed with a "condition" or not) who go in yearly "just in case"?

Do you think that there are not lots of individuals who are not symptomatic at the time (whether they have ever been diagnosed with a “condition” or not) who go in yearly “just in case”?

Well, that's why I asked for a show of hands, isn't it?

LW,
I response to your show of hands request, none of my extended US family reports having had a yearly physical - I have asked before when this came up. I have pointed out to zebra before that the yearly physical is no longer recommended by the AMA: "the American Medical Association and other similar groups have moved away from the yearly exam. They now suggest that medical checkups be referred to as Periodic Health Assessments or Examinations and that they be performed every five years (for adults over 18) until age 40 and every one to three years thereafter".

Still, why talk about the screening program under discussion when zebra's off topic idée fixe can be used to derail the thread.

By Krebiozen (not verified) on 21 Jul 2015 #permalink

zebra,

The “best possible information at this time” is that some very common screening practices, and there I include “the yearly checkup”, do not offer a net benefit.

Having spent more years than I care to remember setting up and/or running various screening programs I disagree. All the screening I have been involved with has been based on firm evidence of risks and benefits. Sometimes, as in the case of mammography, when very large numbers of people are screened we see unexpected consequences, such as over-diagnosis. When this happens the criteria are changed to be sure that benefits exceed any risks.

There will always be arguments about the relative value of different risks and benefits e.g. whether you would prefer to risk prostate cancer being missed or to have an unnecessary biopsy. IIRC Old Rockin' Dave has described how his aggressive prostate cancer would have been missed without PSA screening - it would have been missed by the last NHS biochemistry lab I worked in. Perhaps you would like to persuade him that he should have abandoned his "zeal and disregard for science reminiscent of the woomeisters", even though it saved his life.

By Krebiozen (not verified) on 21 Jul 2015 #permalink

Krebiozen,

First, I am the one trying to get the thread on topic; LW is the one fixating on one particular screening.

Second, "one to three years" after 40, and calling it by a different name, is hardly a decisive change.

But by all means, lets get back to the question of mammography and why there is the hysterical, anti-vax pro-woo type of response to suggestions that it might be curtailed.

Krebiozen #39,

Ah yes, the ultimate science-based argument: Some guy told an anecdote on the internet.

zebra@40

First, I am the one trying to get the thread on topic; LW is the one fixating on one particular screening.

It seems to me you are the one trying to take the thread off topic. Recall that this post was indeed about one particular screening and that the conclusion was not that it provided "[does] not offer a net benefit"* as you suggest in #33 but that it is much more complicated than that.

The other major topic in Orac's post was overdiagnosis. When talking about that you really need to focus on specific tests for specific diagnoses, not the general examine done in a yearly checkup that you hate so much. I don't know why you seem to think this is some kind of sacred cow for us. Do you ever recall someone contesting the lack ofcurrent evidence for checkups when you bring them up?

*This is the proper way to use quotation marks; that is to mark a direct quotation which "'the yearly checkup'" is not.

By capnkrunch (not verified) on 21 Jul 2015 #permalink

...the conclusion was not that it provided “[does] not offer a net benefit”...

By capnkrunch (not verified) on 21 Jul 2015 #permalink

Capnkrunch 42,

"the other major topic"

Well, I realize that you get to assert whatever you like in the interests of avoiding things that make you uncomfortable, but what I thought of as at least "a" major topic was how the response by certain practitioners and interest/advocacy groups to a scientific study whose conclusions they didn't like was remarkably similar to that of those practitioners and groups often criticized here.

Orac at least is willing to report on this; the minions not so willing to acknowledge it.

If you would like to respond to my #33, that's fine; if you want to derail the conversation with a debate about quotation marks yet again, I'm not interested.

zebra,

First, I am the one trying to get the thread on topic; LW is the one fixating on one particular screening.

Then why even mention yearly physicals, especially when they have been discussed here before and not everyone agrees that they are useless? According to the article you linked to, only 14% of Americans get a yearly physical anyway.

Second, “one to three years” after 40, and calling it by a different name, is hardly a decisive change.

It depends what the evidence tells us, doesn't it? Maybe a yearly physical is beneficial in those over 40. The study cited in the NYT article was a review of studies carried out mainly in Europe in the 60s and 70s, with minimal relevance to the US today - just look at the innovations in cardiovascular prevention such as statins, fibrates and antihypertensive drugs that we know improves outcomes. A more recent study by the same authors looked at long-term effect of screening and lifestyle counseling on changes in physical activity and diet and found it had "had sustained effects on physical activity and dietary habits five years after its discontinuation". This area is not as clear-cut as you imply.

But by all means, lets get back to the question of mammography and why there is the hysterical, anti-vax pro-woo type of response to suggestions that it might be curtailed.

The only person responding that way would appear to be Dr. Kopans, unless I have missed something.

By Krebiozen (not verified) on 21 Jul 2015 #permalink

Well, I realize that you get to assert whatever you like in the interests of avoiding things that make you uncomfortable, but what I thought of as at least “a” major topic was how the response by certain practitioners and interest/advocacy groups to a scientific study whose conclusions they didn’t like was remarkably similar to that of those practitioners and groups often criticized here.

This is true and, my apologies, I had not quite correctly read #33.

And yet, doctors and patients both engage in them with a zeal and disregard for science reminiscent of the woomeisters and (as oft described here) overly self-regarding suburban housewives of the anti-vax cabal. And then there’s homeopathy….

This I agree with. However, I wonder about the yearly checkup part, has anyone here ever advocated that or told you that you were wrong about it? Are there even advocates for it like Dr. Kopans is for mammography? Further, there doesn't seem to be much doubt on that topic, mammography is quote clearly more of a grey area. All of this begs the question, why do you feel this is relevant beyond the fact that it is your preferred criticism of medicine?

If you would like to respond to my #33, that’s fine; if you want to derail the conversation with a debate about quotation marks yet again, I’m not interested.

When you use quotations to make it seem like yearly checkups are a topic someone else brought up and not something pulled directly from your behind you are being dishonest. I will call you on that ever time I see it. Use them properly and no one will say anything.

By capnkrunch (not verified) on 21 Jul 2015 #permalink

zebra,

Ah yes, the ultimate science-based argument: Some guy told an anecdote on the internet.

So my decades of professional experience are irrelevant. Fair enough, I could be inventing my background I suppose. Perhaps you would like to provide some evidence to specify of which screening practices specifically is it true that, as you assert:

doctors and patients both engage in them with a zeal and disregard for science reminiscent of the woomeisters and (as oft described here) overly self-regarding suburban housewives of the anti-vax cabal.

I'm not aware of any that are unequivocally useless.

By Krebiozen (not verified) on 21 Jul 2015 #permalink

I apologize for derailing the thread. zebra's obsession with annual check-ups just annoys me.

Orac at least is willing to report on this; the minions not so willing to acknowledge it.

Are minions refusing to acknowledge Orac's point? Really? Want to point out where?

(Raises hand)
I think I had an annual physical about 5 years ago. Don't remember how long ago the annual physical before that one was.

Krebiozen 47

Krebiozen 39:

IIRC Old Rockin’ Dave has described how his aggressive prostate cancer would have been missed without PSA screening – it would have been missed by the last NHS biochemistry lab I worked in. Perhaps you would like to persuade him that he should have abandoned his “zeal and disregard for science reminiscent of the woomeisters”, even though it saved his life.

No anecdotes here, nuh-huh.

@JGC, does it count as annual if you don't do it annually?

@zebra: I have an annual exam. My doctor checks my health, assesses my diet and exercise (and yells at me to exercise more and eat less crap), monitors my elevated blood pressure, checks my cholesterol and hemoglobin. She also asks about my mental health and recommends screenings as suggested by the Preventative Health guidelines. I also get any needed vaccines at that time.

So yeah, annual exam done. Why not? Also annual mammogram done. Age appropriate screenings keep me in the know about my health.

capnkrunch,

How about you let me use quotes my way and I will refrain from correcting you on things like "begs the question"?

If you agree that the kind of response from both practitioners and "patients" can be similar across the spectrum from what you might call "pure woo" to "gray areas" in conventional medicine, then I'm content.

My point is simply that the response is emotional or self-interested, rather than science-based, so nitpicking about shades of gray isn't really useful to the discussion.

zebra,

No anecdotes here, nuh-huh.

You appear to be ignorant of the distinction between the use of an anecdote as an example and the use of an anecdote as evidence of something. It is the latter that is unscientific, not the former. My point is that any screening program balances false positives against true positive and false negatives. You can maximize true positives, but this will also increase false positives, and vice versa. Old Rockin' Dave is an example of a true positive that would have been missed had he been a part of the less comprehensive screening program I am familiar with.

By Krebiozen (not verified) on 21 Jul 2015 #permalink

Krebiozen 54,

I thought we were talking about overdiagnosis not false positives. So wouldn't the claim of ORD "having his life saved" be the issue, rather than the outcome of the test itself?

Just sayin', as someone without your vast experience and expertise, of course.

zebra,

I thought we were talking about overdiagnosis not false positives. So wouldn’t the claim of ORD “having his life saved” be the issue, rather than the outcome of the test itself?

No, that is not a case of over-diagnosis. Over-diagnosis results in the treatment of a condition that would not have resulted in morbidity if left untreated. ORD had an aggressive strain of prostate cancer that, IIRC, he stated would likely have killed him if his elevated PSA hadn't been picked up through screening.

Just sayin’, as someone without your vast experience and expertise, of course.

It is hardly vast, but I have spent a couple of decades working with screening programs of one sort or another, so I have some familiarity with the concept. Enough to understand what over-diagnosis is, anyway.

By Krebiozen (not verified) on 21 Jul 2015 #permalink

zebra,

If you agree that the kind of response from both practitioners and “patients” can be similar across the spectrum from what you might call “pure woo” to “gray areas” in conventional medicine, then I’m content.

Once again you miss the point entirely. All screening programs have advantages and risks as do all conventional interventions. Woo has finite risks (including delayed effective treatment) and minimal to zero benefits other than non-specific ones that could be achieved through lower risk activities. You can argue about the relative value of different risks and benefits, but IMO when there is risk and little to no benefit there is no rational argument to be had.

My point is simply that the response is emotional or self-interested, rather than science-based, so nitpicking about shades of gray isn’t really useful to the discussion.

Whose response? Dr. Kopans'? What parts of his response are "emotional or self-interested, rather than science-based"? If not Dr. Kopans' response, whose response are you referring to?

By Krebiozen (not verified) on 21 Jul 2015 #permalink

#56 Krebioizen

"he stated would likely have killed him"

There you go. I'm convinced, for sure.

zebra,

IDK if it is earth shattering news that there is humanity in medicine but there's nothing in your argument that supports faux medicine. Rather it supports trying to eradicate it.

By Not a Troll (not verified) on 21 Jul 2015 #permalink

zebra@53

How about you let me use quotes my way and I will refrain from correcting you on things like “begs the question”?

Please enlighten me on the proper way to use that phrase. I'd prefer it if you would use punctionation in the generally accepted ways but I'm not the one who comes off as dishonest when you do that.

My point is simply that the response is emotional or self-interested, rather than science-based, so nitpicking about shades of gray isn’t really useful to the discussion.

Except that it is in this case. As Orac said, the evidence on mammography is unclear. Dr. Kopans certainly uses motivated reasoning and ignores the risks but just because of that doesn't mean that there is zero benefit to mammography.

Based on its analysis, the IARC notes that screening mammography could be associated with as much as a 40% reduction in the risk of dying from breast cancer...

It's not one or the other, the world is shades grey.

By capnkrunch (not verified) on 21 Jul 2015 #permalink

"...punctionation..."
Ahem.
"...punctuation..."

By capnkrunch (not verified) on 21 Jul 2015 #permalink

zebra,

“he stated would likely have killed him”
There you go. I’m convinced, for sure.

Does being so disagreeable come naturally, or do you have to practice? What is your problem with me giving an example of a person who had a positive screen could have resulted in his death had it been missed? Or are you suggesting that PSA screening for prostate cancer only results in false positives and overdiagnosis?

By Krebiozen (not verified) on 21 Jul 2015 #permalink

@Krebiozen #39

You draw attention to one important distinction between normal people on the one side and cranks&crackpots on the other.

Normal people understand that there are procedures, and there practices, and there are protocols, and each comes as a bundle with mix of benefits and drawbacks. Nothing stands in isolation: you can do this, or that, or the other, and you make your decision based on the value-weighted assessment of each bundle - knowing that nothing in this life is ever perfect, and that something might turn out differently than expected.

The crank and the crackpot reduce this complex intellectual process to "I have my favorite solution, it is obviously correct for everyone, and anyone who suggests otherwise is ignorant or corrupt or dishonest or malevolent." Life is much easier, lived this way, right up to the moment that the great inevitable catastrophe descends. At which time it is discovered that everything was some one else's fault all along.

By Robert L Bell (not verified) on 21 Jul 2015 #permalink

“I have my favorite solution, it is obviously correct for everyone, and anyone who suggests otherwise is ignorant or corrupt or dishonest or malevolent.”

No where have I seen this more heartbreaking than on the anti-psychiatry boards. They are not cranks and crackpots generally, just those who have gotten a raw deal, but they don't realize that they in turn would impose their own one-size-fits-all solution on others. I would think that after having had the experiences they did that they would be a little more open to letting others make their own choices.

By Not a Troll (not verified) on 21 Jul 2015 #permalink

LW @34: Well, I see the doctor every year to get my prescription renewed and she does some evaluations, so I guess that counts as an annual exam?

I'm sure we'll have some fun talks about when to start screening me for what conditions based on my not-at-all awesome family history.

But I bet the idea of risk-based screening annoys zebra.

By JustaTech (not verified) on 21 Jul 2015 #permalink

@Not a Troll I am in complete agreement.

If I were in charge, psychopharmacology would be managed differently. As it happens, I am not in charge, but anecdotes suggest there may be a problem with drugs being dispensed according to the practitioner's convictions and despite the patient's reasonable suggestions; I am especially wary of piling one drug on top of another, when the fundamental problem may be caused by overprescription of the bottom drug. Those things are powerful, a 70% chance of saving your life and a 0.3% chance of killing you.

Also, like you observe, once bit twice shy: people who have had difficulties with the treatment process can turn adamantly against treatment as an option. And this is where the woowootarians come in: if you are going to reject treatment, they at least will hold your hand and help you feel better in that sense.

As has been discussed here at some length by Orac, the way to square this circle is to change the billing and compensation policies so that the doctors and associates can provide the effective care that is needed.

By Robert L Bell (not verified) on 21 Jul 2015 #permalink

@JustaTech, but that's keeping tabs on some kind of chronic illness involving prescriptions (my pulmonologist does the same thing), and doesn't seem like the "annual check-up" that zebra obsesses about.

LW, I have a yearly check up. It's when I have an EKG to monitor my minor heart problem, blood work, and discussion about medication, life changes, etc.

Daughter (40s) just had a yearly check up, fortunately, because she found her glucose level was 365. It had been normal the year before.

How about you let me use quotes my way and I will refrain from correcting you on things like “begs the question”?

Please enlighten me on the proper way to use that phrase.

"Begging the question" refers to including your conclusion in your premises. I have no idea what Z.'s referring to in this case, but one might have noted his recent, tediously reflexive habit of accusing people of "circular reasoning."

^ Of course, one could also correct his use of "like" in that construction, unless he meant to exclude "begging the question."

Jane is gone now, so I won't bother with her gross mischaracterization of male physicians or telling her horror stories of a couple of female gyns I've had that tried to palm off all manner of woo to me. I would love to tell her, though, that I've been on (estrogen only) HRT for about ten years following hysterectomy. I have never stopped having severe hot flashes and apparently a few women never do (I know one in her 80's). My doc and I evaluate this each year, and each year I do a trial without it to see if symptoms"clear". Each year I worry HE (horrors!) might not renew--I always threaten that I will "get it on the streets" if he doesn't. I use a very low dose patch and the conclusion is that at 65, quality of life trumps limited risk. I have very low breast cancer risk, but realize that is not a guarantee. I get mammos. My gyn is young, well trained, spends nearly an hour with me for this annual chat, and I really, really would like Jane to meet him.

By darwinslapdog (not verified) on 21 Jul 2015 #permalink

Narad@69
Ah ha. "Raises the question" would have to been the correct phrase. Thanks for the correction.

By capnkrunch (not verified) on 21 Jul 2015 #permalink

@Robert L Bell #63,

Normal people understand that there are procedures, and there practices, and there are protocols, and each comes as a bundle with mix of benefits and drawbacks.

Indeed, and it is sometimes necessary to make difficult decisions based on the relative value of those benefits and drawbacks. How many women undergoing unnecessary investigations and treatment equate to one woman whose aggressive breast cancer was caught early, all due to mammography? If you minimize the former, you risk missing the latter, until we have some reliable way of distinguishing one from the other.

There have been attempts to quantify these benefits and drawbacks, using arbitrary units like the QALY. These are often used in discussions about the NHS, where such choices are a little more straightforward than in the US. For example, how many hip replacements in the elderly are worth one heart transplant in a young and otherwise healthy person? I am uncomfortable with this kind of objectification of quality of life, and it remains controversial, but I don't see any other way of making rational decisions in these areas, as long as we have finite resources.

By Krebiozen (not verified) on 22 Jul 2015 #permalink

RL Bell 63, characterizing cranks and crackpots: “I have my favorite solution, it is obviously correct for everyone, and anyone who suggests otherwise is ignorant or corrupt or dishonest or malevolent.”

RL Bell 66: "As has been discussed here at some length by Orac, the way to square this circle is to change the billing and compensation policies so that the doctors and associates can provide the effective care that is needed."

Ah yes, to use one of Orac's forms..."the one handwave to rule them all"

And when the question is raised about how to pay for this miraculous solution, the woomeister's "but big pharma" is replaced with "but big insurance".

No similarities here, nuh-huh.

RL Bell 63 again: " At which time it is discovered that everything was some one else’s fault all along."

Krebiozen 73

I am in agreement with your last paragraph, and I note in particular "the NHS, where such choices are a little more straightforward than in the US".

@zebra # minus infinity to plus infinity

Loon.

By Robert L Bell (not verified) on 22 Jul 2015 #permalink

@Krebiozen #73 In complete agreement

I don’t see any other way of making rational decisions in these areas, as long as we have finite resources.

One of my goals, in the classroom, is that my students come to appreciate how science can tell us how things work and economics can help us to understand the true costs of the various options and statistics can help us avoid fooling ourselves with faulty data - but these tools can not make the decisions for us. They can make certain options (and certain people) look really stupid, but we are responsible for making the best use of the information that we have available. The definition of "best' is very much under our control, and sometimes that definition is going to change - which some people, justifiably or not, are going to find upsetting.

By Robert L Bell (not verified) on 22 Jul 2015 #permalink

"...but I don’t see any other way of making rational decisions in these areas, as long as we have finite resources."

It would be nice if people were able to make their own rational, if not logical, decisions but it appears those days are long gone. Reference an experiment one professor does with his extra credit. Seems like most want to put down a "6" these days, including zebra.

By Not a Troll (not verified) on 22 Jul 2015 #permalink

Robert L Bell,

We cross-posted here. I just saw your reply. If you don't mind sharing, what class/grade do you teach?

By Not a Troll (not verified) on 22 Jul 2015 #permalink

Not A Troll 79,

You just described yourself.

You are the one who said something like "I will continue to request an MD when I go for medical attention", even though it is unclear whether that is necessary.

And one expects the same attitude from RL Bell, who also can't explain how to pay for all that extra service.

And, you don't want to see a MD? You are free to not see one any time you would like.

It'll be clear enough what is necessary once an MD triages me.

The whole shtick of "paying for it" is old. You don't have any suggestions on how to pay for the throngs of non-medical people you would need trained.

Sadly, if you read what I wrote previously, I already described where I would find the money for more physicians it just was not in an answer to your baiting question.

By Not a Troll (not verified) on 23 Jul 2015 #permalink

I think that there needs to be a realization that a one size fits all approach to mammography doesn't really work. I think women over 50 can benefit from mammography at least on an every two year basis. Women between 40 and 50 can benefit if they are at increased risk based upon life history, family history, or genetics. Then there are people like me who are pushing for screening slightly earlier. My mother and material aunt both had breast cancer at 40 (pre-metapause) that was small, fast growing, and aggressive. My mother had a normal mammogram and then three months later a small lump was there that was only a few centimeters big and was stage 4 cancer which had already spread to a lymph node in her arm. My aunt's case was similar although I do not know the specific details.

I think that mammography and other breast cancer screenings as well as treatment (and preventative treatment based upon genetic factors) is in some ways out of control like the original post implies. I think what all of this research is saying is that there is no one-size recommendation for breast cancer screening. For some women it is necessary to screen early and often. For other women a baseline screening at age 40 and then bi-yearly after age 50 is more than sufficient. Also, there needs to be a better understanding of cancer treatment and the potential outcomes from it as a fairly substantial number of cases that are treated are cancers (or pre-cancers) that would likely have no effect on the outcome of the life of the individual if left untreated. Treating all of them actually means less time and money for individuals who need treating in order to live past the next 6 months. Again, I think medicine has been trying to put cancer diagnostics and treatment into a one-size fits all box and that needs to be backed away from.

By K. Richter (not verified) on 30 Jul 2015 #permalink

This may be a naive question from a non-specialist, but is 10 years really the best timing ? I have the impression (which may be wrong) that breast cancer is now among the cancers that are best treated (if you happen to have the "right" type) and that you can sometimes live all your life and die of something else even with breast cancer.
Those screening programs tend to overdiagnose (and thus overtreat) in the sense that, if you hadn't done it in the first place, you would have discovered the cancer anyway at some point, and the treatment then given would in any case help you live longer than 10 years (or 10 minus X years between the screening that hasn't been done and when you actually discovered the cancer).
Could it be that nothing would show up in the data for 10 years, but would for 20 years?

Thank you for an excellent and informative article. I've declined to screen, an informed decision. I didn't get the information I needed from Breast Screen or my doctor, I had to do my own research. It's quite shocking, but celebrity endorsement is still used here to encourage women to screen. I don't know how they get away with it.

I look to the Nordic Cochrane Institute (NCI) for real information, their summary on breast screening was released over 10 years ago now, yet most women here have never heard of it. A recent visit by Professor Gotzsche from the NCI was kept very quiet, he was referred to in the paper as a "Danish Professor with controversial views on breast screening"
Hardly fair...but it's all about keeping women screening-compliant (and in the dark) and, of course, protecting the program.
Breast Screen will never reach their target, too many women are now informed and quite a few have chosen not to screen, scare campaigns, cherry-picking research and urgent reminders have no effect on this group.
Long ago I worked out we can't simply trust screening programs, there are vested and political interests, the pressure/influence of targets/coverage/target payments, scientific ego etc. it all means a program may not be in our best interests.

I dismiss comments by Daniel Kopans, I've always felt he was protecting screening, not women. Why would the NCI or Gilbert Welch or you be motivated to derail screening?
Why would radiologists and others with a vested interest in screening choose to defend the practice? Enough said...

At the very least, anyone who really believes in screening should still respect our right to real information, to choose, to make an informed decision. (and that might be a NO)

We're a long way behind in this discussion, the first article on over-diagnosis to appear in the local papers was about 3 years ago, most women dismissed the concerns. If screening was such a close call, why were we just hearing about it now?
Surely this must be the ravings of a lone dissenter?
Since then a few more articles have appeared and thankfully, more women are starting to listen.
The NCI say about 50% of screen detected breast cancers are over-diagnosed and any benefit of screening is wiped away by those who die from cancers and heart attacks after treatments so the risks of screening may outweigh any benefit.
I also found articles and lectures by Professor Michael Baum helpful, he's a UK based breast cancer surgeon.
I have enormous respect for those prepared to step forward and inform/warn women, to lobby for better brochures/information, to challenge these programs, and for some respect for women, their legal rights and informed consent.

Screening programs should not be implemented without "independent" randomized controlled trials, they must be independently reviewed on a regular basis and change with the evidence, must respect informed consent, and adopt the highest ethical standards. Screening targets and target payments are, in my opinion, inappropriate.
Others do not have the right to make decisions for us or accept risk on our behalf. Screening should be our decision and it should be an informed decision.
Thanks again for your excellent contribution on this important subject.
Kind regards
Elizabeth

By EEB (Aust) (not verified) on 18 Aug 2015 #permalink

@Not a Troll #80

My apologies for not see your comment previously, 'twas merest chance that brought me to this place today.

I teach Chemistry, an umbrella term covering biology to fysics with side orders of economics and statistics, at university with forays into technical consulting and high school tutoring. It's a broad field.

By Robert L Bell (not verified) on 17 Oct 2015 #permalink