I don't get the new guidelines issued by the US Preventive Services Task Force (USPSTF) that have been in the headlines these last two days.
According to the website of the USPSTF, here is what they found when looking at lots of data on breast cancer screening:
"There is convincing evidence that screening with film mammography reduces breast cancer mortality, with a greater absolute reduction for women aged 50 to 74 years than for women aged 40 to 49 years. The strongest evidence for the greatest benefit is among women aged 60 to 69 years. Among women 75 years or older, evidence of benefits of mammography is lacking. Adequate evidence suggests that teaching BSE [Breast Self-Examination] does not reduce breast cancer mortality. The evidence for additional effects of CBE [Clinical Breast Examination] beyond mammography on breast cancer mortality is inadequate. The evidence for benefits of digital mammography and MRI of the breast, as a substitute for film mammography, is also lacking."
Perhaps if there were OTHER options for preventive screening other than mammograms or self-breast exams, then it would make sense to tell people to wait until 50 for the former and to stop the latter all together. But it doesn't appear that there other options - even digital mammography and MRI is inconclusive. What is supposed to take their place?
There is so much about this that bothers me, but let me address one thing. The USPSTF concluded that the HARMS of doing mammography between the ages of 40 and 49 were greater than all the instances where mammography detected cancer that wasn't found any other way. Here is exactly what their website says:
"The harms resulting from screening for breast cancer include psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results . Furthermore, one must also consider the harms associated with treatment of cancer that would not become clinically apparent during a woman's lifetime (overdiagnosis), as well as the harms of unnecessary earlier treatment of breast cancer that would have become clinically apparent but would not have shortened a woman's life. Radiation exposure (from radiologic tests), although a minor concern, is also a consideration.
Adequate evidence suggests that the overall harms associated with mammography are moderate for every age group considered , although the main components of the harms shift over time. Although false-positive test results, overdiagnosis, and unnecessary earlier treatment are problems for all age groups, false-positive results are more common for women aged 40 to 49 years, whereas overdiagnosis is a greater concern for women in the older age groups .
There is adequate evidence that teaching BSE is associated with harms that are at least small. There is inadequate evidence concerning harms of CBE."
WHAT does this mean? I find this part particularly insulting as a woman. Psychological harms - where is there quantifiable data on this? How can they put that on the same level as actual numbers of women who detect cancer via mammograms or BSE or, at worst, those who die because their detection was too late or not at all? What the hell is psychological harm? Are they seriously telling me that dealing with false positives and "unnecessary" bioposies is more detrimental to women than the cancer that could be growing in their breasts but go undetected? This is what it says about CBEs: "The potential harms of CBE are thought to be small but include false-positive test results, which lead to anxiety and breast cancer worry, as well as repeated visits and unwarranted imaging and biopsies." Are ANXIETY and WORRY supposed to go away once women are no longer getting mammograms or doing SBEs?
And here are the parts that boggle my mind.
Under "Burdens of Disease", it states, "Breast cancer is the most frequently diagnosed cancer in women in the United States, not including skin cancer, and is second only to lung cancer as a cause of cancer deaths. In 2008, an estimated 182,460 cases of invasive cancer and 67,770 cases of in situ breast cancer were diagnosed and 40,480 breast cancer deaths occurred. The National Cancer Institute, on the basis of Surveillance Epidemiology and End Result data, estimates the lifetime risk for a woman to develop breast cancer at 12%. The risk for breast cancer increases with age. The 10-year risk for breast cancer is 1 in 69 for a woman at age 40 years, 1 in 42 at age 50 years, and 1 in 29 at age 60 years ." 1 in 69! That's not high enough to overcome the so-called psychological effects or the chances of overdiagnosis?
Under "Effectiveness of Early Detection," it states, "The newly updated meta-analysis by Nelson and colleagues confirms an earlier finding that screening mammography reduces mortality . Improvements in the relative risk (RR) for death due to breast cancer for women aged 39 to 49 years and 50 to 59 years are similar at 0.85 (95% CI, 0.75 to 0.96) and 0.86 (CI, 0.75 to 0.99), respectively. An even greater improvement was found for women aged 60 to 69 years (RR, 0.68 [CI, 0.54 to 0.87])."
Under "Potential Harms of Screening, Mammography", it states, "False-positive results are common with mammography and can cause anxiety and lead to additional imaging studies and invasive procedures (such as biopsy or fine-needle aspiration). False-positive results and accompanying additional imaging studies are more common in younger women . Biopsies may occur as a consequence of false-positive mammography results; biopsy rates are more common among older women. Anxiety, distress, and other psychosocial effects can exist with abnormal mammography results but fortunately are usually transient , and some research suggests that these effects are not a barrier to screening . False-negative results occur at a relatively low rate for all ages , but are slightly higher in women older than 70 years. Other potential harms, such as pain caused by the procedure, exist but are thought to have little effect on mammography use. Overdiagnosis can occur when screening detects early-stage invasive breast cancer or DCIS in a woman, typically older, who is likely to die from another cause before the breast cancer would be clinically detected. Overdiagnosis can also occur in younger women if a detected DCIS or other early-stage lesion never progresses to invasive cancer. Methods for estimating overdiagnosis at a population level are not well established, and thus the proportion of all detected DCIS lesions that constitute overdiagnosis is uncertain . Similarly, unnecessary earlier treatment can occur at any age when screening detects a slower-growing cancer that would have eventually become clinically apparent but would never have caused death. Radiation exposure may increase the risk for breast cancer, but usually only at much higher doses than those used in mammography, although regular mammography could contribute to cumulative radiation doses from additional imaging for other reasons."
Under "Estimate of Magnitude of Net Benefit," it states, "In 2002, the USPSTF concluded that there was fair evidence that mammography screening every 12 to 33 months could significantly reduce breast cancer mortality. The evidence was strongest for women aged 50 to 69 years, with weaker evidence supporting mammography screening for women aged 40 to 49 years. Since that recommendation, 1 new trial and updated data from an older study have been published that specifically address screening in women in the younger age group. These findings were combined in an updated meta-analysis, which resulted in an RR for breast cancer death of 0.85 (CI, 0.75 to 0.96; 8 trials) and a number needed to invite for screening of 1904 (CI, 929 to 6378) to prevent 1 breast cancer death in women aged 39 to 49 years. A meta-analysis of 6 trials among women aged 50 to 59 years and 2 trials among women aged 60 to 69 years provided pooled RRs for breast cancer death in the screened group of 0.86 (CI, 0.75 to 0.99; number needed to invite, 1339 [CI, 322 to 7455]) and 0.68 (CI, 0.54 to 0.87; number needed to invite, 377 [CI, 230 to 1050]), respectively." AND "The USPSTF noted with moderate certainty that the net benefits of screening mammography in women aged 50 to 74 years were at least moderate, and that the greatest benefits were seen in women aged 60 to 69 years. For women aged 40 to 49 years, the USPSTF had moderate certainty that the net benefits were small . "
Some websites to look at:
American Cancer Society's Response (against the new guidelines): "The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider. When recommendations are based on judgments about the balance of risks and benefits, reasonable experts can look at the same data and reach different conclusions."
MD Anderson's Response (against the new guidelines): "If you're of average risk, M. D. Anderson recommends you get your first mammogram at age 40 and return every year after that for regular screenings. If you aren't sure how to assess your risk, we recommend setting up time with your physician. "We believe the benefits of an annual mammogram outweigh the risks for women, starting at age 40," says Therese Bevers, M.D., professor and director of M. D. Anderson's Cancer Prevention Center. M. D. Anderson has studied the effectiveness of breast cancer screening and M. D. Anderson faculty contributed to the modeling analyses used by the Preventive Services Task Force to make its recommendation. "
Letter from Donna , the inspiration for the National Marathon to Finish Breast Cancer (she is against the new guidelines)
Dr. Susan Love's Blog (she is all for the new guidelines). According to US News and World Report , she said, "While studies show that breast cancer deaths can be reduced by 15 percent in women who have mammography screening in their 40s, the absolute number of deaths actually prevented, she says, is so small as to be greatly outweighed by the detriments of screening. About 1 in 10 younger women have false findings that turn out not to be cancer, causing needless worry, additional imaging, and unnecessary biopsies; some of the cancers diagnosed aren't life-threatening and might actually vanish on their own without treatment; younger women may be falsely reassured when a mammogram can't spot a tumor that's hidden by premenopausal breast tissue, which t ends to be dense." I don't know what bioposies are really "unnecessary." I mean, you have to have it to whether the lump in your body is cancer. Either result, is anyone really upset that they did the biopsy? If so, I would like to hear that story to understand that perspective better.
NPR's All Things Considered report on this from yesterday, 11/16
Kathleen Reardon's take , titled "I'd Be Dead By Now"
According to FoxNews, Republican Rep. Phil Gingrey of GA,said "that he and other lawmakers are gravely concerned that insurance companies will seize upon the new guidelines to deny mammogram coverage for women under 50." It also reports that Dr. Cynara Commer, a professor of surgery at Mt. Sinai's Surgical Oncology Department in New York "said she is very concerned that the new guidelines are the top of a slippery slope toward rationing, and questioned the timing as the Senate is about to vote on health care reforms that could end up containing a so-called public option. "The government-run insurance companies are definitely going to be using these federal guidelines as opposed to using the American Cancer Society guidelines, and the American Cancer Society is not going along with these guidelines, and we can only hope that the private insurance companies don't follow suit," she said." I think it's fair to argue that whether we ever have government-run insurance companies, we should all be afraid that our good old, for-profit private insurance companies are already working on denying 40-year-old women the mammograms that they want and some will need.
Article in the Chicago Tribune that shows how the recommendations from the USPSTF compare to those of the American Cancer Society for different types of cancer.
From Woman's Day 's website, which includes a link to a recent interview with Dr. Love.
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A very well-written post, and useful round-up of other reactions to the new guidelines, in the blogosphere.
I added a link to your post to our recent newsmix covering the topic.
Link's here:
http://womensvoicesforchange.org/health-mix-female-viagra-mammogram-obama.htm
(Worth reading- one of our writers is in treatment for breast cancer, and calls the new guidelines "hogwash.")
Again, brava. Great, cogent analysis!
- Elizabeth W.
Contributing Editor, Women's Voices For Change.
A Washington Post article quantifies the number of false positives for yearly screenings starting at 40, instead of 50, which helps explain the decision:
"For every 1,000 women screened beginning at age 40, the modeling suggested that just about 0.7 deaths from breast cancer would be prevented, while about 470 additional women would receive a false-positive result and about 33 more would undergo unnecessary biopsies."
As to the unnecessary biopsies, I can see their point. First of all, the worry and anxiety of maybe having cancer is not like worrying about a test, and it is an anxiety that should be considered. Second, biopsies are expensive (if you don't have insurance, or even if you have crappy insurance) and painful. While I've never had one, I've had acquaintences and friends who have, and if they could have avoided it, they would have.
All that said, I agree with your assessment that these new guidelines are probably not awesome.
"Perhaps if there were OTHER options for preventive screening other than mammograms or self-breast exams, then it would make sense to tell people to wait until 50 for the former and to stop the latter all together. But it doesn't appear that there other options - even digital mammography and MRI is inconclusive. What is supposed to take their place?"
Thermography is being used in Canada, with good results. It's especially effective for women of size or women with dense breast tissue.
What the hell is psychological harm?
The fact that you don't know what you're objecting to and can't be bothered to find out before mocking it does not strengthen your argument as much as you think it does. Have you never heard of psychological abuse? PSTD? Depression? Psychology at all? Is the idea of a false positive for breast cancer doing genuine harm to someone really so laughable?
No and I am not claiming that it is laughable. I don't think any of this is funny. And, yes, of course I have heard of those things.
What I am objecting to is that there is NO discussion in the official report that explains any of it. In fact, the report, to me, makes it sound like women 40 - 49 SHOULD be getting mammograms. The "anxiety" mentioned in the report is a simple, blanket statement without any depth. And my objection is that it claims to be scientific on the same level as the science that goes into counting up women who are helped by screening for breast cancer. Psychology is a soft science that is INCREDIBLY subjective in lots of way (not that hard science isn't subjective, but there are many more ways to test, quantify, and chart results to hard science) and for these scientists, without any descriptive explanation, to claim that women can't handle false positives to the point where it is BETTER for them to forego screening for cancer screams to me the same sort of psychology that kept women from being part of the military, voting, etc. We don't need fainting couches, we need help, we need tests, we need cures.
I have had FOUR close family members diagnosed with breast cancer in the last five years, one of whom was 33 when she passed away from it. I under depression, I understand PTSD, and I get the role that psychology plays in this so please don't go around charging me with some sort of blanket insensitivity. In fact, I understand these things MUCH better than I ever wished that I had to.
I am merely trying to call attention to what the ACTUAL report says about women and their care and to me, it's patronizing, non-specific, and potentially deadly.
I've had a cancer scare. Maybe I'm just a total wuss, but yeah I had some trouble handling it and needed what might as well have been a "fainting couch." There was good reason to believe I might have had cancer, but otherwise it would have been extremely sadistic (yes, psychological) torture to put me through the worry. I don't think it's patronizing or sexist to want to spare people that experience. The current research shows that for the average woman 50 is the age at which the danger of breast cancer outweighs the not inconsiderable price of testing.
If the goal is to set the age and frequency to catch every woman with it, regardless of financial or psychological cost, then they should tell women to start at 20 and get tested every few months. The general recommendation for women without specific risk factors has to be placed somewhere, and in 2002 the Task Force thought that the benefits outweighed the costs beginning at 40. Since then a huge amount of research has been done, and they've come to the conclusion that for most women the tests at 40,41,42,43,44,45,46,47,48, and 49 were providing minimal benefit.
I'm sorry that you went through that process and that it was stressful, but you are lucky that it was not cancer. Like I said above, I have known four women closely related to me who went through the same process and had cancer. And yes, it would be ideal to spare people from that experience but is it better to spare some people that experience in order to let other's cancer go undetected?
As I have said on another comment, it's not clear that the research shows that it should be 50+. That was my point in quoting those huge portions of the report - it's not clear. And that is why there has been such a disparate response, including responses from major organizations that DON'T think the research proves that this change is necessary. But what is at issue is that the guidelines set by the task force are what private insurance companies are going to use in order to deny people preventive care. Trust me, my husband and I have been through this with his care - he is someone who NEEDS preventive cancer treatment based on his history and his family's history and still he fights for every ounce of that prevention. I recognize that we are lucky 1) that we have insurance at all and 2) the time to fight for his care, but I think my point is clear.
I hope I am wrong about this and these guidelines won't affect women's health in a negative way. I want to be wrong.
Those are good points and well stated. My understanding is that this is a recommendation and evaluation from one focused group studying the issue from as objective (not beholden to vested interests) a point of view as possible, not a declaration of government policy or an attempt to "settle the debate" (for one thing, they're the ones who set the 40yo guideline in 2002 according to NPR). The other groups are having their say as well.
What I do think is completely unfair is to tar the researchers involved as sexist assholes who think women are at risk of some kind of vaporesque "Psychological Harm" because of the fragility of ladybrains rather than the seriousness of a cancer false positive.
Two things: first, I saw a comment on the NYTimes that I agreed with. A woman wrote in and said that if it would save the life of another woman, she would be more than happy to take the anxiety and possibly unnecessary procedure. I feel the same way, although I also have anxiety issues. If it means that someone's mom, sister, wife, etc. gets to live in exchange for my panic attack, I see that as a no-brainer. 1 life saved out of 1900 women tested is not an insignificant number, not when you think of the 150 billion women in America, and not when you consider the loved ones of those women. That's a lot of people whose lives and pain can be saved.
On another note, this has made me look much deeper into breast thermography. They recommend that women in their twenties go in to have a baseline reading done and check for precancerous cells. My mom and I are both thinking of having the procedure done. So thanks to this debate for making me be proactive about my breast health!
"The USPSTF concluded that the HARMS of doing mammography between the ages of 40 and 49 were greater than all the instances where mammography detected cancer that wasn't found any other way."
"Psychological harms - where is there quantifiable data on this? How can they put that on the same level as actual numbers of women who detect cancer via mammograms or BSE or, at worst, those who die because their detection was too late or not at all? What the hell is psychological harm? Are they seriously telling me that dealing with false positives and "unnecessary" bioposies is more detrimental to women than the cancer that could be growing in their breasts but go undetected?"
Why don't they recommend that every woman have a yearly mammogram beginning at puberty? There are undeniably young women, not considered to be at high risk, who are diagnosed with and even die from breast cancer each year. Screening absolutely everyone, even in populations where the life-saving benefits of screening everyone are very small, may not make sense. The harms - the financial costs to everyone as well as the psychological and physical costs to women undergoing testing if it's not necessary - may actually outweigh the risks.
Have you read the text of Obama's speech to the AMA this summer? It makes an incredible amount of sense - about how health care reform isn't just about access to insurance. If everyone's insured, but healthcare costs keep skyrocketing, we still won't be able to afford it. And a lot of the unnecessary cost of medicine is the cost of unnecessary medicines and procedures. If things aren't proven effective - this study seem to indicate that routine annual mammograms before 50 aren't - they shouldn't be a regular part of our arsenal.
I get the issue of prevention versus cost and don't deny its importance, but I think stating that we should give women mammograms from puberty is just using hyperbole to skew the facts. Mammograms don't work for younger women. I'm not naive and I'm not asking for 15-year-olds to get them.
But there are a lot of organizations outside of the USPSTF, especially major group and hospitals that deal with cancer patients all the time, that don't like these guidelines and see that the benefits of screening from 40 on outweigh, in most cases, the psychological or financial costs. Just because the USPSTF says these things doesn't mean that it is the end of the conversation except for insurance companies, who, I am sure, are happy to use these guidelines to deny screenings to women that the American Cancer Society and MD Anderson think are necessary.
I find these recommendations to be empowering.
It is very important to understand USPSTF's wording. This recommendation received a grade of "C" which means that they do not recommend regular screening; neither do they *not* recommend regular screening. They simply do not recommend *routine* screening - and routine means for all women at a set schedule. I feel that it is also important to understand the second sentence of their summarized recommendation:
The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
They're saying that it is an individual decision and they each individual should be both given the information she feels she needs to make a decision and to be supported in that decision. I like that.
USPSTF is a very sophisticated group, and one of the leaders in evidence-based medicine. Weighing the potential net benefits and harms is what they do. I'll certainly grant that it may seem skewed towards the "harms" when the "benefits" are 'preventing death' and the "harms" include everything from cost of the test to lost income to anxiety to additional scar tissue and treatment for cancers that would not kill the individual, but they are also limited by the available studies, and screening benefits are traditionally measured by prevented deaths.
I read their latest recommendations as supporting my decision - based on my knowledge of my risk factors and possible mammogram outcomes - that I don't need to start screening at age 40. Some women with risk factors identical to mine may wish to start screening before 50, and they should be able to. If I had a family history of breast cancer or other risk factors I might choose to start mammography.
In 2002, they also hedged their recommendations for women 40 - 49 in their clinical considerations, but the available data at the time led them to a slightly stronger recommendation towards routine screening:
# 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.
You may also be interested in their clinical summary at http://www.ahrq.gov/clinic/uspstf09/breastcancer/brcansum.htm
I am curious about how much of a risk it really is to shoot ionizing radiation through an area that is prone to developing cancer.
I had a cervical cancer scare (non-HPV related) in my mid-20s, and because my mom had breast cancer at age 42, I was GLAD to have the option to receive care. Though the biopsy was painful, I was overjoyed to have it, honestly, and the only psychological scar either myself or my mother has had over cancer treatment concerned the "what if we never went to the doctor?" scenario, not the treatments themselves. Now I'm just freaking out at the fact that my mom (and possibly myself) would have died an early death without detection.
Maybe 0.7 percent doesn't matter to The (human) Powers That Be, but it does to me and the ones I care about. Don't get early breast cancer screenings? Seriously, f*** those people.
I don't think it's as simple as saving .7% or not. Nearly 5,000 women undergo unnecessary procedures for every 7 women saved (if I am reading the above figures correctly). If, for instance, 5% of those 5,000 women are found to have cancers (which would not have killed them) and 3% of those women die due to complications in the treatment of that cancer, then the number of women saved by routine mammogram is equal to the number of women who were, essentially, killed by routine mammogram.
To be clear, I am not claiming that this is true—I have no idea how many women might die due to overdiagnosis of cancer—but I do think this issue is more complicated than it seems at first glance.
Complicating things further is how the prevalence of unnecessary procedures affects the affordability of health care, preventing many people from getting any care at all.
Just want to say that early detection is NOT prevention. Prevention means never getting breast cancer in the first place. Radiation from mammograms does post a serious threat, as does other forms of radiation and especially toxic chemicals in our environment, the products we use and even in the food we eat. Not to say that these new guidelines are not insulting to women, but it is important to get beyond the model that all we can do is try to detect the disease as early as possible.
For more information, check out the Breast Cancer Fund - the only national breast cancer non-profit focused solely on the elimination of the environmental causes of the disease.
hmm...not sure that link worked:
www.breastcancerfund.org
Just for the record, there are similar criticisms of early prostate cancer screenings.
Screenings like this and the unnecessary biopsies and treatments that they inevitably bring with them are one of the reasons that health care is so unaffordable in the United States. It is hard for me to get my head around because I keep thinking that if I had cancer and there were a way to detect it early, I would want a screening. On the other hand, if these tests result in more unnecessary procedures than necessary ones, driving up the cost of health insurance, that could be preventing people from getting treatment that they DO need. The two concerns need to be balanced, and increasing the age at which yearly screenings are recommended is one way to do that. I would hope that even with such a recommendation, doctors would not hesitate to perform early screenings on people with family histories of cancer.
Yes, but the difference is that:
The chief argument against routine prostate cancer screening (as reported in newspapers, not necessarily medical journals) is that treating the cancer is often medically unnecessary but can render men impotent. The argument here is that false positives cause Psychological Harm to women. No one is worried about the "fragile psyches" of men. They're worried about their sex lives.
Yes, only people with stereotypical-view-of-women "fragile psyches" could be traumatized by being told they have cancer. Totes sexist.
I am not trying to diminish the stress of hearing the words "it might be cancer." I have heard them. And ovarian cancer is scary shit. The point is, the media message is:
1. We are concerned about whether men can have sex.
2. We are concerned about women being "too anxious and worried." (CNN)
I want to point out the double standards in the media, NOT imply they are correct.
I didn't see "fragile psyches" in the original post; Where are you quoting it from? The USPSTF guidelines themselves?
The media has long been putting a sexist spin on scientific and medical news in order to sell it to people who really have no interest in science or medicine. I don't think we should call scientists or doctors sexist just because the media interpretation of their work is.
Scare quotes are very fashionable these days. It's nauseating.
My understanding of the recommendation is that it applies to patients WITHOUT additional risk factors. So if you DO have a family history of cancer (breast or other) these guidelines would NOT apply to you: the study (board, whatever) recommends that you still get mammograms at age 40 or earlier.
I REALLY agree with aleks:
"What I do think is completely unfair is to tar the researchers involved as sexist assholes who think women are at risk of some kind of vaporesque "Psychological Harm" because of the fragility of ladybrains rather than the seriousness of a cancer false positive."
I could not have said it better. I think the OP has a point about the report being a little light on quantifying the psychological harms, but that means the study was poorly worded and presented rather than the Patriarchy in White Coats. The board's recommendation may not be the best (as noted the ACA disagrees and individual doctors will more than likely proceed as usual) but it's a recommendation worth, at the very least, rationally considering.
I agree with a lot of what has been said in the comments about not blaming the researchers or labeling them as paternalistic. It actually seems to me that the onus lies with the media and the way these results are portrayed. A study looking into mamography and breast cancer is great! I want to know how important and effective a mamogram is.
BUT, the way this study is being discussed in the news is very black and white "New Recommendation: Don't get mamograms before 50." However, I don't think that was the intent of the researchers at all. Instead, I think this should be looked at as an issue of choice. Here is some new information that doctors should be aware of and that they should discuss with their patients. Women should be provided with all the facts about breast cancer and mamography and come to their own decision about screening. This study should be a positive thing in that it is providing more information. Instead it has somehow been spun into a new mandate, and I will agree that is wrong and paternalistic.
I guess I'm not enough of a feminist, or perhaps I wear my physician hat first, and my feminist hat second, because I'm not getting riled up about this being paternalistic. My thoughts:
1. We have to be reasonable, and logical, if we want to get the most use of our healthcare dollars, and what we can live with and what we can't. Evidence based medicine will continue to change our practice, and more than likely, we're going to have to stop doing what we feel most comfortable doing, and learn something new!
2. It may seem that women are being targeted for psychological distress, and not men. However, I think that if the studies of prostate cancer don't address psychological risk of false positives, it's because they are incomplete, not because psychological effects don't exist in men. I recommend you talk to a man about his prostate exam, and see if there are any psychological issues surrounding the matter.
3. If you really have a problem with delaying mammograms (which diagnose a condition that many women can live with and not die from), steal yourself for the changes down the road concerning cervical cancer screening!
The Lehrer News Hour covered this last night.
GWEN IFILL: So, when is screening for breast cancer a good idea, and when does it fall short?
Here to help us sort all that out are Dr. Diana Petitti, a professor of biomedical informatics at Arizona State University -- she's also vice chair of the task force that released the recommendations -- and Dr. Otis Brawley, chief medical officer of the American Cancer Society and a professor of oncology, hematology, and epidemiology at Emory University School of Medicine.
Welcome to you, both.
Dr. Petitti, since this is your report, I -- I want you to respond to some of what we just heard in Betty Ann's piece. Do you understand the confusion?
DR. DIANA PETITTI: I -- I do understand the confusion.
And I think part of it is because of the subtlety of the language of the task force. The task force recommended against routine screening of women starting in their 40s. What they recommended in favor of was a discussion of a woman with her physician about what age to start screening.
The recommendation has been widely misinterpreted as saying women shouldn't be screened ever in their 40s. And that, in fact, is not what the recommendation was about.
GWEN IFILL: A congresswoman from New York -- or from Florida, Debbie Wasserman Schultz, who is a breast cancer survivor and an activist on these matters, today said she thought that the recommendations were clear as mud.
And a lot of women seem to agree. What do you say to that?
DR. DIANA PETITTI: Well, I -- I apologize for the lack of clarity. I -- I think that hearing the media feedback about the recommendations and how they're being interpreted makes it clear that we need to have better messages.
Again, this is for a recommendation against routine screening of women starting automatically in their 40s. It's a recommendation for a conversation that a woman might have with her physician about when to start screening, and an informed choice about what the tradeoffs are of the benefits of starting earlier vs. the benefits of starting later, and the risks or negatives or harms of starting earlier compared with starting later.
http://www.pbs.org/newshour/bb/health/july-dec09/mammograms_11-17.html
On an MRA blog I used to go to, the guys were reacting to some British researcher who said that mammograms and pap smears were unnecessary, mostly due to the # of cancers they detected vs. the cost of screenings. They got right behind this researcher and the author who agreed with him (this guy hated me and called me "obtuse"). Anyway, I then mentioned that the USPSTF had recently come out with a study that said that men shouldn't ever receive PSA tests and that they shouldn't be treated for protate cancer unless they had 10 years or more to live. I asked the guys twice what they thought of that. Nobody responded to my inquiry. I wonder why.
http://www.ahrq.gov/CLINIC/uspstf/uspsprca.htm for their prostate cancer recommendation.
I tried to post this but it might not have worked. The prostate cancer recommendations from the USPSTF.
http://www.ahrq.gov/CLINIC/uspstf/uspsprca.htm
I listened about this on NPR for about two hours at work today.
It seems to me that the recommendation is that instead of jumping in to get a screening at age 40 you should talk to your doctor and find out if you are in a risk group and discuss the costs (biopsies, false positives) and benefits of the screening. If you are 50 then the benefit of getting screened, whether or not you are in a risk group, is significantly greater. No one is trying to take away the ability to get screened if you choose to before the age of 50. I don't see anything wrong with this. I think it'll initiative more dialogue between physicians and patients about when you should get a screening and why.
The only concern I have is that the US Preventative Task Force also suggested that physicians refrain from teaching patients how to perform a self-evaluation because it takes too much time. Every time I visit on OB/GYN it takes them five minutes to tell me how to perform a self-evaluation. It seems silly to stop this practice. Perhaps if self-examination isn't preventative it is because patients do not comply with the information they are given. So, maybe we need to restructure the method of teaching self-examination rather than getting rid of it.
Isn't it recommended that you get a baseline screening at 35? Then when you get your first screening at 40, you can see if there were any changes. Are we supposed to skip that too?
The only recommendations I know of for screening before age 40 is a very strong family history, very high personal risk, or getting diagnostic mammograms (due to pain, finding a lump, etc.)
If your mother developed cancer in her 40s, you should start about 10 years prior to her age at diagnosis. If you had Hodgkins and were treated with radiation, you should start about 10 years after the radiation treatment. If you have an identified gene mutation, you'll need a different schedule, too.
Your breasts do change dramatically as you age. Younger women have "denser" breasts -- they have more glandular tissue, and mammograms are both harder to read and more dangerous to the tissue due to radiation exposure. If you're at low risk, a screening mammogram under age 40 isn't of much benefit.