The National Institutes of Health (NIH) Consensus Development Conference on Breast Cancer Screening for Women Aged 40-49 … concluded that data on the benefits and risks of screening mammography for women aged 40 through 49 are sufficiently mixed that informed decision making, rather than a blanket recommendation for all women, is an appropriate course of action.
No, those recommendations were not issued yesterday. They were issued on January 23, 1997.
The recommendations issued yesterday November 16, 2009 by the US Preventive Task Force were these:
The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient's values regarding specific benefits and harms.
In other words, the new guidelines are almost exactly the same as the old. So why have women age 40-49 been undergoing routine screening mammography in the intervening 12 years. The answer is a cautionary tale about allowing Congress to make medical decisions.
Epidemiology Professor Virginia Ernster, in a commentary in the American Journal of Public Health in July 1997, described the NIH 1997 Conference and its aftermath.
[A] panel of 12 individuals had been chosen by the NIH … on the basis of their having relevant clinical, methodologic, or consumer perspectives but not having published on the subject of mammography screening. This panel had extensively reviewed the relevant literature and … considered the evidence presented at the conference.
The evidence was presented by:
32 speakers-investigators from the eight major international trials and other radiologists, clinicians, epidemiologists, statisticians, and consumer representatives- presented data on the potential benefits and risks of screening for women aged 40-49 women aged 40 through 49.
As described above the Conference concluded that the evidence of benefit was not strong enough to warrant recommendation of routine screening mammography for women aged 40-49. Any potential benefits were outweighed by the unnecessary biopsies, treatments and even the unnecessary radiation.
What happened next?
While some speakers lauded the panel for its conclusions, many (radiologists in particular) expressed outrage and criticized not only the panel's conclusions but the objectivity of the panel members and the planning process that preceded the conference…
And then the politicians got involved.
Within days … the Senate voted 98 to 0 to endorse a nonbinding resolution that the National Cancer Advisory Board (NCAB, the presidentially appointed committee that advises the NCI director) consider recommending mammography screening for women aged 40 through 49 or "direct the public to consider guidelines issued by other organizations."…
A letter sent to NCAB members and signed by 39 women members of Congress stated, "We believe the only real option is to give guidance to the women in this country." It went on to say, "Without definitive guidelines, the lives of too many women are at risk …
On March 27, 1997, a press conference was held to announce the NCAB's recommendation … that NCI advise women aged 40 through 49 at average risk of breast cancer to have screening mammograms every year or two. A "Joint Statement on Breast Cancer Screening for Women in Their 40s" was issued by NCI and ACS. Although the possible limitations of screening were mentioned, the clear message to the American public was that women in their 40s should be screened…
Europe, in contrast, took the scientific evidence to heart and screening mammography is restricted in low risk women to biennial mammograms from age 50-69.
That brings us to yesterday’s recommendations published in the Annals of Internal Medicine:
The USPSTF … commissioned 2 studies: 1) a targeted systematic evidence review of 6 selected questions relating to benefits and harms of screening, and 2) a decision analysis that used population modeling techniques to compare the expected health outcomes and resource requirements of starting and ending mammography screening at different ages and using annual versus biennial screening intervals…
For biennial screening mammography in women aged 40 to 49 years, there is moderate certainty that the net benefit is small. Although the USPSTF recognizes that the benefit of screening seems equivalent for women aged 40 to 49 years and 50 to 59 years, the incidence of breast cancer and the consequences differ. The USPSTF emphasizes the adverse consequences for most women—who will not develop breast cancer—and therefore use the number needed to screen to save 1 life as its metric. By this metric, the USPSTF concludes that there is moderate evidence that the net benefit is small for women aged 40 to 49 years.
The new (actually old) recommendations have predictably ignited a firestorm of controversy. However, the USPSTF is receiving support even from breast cancer activists. According to The National Breast Cancer Coalition, which describes itself as a powerful voice, speaking for women and men across the country, demanding victory in the war against breast cancer:
The over-emphasis on the importance of screening, despite a lack of strong evidence, has been elevated to such a degree that some even equate screening with prevention of breast cancer. The National Breast Cancer Coalition hopes that today’s release of the US Preventive Services Task Force (USPSTF) revised recommendations will put the brakes on this run-away train and will put screening and its limitations into proper perspective.
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But if you ARE NOT supposed to do breast self-exams (so I basically wasted doing these, at the insistence of my OB-GYN, for 20 years!), and you are not supposed to have mammograms (as I have, faithfully, for the past 19 years), then what the hell are you supposed to do? Just sit there and pray, and hope you don't get cancer?
Do you, or other medical professionals (particularly OB-GYNs) realize what it does to our sense of trust, our belief in science, our patient/physician relationships, when we read (over and over) that EVERYTHING WE HAVE BEEN TOLD IS WRONG, or bogus, or WHOOPS! don't do that. Breast exams, pap tests, HRT, now mammograms -- all an expensive waste of time, and in some cases, maybe even dangerous.
So the women like me, who BELIEVED, and trusted our doctors and read all the articles, and did "the right things" are now revealed to be TOTAL FOOLS AND DUPES, and the women who were lazy and blew off their medical exams and never did self-exams and skipped their yearly Pap tests...are now revealed to be secret clever geniuses.
So -- what do we do now? What do you, as an OB-GYN, tell your patients (or told them in the past)? Just "don't show up"? Because if we don't need our breasts examined, and we don't require a mammogram, and we have no need of yearly Pap tests, and basically we only need to see an OB-GYN every 2-3 years (which oh-so-easily can slide into every 4-5 years, as people are forgetful), then are we all idiots for trying to do better, for trying to be healthy? WTF? What was the point? Why bother with the pink ribbons and the SGK breast cancer awareness and the walkathons, when there is no hope and no prevention and no point in bothering?
Just sit there, and pray and maybe the cancer Angel of Death will pass by your house. Or maybe not.
BTW: I had my first mammogram at 35, because I had very large breasts and didn't feel that I was capable of a truly accurate or thorough breast self-exam. I had to fight to get this mammogram paid for by insurance. It found not one but THREE large tumors. Though benign, I was told that given enough time one or more might have eventually turned cancerous. For two decades, I've been patting my own self on the back, for saving my own life. Now, I just feel like a stupid dupe who swallowed the Kool-Aid.
“We will give you better health care for less money”
" If there's a blue pill and a red pill, and the blue pill is half the price of the red pill and works just as well, why not pay half for the thing that's going to make you well."
That all sounds great – who would not be for that !!!!!!
Unfortunately the government came out today with these cost saving recommendations-
A government task force said Monday that women don't need mammograms in their 40s this will prevent excess anxiety in women — a stunning reversal and a break with the American Cancer Society's long-standing position.
It was found mammography will only save one life out of 1900
(conveniant this does not get mentioned in the article !- Dr. Tuteor ony mentions "benefits"- THE BENEFITS ARE SAVING WOMENS LIVES !!!)
There are 25 million woman in their 40’s
25 000 000 / 1 900 = 13, 158 woman’s lives saved by mammography- IF EVERYONE HAD A MAMMOGRAM-
BUT I GUESS DR. AMY THINKS THAT WOULD BE TOO EXPENSIVE
How does the government go from the “blue pill and a red pill” story to “let’s just let 13,000 woman die”
How is that “better health care” !!!!
Fasten your seat belts folks- this is the new health care in this country !!!
But then my friend has no history in her family, and they found an aggressive stage 3 tumor in her breast, even though the year before the mammogram showed no tumor. She was 43 or 44 when diagnosed... if she hadn't been getting regular mammograms, she would be dead now. Instead she got chemo and is in remission.
This just seems too conveniently timed for my tastes...
I don't understand it, truly.
"Do you, or other medical professionals (particularly OB-GYNs) realize what it does to our sense of trust, our belief in science, our patient/physician relationships, ..."
First of all, I want to say that I am not sure where I personally stand on these new guidelines. I have been discussing them with breast cancer doctors and researchers and those professionals seem equally divided.
Second, I realize that for many, this is a terrible blow to their faith in medical advice, but, in part, that's because public health officials have felt the need to hide the ongoing controversy and present the issue as settled when it was never settled at all. Indeed, as I pointed out, the recommendations were influenced by politics as well as by science.
Third, our understanding of cancer including breast cancer has changed. It is a not a single disease, but multiple albeit related diseases. Different cancers, even different breast cancers, behave very differently. No all turn out to require aggressive treatment. That's important because the treatment is often not trivial, involving the removal of a breast or months of chemotherapy.
Fourth, our understanding of screening tests is more sophisticated. It seems reasonable to assume that all screening saves lives, but that's not the case when a particular screening test leads to lots of false positives and when further diagnosis and treatment involves surgery and chemotherapy.
Fifth, and this is the issue that I am struggling with, how many lives does screening yearly between 40-49 save and how much does it cost to do so? How many mammograms is it worth to save one life 1000, 100,000, a million?
Critics are howling about "rationing" while conveniently ignoring the fact that we already ration healthcare, just in ways that are not defensible. Tens of millions of people have no access to healthcare. Does it make sense to spend hundreds of thousands of dollars to save the life of one woman with breast cancer aged 40-49 when the same money could be used to provide healthcare for 500 people who currently have none?
Unfortunately, the situation is complicated. I happen to feel that it is a better idea to enlist women as partners in dealing with the confusion as opposed to pretending that there is one "right" recommendation that every woman should follow.
Simply put, I think that you have a right to have the same information that I have. I've known all along that mammography has over promised on its ability to save lives. You haven't. It's distressing to find out, but you deserve to know.
"How does the government go from the “blue pill and a red pill” story to “let’s just let 13,000 woman die”
Excuse me, but the government already "lets" tens of thousands of people die by allowing the price of health insurance to be a barrier to getting care.
If we have limited money to spend on healthcare, and we do have limited money, it is both intellectually and morally imperative that we should spend it on what works best instead of providing unlimited benefits to the "worried well" and letting those less fortunate die.
"But then my friend has no history in her family, and they found an aggressive stage 3 tumor in her breast, even though the year before the mammogram showed no tumor. She was 43 or 44 when diagnosed... if she hadn't been getting regular mammograms, she would be dead now. Instead she got chemo and is in remission."
I'm glad for your friend, but what if it turned out that 2 extra women died of complications of diagnosis and treatment or got breast cancer because of the repeated exposure to radiation?
We don't know what the explicit tradeoff is, but there is no doubt that there are risks to widespread screening, some potentially fatal.
"The timing of this recommendation seems suspect and overtly political"
I wrote this post specifically to counter that claim. I want people to understand that the new recommendations date back more than a decade, were adopted by most other first world countries, but were not adopted here for political reasons.
If you look at the medical literature you will see that doctors have been arguing about this for 20 years or more. This is not new even though it seems new to you.
Medical people, whose good intentions are only directed at the health of their patients, have to change their protocols fairly regularly, which again annoys patients who want definitive answers.
Part of the blame lies with media doctors. My current beef is with Dr. Holly Phillips of CBS TV. She's been on-screen warning lately about eating red meat, telling us that people who do so, die! That's just the most recent, most egregious example of correlation presented as causation.
I had one mammo, it hurt like hell and I won't do it again. I'm also at low risk (by today's standards) for breast cancer. However, I understand that women who are in high risk groups are now scared.
If more doctors would admit that medicine is as much an art as a science, and present patients with options rather than declaring that they, as doctors, know everything, perhaps more people would get involved in managing their own health.
Another question...it's my understanding that mammography is a notoriously inaccurate screening method especially in younger women and older women with dense, fibrous breast tissue. Ultrasonography is thought to be much more accurate . Can you comment on this and whether the task force addressed this issue?
This is the only thing recommendation that I didn't follow, so to me, such a response seems an egotistical or emotional response to my decision.
I do BSE regularly and I have had mamograms periodically, just not every two years since I was 40. If I thought something was different, or if my doctor thought so I would have complied. Now that I am older, I am doing these exams regularly. We waste enough money and resources on tests without doing tests that we don't need. I'd rather donate that unused, unneccessary expense to someone who can't afford healthcare for something that they need.
I agree totally- let's get healthcare for everyone !! (did I say otherwise ?)
again, we were told we could save money by--
Electronic Medical Records
preventative care
making the insurance companies more "competitive"
I don't remember Obama saying anything about "just let a few more 40 year old women die and we could save some precious dollars"
I apologize for being so passionate about this- but these are the very people who have been saying how bad our health care system is- AND THIS IS PART OF THE SOLUTION ??? (also my wife has breast cancer- she was what you call "the worried well")
No- we should save money by not sending our kids to a useless war in Afghanistan, and continue paying for our woman to have mammograms
Of course my 13,000 number assumes all woman would have mammograms without this recommendation (which they would not)- and that no woman would have mammograms after the recommendation (which is not the case)
the point is- decisions are being made that will cost the lives of women in their 40's --and that is a pretty damn important group of people !! (leaders, moms , business owners etc...)
How many women found their lumps early because of mammograms and now the digital mammogram? I know at least three. How many women know women who were diagnosed with breast cancer before they were 40? I know at least two.
This "recommendation" smells of the "master plan" to ultimately bring universal health care and all of the waiting and rationing that we have all talked of and basically rallied against. I smell a rat and it is coming in the form of lousy and half-baked health care program that all of us will complain about even more than we complain about with what we have now. Let's grab out backbones ladies and scream NO WAY with this old/new recommendation.
"The average person does not want to hear "our understanding of the disease has changed." They want to hear "Do this and you won't get sick," and get quite annoyed when told everybody's been getting it wrong."
That's one of the key differences between medicine and "alternative" health. Medicine has uncertainties and is constantly changing in response to new information.
"Alternative" health deals only in certainties and the recommendations never change. They don't even bother to publish new books since they never acquire new knowledge.
"It would seem to me that if there is comparable diagnosis and "cure/survival" between the EU and the US then perhaps the guidelines the Europeans are following (which would be similar to the US task force's recommendations) aren't so menacing."
It is difficult to do direct international comparisons because they are based on the overall population, not just women between 40-49.
The central issue though is this: since recommending screening of women 40-49, more cancers have been diagnosed, more cancers have been treated, but the incidence of later stage and more aggressive breast cancers has not decreased.
In other words, we are diagnosing early breast cancers and treating them and having virtually no impact on the death rate from the breast cancers that actually kill women, the later stage and more aggressive cancers. So it appears that all we are doing is diagnosing cancers that didn't need to be treated in the first place.
"We waste enough money and resources on tests without doing tests that we don't need."
I agree. People claim to be in favor of evidence based medicine, but this is where evidence based medicine leads. Decisions are based on what happens in large populations, not on individual stories. So people need to decide whether they believe in evidence based medicine or not.
http://www.sciencebasedmedicine.org/?p=2249
"AND THIS IS PART OF THE SOLUTION ??? "
Yes, this is potentially part of the solution because this is where the scientific evidence leads us.
"also my wife has breast cancer- she was what you call "the worried well"
There is no doubt that more breast cancers are being diagnosed with screening mammography between 40-49, but there is a real question whether it has made any difference in the survival of women from breast cancer.
Women who receive a diagnosis of early breast cancer, have lumpectomy and chemo or radiation and don't recur assume that they have been cured by the treatment. However, it appears highly likely that they would not have died of the disease in the first place because they had slower growing, less aggressive tumors.
"Let the rationing begin"
The rationing began several decades ago. There is not enough money to take care of everyone, so some people get no care at all. It is entirely reasonable to devote our limited financial resources to saving the maximum number of lives.
Even those who have insurance endure rationing. Most health insurance policies have lifetime caps. If you exceed your cap (for treatment of aggressive breast cancer, for example), your insurance company will no longer pay regardless of how desperately you need treatment or how successful the treatment is likely to be. Why is that rationing fair, knowingly condemning an ill woman to death, but making you pay for your own mammogram if you want one between 40-49 unfair?
thanks.
You're completely full of shit and no NOTHING about holistic healing. Stop acting like you know something about it.
Also, you're the one always touting how the scientific and allopathic medical community know so much, based on studies and numbers... yet you are saying here that things change. If the studies were so full-proof, why would anything have to change? Which is it... are the studies reliable, or are they simply full of shit like you are?
Why should any of us trust anything the scientific and allopathic medical field tell us?
Even though the data shows no significant improvement in mortality but a large cost to the system people will still want to find a relative or friend that would be dead if it wasn't for screening.
As an engineer with some experience in imaging it is well known that false positives far exceed actual detections. What happens then is that healthy people get operated on to "play it safe".
Colon test data shows the same problem, they don't detect enough real cancers for the cost and risk involved in the testing, the science was oversold by Katie Coric and others that made it a cause.
Causes are great but when they actually result in lower quality health care for all because money and resources are being directed to care that doesn't make a difference as measured then they are a problem.
The bad news is that the system is riddled with science and tests that don't really save lives as much as make money and provide a celebrity cause, tee-shirts and cute logos.
Tough decisions folks and if we don't use the facts our emotions will lead us down the wrong path of bloated ineffective health care system.
It is a matter of logic-
When we are told- "You are going to get better health care for less money"-- one would assume we were going to have LESS DEATHS (better !!) for less money
The government is now saying with this recommendation- "we will have slightly more deaths for less money- but it is BETTER because it is LESS MONEY"
Not logical
"That's one of the key differences between medicine and "alternative" health. Medicine has uncertainties and is constantly changing in response to new information."
Indeed, this is the type of reality the public needs to understand and science and medicine.
*understand ABOUT science and medicine*
"but the rationing that is coming down the pike will be something like we have never seen before"
No, it will be something like YOU have never seen before. I've seen people die because care is rationed according to ability to pay.
Your fear of rationing would be a lot more compelling if it involved somebody besides yourself.
"Causes are great but when they actually result in lower quality health care for all because money and resources are being directed to care that doesn't make a difference as measured then they are a problem."
You've hit the nail on the head.
"The government is now saying with this recommendation- "we will have slightly more deaths for less money- but it is BETTER because it is LESS MONEY"
No, they're not.
This issue is not new, even though it seems new to you. There has been ongoing debate for almost 2 decades and the Europeans have the exact same recommendations (and have always had the exact same recommendations).
I would be far more impressed with your argument if you were concerned about the people who die because of lack of healthcare. But you're not, you appear to limit your concern to people of your own economic class who already suck up a vast amount of money for their care, while others have no care at all.
Your analysis is flawed. You can't give one fact that shows that death rates for first world countries for 40-49 year olds was impacted postively by this strategy, as their data is masked and not easy to get to. Yet you suggest that USA's lower death rate was not assisted because of the findings of the study. Though the study had to be revived in the US only and yet no data exists for other first world countries --- which should be a natural control group---it's a ten year panel!!! That's a convenient argument (data is not easy to get too)---and the identification of a natural control group is something I would have thought a panel of statisticians would have identified easily.
So just a little extra work would prove this all out. For that reason I conclude it's political.
"I would be far more impressed with your argument if you were concerned about the people who die because of lack of healthcare. But you're not"
WOWZA !! That is putting some pretty nasty words in my mouth !!- As I have said in a previous post-- I AM FOR UNIVERSAL HEATHCARE.
I just think that there are a lot of other ways to pay for it.
For instance-
1)- Spending less on a useless war in Afghanistan (and countless other defense projects)
2) Getting rid of the fraud in Healthcare (which accounts for approximately 5% of all healthcare dollars spent !!)
3) Raising taxes (If needed)
4) etc…etc..… (the list of waste in Government goes on and on….)
I just don’t see why I would tell my patients not to get a mammogram in their forty’s when even the Government Task Force says it will save the lives of one woman in 1900
That is 50 women - wives, mothers, daughters - in every 100,000 women. That's 500 women in every 1 million. That's 5000 women in every ten million- that’s 13,000 woman alive today !!!
Amy-I respect you very much, I have enjoyed reading your articles- but you are wrong on this one- let’s get Universal Healthcare- but let’s not pay for it by letting a significant number of woman die
Most women find that if they tell a PCP or OB-GYN that they have NOT had a mammogram, they get read the riot act and pushed to do so. (BTW, ditto on the colonoscopy.)
But now it is not just that mammography is revealed to be totally useless and waste of time and money, and dangerous exposure to radiation BUT that apparently now THERE IS NOTHING WHATSOEVER that a woman in her 40s can do to prevent breast cancer, but sit there and wait for it to hit...whistling in the dark, or as I said earlier, waiting for the Cancer Angel of Death to pass by her house or perhaps not.
What we are hearing is that IT IS USELESS, there is NO PREVENTATIVE treatment at all and mammograms are a waste of time and money. Therefore, I want a refund for all those mammograms I have had religiously since December 1990!!!! (Not to mention, what about the one I have already scheduled for next week? Skip it? How do I know what to do????)
BTW, you talk about rationing and allocating medical resoures properly, which I agree with...in principle. But there is principle. and there is reality. There is watching women DIE of a preventable disease because they waited until a microscopic lump became a palpable tumor. There is watching your friends die while they are still young, while they have young children. One woman in 1900 to ME sounds like a LOT.
And for what it is worth, there were several times over the last 19 years when I had NO HEALTH INSURANCE, and was out of work, and I scraped the bottom of what I had and borrowed to pay for my own mammograms BECAUSE I THOUGHT I WAS SAVING MY LIFE, not to mention my breasts. I did it because every source available to me said it was medically necessary and prudent. That is what I resent. This is not all about forcing health insurance to pay for unnecessary treatment; THIS IS ABOUT BEING LIED TO AND DECEIVED...this is about having NO preventative strategy at all, when women clearly DO get breast cancer in their 40s...this about how any of us can trust anything we read, anything our doctors tell us to do, when we have been lied to about something as basic as this.
Most women find that if they tell a PCP or OB-GYN that they have NOT had a mammogram, they get read the riot act and pushed to do so. (BTW, ditto on the colonoscopy.)
But now it is not just that mammography is revealed to be totally useless and waste of time and money, and dangerous exposure to radiation BUT that apparently now THERE IS NOTHING WHATSOEVER that a woman in her 40s can do to prevent breast cancer, but sit there and wait for it to hit...whistling in the dark, or as I said earlier, waiting for the Cancer Angel of Death to pass by her house or perhaps not.
What we are hearing is that IT IS USELESS, there is NO PREVENTATIVE treatment at all and mammograms are a waste of time and money. Therefore, I want a refund for all those mammograms I have had religiously since December 1990!!!! (Not to mention, what about the one I have already scheduled for next week? Skip it? How do I know what to do????)
BTW, you talk about rationing and allocating medical resoures properly, which I agree with...in principle. But there is principle. and there is reality. There is watching women DIE of a preventable disease because they waited until a microscopic lump became a palpable tumor. There is watching your friends die while they are still young, while they have young children. One woman in 1900 to ME sounds like a LOT.
And for what it is worth, there were several times over the last 19 years when I had NO HEALTH INSURANCE, and was out of work, and I scraped the bottom of what I had and borrowed to pay for my own mammograms BECAUSE I THOUGHT I WAS SAVING MY LIFE, not to mention my breasts. I did it because every source available to me said it was medically necessary and prudent. That is what I resent. This is not all about forcing health insurance to pay for unnecessary treatment; THIS IS ABOUT BEING LIED TO AND DECEIVED...this is about having NO preventative strategy at all, when women clearly DO get breast cancer in their 40s...this about how any of us can trust anything we read, anything our doctors tell us to do, when we have been lied to about something as basic as this.
We can't stand to do nothing when we feel like there's a wolf at the door. Somebody's gonna have to come up with some sort of magic talisman for people to latch onto if they actually expect American women to take these recommendations seriously while we wait for scientists to research screening tests that actually pass the cost/benefit analysis.