The newest guidelines on mammograms have stirred up intense debate. But very little of it is about the numbers. It’s almost entirely about emotions. Whether it is individual women who speak poignantly about their own cancers or irresponsible politicians who talk about “rationing” to score cheap political points.
As hard as it may seem to accept, neither of these should be the angle from which to consider the mammogram debate. This is not to minimize the life-or-death situation that individuals have faced with their own cancers. But the reality is that every medical intervention has benefits and harms. We have to be unafraid to look coldly at the data to see if the harms outweigh the benefits.
Unfortunately, any time anyone tries to talk about the data regarding mammography, we are swamped with accusations that we are out to deny women a lifesaving procedure. This response makes it impossible to properly and responsibly evaluate the data.
I have both friends and patients who have faced breast cancer, and I would never want them to suffer more. But this emotional response is in a separate category from evaluating the data.
If an anti-inflammatory medication caused unacceptable harm (eg Vioxx), I’d want it pulled off the market. If an implantable defibrillator was found to be malfunctioning (eg Guidant defibrillators) I’d want it recalled. If a traditional medical treatment was found to cause more harm than good (eg estrogen replacement therapy), I’d want doctors to cease using it.
Cancer screening tests should be treated like any other medical intervention. We want smart, dispassionate scientists to evaluate the data. I can’t predict how the mammogram data will eventually settle, but we should not be afraid to look at the data and re-evaluate our preconceptions. That’s the definition of science.
We also, though, have to consider our emotional attachments to certain medical tests. In order to help our society interpret the scientific data, we need to understand the complex interplay of emotions and personal history.
But this should not cloud the scientific analysis of the data. To do so would be to put our health truly at risk.
Read Danielle’s article in the Los Angeles Times about mammograms and screening tests.
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Danielle Ofri is a writer and practicing internist at New York City’s Bellevue Hospital. She is the editor-in-chief of the Bellevue Literary Review. Her newest book is Medicine in Translation: Journeys with my Patients.
You can follow Danielle on Twitter and Facebook, or visit her homepage.
This blog post appears in Danielle’s blog on Psychology Today: Medicine in Translation.
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Kerry Lauerman
Joan Walsh
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Comments
"As we physicians help interpret the task force analysis for our patients, we need to consider the emotional reactions of our patients. A scientific explanation of multivariate analysis is not necessarily helpful when a person is terrified of a disease."
Reflecting on this quote, what I do not understand is why the "emotional reaction" of 'annual anxiety', given by the panel as a harm to women, was factored in to the study. CT is a high dosage exam--MRI and digital mammography are not. I don't believe the radiation risk was given as a harm in the mammography guidelines.
The thing is that women ought to have the freedom to decide for themselves and not be under the direction of a physician who, however well meaning, is not the patient. Present the risks as well as you may but allow the patient her own empowerment.
If you go to my site, you will find a post about twenty states which have mentioned these new guidelines in their budgetary cuts for screening mammograms for the poor. These guidelines matter.
Moreover, every time I hear a "thank heaven they caught it early!" story, I wonder if they put this person through all that for no reason, simply because they saw something on a mammogram. The doctors certainly won't admit it.
This myth of the "benign cancer" is an contradiction in terms if there ever was one. DCIS is non-invasive but can and will turn into LCIS or any other kind which is invasive. Breast cancer tends to be heterogenous. There is no way to tell which woman will develop invasive cancer and which woman can carry that cancer until her death by other means.
Even though the title of this post appears to promise data, it does not. The graph is data without labeling and might as well be a photo of a sunset. What I read in this--and the linked article--is that hte doctor will "interpret" for the woman. Doctor knows best.
One more observation is that you portray the panel as "smart dispassionate scientists". If that is all they are why then does their website list a large mumber of partners, among them the "America’s Health Insurance Plans" which represents 1300 insurance companies? What exactly do the insurance companies add to the scientific analysis?
Likewise, organizations such as the American Cancer Society and the American Heart Associations may not be as completely unbiased as we'd like to think. Although their aims and goals are good, they definitely have an established perspective from their particular disease.
As a doctor in a non-profit, academic, city hospital, I can tell you that the USPFTF is viewed as the least biased institution out there. They are as smart and as dispassionate as we are ever going to get. They do not get pharmaceutical funding, and they do not factor costs into their recommendations. As best as possible, they look at harms and benefits of treatment. If you can find another panel that is less biased, let me know.
Thanks for your thoughtful comments.
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from USPFTF website:
Primary care partners include:
* American Academy of Family Physicians (AAFP)
* American Academy of Nurse Practitioners (AANP)
* American Academy of Pediatrics(AAP)
* American Academy of Physician Assistants (AAPA)
* American College of Obstetricians and Gynecologists (ACOG)
* American College of Physicians (ACP)
* American College of Preventive Medicine (ACPM)
* American Osteopathic Association (AOA)
* National Association of Pediatric Nurse Practitioners (NAPNAP)
Policy, population, and quality improvement partners include:
* America's Health Insurance Plans (AHIP)
* AARP
* National Committee for Quality Assurance (NCQA)
Federal partners include:
* Centers for Disease Control and Prevention (CDC)
* Centers for Medicare & Medicaid Services (CMS)
* U.S. Food and Drug Administration (FDA)
* Health Resources and Services Administration (HRSA)
* Indian Health Service (IHS)
* National Institutes of Health (NIH)
* Veteran's Health Administration (VHA)
* Department of Defense/Military Health System (DoD/MHS)
* Office of Disease Prevention and Health Promotion (ODPHP)
* Office of the Surgeon General
As you note, 20 of these organizations are non-profits, who may nonetheless have their own mandate as you state;however, the AHIP represents 1,300 for-profit businesses . Obama recently embraced a policy which will result in a ban on lobbyists or industry advisors to all federal advisory panels such as AHIP on the USPFTF. I would then feel more comfortable in their guidelines.
Historically, guidelines have gone back and forth, and one can only wonder how much subjectivity goes into these decisions, particularly when "women's annual anxiety" is listed as a harm to women. One thing for certain is that this guideline will harm poor women who depend upon programs offering free cancer screenings. This is already happening a scant month after the press release.
I am not afraid of data but am afraid of the experts who translate it into public policy which has a real effect upon women's lives.
Obviously, any of us would take this in exchange for preventing death. But if it's happening and perhaps not preventing disease in the way we expect, it is indeed something to consider.
(PS: MRI does have harms. There's a whole literature on the fibrotic diseases, esp renal, related to the gadolinium used in MRIs). There are also some practical reasons why MRIs are difficult to use for mass screening.)
Cancer screening of all kinds--breast, prostate, cervix--is a science of numbers but also a a sociological phenomenon. The panel was only surprised at the cultural outcry because their perspective was limited to their own field. They did not consider the people but decided for them.
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