I was impressed by comments made in the recent Op-Ed piece in the Times by three breast-care physicians last week: http://www.nytimes.com/2015/10/29/opinion/why-the-annual-mammogram-matte...
In it, they commented that the difficulties associated with false positives and unnecessary biopsies (frequently cited as a reason to delay or reduce mammograms) were nothing compared to the "collateral damage"--psychic and real--suffered by women requiring additional treatment because their cancers were discovered later than would otherwise have been the case.
I know it's impossible to quantify or properly compare degrees of "suffering", but I'm sure we could agree that dealing with a cancer diagnosis and its attendance worried and pain, is way more than dealing with the uncertainty one might feel before having a biopsy.
In it, they commented that the difficulties associated with false positives and unnecessary biopsies (frequently cited as a reason to delay or reduce mammograms) were nothing compared to the "collateral damage"--psychic and real--suffered by women requiring additional treatment because their cancers were discovered later than would otherwise have been the case.
I know it's impossible to quantify or properly compare degrees of "suffering", but I'm sure we could agree that dealing with a cancer diagnosis and its attendance worried and pain, is way more than dealing with the uncertainty one might feel before having a biopsy.
I try to leave well enough alone and avoid doctors as much as possible because I believe our "health care" system is driven purely by profit.
I was forced to get a mammogram this year by my primary care physician who said he would not continue to accept me as a patient unless I had one (I am 41). Well, of course, at my age, the breast tissue was too dense and I had to waste even more time having an ultrasound which showed what I could have told them minus all the technology... my breasts are fine.
I would love to see how treatment protocols and guidelines change if we ever get a true non-profit health care system.
I was forced to get a mammogram this year by my primary care physician who said he would not continue to accept me as a patient unless I had one (I am 41). Well, of course, at my age, the breast tissue was too dense and I had to waste even more time having an ultrasound which showed what I could have told them minus all the technology... my breasts are fine.
I would love to see how treatment protocols and guidelines change if we ever get a true non-profit health care system.
5
I had biennial mammograms beginning with a baseline at 38, annually in my forties and fifties until 2008 when I was 57. I was shamed into resuming them annually in 2013 when I was 62. I had my annual mammo this year in Aug. at 64. Within 18 hrs. I got a call and inbox message reporting a “focal asymmetry” that hadn’t been on my 2013 and 2014 mammos, and followed it up with a diagnostic spot-compression mammo followed by ultrasound, which confirmed a solid mass about 7mm long. Had a core-needle biopsy that confirmed it was invasive ductal carcinoma, grade 2 (moderate growth & differentiation). Hmmm...from NOTHING in 2014 to an invasive cancer that was not “indolent.” After lumpectomy a month later, the mass’ actual size was nearly twice as large: 1.3 cm. Fortunately, while grade 2 it was mitotic (speed of growth) score of 1, or nonaggressive. No nodes involved, all margins clear. Low OncotypeDX score--so no chemo, just partial-breast radiation followed by 5 years of an estrogen-synthesis-preventing oral pill (letrozole).
However, what if I had been told in 2014 to wait two years to have my next screening mammogram? How much bigger would the tumor have been? Would it have spread to the lymph nodes (or even metastasized into bone or brain)? Do I want to be part of the “collateral damage” of NOT being among the handful of extra lives saved?
However, what if I had been told in 2014 to wait two years to have my next screening mammogram? How much bigger would the tumor have been? Would it have spread to the lymph nodes (or even metastasized into bone or brain)? Do I want to be part of the “collateral damage” of NOT being among the handful of extra lives saved?
3
I find it hard to read this article, which even seems to put clinical breast exams into question. Really? As a healthy young woman with no family history, i was twice told by physicians to just ignore my growing breast lump before it was finally biopsied and later staged at 3b. Breast cancer rates are high, and women who are requesting screenings and later prophylactic mastectomies are simply grasping at the only tool they have to fight the disease. Give us better diagnosis tools and a cure, and then we'll stop.
2
As a patient I learned to "just say no" to too frequent mammograms decades ago. With no family predisposition & excellent health why would I irradiate my body unnecessarily?
4
Because 85% of breast cancers occur in women with NO family history whatsoever. Nobody on either side of my family had any kind of breast or reproductive cancer, and when my routine annual screening mammo revealed what turned out to be an invasive Stage 1A cancer (after two consecutive annual negative mammos), I was feeling stronger and healthier than I have in years (still do). Complacency can kill.
6
I would love to see a woman writing in this detail about prostate cancer screening for men. There's always something weird about the male voice proclaiming about women's health. Just saying.
7
Statistics do not comfort those of us who have had loved ones die of breast cancer. What do I say to my nephews who lost their mother, Kathy, two weeks after her 40th birthday? One nephew now has a two-year-old daughter. Her grandmother was diagnosed at the age of 37 when she had swollen lymph glands and no cancer history on her mother's side. But her aunts on her father's side had plenty of it, but no one asked or counted that as a risk. Are we statistics or are we individuals? The last figure I recall is that the majority of women who do develop breast cancer have no history in the family that they can report. If only my sister-in-law had had a mammogram much earlier, not later, as these guidelines suggest. And I wonder what my principal/friend would say about these guidelines when his daughter, whom I taught in my class when she was 17, died at the age of 28 after a three-year battle with the disease? My point is simply this: if technology is here to help us make a diagnosis earlier--with some low-risk or pesky inconveniences or even false positives--why should we decline the procedure based on statistical analysis? After all, the average is a nothing more than a "regression toward the mean"--but individuals fall outside that average. Do you want your daughter, mother, sister to turn down a baseline procedure? Let's not overdo it, of course, but statistics do obscure the impact on the individual. One life at a time!
7
Lyndda, I am sorry for your and your family's loss. But your family's case is one in which the guidelines wouldn't apply, anyway. This is one of the problems with the public perception. I keep seeing women say that they were diagnosed in their 30s, or between mammograms. Those cases make the point that mammography won't find everything and isn't necessarily the livesaver that many think it is.
6
At 40 I got a mammogram that showed micro-calcifications a sign of DCIS, possible more. After a biopsy it was determined I had DCIS that had spread in a large area in a duct. It was the more aggressive grade (comedo) and so I opted for a mastectomy. Pathology showed that the cancer had just begun to break through the duct and become invasive.
The mammogram allowed me, as my surgeon noted, to "dodge a bullet." I was lucky and was saved further heartache due to a mammogram. 12 years later, I'm fine.
Hopefully as medicine advances there will be better options than the mammogram, but for now, it's a tool to find (some forms of) breast cancer. I feel fortunate to have had my cancer diagnosed at a stage where I required only surgery...no radiation, no chemo. I think it's up to each woman--in consultation with her doctor--to inform herself and make a choice as to what is best for her.
The mammogram allowed me, as my surgeon noted, to "dodge a bullet." I was lucky and was saved further heartache due to a mammogram. 12 years later, I'm fine.
Hopefully as medicine advances there will be better options than the mammogram, but for now, it's a tool to find (some forms of) breast cancer. I feel fortunate to have had my cancer diagnosed at a stage where I required only surgery...no radiation, no chemo. I think it's up to each woman--in consultation with her doctor--to inform herself and make a choice as to what is best for her.
5
I started going longer between mammograms because I have never had any problems and it has been so many years of mammograms, I think I should cut back on the radiation I am getting from those scans.
1
Well, yeah--that’s what I thought when I decided, after decades of normal films, to take a 5-year break between 2008 (age 57) and 2013. My primary care doc (who has no financial interest in the mammography center I use--in a different hospital system) nagged me into resuming annual mammos in 2013. This past August revealed a mass not present in 2013 & 2014, which turned out to be an invasive breast cancer. They got it all, tested it genetically & hormonally, and I’ve been able to avoid mastectomy, chemo and the full course of whole-breast radiation. Had I waited till next year to get screened my situation might have been far different.
You get more radiation from dental x-rays, which most dentists insist on annually and few patients contest. I started refusing routine dental x-rays as long as my teeth are asymptomatic.
You get more radiation from dental x-rays, which most dentists insist on annually and few patients contest. I started refusing routine dental x-rays as long as my teeth are asymptomatic.
3
There is a compelling reason why these guidelines will be ignored for sometime by those of us who practice medicine. That is labeled, "failure to diagnose." Any women who present with just lumps, perceived lumps, or additionally, itching, discharge or pain in her breasts during an examination, that are then not referred for a mammogram, will be litigants if cancer at any stage presents in the future. And, for the patient's peace of mind one must rule out any suspicious finding, no matter how minor, to the fullest extent possible.
1
"Any women who present with just lumps, perceived lumps, or additionally, itching, discharge or pain in her breasts during an examination, that are then not referred for a mammogram,"
Hold it right there. These recommendations are about screening asymptomatic low-risk women -- they have absolutely nothing to do with "ruling out suspicious findings."
Hold it right there. These recommendations are about screening asymptomatic low-risk women -- they have absolutely nothing to do with "ruling out suspicious findings."
12
There are statistics and there are individuals.
Were I a woman I'd rely on my physician's recommendation based on family and medical history as to how often to have a mammogram. Breast cancer runs in our family, hence my siblings opt for diagnostic modalities as frequently as they can, accepting the possibility of false positives, which although inconvenient don't often kill.
Second: the competence of the physician reading the imaging is extremely important. The radiologist "reads" the image and writes a report which usually includes a notation that mammography has an 8-10% error rate. A Primary Care Physician ordinarily reads just the report.
If the referring physician is an oncologist he or she is likely to actually view the mammogram itself. One family member's oncologist eyeballed an image [It can be done on line now], and seeing what he perceived to be a slight density, ordered additional tests which disclosed a malignancy which to all reports was successfully removed.
Bottom line, in addition to relying on the radiologist's report ][often a resident] have the image reviewed by an oncologist.
Were I a woman I'd rely on my physician's recommendation based on family and medical history as to how often to have a mammogram. Breast cancer runs in our family, hence my siblings opt for diagnostic modalities as frequently as they can, accepting the possibility of false positives, which although inconvenient don't often kill.
Second: the competence of the physician reading the imaging is extremely important. The radiologist "reads" the image and writes a report which usually includes a notation that mammography has an 8-10% error rate. A Primary Care Physician ordinarily reads just the report.
If the referring physician is an oncologist he or she is likely to actually view the mammogram itself. One family member's oncologist eyeballed an image [It can be done on line now], and seeing what he perceived to be a slight density, ordered additional tests which disclosed a malignancy which to all reports was successfully removed.
Bottom line, in addition to relying on the radiologist's report ][often a resident] have the image reviewed by an oncologist.
4
As a retired mammogram specialists I can say that it is probably true that not much will change. Even years ago when it was attempted to be more selective as to who gets mamms or followups i always heard, You can't get sued for doing a mammogram but you can for not doing one.
7
In my clinical practice as a nurse practitioner I have seen two women with advanced breast cancer found on clinical exam. These women had for personal reasons declined mammography. There is a place for CBE and I for one will not eliminate this from my practice. Guidelines are guidelines, clinical judgment supersedes as always.
10
Hospitals will grab any excuse they can find to charge for the more expensive treatment. Doctors are judged based on how regularly they order these tests. The whole system is rigged to run as inefficiently as possible.
5
Oh but this is changing from a reimbursement perspective. Doctors are going to be paid for quality outcomes.
After several years of treatment, a family member died of breast cancer at age 46. Another has had double mammectomy after discovery- mammogram- of cancer just before her 40th birthday.Each would probably have died before she was 45 and eligible for first mammogram under new guidelines. New guidelines to be all about money not about women's health.
5
I am 67 years old. I just had a 6 month check up following a negative ultrasound. My doctor wants me back in 8 months. I have had an annual mammogram for the last 27 years. I recently had a gyn check-up that included a breast exam. Are the physicians aware of these guidelines? Shouldn't they be printed in the doctor's offices so women know what the recommendations are? What if a woman has dense breasts? Does that change the recommendations? Am I suppose to have a mammogram every 2 years? Why isn't there clear information on this subject? Who are the "authorities" on this?
7
Yes many Drs. Are aware but once a test becomes part of their routine ordering process it can be difficult for them to change. Not sure why that is the case.
2
I got a couple of mammograms after age 40, but when the new recommendations came out I waited until I turned 50 for the next. My doctor gave me a prescription. I just didn't go. We can all educate ourselves and make our own decisions.
1
There's really no 'gold standard' of authority here - and no guarantee about life and health. Each 'authority' has its own biases. It's really best for people to take charge and to make their own decisions about the best approach - that's custom patient-centered care, again with no guarantee. Sometimes you'll do nothing at all, and be just fine. Sometimes you'll follow all the recommendations for screening, prevention, etc. and still die of the disease. Sometimes you take the middle ground: do your self-breast exams, get a screening when you feel like it, go your merry way -- and die of something else. Healthcare is meant to serve the people, not dictate behaviors. Standards and guidelines presume that we're all alike; deviations show that we're all different. There are no guarantees! None! So the real 'authority' is within.
Given the opinions below, it would appear that we have many doctors commenting on this article. Or just an absurd amount of circumstantial evidence.
How does the layman, one who is not schooled in science or clinical studies, deal with this new stance? We have the ACS switching its opinion, and doctors overwhelmingly rejecting this new view. How to interpret? Well, objectively would seem appropriate.
The ACS is not in the room with you breaking down the next steps in your yearly check-up, your exam, or your results. The ACS is not standing over you on the surgery table. The ACS is not liable for a botched procedure or mis-diagnosis.
The ACS is a billion-dollar organization that is, right now, seeking donations to help "cure" breast cancer while simultaneously issuing new guidelines to reduce screening procedures -- that is difficult to get on board with.
"Once physicians believe they are doing good, it is hard to get them to change their minds."
Well, sure, until the physician is on the Board of Directors for the ACS, seeking to increase their donorship base and evaluating new guidelines a few years from now, I would not expect the doctor to change. They still have real-life patients to assist. Real-life liabilities and responsibilities to consider.
How does the layman, one who is not schooled in science or clinical studies, deal with this new stance? We have the ACS switching its opinion, and doctors overwhelmingly rejecting this new view. How to interpret? Well, objectively would seem appropriate.
The ACS is not in the room with you breaking down the next steps in your yearly check-up, your exam, or your results. The ACS is not standing over you on the surgery table. The ACS is not liable for a botched procedure or mis-diagnosis.
The ACS is a billion-dollar organization that is, right now, seeking donations to help "cure" breast cancer while simultaneously issuing new guidelines to reduce screening procedures -- that is difficult to get on board with.
"Once physicians believe they are doing good, it is hard to get them to change their minds."
Well, sure, until the physician is on the Board of Directors for the ACS, seeking to increase their donorship base and evaluating new guidelines a few years from now, I would not expect the doctor to change. They still have real-life patients to assist. Real-life liabilities and responsibilities to consider.
1
Love your stuff Aaron. Keep up the great work!
3
Here's the best prevention and risk reduction out there: eat real food, mostly plants, not too much, and get some physical activity. Barring the rare cases of true genetic susceptibility, this will do much more to decrease your risk of breast cancer morbidity and mortality than any mammogram or manual breast exam. It has the added benefit of preventing and treating a host of other industrial society killers, like diabetes, other cancers, and cardiovascular disease. Plus it keeps you away from the medical money making machine.
11
"Here's the best prevention and risk reduction out there: eat real food, mostly plants, not too much, and get some physical activity."
Sorry, but provided the patient is not obese, there's not much evidence to support this claim, either.
Sorry, but provided the patient is not obese, there's not much evidence to support this claim, either.
8
Tell that to all the teetotaling, nonsmoking, athletic, slender vegans who nonetheless developed breast cancer. (There are plenty on the online breast cancer discussion groups in which I participate). All a healthy lifestyle and plant-based diet will do vis-a-vis breast cancer is reduce the odds--it is NOT a guarantee one won’t develop breast cancer. You have no control over your family history, genes, and age at menarche and menopause--all of which influence your chances of getting the disease far more than does your lifestyle. Practice good health habits as their own reward, and to prevent other diseases, but don’t kid yourself.
3
As long as there is the assumption that more care is better care (read specialist care) and as long as there is profit to be made, there is going to be more care in the US. Medicine has stopped being a profession here and is instead a business that is making a lot of money for some people. Patients are mere widgets in the gears of the medical-industrial complex. The solution to the problem is for people to take control of their own lives and stay away from hospitals. 85% of your health is lifestyle, not medicine.
11
'No clinical breast exams'.......wow! And by a Physician! Remember the early days of 'BSE' - Breast Self Examination? Long since discarded. But how many women first present having found a lump? But, of course, its not a kosher screening method. And trying to train specialists not to 'over treat'? How does one achieve that or even measure it? Some big shifts; real challenges.
3
Mammograms are the biggest medical scam practiced on women in this country. I am one of the 40% of women with "dense tissue" meaning that the mammogram, which shoots me full of potentially cancer causing radiation, shows absolutely nothing!
I have had 3 in my lifetime. The first time the doctor told me "you have dense tissue, I can see nothing here." The second time I told the clinic I had dense tissue so they added a filter to the machine, but again I was told "I can see nothing here."
The third time, despite a supposedly improved filer and a metallic marker pasted on my skin to mark the lump that I, my gynecologist, the radiologist, and nurse all felt, the mammogram showed absolutely nothing.
Thanks, but no thanks. I see no purpose to these machines other than enriching the corporations that build them and sell them and the clinics and doctors that operate them and mislead women into thinking th
is procedure is anything other than a scam.
I have had 3 in my lifetime. The first time the doctor told me "you have dense tissue, I can see nothing here." The second time I told the clinic I had dense tissue so they added a filter to the machine, but again I was told "I can see nothing here."
The third time, despite a supposedly improved filer and a metallic marker pasted on my skin to mark the lump that I, my gynecologist, the radiologist, and nurse all felt, the mammogram showed absolutely nothing.
Thanks, but no thanks. I see no purpose to these machines other than enriching the corporations that build them and sell them and the clinics and doctors that operate them and mislead women into thinking th
is procedure is anything other than a scam.
8
Typically if a lump is felt but does not show up on a mammogram further testing should occur . Hope they did not just stop with the mammogram.
1
Demand periodic screening ultrasounds and even MRIs rather than mammos if you have dense breasts--go straight to those noninvasive types of imaging (which measure echo reflection and differences in water content rather than exposing you to radiation). That can save your life or at least reduce lifetime radiation exposure risk. Be sure to mention to your gyne that you have dense breasts and would prefer sonograms and MRIs. Your insurance will pay for them if your doctor certifies you have dense breasts. You do not want to miss detecting and timely treating an invasive cancer that is neither palpable nor radiologically visible.
1
If we successfully treat a whole bunch false positive cancers, that didn't need to be treated to begin with, which is essentially what results from aggressive mammogram screening, you are going to end up with statistics that imply that mammograms are making significant beneficial improvements in morbidity and mortality.
If you visit a doctor whose practice provides mammograms, I have a hunch they are going to err on the side of having you get the screening. Its not unlike all the unnecessary ultrasound imaging we were put through when pregnant in the 1980s when machines were being installed in OBGYN offices, or the routine dental X-rays which we get pressured to have done. Just say No.
If you visit a doctor whose practice provides mammograms, I have a hunch they are going to err on the side of having you get the screening. Its not unlike all the unnecessary ultrasound imaging we were put through when pregnant in the 1980s when machines were being installed in OBGYN offices, or the routine dental X-rays which we get pressured to have done. Just say No.
14
Fun Facts --
Many more of us will have a stroke this year than will be diagnosed with breast cancer. Many more of us will die of a stroke than will die of breast cancer.
That the ACS has modified population screening recommendations more closely aligned with the USPSTF is welcome. The over emphasis on early detection has seeped into the public consciousness causing millions to believe that mammograms reduce the likelihood that you'll get cancer. They won't. They can't. But the "early detection saves lives" mantra has crowded out discussion of not just actual risk, but methods of prevention, too.
If we took the resources, effort and money dedicated to Big Pink and focused instead on preventing heart disease and diabetes, we'd reduce not just heart disease and diabetes, but also stroke and several types of cancer, including cancers of the breast.
The great-aunt for whom I'm named had a fatal stroke upon hearing the news that she had breast cancer. She, like many women, was desperately afraid of the thing that would not kill her, and ignorant of the one that did.
Many more of us will have a stroke this year than will be diagnosed with breast cancer. Many more of us will die of a stroke than will die of breast cancer.
That the ACS has modified population screening recommendations more closely aligned with the USPSTF is welcome. The over emphasis on early detection has seeped into the public consciousness causing millions to believe that mammograms reduce the likelihood that you'll get cancer. They won't. They can't. But the "early detection saves lives" mantra has crowded out discussion of not just actual risk, but methods of prevention, too.
If we took the resources, effort and money dedicated to Big Pink and focused instead on preventing heart disease and diabetes, we'd reduce not just heart disease and diabetes, but also stroke and several types of cancer, including cancers of the breast.
The great-aunt for whom I'm named had a fatal stroke upon hearing the news that she had breast cancer. She, like many women, was desperately afraid of the thing that would not kill her, and ignorant of the one that did.
18
Here's a fun fact I'd like to know: how much life expectancy do we lose from the stress of trying to be "good patients," doing all the required screening and followup?
My last round of screening was absolutely nightmarish and took months to resolve (ultrasounds, mammograms, biopsy, surgery, genetic counseling and testing...). As it turns out, everything was OK, but all-in, it took 9 months for the system to put me through the wringer and spit me out. I always thought I was a pretty well adjusted person, but by the time I was through, I was walking out of my PCPs office with a prescription for Xanax.
My last round of screening was absolutely nightmarish and took months to resolve (ultrasounds, mammograms, biopsy, surgery, genetic counseling and testing...). As it turns out, everything was OK, but all-in, it took 9 months for the system to put me through the wringer and spit me out. I always thought I was a pretty well adjusted person, but by the time I was through, I was walking out of my PCPs office with a prescription for Xanax.
32
I can relate. I have often been called back after mammos for a second round of pictures. One time, I was called back because the radiologist saw a shadow (possible cancer) in each breast - but they had no appts for me to come back for a follow up mammo for 3 days. All was fine in the end, thankfully. But I did have serious anxiety waiting for the second round results.
I am a mammographer in a small community hospital and I'm always amazed when I have to perform a mammogram on a 90 year old.
22
The assumption that mammograms are innocuous as tests is simply not true. The procedure, including the ridiculously invasive and judgemental "interview" - usually conducted by a 20-something clerk - is humiliating, prying and, if you have had trauma associated with the topics they demand you respond to, traumatizing. The screening itself is a hassle, but the interview beforehand brings women to tears. Think about it, one of the first questions is "How many children have you had?" Good grief. I applaud doing less of these horrific, patronizing experiences, especially when the evidence shows that they don't help. As physicians you think only of the result; the experience is dehumanizing in an extremely personal way. The last thing I will ever do is lay out the history of my sexuality/reproduction for someone I just met, to be reviewed by a physician I will never see. No thank you.
20
These "invasive" questions are an important part in helping the physician make a diagnosis of your mammogram.
5
You have to give your entire life away if you apply for a mortgage. A mortgage is not life saving. This is a minimal price to pay for the interpreting physician to arrive at a scientific conclusion
5
When I applied for a mortgage, nobody asked me about my sexual history, or how many children I have, or what kind of birth control I use . . .
12
Breast self exam, properly performed, can detect the 10% of tumors in the breast that mammography does not show. It is free of expense and radiation. It should be performed 5 days after the cessation of menstruation in pre- menopausal women to minimize lumps caused by fibrocystic disease. It is important for women to learn the architecture of their breasts in order to detect change. But the exam, done monthly, must be done according to ACS recommendations, not upright primarily and not in the shower primarily. Persistent masses, present after a subsequent menstrual cycle should be further investigated. Cancer of the breast may not wait for age 45 and self detection has an important role to play.
12
Dr Canter
As a radiologist dedicated to mammography, I have no intention of objecting to your statement, but you are in Alice in Wonderland. After interpreting, over 400 cases per week, the ONLY masses detected by patient or referring physicians are within 1 cm of the skin. Anything deeper is totally missed. Most breast cancers occur at the end of the lobules, much deeper, so I respectfully disagree with your statement.
As a radiologist dedicated to mammography, I have no intention of objecting to your statement, but you are in Alice in Wonderland. After interpreting, over 400 cases per week, the ONLY masses detected by patient or referring physicians are within 1 cm of the skin. Anything deeper is totally missed. Most breast cancers occur at the end of the lobules, much deeper, so I respectfully disagree with your statement.
12
Two years ago I was diagnosed with Stage 1 breast cancer. On the way to the biopsy four different doctors were unable to find the "lump." Nor was I able to feel it.
3
Yes. I had to find my own lobular cancer. Mammography showed nothing but MRI confirmed it. I have to thank the health insurance company for a lecture on BSE and providing foam "breasts" with fake lumps so women could know how a tumor is different from a cyst. Many years later it came in handy.
To avoid MRI of my one remaining breast for 5 years and then back to useless (to me) mammography, I had the healthy breast removed. Also, flatness with or without prostheses makes clothes fitting easier which affects quality of life.
Young nurses and PAs still ask if I have had a mammogram yet this year. I say I've had a bilateral mastectomy. They have never had a mammo themselves and don't see the contradiction. To them mammography screening is just a box to be checked.
Once I wore my falsies to a gyn appointment and the doctor asked if I was having mammograms done and tried to examine the prostheses thru the paper gown. I felt embarrassed for her and quickly flipped them up to show my incision. The aftermath of breast cancer can have its humorous side.
I learned BSE in nursing school and was helped by the insurance company demo. But it is a fading art, even though mammograms are not up to the task of early detection of lobular cancer or the problem of dense breasts.
To avoid MRI of my one remaining breast for 5 years and then back to useless (to me) mammography, I had the healthy breast removed. Also, flatness with or without prostheses makes clothes fitting easier which affects quality of life.
Young nurses and PAs still ask if I have had a mammogram yet this year. I say I've had a bilateral mastectomy. They have never had a mammo themselves and don't see the contradiction. To them mammography screening is just a box to be checked.
Once I wore my falsies to a gyn appointment and the doctor asked if I was having mammograms done and tried to examine the prostheses thru the paper gown. I felt embarrassed for her and quickly flipped them up to show my incision. The aftermath of breast cancer can have its humorous side.
I learned BSE in nursing school and was helped by the insurance company demo. But it is a fading art, even though mammograms are not up to the task of early detection of lobular cancer or the problem of dense breasts.
There are many types of cancer and mammography does not recognize all of them. Indeed in 2012, a law passed in CA requiring women to be advised if they have dense breasts so that they can pursue other diagnostic techniques, such as sonography. At least five states have passed such a law. Yet, the author has taken the position that pursuing a second screen is a “harm” that justifies reducing the date women first have a mammogram and the frequency thereafter. Mind-boggling. If the mammogram is the event where women are advised about breast density then delaying this information is absurd. The other recommendation that there are no clinical exams of breasts, which is another way of determining density of breasts and identifying lumps, is also absurd. Instead, women should be referred to the appropriate diagnostic technique: women should be able to get a sonogram, even if they have mammogram, and such a procedure should not be categorized a s a “harm”.
9
The American College of Physicians changed the recommendations on pelvic exams, and yet my ob/gyn insists on continuing those too - even though they basically accomplish nothing (if you don't need a Pap test).
And American Congress of Ob/Gyns (ACOG) says this, "No evidence supports or refutes the annual pelvic examination or speculum and bimanual examination for the asymptomatic, low-risk patient. An annual pelvic examination seems logical, but also lacks data to support a specific time frame or frequency of such examinations. The decision whether or not to perform a complete pelvic examination at the time of the periodic health examination for the asymptomatic patient should be a shared decision after a discussion between the patient and her health care provider."
https://www.acponline.org/newsroom/screening_pelvic_exam.htm
And American Congress of Ob/Gyns (ACOG) says this, "No evidence supports or refutes the annual pelvic examination or speculum and bimanual examination for the asymptomatic, low-risk patient. An annual pelvic examination seems logical, but also lacks data to support a specific time frame or frequency of such examinations. The decision whether or not to perform a complete pelvic examination at the time of the periodic health examination for the asymptomatic patient should be a shared decision after a discussion between the patient and her health care provider."
https://www.acponline.org/newsroom/screening_pelvic_exam.htm
5
And you are continuing to see this ob-gyn ...why?
6
'Cause she needs the yearly birth control prescription refill!
6
doctors are like everyone else. once we have stated something as true we are stubborn about admitting that something else might be true. as a pediatrician, when the new sleep on your back protocols came out (to help prevent sids) I watched older doctors tell people (despite clear factual arguments) that babies were better off sleeping on their bellies. After telling people this, they were unable to accommodate new facts. But the younger docs did and eventually the older docs either came around or retired. So to will be these new guidelines. Docs who believe that yearly mammograms in women under 45 or over 55 save lives will ignore the fact that not only don't they save lives, but that they cause harm. Younger docs will learn and follow the new consensus, and in 5-10 years everyone will be on the same page and wonder why it was ever an issue. My 84 year old mother with Alzheimer's still gets a notice from the mammogram center to get hers yearly!
15
You are correct in your statement, however, unfortunately, the newer generation of physicians coming out go by rules, lab tests and imaging studies and do not treat patients as a whole, so that even with their newer knowledge, some of that knowledge is gathered from writers in ivory towers, who have never seen a patient in their lives and only publish or perish to fulfill their requirements. The statistics are wonderful but as I was taught, the chances of developing a bone infection (osteomyelitis) from a compound fracture treated appropriately are 1/1000 but if it is you who develop the infection, for you, it is 100%.
When you are working in the field every day, you come across scary things and it is quite hard to convey to referring doctors your reasoning - if they don't believe the exam has value.
A shame is this is where we are heading
When you are working in the field every day, you come across scary things and it is quite hard to convey to referring doctors your reasoning - if they don't believe the exam has value.
A shame is this is where we are heading
9
My cousin had quite the struggle to get mammograms stopped for her mother with Alzheimer's. The nursing home loaded her into an ambulance yearly for that test.
"Doctors orders" they said.
Why ambulance? She was an amputee as a consequence of diabetes.
"Don't you love your mother?" they said when she complained.
"Doctors orders" they said.
Why ambulance? She was an amputee as a consequence of diabetes.
"Don't you love your mother?" they said when she complained.
11
This is just heartless.
The only ways to change physician and patient behavior are to:
1) stop paying for tests: The Affordable Care Act promised to fund only "Evidenced-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF) with respect to the individual involved" or "With respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by Health Resources and Services Administration (HRSA), to the extent not already included in certain recommendations of the USPSTF."
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementat...
Annual mammograms were rated a "C", so if Obama follows his own law, annual mammograms would no longer be funded by the ACA.
2) malpractice protection against excessive tests: Most medical malpractice claims come down to "why didn't you order a particular test", and then "Breast disease, according to our classification scheme, accounted for the highest rate (4.13 [95% CI: 3.80, 4.49]) claims per 1000 person-years) of malpractice suits."
http://pubs.rsna.org/doi/full/10.1148/radiol.12111119
Do you think physicians will stop ordering tests when they know they will be sued if they don't?
3) ad campaign convincing the public: do you see anyone paying for these ads? Too many people make money from annual mammograms, and no one wants to stop the gravy train (even if the evidence doesn't support it).
1) stop paying for tests: The Affordable Care Act promised to fund only "Evidenced-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF) with respect to the individual involved" or "With respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by Health Resources and Services Administration (HRSA), to the extent not already included in certain recommendations of the USPSTF."
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementat...
Annual mammograms were rated a "C", so if Obama follows his own law, annual mammograms would no longer be funded by the ACA.
2) malpractice protection against excessive tests: Most medical malpractice claims come down to "why didn't you order a particular test", and then "Breast disease, according to our classification scheme, accounted for the highest rate (4.13 [95% CI: 3.80, 4.49]) claims per 1000 person-years) of malpractice suits."
http://pubs.rsna.org/doi/full/10.1148/radiol.12111119
Do you think physicians will stop ordering tests when they know they will be sued if they don't?
3) ad campaign convincing the public: do you see anyone paying for these ads? Too many people make money from annual mammograms, and no one wants to stop the gravy train (even if the evidence doesn't support it).
10
I fully agree with your comment above - nobody gets sued for testing too much but you can get sued for not testing enough - even when the test is poor and can have real downsides.
I would also add this:
4) Patients are now sent routine questionnaires asking them to evaluate the physicians and other providers who took care of them - and the doctors face real consequences (financial) for poor evaluations. While this sounds like a good idea, most patients have absolutely no idea if the care they are receiving is good or not - just the manner in which it is delivered and whether they got the test or treatment that they think they need. After 12 years of practice, I can tell you that overall, there is a bias in my patient population for more tests. Now that I am tasked with not only taking care of my patient's health I am also tasked with making them enjoy the experience - in a way that can be detrimental to their and our nation's financial health.
I would also add this:
4) Patients are now sent routine questionnaires asking them to evaluate the physicians and other providers who took care of them - and the doctors face real consequences (financial) for poor evaluations. While this sounds like a good idea, most patients have absolutely no idea if the care they are receiving is good or not - just the manner in which it is delivered and whether they got the test or treatment that they think they need. After 12 years of practice, I can tell you that overall, there is a bias in my patient population for more tests. Now that I am tasked with not only taking care of my patient's health I am also tasked with making them enjoy the experience - in a way that can be detrimental to their and our nation's financial health.
2
Data and guidelines are not nearly as convincing to the public as "My mother/sister aunt friend..."
17
The guidelines make sense if your endpoint is strictly limited to disease related mortality (ie. affecting who dies from breast cancer) rather then including other worthy goals (decreasing morbidity of treatment, local recurrences, and fewer instances of second breast cancers).
Those of us who actually treat breast cancer patients recognize that the treatment (surgical and medical) for delayed diagnosis is SIGNIFICANTLY more morbid and debilitating then treating them early, even when survival rates may not be significantly different. This is particularly true with the criticism of women choosing mastectomy or double mastectomy who may choose those procedures to avoid radiation, simplify cancer surveillance of the affected breast, and avoid the anxiety of close annual followup for local recurrence.
Those of us who actually treat breast cancer patients recognize that the treatment (surgical and medical) for delayed diagnosis is SIGNIFICANTLY more morbid and debilitating then treating them early, even when survival rates may not be significantly different. This is particularly true with the criticism of women choosing mastectomy or double mastectomy who may choose those procedures to avoid radiation, simplify cancer surveillance of the affected breast, and avoid the anxiety of close annual followup for local recurrence.
15
"Those of us who actually treat breast cancer patients recognize that the treatment (surgical and medical) for delayed diagnosis is SIGNIFICANTLY more morbid and debilitating then treating them early, even when survival rates may not be significantly different."
Death from cancer is not the only thing to consider. Thank you for pointing this out, Dr. Oliver.
Death from cancer is not the only thing to consider. Thank you for pointing this out, Dr. Oliver.
2
Having my most recent screening mammograms annually revealed this year a mass not present the two years before. It turned out to be an invasive ductal cancer. As a result of catching and removing it early (the core-needle biopsy was painless and quick), I underwent a very minimally invasive and non-disfiguring lumpectomy, didn’t need chemo, and will even have a shorter and more focused round of radiation. Had I waited a year to be re-screened, I might have had to face disfiguring mastectomy (with painful reconstruction), and debilitating chemo; or at the very least a larger, more invasive and possibly disfiguring lumpectomy or quadrantectomy, followed by a long course whole-breast radiation. Not to mention the possibility of metastasis and a shorter and more painful life expectancy
1
Great to see the ACS heading in the right direction.
3
They are following the lemmings, committing suicide by following each other into the water and drowning. Except, the ACS and Task force doesn't drown. they just save money for the government and insurance companies. The women drown on ill-advised stides
1
Robert Aronowitz, in his book"Risky Medicine" suggests that screening decisions are not presented to patients in the correct way. It's not really a straightforward choice about risk, it's about choosing which set of risks you want to take. it's about walking into a casino and choosing your roulette wheel.
Lay out the risks for the patient if she screens once a year for the next 10 years:
The chance of finding something, treating it, and saving your own life
The chance of having a false positive resulting in call back
The chance of having a false positive that results in call back and biopsy
The change of having multiple false positives, multiple call backs, multiple biopsies and multiple surgeries
the chance of finding some non-cancer breast "stuff" that the pathologists can't agree on or doctors are afraid to ignore, and ending up with surgery.
The chance of finding something (like DCIS) and joining the ranks of the 50%-80% who get mastectomies, lumpectomies and/or radiation for something that never would have killed them.
The chance that you flush your quality of life down the toilet, living a life of patienthood, chasing the delusion that all this screening and treatment gives you more control over your future than it actually does...
Lay out the risks for the patient if she screens once a year for the next 10 years:
The chance of finding something, treating it, and saving your own life
The chance of having a false positive resulting in call back
The chance of having a false positive that results in call back and biopsy
The change of having multiple false positives, multiple call backs, multiple biopsies and multiple surgeries
the chance of finding some non-cancer breast "stuff" that the pathologists can't agree on or doctors are afraid to ignore, and ending up with surgery.
The chance of finding something (like DCIS) and joining the ranks of the 50%-80% who get mastectomies, lumpectomies and/or radiation for something that never would have killed them.
The chance that you flush your quality of life down the toilet, living a life of patienthood, chasing the delusion that all this screening and treatment gives you more control over your future than it actually does...
40
Accumulative radiation from x-rays in itself can and does cause cancer. Mammograms, which expose women to varying degrees of radiation (ex. 3-D mammography has higher radiation levels than traditional mammography), add to the risk of developing cancer. Doctors and radiologists tend to ignore or minimize this fact. All women need to weigh the risks of perhaps too frequent and/or unnecessary mammographies. I am glad to see the American Cancer Society increasing the recommended interval between mammograms. However, with less invasive and non-cancer causing alternatives available to detect tumors, I continue to question why x-rays are the screening mechanism of choice. (See earlier post by Ludmilia re: sonogram for example.)
11
Linda, I wonder if women at high risk of getting breast cancer are also more susceptible to radiation, such as is encountered during annual mammograms.
1
Totally and absolutely wrong. Don't know where you got your facts from but digital mamms have 1/3 less radiation than older film mammograms. Digital and 3D combined give less radiation than flying 1200 miles, driving 600 miles or breathing NYC air for 4 days.
Maybe you should eliminate driving, flying and breathing to minimize your radiation risk.
Radiation from a mammogram starting at 35 to 75, every year, increases risk by 3/100,000. Can you say that about driving risks or everyday living risks.
Maybe you should eliminate driving, flying and breathing to minimize your radiation risk.
Radiation from a mammogram starting at 35 to 75, every year, increases risk by 3/100,000. Can you say that about driving risks or everyday living risks.
1
Nobody has actually proved that medical radiation (small intermittent doses with ample recovery time in between doses) is associated with increased cancer risk. All the models we use are extrapolated from H-bomb exposed people who received radiation doses in a markedly different way, with much larger doses and in a much more continuous fashion. The models assume a worst case scenario (a linear correlation between cumulative dose and cancer risk) vs the more likely exponential correlation - in which low doses have much lower cancer risks than the linear model would predict.
No mention is made of the new 3-D mammogram technology and its effectiveness. My early stage invasive breast cancer was originally found this year using this technology. I was told that it would never have been found with older technologies so it appears to me that the recommendations be based upon the 3D mammogram technology that everyone should have access to at the screening stage so these cancers can be found and treated earlier.
5
Very true but the equipment costs over $400,000 and there is no reimbursement. Good profit decision, yet we have 15 3D machines
The only end point for comparing the usefulness of screening tests is deaths prevented, not new diagnosis or stage. That is old business. The question remains is will women still prefer yearly studies?
3
Not me. I live with a husband that was "treated" for prostate cancer (with very bad and sad side effects)...another over-diagnosed and over-treated cancer. I've learned my lesson. Don't go looking for trouble if it's not supported by science. However, both my ob/gyn and my GP were not happy about my decision to switch to an every other year mammogram schedule. Too bad.
14
I couldn't disagree with you more.
"Those of us who actually treat breast cancer patients recognize that the treatment (surgical and medical) for delayed diagnosis is SIGNIFICANTLY more morbid and debilitating then treating them early, even when survival rates may not be significantly different." Comment here by Dr. Oliver. And I agree wholeheartedly with him/her.
"Those of us who actually treat breast cancer patients recognize that the treatment (surgical and medical) for delayed diagnosis is SIGNIFICANTLY more morbid and debilitating then treating them early, even when survival rates may not be significantly different." Comment here by Dr. Oliver. And I agree wholeheartedly with him/her.
1
OK, so survival time is not significantly different -- what does that say about the treatments? Earlier detection = less morbid and debilitating treatment but NO survival benefit?
2
My fear as a Radiologist/Mammographer is how all of these conflicting guidelines will play out in terms of medical malpractice.
These new guidelines (for now) seem to be voluntary. Will I be sued if (when) the first malignancy appears in my patient who switched to follow them, as opposed to the established yearly cycle? The subsequent lawsuit is a guarantee, considering the state of Malpractice in this country. The deeper question is, will I lose?
These new guidelines (for now) seem to be voluntary. Will I be sued if (when) the first malignancy appears in my patient who switched to follow them, as opposed to the established yearly cycle? The subsequent lawsuit is a guarantee, considering the state of Malpractice in this country. The deeper question is, will I lose?
6
The legal "standard of care" is gong to be the most aggressive guideline or the personal experience or the jury
Why so focused on lawsuits? How about doing what's best for the patient with the best evidence available? You are not committing malpractice if you follow these guidelines. And the guidelines explicitly state that starting at age 40, the decision is between physician and patient. The bigger issue may be these conflicting guidelines on payment by insurers.
3
If you are following the guidelines, you may be sued, but you will probably not lose. If a woman specifically asks for a diagnostic mammogram because she found a lump, that's a different story. Order the mammogram and ultrasound, and a biopsy if necessary.
1
A study that came out a few years ago found that women who get mammograms are no less likely to die of breast cancer than those who do. "But what's the harm?" you may ask. The article notes:
"Harms also result from screening mammography. More than half of women screened annually for 10 years will have at least one false positive finding. These can result in as little as a second exam and as much as a biopsy, which also carries small but real risks."
Those "small but real risks" likely include infection, bleeding, and the other risks of minor surgery. What the author doesn't mention is the psychological cost to the patient of unnecessarily undergoing a painful, invasive procedure and possibly suffering disfigurement of the breast after a biopsy. I'm glad the medical profession is starting to realize that these concerns are not trivial and that diagnostic procedures should not be ordered "just in case" when the evidence shows that it doesn't improve prognosis.
"Harms also result from screening mammography. More than half of women screened annually for 10 years will have at least one false positive finding. These can result in as little as a second exam and as much as a biopsy, which also carries small but real risks."
Those "small but real risks" likely include infection, bleeding, and the other risks of minor surgery. What the author doesn't mention is the psychological cost to the patient of unnecessarily undergoing a painful, invasive procedure and possibly suffering disfigurement of the breast after a biopsy. I'm glad the medical profession is starting to realize that these concerns are not trivial and that diagnostic procedures should not be ordered "just in case" when the evidence shows that it doesn't improve prognosis.
27
When the end result is a diagnosis of invasive breast cancer, the call backs and biopsies don't feel useless at all.
2
Most small tumors these days are biopsied not via excision or even incisional surgery, but with a core-needle guided by imaging--a half-hour procedure (the core-punch taking less than a minute) that doesn’t even require completely disrobing. More pain from the local anesthetic (only momentary) than from the procedure (itself painless because the breast was numb), little bleeding (easily stopped before going home), no hospital admissions, and NO “disfigurement.” As a result, my 1.5 cm invasive ductal cancer was caught early (no spread) and treated with the least possibly invasive lumpectomy, partial (and abbreviated) irradiation and hormone therapy. Had I waited two years after my 2014 mammo, who knows how big the tumor would have grown, how far it would have spread and how invasive and grueling the treatment would have had to be?
Easy to spout statistics when it’s not your own life on the line. And having been there, I vastly prefer the inconvenience of a false positive than the tragic consequences of “ignorance is bliss."
Easy to spout statistics when it’s not your own life on the line. And having been there, I vastly prefer the inconvenience of a false positive than the tragic consequences of “ignorance is bliss."
1
The trend of not ordering as many tests is slippery. Insurance companies are getting squeezed tight these days so are putting that pressure on providers/facilities and next thing you know we are not practicing preventive medicine anymore but rather reacting... which in turn will cost more. I think any well trained practitioner knows when it is and is not appropriate to order tests/diagnostics/labs, etc; Of course studies are utilized but ultimately clinical judgement trumps all. That is what sets apart a robot and a highly educated individual.
What I focused on was not the 40 vs. 45 issue but rather the recommendation that older women have mammograms every other year despite the fact that the risk of breast cancer rises as one ages. In fact, it is highest for women in their 70's at it is at that age that it appears we are trying to curtail screening presumably for some money saving objective.
7
I believe the recommendation data is based on mortality rates of one year versus two year screening - apparently they aren't significant. In other words, in that age range the cancers found don't respond any better or worse if they're found in year one or year two.
3
But DP, the cancer is much more likely to be slower growing in older women. So screening every two years should be more than sufficient.
6
No, not because of costs. "Mammogram breast cancer screenings for women aged 70 and older may cause more harm than good, according to a large new study. The screenings don't decrease the number of advanced breast cancer cases diagnosed in these older women. But the tests can lead to overtreatment in a large number of women and put them at risk from the harmful side effects of breast cancer treatment, the researchers said...
"For a screening program to be effective, one would expect that the incidence of early stage breast cancer would increase while the incidence of advanced stage cancer would decrease because any cancer would have been detected at an earlier stage," study author Dr. Gerrit-Jan Liefers, a surgical oncologist and head of the geriatric oncology research group at Leiden University Medical Centre in the Netherlands, said in a conference news release.
"However, when we investigated the effect of extending the screening program in the Netherlands from age 69 to 75, we found that it had not led to a decrease in the rate of advanced breast cancers detected, while the number of early stage tumors strongly increased," Liefers said...
"The researchers said women aged 70 to 75 were more likely to die from other causes than from any early stage breast tumors detected through mammogram screening."
http://www.webmd.com/breast-cancer/news/20140321/routine-mammograms-foun...
"For a screening program to be effective, one would expect that the incidence of early stage breast cancer would increase while the incidence of advanced stage cancer would decrease because any cancer would have been detected at an earlier stage," study author Dr. Gerrit-Jan Liefers, a surgical oncologist and head of the geriatric oncology research group at Leiden University Medical Centre in the Netherlands, said in a conference news release.
"However, when we investigated the effect of extending the screening program in the Netherlands from age 69 to 75, we found that it had not led to a decrease in the rate of advanced breast cancers detected, while the number of early stage tumors strongly increased," Liefers said...
"The researchers said women aged 70 to 75 were more likely to die from other causes than from any early stage breast tumors detected through mammogram screening."
http://www.webmd.com/breast-cancer/news/20140321/routine-mammograms-foun...
3
Whose "war on women" is this?
3
The medical community has a dreadful reputation for adopting changes supported by evidence. From Semmelweis who advocated hand-washing to Barry Marshall, recipient of the Nobel Prize in 2005 for discovering the cause of peptic ulcers in 1985, the medical community ignored and resisted the evidence. The causes: complacency, and laziness, and profit....monetary advantage. Mammograms are money makers for radiologists, referring physicians, hospitals, and radio-logical clinics and of course all manufacturers of mammographic equipment.
US Preventitive Service Task Force recommended that women, not at risk for breast cancer delay mammography until age 50, in 2009 (http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummary....
Push back by the ACA, and the medical community led to Kathleen Sebelius's withdrawal from this recommendation. As a result thousands more women have been radiated, false-positive follow-up, including biopsies and unnecessary surgery etc. Billions of dollars six years later the ACA came around to partial acceptance of the recommendation. There will be resistance to this too.
US Preventitive Service Task Force recommended that women, not at risk for breast cancer delay mammography until age 50, in 2009 (http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummary....
Push back by the ACA, and the medical community led to Kathleen Sebelius's withdrawal from this recommendation. As a result thousands more women have been radiated, false-positive follow-up, including biopsies and unnecessary surgery etc. Billions of dollars six years later the ACA came around to partial acceptance of the recommendation. There will be resistance to this too.
24
Close to 10 years ago, I had surgery to remove a lump from my breast. At that time, the doctors I'd seen all referred to mammography as "the gold standard" for catching the problem in time. I'm writing to report that several mammogram tests did not expose the lump. What caught the lump was a sonogram, taken on the same day. The only effect I have experienced from
mammograms is a cruelly squashed breast.
mammograms is a cruelly squashed breast.
19
Good point. A cancerous lesion has to have calcifications to show up on mammography. Some lesions may not have radioopaque elements.
Did you have cancer or was it just a cyst?
1
Yes, is there any research on using sonograms to replace some mammograms or in addition to them?
One enormous elephant in the room is the malpractice attorney.
If a woman comes in trying to convince her provider to order a mammogram, and the provider tries to use science and the art of medicine taking into account risk factors of family history, etc, and won't order the mammogram and a cancer develops later, the temptation to contact an avaricious malpractice firm to secure some money to help her family if she dies is a real concern.
In most cases few doctors will hold their ground and not order a requested test, especially with the great unknown of having something there that hasan't been detected or has symptoms yet.
This seems far fetched but the burden of being perfectly prescient and held to that in front of a jury is potent leverage. Even if there is a slam dunk defense and the case is resolved in the favor of the doctor, the whole experience is enormously difficult for doctors to go through. Being in the helping and caring profession and have the opposing attorney try to make you appear to be stupid, avaricious, uncaring along with every other trick is a very demeaning experience.
I have seen this happen more than a few times with good friends who are physicians, and an overriding federal law that says if a doctor follows accepted guidelines and no extraordinary factors are present, that s/he should have no liability of the unusual situation does exist where a problem develops later on.
If a woman comes in trying to convince her provider to order a mammogram, and the provider tries to use science and the art of medicine taking into account risk factors of family history, etc, and won't order the mammogram and a cancer develops later, the temptation to contact an avaricious malpractice firm to secure some money to help her family if she dies is a real concern.
In most cases few doctors will hold their ground and not order a requested test, especially with the great unknown of having something there that hasan't been detected or has symptoms yet.
This seems far fetched but the burden of being perfectly prescient and held to that in front of a jury is potent leverage. Even if there is a slam dunk defense and the case is resolved in the favor of the doctor, the whole experience is enormously difficult for doctors to go through. Being in the helping and caring profession and have the opposing attorney try to make you appear to be stupid, avaricious, uncaring along with every other trick is a very demeaning experience.
I have seen this happen more than a few times with good friends who are physicians, and an overriding federal law that says if a doctor follows accepted guidelines and no extraordinary factors are present, that s/he should have no liability of the unusual situation does exist where a problem develops later on.
8
To avoid lawsuits, instead of ordering unnecessary tests, talk to your patients. Dr. Carroll wrote an excellent blog on this topic this summer: http://mobile.nytimes.com/2015/06/02/upshot/to-be-sued-less-doctors-shou...?
3
The Medical-Insurance-Research complex has been providing "recommendations" for a long time that favor less screening, less testing and less cost. I've had 35-year-old women in my practice who got a baseline mammogram and found cancer. They are still alive 20 years later. Which 35-year-old, 40-year-old or 45-year-old women should be denied the chance to save their life? Yes the test can be uncomfortable, yes there are false positives and yes there is the potential for increased worry and anxiety, but do these really justify not being pro-active with an individual human being? The patient's autonomy and right to informed decision making is far more important and fundamentally sacred than any recommendation from the ivory towers of epidemiology and board rooms of cost control.
22
This comment is frightening to me as a patient.
The problem is that patients are not truly informed about the actual risks of testing, and even if they were, human beings are absolutely terrible at making rational decisions about risk; we fear airplanes and snakes more than cars and Dunkin Donuts. The job of a doctor is to inform and guide risk management decisions. , The rates of contralateral prophylactic mastectomy are far too high because women don't cooly calculate risk, they feel it. And doctors are happy to cut and bill.
I've gone into doctors to discuss the issue of breast cancer screening, and they say things like "I've seen women die of breast cancer at 35, so that's my perspective." Um, right, but your perspective also doesn't include the horrible experience of a false positive, and the reality of over treatment (I've been through the former, and I'm well aware of the risks of the latter). Doctors should not ignore the vast crowd of over tested and overtreated women just because they never come back to sue you.
I want evidence-based medicine from my doctors, not sentiment. Why would I go to a doctor for advice based on anecdata, emotion, and fear of liability?
The real risk here is the erosion of trust in the doctor patient relationship. If we can't trust doctors to give us evidence-based medicine, if testing and treating "less" is never even researched (as in the case of DCIS), then tell me why I should trust my doctor's advice at all?
The problem is that patients are not truly informed about the actual risks of testing, and even if they were, human beings are absolutely terrible at making rational decisions about risk; we fear airplanes and snakes more than cars and Dunkin Donuts. The job of a doctor is to inform and guide risk management decisions. , The rates of contralateral prophylactic mastectomy are far too high because women don't cooly calculate risk, they feel it. And doctors are happy to cut and bill.
I've gone into doctors to discuss the issue of breast cancer screening, and they say things like "I've seen women die of breast cancer at 35, so that's my perspective." Um, right, but your perspective also doesn't include the horrible experience of a false positive, and the reality of over treatment (I've been through the former, and I'm well aware of the risks of the latter). Doctors should not ignore the vast crowd of over tested and overtreated women just because they never come back to sue you.
I want evidence-based medicine from my doctors, not sentiment. Why would I go to a doctor for advice based on anecdata, emotion, and fear of liability?
The real risk here is the erosion of trust in the doctor patient relationship. If we can't trust doctors to give us evidence-based medicine, if testing and treating "less" is never even researched (as in the case of DCIS), then tell me why I should trust my doctor's advice at all?
20
Wow, not much of a scientist are you? Anecdotes do not prove causation.
7
Well said, MD! I sure wish you had been on the panel that made these new recommendations.
3
It wasn't so long ago that menopausal women routinely received a recommendation to start hormonal therapy to protect against heart disease - until a large study proved this wasn't as safe and effective as believed. Might a significant part of the problem be that population-based screening procedures or treatments have been recommended based on expert opinion, rather than research-based evidence? Perhaps medicine needs to examine more closely the role of expert opinion v. evidence-based recommendations.
28
Patients have been conditioned to demand invasive diagnostics because they've been led to believe that early diagnosis will result in "survival". But study after study have shown that early diagnosis does not extend the life of the patient; rather, it increases "survival" because survival is measured from the time of the diagnosis. The patient will die at roughly the same time but she will know she is dying for a much longer period. I am exaggerating (early diagnosis may extend the life of the patient for a while and in exceptional cases may even "cure" the patient), but for the average patient only a little or not at all. On the other hand, early diagnosis usually results in painful and sometimes risky treatment, including surgery, that may even shorten the life of the patient. My point is that physicians are only responding to the expectations and demands of their patients, expectations and demands that are based on erroneous information about "survival".
40
I agree. See antibiotics, increased use of
3
Tell all this to my 95 y/o mother who had a radical mastectomy at 62 and see if she would have changed her mind as to course of therapy.
10
"My point is that physicians are only responding to the expectations and demands of their patients"
Not when it comes to mammograms, they're not! My OB/GYN (not me) has brought up mammograms at every annual visit in the last 15 years. I have a thyroid condition and see my PCP at twice a year to get my thyroid prescription renewed - and every single time, he brings up mammograms -- not because there's some connection between hypothyroidism and breast cancer, but because his EMR prompts him to ask and some bean counter penalizes him for every patient who hasn't followed the latest set of guidelines for cancer screenings.
Not when it comes to mammograms, they're not! My OB/GYN (not me) has brought up mammograms at every annual visit in the last 15 years. I have a thyroid condition and see my PCP at twice a year to get my thyroid prescription renewed - and every single time, he brings up mammograms -- not because there's some connection between hypothyroidism and breast cancer, but because his EMR prompts him to ask and some bean counter penalizes him for every patient who hasn't followed the latest set of guidelines for cancer screenings.
4
Yeah, I hate mammograms. They are especially painful for women with small breasts. Thanks a whole lot. This type of thing has happened to me since I began getting mammograms. Someone, please, design something more humane.