But here's one problem: I had a recent call-back on a mammogram (a frequent occurrence for me). The ultrasound (uncomfortable and very time consuming) showed "something." I was flippantly given an option to wait six months and re-image it, or have a biopsy. Now, if I was a nervous Nelly I might have opted for a biopsy - for no reason whatsoever, since the re-image was fine. Also, I have implants presenting further risk to an unnecessary biopsy.
2
Guess they never read "Overkill," Dr. Atul Gawande's indictment overdiagnosis in America.
http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
6
These doctors and their respective hospitals and private groups are going to have their income negatively affected by the decrease in unnecessary radiological testing, followed by the unnecessary biopsy, and the rest of the useless production at their offices and hospitals that costs a ton money also decrease, which explains this op-ed. The fact of the matter is that I have seen a number of breast cancers in women that were entirely missed by mammograms even a month or two prior, then for them to return to the clinic with complaints of palpable lump. Aggressive breast cancers do not follow rules, and while recommendations are based on sound data and reasoning, these doctors just want a revolving door of captive audience so they can keep milking the system. However, I do think that patients should make educated choices based on their concerns, family histories, and proactively, seek out options with regards to their health and being healthy, while not subjecting themselves to a lot of unnecessary tests and biopsies. Often, the first line of defense in doing so is the primary care doctor who can give advice and guide medical decisions.
8
An annual dose of radiation every year for 30-40 years! Did you know that doctors lose money if their patients don't get mammograms? Maybe good for people with a genetic risk for cancer - but for the general population?
10
I applaud these women and agree 100% with their article. I am a cancer survivor and because of a routine YEARLY mammogram my cancer was caught in its beginning stages. I am now cancer free for five years!!! I hate to think where I would be today if I had followed the new guidelines of the American Cancer Society. DEAD!!!!! Most likely. I wonder what exactly is behind this change? I challenge you to follow the money. Just how much money does the American Cancer Society receive from insurance companies and how soon will they be denying payment for routine yearly mammograms??
5
Dear Doctors, THANK YOU SO MUCH for writing this op-ed piece !
It must be very frustrating for you to see this development.
Please keep fighting for us women - and be proud of the 90 % survival rate, that is due to your long and hard work every day with us breast cancer patients.
I am deeply thankful for every doctor in every country.
Fondly
CHG
It must be very frustrating for you to see this development.
Please keep fighting for us women - and be proud of the 90 % survival rate, that is due to your long and hard work every day with us breast cancer patients.
I am deeply thankful for every doctor in every country.
Fondly
CHG
3
What in God's name is the relevance of the authors' having been awarded the title of "Mother of the Year"? What a ridiculous and inappropriate point to make here.
16
My mother survived breast cancer. She didn't survive the cancer industry, which put her on a *preventive* drug that caused her to faint and fracture her spine. Because of the failure of her oncologist to insist she go to the emergency room after her fall, that fracture wasn't discovered for five agonizing months. By the time it was surgically repaired, my mother was so debilitated from pain medication and a frightful bedsore that she was not able to recover.
She had the *best* doctors; was seen at the *best* facilities in NY, including a major teaching hospital and one of the highest-rated rehab facilities. All together, their mistakes, their omissions and their failures caused the death of a woman who had been vibrant, independent and functioning as someone decades younger than her chronological age.
I*ve described my mother*s history with breast cancer detection, treatment and prevention in other posts and need not repeat it here.
We need to emphasize again and again--aggressive cancer in younger women is not the same disease as abnormal cells slow to proliferate, especially in older women. Not every woman commenting here, claiming that her mammograms and subsequent treatment *saved her life,* would actually have died from breast cancer without medical intervention.
By relying so much on a primitive tool like mammography, we are not pushing hard enough or fast enough for sophisticated diagnostic tools that can diagnose cancer accurately.
She had the *best* doctors; was seen at the *best* facilities in NY, including a major teaching hospital and one of the highest-rated rehab facilities. All together, their mistakes, their omissions and their failures caused the death of a woman who had been vibrant, independent and functioning as someone decades younger than her chronological age.
I*ve described my mother*s history with breast cancer detection, treatment and prevention in other posts and need not repeat it here.
We need to emphasize again and again--aggressive cancer in younger women is not the same disease as abnormal cells slow to proliferate, especially in older women. Not every woman commenting here, claiming that her mammograms and subsequent treatment *saved her life,* would actually have died from breast cancer without medical intervention.
By relying so much on a primitive tool like mammography, we are not pushing hard enough or fast enough for sophisticated diagnostic tools that can diagnose cancer accurately.
19
I've had breast cancer, and I find this paragraph so deliberately misleading as to destroy the authors' credibility. "Today, the overall survival rate for breast cancer in the United States is very close to 90 percent, the highest it has ever been, giving most newly diagnosed patients every reason to be optimistic. Early detection with mammography and better treatment options are both directly responsible for that."
While better treatment options are helping with survival rates, early detection merely turns up lots of non-life-threatening cancers, so of course the "survival" rate is better. I "survived" a non-life-threatening cancer. That is an insult to the women who don't survive metastatic breast cancer, like the two I lost this year. These doctors should be ashamed of themselves.
While better treatment options are helping with survival rates, early detection merely turns up lots of non-life-threatening cancers, so of course the "survival" rate is better. I "survived" a non-life-threatening cancer. That is an insult to the women who don't survive metastatic breast cancer, like the two I lost this year. These doctors should be ashamed of themselves.
17
Ridiculous. This isn't an insult to anyone. Some women tragically still do not survive. People's capacity to be insulted never ceases to amaze me.
3
I am a breast cancer survivor diagnosed as a result of an annual mammogram. The mammogram taken the previous year showed no sign of a tumor so it had developed in the one-year interval. I absolutely shudder to think of what would have happened had I skipped a year before my next mammogram. My cancer was caught at a curable stage IIA and thankfully had not spread to my lymph nodes. Almost certainly, the tumor would have grown substantially given an extra year and would have likely spread into my lymph nodes and beyond. I attribute my now nearly 19 year survival in large part to early detection through mammography. My story and experience is far from unique. For those who complain of pain during the exam, newer mammogram machines seem to compress breast tissue less. Also, whatever discomfort I may experience from the exam is so brief as to be inconsequential. I have read some recent articles saying we should focus less on early detection and more on a cure. I say we should do both. Also, until a cure is found, early detection is truly the best option. I also have been puzzled by arguments saying that one can die as easily from a small as a large tumor. However, ALL THINGS BEING EQUAL (e.g. aggressiveness, stage, etc.), smaller tumors are less lethal than larger tumors. I urge all my family and friends to have annual mammograms.
5
If the writers are so interested in detecting early cancers, why do they use alarmist language about the risks of colonoscopy, a test that has been proven to save lives while being cost effective? The writers reference complications that occur at a rate of around 1:10,000 or less without mentioning the thousands of lives saved by colonoscopy. I wonder how many people will skip their colonoscopy because of this careless, alarmist writing. Do the writers believe it's in the best interest of patients to scare them about colonoscopy so mammograms dont look so bad?
You can die from a CT scan? Come on.
You can die from a CT scan? Come on.
6
I too am a physician, primary care. The colonoscopy comment angered me as well. Only Pap tests are a better screening test than colonoscopies when it comes to improvements in mortality. Mammograms can't remotely approach the numbers achieved with either of the other two. The recommendations for screening will continue to evolve as more data is evaluated. I am a huge fan of the USPSTF, not the anecdotal tripe served up by those who depend upon the tests for their income. It took gynecologists a little very long time to come around to reduced pap screening, based on very similar arguments. Now it's widely accepted and much more cost effective.
7
Not once in their editorial do these women acknowledge the brutal maiming and long term side effects caused by the procedures used to treat breast cancer - which might bearable if the cancer was truly life-threatening, but which is simply torture when applied in the context of over-diagnosis and over-treatment.
I'll trust physicians when they are willing to come right out and say: you will be horribly disfigured, you will experience chronic pain the rest of your life in ways that are debilitating, even if your nipples are spared, you will lose most pleasurable sensation in your breasts.
Until the industry can be transparent in all ways and at all times regarding ALL impacts of treatment, the more-more-more invasive folks are simply not to be trusted.
I'll trust physicians when they are willing to come right out and say: you will be horribly disfigured, you will experience chronic pain the rest of your life in ways that are debilitating, even if your nipples are spared, you will lose most pleasurable sensation in your breasts.
Until the industry can be transparent in all ways and at all times regarding ALL impacts of treatment, the more-more-more invasive folks are simply not to be trusted.
15
What data was relied upon to determine the time between mammograms? Detecting cancer as soon as possible is laudatory. But there is a huge difference between never having a mammogram and a 6 month spacing between exams. Is cancer survival dependent on the type of cancer and the age of the patient? As a 67 year old woman, with no family history, I am confused by the conflicting advice. The data relied upon by both sides should be publicized. Women should be able to make their own informed decision. This debate reminds me of HRT for the post-menopausal and the profit motive of the drug companies to sell it.
1
In my 29 years as a physician, health care has gone from 8% of the GDP to 18%. We have not improved either quantity of life quality of life by 2.25 times. Something is wrong.
Folks, more is not necessarily better. sometimes it is just more, and sometimes it leads to even more. Breast cancer discussions are dominated by anecdotal, not statistical evidence (see the comments above), yet it is the latter that has provided all of the advances in medicine since the randomized clinical trial was popularized just after WWII. We need to practice evidence based medicine, and the evidence is NOT THERE for annual mammograms. The explosion of cases of DCIS will increase survival rates and women's worry levels, but the idea that all of those women were "saved" from an advancing and life-threatening cancer is bunk. The US Preventive Services Task Force recommends mammograms every two years at age 50 (and even there, the evidence gets only a "B" rating, not an "A") and they have no economic interest in the outcome (unlike our writers).
Our writers note conveniently that repeat mammograms and ultrasounds do not result in deaths, and so the imaging industry is safe. What about the women who die in surgery (yes, anesthesia results in death) or chemo (also causes death) for cancers that would not have harmed the woman? Where is that data in their presentation?
The medical-industrial complex is real. Money is the object; patients are sometimes "collateral damage". Enter at your own risk...
Folks, more is not necessarily better. sometimes it is just more, and sometimes it leads to even more. Breast cancer discussions are dominated by anecdotal, not statistical evidence (see the comments above), yet it is the latter that has provided all of the advances in medicine since the randomized clinical trial was popularized just after WWII. We need to practice evidence based medicine, and the evidence is NOT THERE for annual mammograms. The explosion of cases of DCIS will increase survival rates and women's worry levels, but the idea that all of those women were "saved" from an advancing and life-threatening cancer is bunk. The US Preventive Services Task Force recommends mammograms every two years at age 50 (and even there, the evidence gets only a "B" rating, not an "A") and they have no economic interest in the outcome (unlike our writers).
Our writers note conveniently that repeat mammograms and ultrasounds do not result in deaths, and so the imaging industry is safe. What about the women who die in surgery (yes, anesthesia results in death) or chemo (also causes death) for cancers that would not have harmed the woman? Where is that data in their presentation?
The medical-industrial complex is real. Money is the object; patients are sometimes "collateral damage". Enter at your own risk...
22
It is totally irresponsible for the NYT to even publish this opinion piece. Are they now also going to allow anti-vaccine propaganda, rebuttals of theory of evolution, arguments pointing to the validity of astrology, maybe a few anecdotes about lives saved by palm readers... ?
11
So two breast radiologists and a breast surgeon are against a recommendation by ACS for fewer mammograms? How shocking. Reminds me of the famous quote from Upton Sinclair: “It is difficult to get a man to understand something, when his salary depends on his not understanding it.”
How ironic that this article came out the same day as this op-ed:
http://www.theguardian.com/society/2015/oct/29/mammograms-not-catching-c...
We need to be led by science and facts not emotions and big business when making medical policy and decisions. The NYTs does nobody any favors by publishing such a blatantly biased op-ed. What is next: An op-ed from Exxon on how cutting back on our oil use is dangerous and bad policy because of the wonderful ways cars drive with gasoline?
How ironic that this article came out the same day as this op-ed:
http://www.theguardian.com/society/2015/oct/29/mammograms-not-catching-c...
We need to be led by science and facts not emotions and big business when making medical policy and decisions. The NYTs does nobody any favors by publishing such a blatantly biased op-ed. What is next: An op-ed from Exxon on how cutting back on our oil use is dangerous and bad policy because of the wonderful ways cars drive with gasoline?
14
I know several women who have had breast cancer. The ones who were under 40 when diagnosed all died within a couple of years post-diagnosis. My doctor found my first tumor when I was 30 and i had a lumpectomy.. Diagnosis: non-cancerous fibroid tumor. I had never had a mammogram. My next tumor appeared 20 years later in the very same spot. Again I had a lumpectomy but with a larger margin of tissue taken. It was a non-cancerous phalloides tumor, which can be mistakenly diagnosed as a fibroid tumor. I had two more recurrences in the same spot, the last when I was 65. Extensive research told me if it was again a phalloides tumor and it was cancerous that there was no known treatment for it so I opted for a mastectomy. At my follow-up after surgery my surgeon asked if I thought my first tumor was actually a phalloides tumor. I answered in the affirmative and my doctor agreed. No two people are alike and I would hate to think that this new view would keep any insurance company from covering a mammogram before age 45. As far as I knew, I wasn't at risk and most women who have breast cancer aren't either. It's almost ten years since my mastectomy and I have had no further problems. I hope that other women have the same option for taking care of their health that I had.
3
Mammography and ultrasounds have been a necessary yearly testing appointment for me since I was 33. I've had numerous biopsies over the years and biopsy has gotten significantly better. I wish that an ultrasound was all that was needed, unfortunately it's not. I wish that mammography was less uncomfortable, but, it's not. That does not distract from it's has value. Last year, I had to have a double biopsy and fortunately at 63 I'm fine. I hadn't needed a biopsy performed in 10 years, so, I was a little concerned. I also can find cysts on any given day of the week despite being post-menapausal.
Biopsy, and if you're fortunate enough, aspiration, are the only certain way to determine if that lump is cancerous. Three-quarters of people found with a cancerous tumors do not have a family history of cancer, so to have a panel that excludes experts in the field decide on the merits of this testing is absurd and suspect.
Biopsy, and if you're fortunate enough, aspiration, are the only certain way to determine if that lump is cancerous. Three-quarters of people found with a cancerous tumors do not have a family history of cancer, so to have a panel that excludes experts in the field decide on the merits of this testing is absurd and suspect.
2
I don't understand how a woman in your situation would believe they had benefited in any way from all the testing, false positives and invasive procedures over the past three decades.
10
I would like to give people the benefit of the doubt, but all three of these authors derive a substantial part of their income from the provision of radiology services and the biopsies and other surgical procedures that often follow. Even so, their command that we should "stop overemphasizing the 'harms' related to mammogram callbacks and biopsies" is disconcerting and transparently self-serving. Their justification, that they have never seen anyone's life threatened by the incidence of false positives and resulting procedures, is not a good enough reason continue administering tests as evidence mounts that those tests are not ultimately beneficial.
14
This piece simply presents a series of statistics that are oft repeated but are myths that do not stand up to scientific scrutiny. I will challenge two of them. The fact that these authors are "Mothers of the year" do not make their claims valid. The fact that all three authors have a financial conflict of interest should make one questions the validity of their claims.
Myth 1: Mammography saves lives. There is reasonable evidence that regular mammograms reduce the risk of dying from breast cancer (but not by as much as 30%). There is NO study showing that screening reduces mortality, perhaps because of the mortality associated with overdiagnosis and overtreatment.
Myth 2: Screening results in detection of disease earlier and so reduces the chance of needing invasive treatments. Women who go for screenign are more likely to have a lumpectomy and more likely to have a mastectomy than those who do not go for screening. This is because of the problem of overdiagnosis and overtreatment.
Furthermore, screening has not resulted in a reduction in the incidence of late stage breast cancer.
There are other inaccuracies and flaws in their argument but space precludes a more detailed refutation.
Myth 1: Mammography saves lives. There is reasonable evidence that regular mammograms reduce the risk of dying from breast cancer (but not by as much as 30%). There is NO study showing that screening reduces mortality, perhaps because of the mortality associated with overdiagnosis and overtreatment.
Myth 2: Screening results in detection of disease earlier and so reduces the chance of needing invasive treatments. Women who go for screenign are more likely to have a lumpectomy and more likely to have a mastectomy than those who do not go for screening. This is because of the problem of overdiagnosis and overtreatment.
Furthermore, screening has not resulted in a reduction in the incidence of late stage breast cancer.
There are other inaccuracies and flaws in their argument but space precludes a more detailed refutation.
10
Thank you for outlining these points. It's an uphill battle overcoming the politicization of breast cancer. Not all cancer is created equal, which leads to great difficulty in finding the balance between finding enough of the bad ones and not bothering to find "benign" cancers. But again as in many things American, fear and ignorance take the day.
3
Mammograms lull women into a false sense of security. I know a woman who had breast cancer twice, in spite of annual mammograms. Both times she found it herself. There's always a story of someone that was saved, but the statistics show mammograms do more harm than good. It's time for women to accept this and start checking themselves. Breast cancer tumors grows within a month or two and a yearly mammogram only catches less than 2% of cancers and causes a lot of anxiety for women with false positives that would have gone away if left alone.
9
Just adding my own personal testimony to the chorus: eight years ago, my life was saved by a routine annual mammogram at age 57, which detected an aggressive and fast-moving cancer that was not detectable by self- (or physician-) examination, and did not yet exist on the previous year's clean mammogram. Please, ladies, believe the survivors who point out that the discomfort of the mammogram procedure, the stress of a false-positive callback, even the experience of a negative-result biopsy--all are WAY less stressful and far less dangerous than actually having breast cancer!
5
I am a radiologist who reads mammograms. I believe they do reduce mortality from breast cancer, but have no idea, really, after reading all the literature, by how much. We have had several decades now of high quality mammography involving millions of women. If mammography made a huge difference, it shouldn't be hard to prove it.
I think women should get mammograms, but choose whatever schedule gives them the most peace of mind.
And please, it you get called back from a screening mammogram for more imaging or an ultrasound, relax, it happens up to 10 percent of the time, just to get a clearer picture of something, and, as the authors say, is usually nothing. I wish they would stop calling a call-back a false positive. A negative biopsy is a false positive, not a call-back.
I think women should get mammograms, but choose whatever schedule gives them the most peace of mind.
And please, it you get called back from a screening mammogram for more imaging or an ultrasound, relax, it happens up to 10 percent of the time, just to get a clearer picture of something, and, as the authors say, is usually nothing. I wish they would stop calling a call-back a false positive. A negative biopsy is a false positive, not a call-back.
19
The argument that Public Health experts might be biased towards "saving money" instead of "saving lives" demonstrates that the writers have no actual understanding of what professionals in Public Health do. What they've said is offensive and demeaning to the many men and women who work in Public Health.
23
I had an annual mammography in October, 2014, with no visible tumors. In July, 2015, during my annual physical I pointed out a small lump to my physician and he sent me for a diagnostic mammogram (2 views). A suspicious area, not the one I felt, was seen on both mammogram and using ultrasound. I had a biopsy 2 days later and a diagnosis of invasive ductal carcinoma the following day. It was unpalpable even though we knew it was there. I had a lumpectomy and the tumor was very small (8 mm), about the size of a large pea. It was stage 1, grade 1 and there was no lymph node involvement. Because it was discovered so early, I needed only simple treatment... no radiation or chemo. Remember, it had popped up only 9 months after my last mammogram. I am 62 and if I had followed the new guidelines and waited 2 years, who knows how my diagnosis and treatment would have changed. This change in recommendations may save money but not lives.
3
Unfortunately, despite the hype, there is absolutely no hard evidence that early detection--or mammograms-- actually saves lives. The number of deaths from breast cancer remains stubbornly the same as it was 30 years ago, at more than 40,000 per year. 100% of the women (and a few men) who die die of metastatic breast cancer, which is cancer that has left the breast and invaded vital organs. Of these, nearly 95% were previously early stage --even stage 1--"survivors" whose disease lapsed--not women who failed to get mammograms (the study you cite from Massachusetts is therefore highly misleading, as only 6% of women are Stage IV at initial diagnosis--and many of these are younger women who wouldn't have had a mammogram, anyway.) Statistics on "disease free survival" of 5 years dramatically understate the reality that breast cancer can return years--even more than a decade--after its original recurrence, and in its most deadly form. Until we understand how and why this happens and have a real cure, the mammogram remains a very imprecise and much overrated tool.
24
It is important to know that these author's paychecks are dependent on more screening, more testing, more treatment whether we need it or not. Take what they say with a grain of salt. The people that write the recommendations do not have that financial incentive.
The value of cancer screening is difficult to measure and the data can be manipulated in many ways.
I highly recommend that all women and men read this article from the NYTIMES a couple years ago. It is the best most informative article for "laypeople" that I have ever read http://www.nytimes.com/2013/04/28/magazine/our-feel-good-war-on-breast-c...
The value of cancer screening is difficult to measure and the data can be manipulated in many ways.
I highly recommend that all women and men read this article from the NYTIMES a couple years ago. It is the best most informative article for "laypeople" that I have ever read http://www.nytimes.com/2013/04/28/magazine/our-feel-good-war-on-breast-c...
8
What are the guidelines on self-examination? I have a 45 year old friend who had a mammogram last December that was negative. No lumps or cancer to worry about, right? Wrong! In June during a breast self exam she found a lump, went to the doctor who said to wait. She did not take that advice and went for a second opinion to find out that she has an aggressive breast cancer.
3
As former pediatric neurosurgeon Ben Carson has reminded us over countless news cycles, physicians are not usually trained as scientists. The subject of breast cancer screening evokes strong emotions from breast surgeons, radiologists, cancer survivors, and victims' families, but there has never been much credible scientific evidence that mass screening saves lives. The authors have knocked down a few straw men in this article, but they've done little to contradict the plainly obvious fact that our health care dollars would be better spent on prenatal care, childhood vaccines, water fluoridation, scaling back the prescription opioid epidemic, or any number of high-impact public health interventions. Beware the breast cancer medical-industrial complex.
18
As an ethicist and one of the first women urologists, I think the issue of frequency of breast cancer screening exemplifies how practical women are versus how mostly men and researchers think. Women view mammograms as life-saving: after a certain youngish age, we all have known of a contemporary who has died of the disease. For other common cancers that affect older people, it may make sense to consider cost-benefit analysis. However, in breast cancer that affects women in their prime--and their families and friends-- lives and years saved must be the measure applied. Women are used to making husbands and other family members see doctors when something might be wrong. We want to be able to deal with our own breast cancer as quickly as possible if we have it.
5
Two weeks ago, I sat in a waiting room with 6 other women. Two of them were in tears, worrying out loud about being called back in for a second mammogram. It turns out that EVERY woman in that waiting room was there for a "call-back." As we all discussed how odd that seemed, we also discovered that every one of us were paying out of pocket for the second mammogram, where the first one was covered under wellness. That second mammogram cost all of us between $450 and $750 each. One of the women also said that the person who checked her in that morning told her that 24 women had already been at the facility that morning for a second mammogram. This was at 9:30 a.m. I have not exaggerated a single fact here. I'd love to believe that the system is in place to help improve our health. But I also know that the breast has become an enormous business these days. Everything I read continues to say that more mammograms do not improve outcomes. When I add that to my experience that morning, it seems more than a little suspect. And it also makes me sad.
17
I agree. I have a mammogram every other year with the complete agreement of my primary care physician. This year, before I was even dressed, the technician was pushing me to book an appointment for next year. When I told her that I don't subject myself to annual mammograms, having weighed the evidence and my health history, she told me that I would probably get a tumor if I waited the two years. Now although that is a possibility, it is not a probability. I could develop a tumor next month for all she knew. When I told her this, she dismissed it. I realize that she may see some worst care scenarios but to deny my perspective made me completely suspect a financial aspect to her nagging. .
3
Hospital-employed physicians, those working for HMOs, and for most large medical groups are subject to compliance studies from the government and from various accrediting agencies concerning mammography, and, for those directly involved - breast radiologists, breast surgeons, pathologists, radiation oncologists, and medical oncologists - minute regulation and regular inspection through the politically-motivated MQSA (Mammography Quality Standards Act). No one can deviate from MQSA, which reinforces the current wasteful and futile screening program. No physician can refuse to participate in the screening program, if that is what the compliance authorities of his or her employer require. They get rated and paid as to the percentage of their patient panel getting mammograms, whether the patient wants it or not.
These bureaucracies and entrenched interests - such as the three breast doctors writing this opinion piece - will never give up this racket voluntarily.
The only hope is to get the message out to the public that this is indeed an ineffectual racket, "something that really is not what it appears to be." Most of the messages coming out from the breast establishment are false and self-serving. Women need to find medical advice independent of Big Mammo, and they need the knowledge and the right to refuse if they wish. There may be instances where diagnostic, not screening, mammography under the guidance of a skilled and intuitive medical expert is helpful.
These bureaucracies and entrenched interests - such as the three breast doctors writing this opinion piece - will never give up this racket voluntarily.
The only hope is to get the message out to the public that this is indeed an ineffectual racket, "something that really is not what it appears to be." Most of the messages coming out from the breast establishment are false and self-serving. Women need to find medical advice independent of Big Mammo, and they need the knowledge and the right to refuse if they wish. There may be instances where diagnostic, not screening, mammography under the guidance of a skilled and intuitive medical expert is helpful.
10
Oh, thank you thank you thank you for this! I'm an ultrasound technologist who every day sees the reality of early detection vs. late, and I've wondered "Who are these people talking to?" when they go on and on about the anxiety caused by call backs and biopsies. And I've wondered about young women, so many with young children, not having access to clinical breast exams and yearly screenings. I've wondered why on earth women as vital and healthy as my mother and my grandmother shouldn't be screened yearly. I just can't understand why such an inexpensive, low-risk, proven screening test can be under attack. Finally, an argument from people who treat PATIENTS, not just analyze statistics. I only hope this gets as much press coverage as the anti-mammogram articles.
3
Yes. Having had cancer detected 60 days ago during a routine mammogram, I'm shocked that there is any debate about the usefulness of the test. My breast cancer was found very early and I opted for a lumpectomy.
It seems that cold statistics are used for recommendations.
Hey, here's a warm body that tells every woman to GET YOUR ANNUAL MAMMOGRAM.
It seems that cold statistics are used for recommendations.
Hey, here's a warm body that tells every woman to GET YOUR ANNUAL MAMMOGRAM.
5
I see no indication in the article of an evaluation of the risks from the high dose of radiation that goes along with mammograms. The risk of cancer from medical X-rays is not negligible, no matter what radiologists may think (I've spent my career doing nuclear and particle physics experiments).
It would be hard to identify a cancer caused by a single mammogram, but I would bet you could a component of risk that was proportional to the number of mammograms a woman undergoes. That's a good reason for reducing screening modestly.
I bet it's higher than from eating bacon.
It would be hard to identify a cancer caused by a single mammogram, but I would bet you could a component of risk that was proportional to the number of mammograms a woman undergoes. That's a good reason for reducing screening modestly.
I bet it's higher than from eating bacon.
5
I am a physician who had breast cancer, treated successfully with a lumpectomy and a few lymph node dissection, followed by chemo and radiation therapy. I agree with you 100%. But as a physician, I would like to point out some incorrect facts. The complications for breast biopsy, colonoscopy and CT scan have to be guaged on the same scale. You cannot compare the worst possible complication during colonoscopy and CT scan to the least possible complication in breast biopsy. That would be disseminating wrong information leading patients to fear necessary procedures.
3
Well as one of those people (at age 40) who has benefited from mammography, I.e. Avoided chemo and only had to do radiation, I say it works. I guess if most people want to spin the roulette wheel for themselves or for their relatives, and call personal experiences with cancer anecdotal, I say go for it. I think this is a move to deny reimbursement for mammograms as a cost cutting measure. Instead there will be the cost for cancer treatment, which is big bucks. Over 20 years ago my radiation treatments were almost 100,000. Can't imagine what full chemo would have been. So get ready to pay for that. These doctors are right.
3
The authors would likely try to explain the results of a study done by Dr Gilbert Welch and Dr Archie Bleyerfrom Dartmouth published in the New England Journal of Medicine. " The effect of 3 decades years of Mammography on breast cancer incidence".
http://www.nejm.org/doi/full/10.1056/NEJMCalledoa1206809
Unfortunately, despite good efforts by good doctors like Dr Drossman Dr Port and Dr Sonnenblick, there has been very very little decrease in late stage breast cancer incidence. Yet early stage breast cancer incidence has greatly increased. Think about that.
Somehow despite this effort , it has barely decreased. If we are catching breast cancers early (and we are the incidence of breast cancer is very high) why is the late stage breast cancer so close to the same level as it was 30 years ago? Likely it because late stage breast cancer is extremely aggressive and is missed by annual mammograms. By the time they are detected by the patient or the mammogram it has already spread.
Furthermore, the authors stating that women with breast cancer have a 90 % survival rate is either misleading or they are ignorant of biases. If you include a lot of DCIS and indolent cancer destined never to leave the breast OF COURSE you can get an impressive survival rate. Label enough people with cancer who are destined to die of something else and the survival rate can always approach 90-95%.
http://www.nejm.org/doi/full/10.1056/NEJMCalledoa1206809
Unfortunately, despite good efforts by good doctors like Dr Drossman Dr Port and Dr Sonnenblick, there has been very very little decrease in late stage breast cancer incidence. Yet early stage breast cancer incidence has greatly increased. Think about that.
Somehow despite this effort , it has barely decreased. If we are catching breast cancers early (and we are the incidence of breast cancer is very high) why is the late stage breast cancer so close to the same level as it was 30 years ago? Likely it because late stage breast cancer is extremely aggressive and is missed by annual mammograms. By the time they are detected by the patient or the mammogram it has already spread.
Furthermore, the authors stating that women with breast cancer have a 90 % survival rate is either misleading or they are ignorant of biases. If you include a lot of DCIS and indolent cancer destined never to leave the breast OF COURSE you can get an impressive survival rate. Label enough people with cancer who are destined to die of something else and the survival rate can always approach 90-95%.
13
Am I the only person who sees this need to spare women the "stress" of dealing with false positives infuriatingly patronizing? Seriously, women are not delicate flowers who need to be shielded from any anxiety that may come from medical testing and are perfectly capable of making their own healthcare choices and decisions. My breast cancer was discovered at age 59 at an annual screening while it was still stage one. In another year, the progression may have required more extreme surgery and treatment. These new guidelines are dangerous, and downright misogynistic. If insurance companies start refusing to cover annual mammagrams because that is no longer the standard, the price will be paid by countless women whose cancers won't be found at an early stage, and can make all the difference.
3
My experience as a physician is that patients of all kinds, male and female, prefer false positives to fall negatives. I agree that it is patronizing and condescending to think that women are too frail to deal with the "stress" of an extra test.
2
The willingness of these authors to shirk their responsibility for doing their due diligence and taking an honest look at the data, and then to exploit and mislead their fellow human beings for the sake of preserving a business which harms many people through false positives, unnecessary anxiety, unnecessary biopsies, unnecessry surgery, excessive radiation, toxic medications, wasted time and resources for the patient as well as their caregivers/family/friends and society is truly disgusting.
9
Please note that all three authors are radiologists (= clear conflict of interest).
6
That is really unfair. I am a radiologist - I work for a salary. My compensation isn't tied to how many exams I read or recommend. I get to do the right thing for patients every day. Not everyone is getting rich in medicine - and breast radiologists are among the worst paid in our specialty - mostly because that subspecialty is dominated by women. No one ever accuses Zeke Emanuel of a COI for speaking about health.
4
I am dismayed over how many more commenters here (by a factor of 5 or even 10) find containing health care costs to be more important than detecting and treating breast cancer at an early stage when treatment is less onerous and risky. So “overall mortality” is not reduced? There’s a profound quality-of-life difference between dying of a heart attack and dying at the same age after years of the pain of late-stage cancer and its treatment. Would you rather die at 80 painlessly in your sleep, or after a dozen years of grueling treatments and pain because of an aggressive breast cancer caught at 68 that could have been found at 67 and treated (with less pain, mutilation, and--yes--expense) before it had a chance to spread?
My invasive 1.3cm cancer was found at 64 by an annual mammogram. It wasn’t there on the mammo a year earlier. Because it was found this year, I had a lumpectomy (not mastectomy), will have short and narrowly-focused radiotherapy (instead of 7 weeks of full-breast irradiation), and only a daily hormone-suppressor pill instead of chemo. I can resume my life with minimal pain and interruption. Had I waited till next year for my screening mammo, how big might the tumor have been, how far would it have spread, how onerous and disruptive the treatment, and how well would it work?
Stop talking about the hypothetical number of lives “saved” or “not saved,” and start considering the preservation of QUALITY of life made possible by early diagnosis and treatment!
My invasive 1.3cm cancer was found at 64 by an annual mammogram. It wasn’t there on the mammo a year earlier. Because it was found this year, I had a lumpectomy (not mastectomy), will have short and narrowly-focused radiotherapy (instead of 7 weeks of full-breast irradiation), and only a daily hormone-suppressor pill instead of chemo. I can resume my life with minimal pain and interruption. Had I waited till next year for my screening mammo, how big might the tumor have been, how far would it have spread, how onerous and disruptive the treatment, and how well would it work?
Stop talking about the hypothetical number of lives “saved” or “not saved,” and start considering the preservation of QUALITY of life made possible by early diagnosis and treatment!
7
Make yourself heard - Stop sending your dollars to the ACS, a 501(c)(3) non-profit. Let the ACS hunt for dollars. Refuse to sustain their existence until they unyoke themselves from their corporate masters, the insurance companies. Until they again focus on helping women by encouraging early detection by any means - improved imaging formats, manual exams at physician's offices, any newer diagnostic methods - withhold your dollars. The ACS is a business - boycott them.
4
I am appalled by the comments made by E.Wong "that mammograms confer no reduction in mortality from breast cancer". Breast cancer is not "one size fits all". A triple negative breast cancer caught at stage 1 can afford a patient early intervention which CAN and DOES reduce mortality. It seems that many "experts" view from the top down, but for those of us who have been diagnosed, we view from the bottom up. Mammograms may not be the end-all of breast cancer diagnostics, but they are the best modality we have at the present time.
To state "We should also note carefully that the authors of this article make money by diagnosing and treating breast cancer, and that they get paid whether their diagnoses and treatments provide actual benefit or not." is a blatant lie. They are respected physicians who are trying to save lives. They are not creating breast cancer patients; they are treating them to the best of their abilities. It is unconscionable to malign these, as well as other physicians who are on the front lines, battling this disease with the hope of finally finding a cure.
"...whoever saves a life, it is considered as if he saved an entire world." — Mishnah Sanhedrin 4:9; Yerushalmi Talmud, Tractate Sanhedrin 37a.
To state "We should also note carefully that the authors of this article make money by diagnosing and treating breast cancer, and that they get paid whether their diagnoses and treatments provide actual benefit or not." is a blatant lie. They are respected physicians who are trying to save lives. They are not creating breast cancer patients; they are treating them to the best of their abilities. It is unconscionable to malign these, as well as other physicians who are on the front lines, battling this disease with the hope of finally finding a cure.
"...whoever saves a life, it is considered as if he saved an entire world." — Mishnah Sanhedrin 4:9; Yerushalmi Talmud, Tractate Sanhedrin 37a.
5
We hear a lot about the downsides of "false positives." What about the downside of too much radiation after years of faithfully getting mammograms? THAT is the unaddressed variable in this new calculation. THAT has the power to do real harm.
6
The authors obviously prefer (their) experience-based medicine over evidence-based medicine.
8
Dr Port I think you are wrong. You, and your belief in mammograms, missed my breast cancer.
When I ended up no longer your patient, and with a new doctor through a series of events not in my control, the new doctor recommended an MRI. (I had above average risk of bc). The MRI, then the ultrasound follow up, confirmed breast cancer.
The mammogram, repeated, still, showed nothing.
I learned from this experience to look deeper than the authority of the white coat, the byline, the hospital name. To educate myself. I learned that mammograms miss many many cancers,20% at least across the board, and the number is higher in younger women (40s). Perhaps this accounts for the ACS recommendation change. It's just not that good a test for younger women. If only I had known. If only you told me those facts, I would have sought out additional screening on my own. Instead, I relied on false security of the false negative.
When I ended up no longer your patient, and with a new doctor through a series of events not in my control, the new doctor recommended an MRI. (I had above average risk of bc). The MRI, then the ultrasound follow up, confirmed breast cancer.
The mammogram, repeated, still, showed nothing.
I learned from this experience to look deeper than the authority of the white coat, the byline, the hospital name. To educate myself. I learned that mammograms miss many many cancers,20% at least across the board, and the number is higher in younger women (40s). Perhaps this accounts for the ACS recommendation change. It's just not that good a test for younger women. If only I had known. If only you told me those facts, I would have sought out additional screening on my own. Instead, I relied on false security of the false negative.
6
Who at the Times decides what pieces are suitable for Op-ed? Controversies in medical/scientific evidence belong in PEER-REVIEWED journals, and do not include or benefit from incendiary, emotional arguments. This type of writing just helps ensure continued consumer demand billing opportunities.
All patients should know:
A PCP’s ever-multiplying, time-consuming minute tasks (eg. computerized box checking, looking up codes, restarting the computer, calling insurance companies), mean that patients have LESS TIME THAN EVER to talk to their doctor about healthy lifestyle counseling, or anything else relevant to that patient’s health.
The reduction in meaningful time with the PCP has never been accounted for when trying to evaluate the impact of mammograms on mortality --- but it should be.
All patients should know:
A PCP’s ever-multiplying, time-consuming minute tasks (eg. computerized box checking, looking up codes, restarting the computer, calling insurance companies), mean that patients have LESS TIME THAN EVER to talk to their doctor about healthy lifestyle counseling, or anything else relevant to that patient’s health.
The reduction in meaningful time with the PCP has never been accounted for when trying to evaluate the impact of mammograms on mortality --- but it should be.
It's not one disease. We can't distinguish aggressive disease from non aggressive based on imaging. What we're "detecting early" is DCIS, which may or may not become invasive in any given individual. And when we find invasive, but indolent lesions, it doesn't matter as much that we caught them small. They *stay* small for a very long time. Sometimes long enough for a woman to die of, say, heart disease - the #1 killer of US women.
9
Funny...these authors are breast radiologists whose earnings go up when more women get mammograms.
6
Listen to the experts here, not the statisticians and economists. As these doctors say -- if necessary, better to go through the trouble of a sonogram- guided fine needle biopsy, with zilch risk, than let DCIS or invasive tumors fester for several years. It would be a service to have the team at MSK contribute to this discussion -- but I would bet they agree.
I'm a medical student and this has been a frequent topic of debate in our small groups. From a public health standpoint, I get why the American Cancer Society relaxed their guidelines on mammograms, but I can't help but think of the individual lives that are saved by earlier screening. I think when I'm a doctor I'll bring up both sides of the argument and let my patients decide.
1
An ounce of prevention is worth a pound of cure!
Yes, absolutely, thank you. And I speak not as a breast cancer survivor -- I have been fortunate -- but as a prize-winning health journalist (retired) who has written dozens of articles about breast cancer and interviewed many, many women who are breast cancer survivors, and many many breast surgeons and oncologists.
"Mammograms are the only technology ..." -- But mammograms DON'T reduce the risk of dying. That's the point! Maybe they improve the 5-year survival rate, but only because of earlier detection. There's pretty solid evidence on this from places (whole countries) where they implemented screening at a certain age in a certain year, and could then follow the mortality rates in that group compared to the age cohort just ahead of them. If it's true that early detection reduces death rate, that curve on the graph should go down. But it doesn't. And that's no even looking at deaths caused by leukemia from chemo or heart damage from repeated radiation in the area.
26
Rate of death has dropped 35% since screening started in this country.
Swedish 2 county trial exactly contradicts what you suggest, and it is the gold standard of a randomized control trial. Many other trials confirm benefit.
Recently article in BMJ accounts for modern treatment and finds significant benefit.
If you don't know what you are talking about, perhaps you should remain silent.
Swedish 2 county trial exactly contradicts what you suggest, and it is the gold standard of a randomized control trial. Many other trials confirm benefit.
Recently article in BMJ accounts for modern treatment and finds significant benefit.
If you don't know what you are talking about, perhaps you should remain silent.
1
Leave it to two radiologists and a breast surgeon -- who directly benefit economically from increased screening, biopsies, surgeries, and radiation treatment — to decry the new guidelines which are based on actual data, not anecdote. An “overall survival rate of 90%" only means that cancer is generally a slow growing disease; of course, the earlier it’s detected, the longer the survival period after diagnosis. What matters is death rate from breast cancer — and this has barely budged in decades, despite increasing screening. They dismissively write "breast biopsies can be temporarily painful;” my biopsy was much more painful than subsequent surgery. I resent the implication that the inclusion of economists and health experts on the panel resulted “in bias the other way — in favor of cutting costs over saving lives.” They don’t think that their financial interests ever cloud their judgment — resulting in the harms of unnecessary mutilation and pain? Maybe the reason that radiologists, surgeons, and oncologists were omitted from the panel is that they don’t understand science — because that’s not mentioned once in this opinion piece. The guidelines were based on data; if you have data which supports another position, present it, and explain how it supports that position. But don’t flagellate women with fear caused by false and misleading statements, which is what this piece does. It is biased, self-serving, and pure drivel.
23
Doctor - please check your facts, DATA and THE SCIENCE The death rate from breast cancer was unchanged going back to at least 1940. Screening mammography began in the U.S. in the mid 1980's and soon after, the death rate (contrary to your comment) began to fall. As more and more women have participated in screening the death rate has continued to fall. Each year there are now 35% fewer women dying from breast cancer than would have had screening not been instituted. Therapy has improved, but therapy saves the most lives when cancers are treated earlier.
Although not proof, the death rate from breast cancer for men went up in 1990, despite access to new therapies. It came back down to 1990 levels and has remained there, while the death rate has continued to decline for women - men are not screened.
You are correct in suggesting that improved "survival" does not prove lives are being saved. This is the reason for randomized, controlled trials which do not rely on survival, and these have clearly shown mortality reduction for women who participate in screening starting at the age of 40.
Although not proof, the death rate from breast cancer for men went up in 1990, despite access to new therapies. It came back down to 1990 levels and has remained there, while the death rate has continued to decline for women - men are not screened.
You are correct in suggesting that improved "survival" does not prove lives are being saved. This is the reason for randomized, controlled trials which do not rely on survival, and these have clearly shown mortality reduction for women who participate in screening starting at the age of 40.
1
35% drop in mortality. I guess this is insignificant?
If you are ignorant please stop misinforming.
If you are ignorant please stop misinforming.
A routine mammogram found my Stage One breast cancer. Lumpectomy and radiation was all I needed. So happy to have been diagnosed early so that I was able to forego chemo.
14
The most egregious omission in this op-ed is a discussion of the cumulative effect of yearly radiation exposure to breast tissue. In the past few years, studies have indicated that about 2% of all cancers diagnosed in Americans are a result of excess exposure to radiation - as in too many CT scans, x-rays and mammograms over the course of a lifetime. We know that radiation of all kinds induces mutations and potentially carcinogenic changes in human cells. The authors are seriously remiss in not considering that repeated mammograms, over a lifetime, can raise the risk of getting breast cancer in some individuals.
11
We are all concerned about unnecessary radiation exposure, and radiologists have led the effort to reduce doses used for mammography going back to the 1980's. The good news is that, although the breast of very young (teenage) women is at risk from radiation, the risk drops dramatically with increasing age so that by the age of 40, when we urge screening to begin, there is no measurable risk to the breast from even large amounts of radiation, and even the theoretical, extrapolated risk is very low if not nonexistent. The benefit of lives saved by screening far outweighs even the estimated risk for women ages 40 and over which is why none of the medical groups now consider this a major issue.
You need to study the Linear No Threshold model and learn something about the assumptions made.
Then you need to read about hormesis.
You are discussing things you clearly don't understand.
Then you need to read about hormesis.
You are discussing things you clearly don't understand.
Galia
I, a breast cancer survivor, strongly agree with Doctors Port, Drossman and Sonnenblick editorial. My cancer had no symptoms and if it was not for the annual visit to the doctor and the annual recommendation to have a mammogram that then lead to a diagnosis, I may not be here today. I hope the American Cancer Society reverts its recommendation.
I, a breast cancer survivor, strongly agree with Doctors Port, Drossman and Sonnenblick editorial. My cancer had no symptoms and if it was not for the annual visit to the doctor and the annual recommendation to have a mammogram that then lead to a diagnosis, I may not be here today. I hope the American Cancer Society reverts its recommendation.
2
What relevance do the painful stories of younger women dying of breast cancer have to the older woman in good health now? If you are post-menopausal, the terrifying stories of cancers spreading like wildfire in women several decades younger are not a foreshadowing of what might happen to you, if you skip those mammograms.
My mother died at 87, after nearly four decades of interventions by the cancer industry: aspirated cysts in her forties; a simple mastectomy with no chemo or radiation advised, in her early sixties; and then twenty years of six-monthly mammograms; aspirations, biopsies and excisions; and then the "preventative drugs" whose side effects did kill her. Until the final few months of her life, marked by unspeakable suffering because of medical mistakes, my mother was vigorous and independent. In fact, she was in better shape at 86 than she'd been at 65, disabled by heart disease. Helping to care for a newborn grandchild got her back into the world of the purposeful and active and added two healthy decades to her life. Note: genetics are not destiny; her maternal aunt died at 42, her mother at 66 and her father at 56, all of heart disease.
I am 65 and have never had a mammogram. I am healthier than my mother ever was. If something is slowly growing in my breasts, I do not wish to know because I do not intend to be carved up by high-tech butchers. And with my dad still ticking at 94, I figure the odds are acceptable.
My mother died at 87, after nearly four decades of interventions by the cancer industry: aspirated cysts in her forties; a simple mastectomy with no chemo or radiation advised, in her early sixties; and then twenty years of six-monthly mammograms; aspirations, biopsies and excisions; and then the "preventative drugs" whose side effects did kill her. Until the final few months of her life, marked by unspeakable suffering because of medical mistakes, my mother was vigorous and independent. In fact, she was in better shape at 86 than she'd been at 65, disabled by heart disease. Helping to care for a newborn grandchild got her back into the world of the purposeful and active and added two healthy decades to her life. Note: genetics are not destiny; her maternal aunt died at 42, her mother at 66 and her father at 56, all of heart disease.
I am 65 and have never had a mammogram. I am healthier than my mother ever was. If something is slowly growing in my breasts, I do not wish to know because I do not intend to be carved up by high-tech butchers. And with my dad still ticking at 94, I figure the odds are acceptable.
13
Thank you NYTs and authors of this column. That E. Wong and others put forth blatantly spurious claims like "mammograms confer no reduction in mortality from breast cancer" are baldly ludicrous and that they would do so is very troubling.
Why can't they simply state that in their opinion it is ok if a percentage of women die if it saves the system money?
Why can't they simply state that in their opinion it is ok if a percentage of women die if it saves the system money?
1
"spurious claims like 'mammograms confer no reduction in mortality from breast cancer'"
Can you cite some published, peer-reviewed studies to support that annual mammography *does* in fact reduce mortality? Can you cite studies to support that "women will die" under these new guidelines?
If not, what grounds do you have for your statements?
Can you cite some published, peer-reviewed studies to support that annual mammography *does* in fact reduce mortality? Can you cite studies to support that "women will die" under these new guidelines?
If not, what grounds do you have for your statements?
1
Let's let the science govern. As with vaccines, e-cigarettes, nutrition guidelines and other hot button health issues, let's not be swayed by anecdotes, emotions and egos. Our personal stories are irrelevant. What happened to our sister's best friend's niece is of little importance. What we "feel" does not matter. This is the 21st century. We have scientific studies - rigorous studies - that tell us what is right and what is wrong. Let's let them be our guide.
11
I am a board-certified radiologist, currently practicing in California. One of the problems with mammography which is not properly addressed in the article is the high number of patients that we need to screen in order to save one life. Many cancers crop up between mammograms, are extremely aggressive, and are already widespread once discovered. You would have to increase the screening frequency to reliably catch these (mammograms every other week anyone?) Many other cancers grow slowly, and even though we find them and treat the patients, perhaps these cancers could have been left alone.
Given the (at best) ambiguous data, the only reason we are even having this conversation is because the concept of screening mammograms is so ingrained in our country's medical culture. If routine screening mammography didn't currently exist, and someone looked at the available evidence and then suggested that we start screening women with yearly mammograms (especially women in their 40s), that person would be laughed out of the room.
Breast cancer is too common and it kills too many women, but the sad reality is that we need a better screening test. To that end, it will be interesting to see how digital breast tomosynthesis pans out. This technology is becoming more commonplace and can detect tumors earlier than mammography while potentially limiting false positives.
Given the (at best) ambiguous data, the only reason we are even having this conversation is because the concept of screening mammograms is so ingrained in our country's medical culture. If routine screening mammography didn't currently exist, and someone looked at the available evidence and then suggested that we start screening women with yearly mammograms (especially women in their 40s), that person would be laughed out of the room.
Breast cancer is too common and it kills too many women, but the sad reality is that we need a better screening test. To that end, it will be interesting to see how digital breast tomosynthesis pans out. This technology is becoming more commonplace and can detect tumors earlier than mammography while potentially limiting false positives.
20
Swedish 2 county trial amongst others. Ambiguous?
You may be a radiologist, but you are clearly not a breast imager; you have no idea what you are talking about.
You may be a radiologist, but you are clearly not a breast imager; you have no idea what you are talking about.
It's doctors like these that have scared women into having their breasts cut off for a cancer that was unlikely to kill them. And these doctors better than any should know the survivor rates are rigged because of the over-testing we do in this country. They accuse the panel of balancing economics of health care against women's safety, yet it's their revenue stream at risk, so they have that stake in the game, too. And yes, I'm a female, whose had about 5 mammograms in 30 years. You want to save women's lives? Talk to them about heart disease. It kills way more women than breast cancer.
19
It seems the authors have almost zero understanding of epidemiology and public health 101, big data analysis, risk-benefit and cost-benefit analysis.
19
They must have some understanding of it - after all, they're not advocating for monthly screenings that would catch extremely aggressive tumors that emerge between annual mammograms, or mammograms for women in their 30s, who do occasionally get breast cancer.
Everyone does risk-benefit and cost-benefit analyses -- but a lot of people do it subconsciously, and vigorously oppose looking at risk/benefit tradeoffs directly so that they can pretend that they don't do it.
Everyone does risk-benefit and cost-benefit analyses -- but a lot of people do it subconsciously, and vigorously oppose looking at risk/benefit tradeoffs directly so that they can pretend that they don't do it.
1
Why don't you simply say that a few thousand women can die, if it saves the system a few million dollars. There, no need to showoff technojargon.
1
In non technojargon, tell me how many years for women's lives will be saved by doing earlier mammograms? What would be side-effects for doing earlier mammograms? and finally, no one can stop you from paying out of pocket for a screening that public health experts dont recommend. Dont put the cost on your insurance provider and you can go through screening for pancreatic, gastric, ovarian, cervical, lung, brain, rectal, bone, you-name-it-organ from age 25 at a frequency of whatever-you-fancy.
2
There are other ways of detecting breast cancer so I am told my doctors. Why are we using something that after 40 years could be dangerous for the patient. I know, MONEY. So what is the point of developing better ways to detect cancer not use it regardless of the cost. Are we truly back to the days of many laters of treatments with the rich getting the best and the middle class a big less and the poor - crumbs left for people our medical system doesn't think it is worth it?
1
One reason why the confusion about the benefit, or lack thereof, of early breast cancer detection is poor understanding of “lead time bias”. The concept of lead time is not hard to understand, but in my experience even doctors (authors of this blog article included?) sometimes forgot the influence of lead time when comparing the effects of two different treatment modalities. Early detection of cancer sometimes prolong "perceived" survival time, but it may or may not improve mortality, depending on the type cancer involved. Unfortunately in the case of breast cancer, early detection does not seem to improve mortality.
21
You need to read more carefully. Lead time bias is eliminated by randomized, controlled trials that have shown a 20-30% mortality reduction for screening women ages 40 and over.
By publishing such letters by physicians who have a financial interest in maximizing the performance of mammograms, you do a disservice to your readers and contribute to the decline in critical reasoning skills of your reading population.
Such letters represent what is called "special pleading" and simply have no place in scientific studies. If physicians like this disagree with the results of multicenter large scale studies, let them do their own studies to refute and not simply give their own biased, obviously self-serving opinions.
Such letters represent what is called "special pleading" and simply have no place in scientific studies. If physicians like this disagree with the results of multicenter large scale studies, let them do their own studies to refute and not simply give their own biased, obviously self-serving opinions.
16
By including economists on panels making health policy, bias is already there, especially when we have sworn liars like MIT based Dr. Gruber in charge of health policy. The panels should have participants from all sides. These doctors have as much right to put forward their opinions as public health experts and economists.
1
Agreed, recommended reading, "Less Medicine, More Health" by H Gilbert Welch MD
2
Thank you for speaking out for us, Doctors Drossman, Port, and Sonnenblick. I trust you more than the ACS, influenced by God knows who or what and another platform of statistical belief and abandoning the individual. What a foul way to attempt to reduce medical costs through reduced mammograms and physical breast office exams. I plan as an elder woman to keep asking my doctor for these early detection measures. We women have to stand up and continue to insist on proper medical care.
3
"Proper medical care" is based on evidence, not anecdotes from a small handful of providers.
2
Tell me about it. My annual mammogram found my first breast cancer (in my 40's), when it had already spread to my lymph nodes. My annual mammogram found my second breast cancer (age of 59), when it also had already spread to my lymph nodes. The only "risk factor" I had was never having been pregnant. No convincing me (age of 69)!
14
With all due respect to these three doctors, an article written by two radiologists and a breast surgeon that disputes the American Cancer Society’s recent mammogram recommendations is akin to the producers of beef and pork telling us not to pay attention to the recent warning about eating their products.
18
The women should emphasize that the two radiologists directly benefit from overscreening that results from the previous policy and that the new policy will impact their profits. They should feel shame to even suggest that it was not having mammograms that leads to deaths. It's a lack of treatments for metastasis that leads to death (and the improved survival has been the result of drugs such as tamoxifen, herceptin, and the aromatase inhibitors). They also should know better to use the "90% survival". That's a 5 year number. I was diagnosed "early" at Stage II at 37...I made it the five years, but later the cancer metastasized to my lung and now probably won't make it to 55. Yet I would be measured in the 90% figure. I support the new ACS guidelines. let's get money directed to a cure.
20
Thank you for your pragmatic response. All best to you.
At least two of these individuals have a bias as their business is breast mammography. Therefore it's hard to know how seriously to take their views.
10
A good cancer screening test will identify early lesions that have a high probability of progressing and killing the patient. After instituting the test on a wide scale, studies will show an increase in the diagnosis of early lesions and a decrease in larger tumors. Early lesions are cured more easily, so the death rate from the cancer will decrease.
The Pap test is the best example of this. Women who follow cervical cancer screening guidelines are unlikely to die from cervical cancer. We have a very good biological understanding of which Pap results will progress to cancer and, just as importantly, which have a high probability of resolving on their own. The test improves survival without increasing morbidity.
Mammography is not like the Pap test. Mammography has increased the incidence of breast cancer but has not been shown to decrease breast cancer mortality. Increased detection of small lumps almost entirely accounts for this increase. Incidence of large tumors has not decreased. Mammography identifies small lumps and lesions that will not kill the patient. Nonetheless, these lumps are removed by disfiguring procedures and treated with harmful chemotherapy.
We do not understand the biology of small breast lesions identified by mammography well enough to determine which will progress and require intervention and which will not. Until we understand the biology of early breast lesions, mammography will continue to cause morbidity without reducing mortality.
The Pap test is the best example of this. Women who follow cervical cancer screening guidelines are unlikely to die from cervical cancer. We have a very good biological understanding of which Pap results will progress to cancer and, just as importantly, which have a high probability of resolving on their own. The test improves survival without increasing morbidity.
Mammography is not like the Pap test. Mammography has increased the incidence of breast cancer but has not been shown to decrease breast cancer mortality. Increased detection of small lumps almost entirely accounts for this increase. Incidence of large tumors has not decreased. Mammography identifies small lumps and lesions that will not kill the patient. Nonetheless, these lumps are removed by disfiguring procedures and treated with harmful chemotherapy.
We do not understand the biology of small breast lesions identified by mammography well enough to determine which will progress and require intervention and which will not. Until we understand the biology of early breast lesions, mammography will continue to cause morbidity without reducing mortality.
20
"In our collective experience of 60 years" This rationale is goes by many names; I like to call it "old fart evidence". Two classmates from my medical school can easily exceed that number; plus, we have no financial incentive to perform breast imaging.
The unbiased data are consistent that yearly screening of the general, not-at-risk population before age 50 confers no benefit to mortality rates and does confer risks. This op-ed demands an evidence-based response.
Janet Groff, MD, MSPH, PhD
Preventive Medicine/Public Health
The unbiased data are consistent that yearly screening of the general, not-at-risk population before age 50 confers no benefit to mortality rates and does confer risks. This op-ed demands an evidence-based response.
Janet Groff, MD, MSPH, PhD
Preventive Medicine/Public Health
28
I am a physician and, more important to this discussion, a PhD-trained scientist.
Setting aside the relevant data for a moment, it is on its face profoundly irresponsible for 3 clinicians to attempt to discredit (in a non-peer reviewed setting) what amounts to the life's work of literally thousands of epidemiologists, statisticians, and cancer biologists. If one reads carefully, the crux of this editorial's argument are scare-story anecdotes. Who cares if the authors encountered a few grateful patients in the week following the guidelines' announcement? Are we all to disregard 2 decades' worth of population-level studies based on this? Similarly, the statement "the anxiety caused by being called back for further imaging or a biopsy is modest compared with the stress of treatment for a late-stage breast cancer that might have been detected earlier" is nonsensical - of course it seems that way to a breast surgeon, whose patients are by definition enriched for having the disease in question. Furthermore, is the suffering of, say, tens of thousands of false-positive women really just a "modest" stress in aggregate?
The ACS, the USPSTF, and various other bodies that have weighed in on this topic exist specifically to use science to reduce mortality from cancer. It's working. Let them do their job without lay-press invectives from non-scientist clinicians who both lack the requisite skills to analyze large datasets and stand to gain from their own unsophisticated approach.
Setting aside the relevant data for a moment, it is on its face profoundly irresponsible for 3 clinicians to attempt to discredit (in a non-peer reviewed setting) what amounts to the life's work of literally thousands of epidemiologists, statisticians, and cancer biologists. If one reads carefully, the crux of this editorial's argument are scare-story anecdotes. Who cares if the authors encountered a few grateful patients in the week following the guidelines' announcement? Are we all to disregard 2 decades' worth of population-level studies based on this? Similarly, the statement "the anxiety caused by being called back for further imaging or a biopsy is modest compared with the stress of treatment for a late-stage breast cancer that might have been detected earlier" is nonsensical - of course it seems that way to a breast surgeon, whose patients are by definition enriched for having the disease in question. Furthermore, is the suffering of, say, tens of thousands of false-positive women really just a "modest" stress in aggregate?
The ACS, the USPSTF, and various other bodies that have weighed in on this topic exist specifically to use science to reduce mortality from cancer. It's working. Let them do their job without lay-press invectives from non-scientist clinicians who both lack the requisite skills to analyze large datasets and stand to gain from their own unsophisticated approach.
42
The physician and, more important to this discussion, PhD-trained scientist in me loved your comment! beautifully explained :)
1
This editorial helps one understand why health care costs in the USA are twice that of other wealthy countries, while outcomes are no different. I am a retired hematologist who attended joint meetings with oncologists once a week for many years. The question of the age of screening with mammograms has been ongoing for decades, and I have personally felt that the data for screening before age 50 were unconvincing in patients without a family history of breast cancer. I still believe this despite my own diagnosis of breast cancer at age 45 when I felt a mass that was highly suspicious for breast cancer on mammogram (and was indeed breast cancer), and despite the fact that I had a recurrence of this breast cancer 12 years after my initial diagnosis (roughly a year ago, which explains why I am home blogging on the NYT website and not working!!). The data are just not there that starting mammograms before age 50 saves lives in women without a strong family history of breast cancer as compared with starting mammograms at age 50, and I have looked at this carefully. The UK gives mammograms once every 3 years starting at age 50. Our health care system needs to learn how to prioritize our health care dollars for tests and treatments that are clearly beneficial.
82
The lump in your breast was detected when you were 45 years old. If you had begun annual screening when you were 40 the cancer might have been detected well before it became palpable and it may have been treated early enough to completely cure you instead of having a recurrence.
1
To the person who wondered whether catching cancer early increased her chances of survival, I think the studies are saying, No. The rates of survival are the same whether you have a mammogram or find a lump. Treatment saves lives, not the mammograms. From Prevention magazine: "Catching breast cancer early with a mammogram may make no difference in a woman's prognosis or treatment, compared with catching it when she notices a lump." (Why Getting A Mammogram May Cause More Trouble Than It's Worth)
I'm opting out. My percentage chance of getting breast cancer in the next 10 years is exactly the same as dying in a land vehicle accident. About 1.2%
I'm opting out. My percentage chance of getting breast cancer in the next 10 years is exactly the same as dying in a land vehicle accident. About 1.2%
13
Good luck to you, betterangels. If I had had that attitude in 1999, I would most likely be dead by now. I didn't find my lump, my mammogram did! If I had had to wait another year, I might not be alive today. Or I would have had to have extensive chemotherapy. I thought my chances of breast cancer were small, too. No one on my maternal side of the family had ever had breast cancer. I was lucky to be diagnosed early.
2
I'm a radiation oncologist, who also lost a mother to breast cancer when she was 33. I have dedicated my professional life to this, my #1 enemy.
Breast cancer is not 1 disease. And I'm not talking about DCIS, here. There are indolent phenotypes which will safely be picked up with biannual screening without harm. There are highly aggressive tumors, which can spread even at early stages, in which detection with mammography may not have helped anyway. Then there is intermediate risk, which is not a small minority, which can be effectively detected with screening, and effectively treated before they become lethal. This is the subgroup that most benefits from screening.
Some 50,000 invasive breast cancers are diagnosed in women before the age of 50 in the US. Pre-menopausal women are more likely to have non-indolent cancers, and have many decades of life left to live, and this group, in particular, is the group that most benefits from early detection.
It's hard to tease out the effect of screening mammography on overall survival of a population, because of competing risks of death. In women who have breast cancer, early stage disease is more curable. Not necessarily because it was caught with greater "lead time", but because the disease has not had a chance to metastasize yet.
Nothing would make me happier than to never treat another breast cancer patient again, especially not another locally advanced cancer.
Breast cancer is not 1 disease. And I'm not talking about DCIS, here. There are indolent phenotypes which will safely be picked up with biannual screening without harm. There are highly aggressive tumors, which can spread even at early stages, in which detection with mammography may not have helped anyway. Then there is intermediate risk, which is not a small minority, which can be effectively detected with screening, and effectively treated before they become lethal. This is the subgroup that most benefits from screening.
Some 50,000 invasive breast cancers are diagnosed in women before the age of 50 in the US. Pre-menopausal women are more likely to have non-indolent cancers, and have many decades of life left to live, and this group, in particular, is the group that most benefits from early detection.
It's hard to tease out the effect of screening mammography on overall survival of a population, because of competing risks of death. In women who have breast cancer, early stage disease is more curable. Not necessarily because it was caught with greater "lead time", but because the disease has not had a chance to metastasize yet.
Nothing would make me happier than to never treat another breast cancer patient again, especially not another locally advanced cancer.
34
To quote one of your "Times Picks:"
"Massive studies (90,000 women over 25 years) have examined the morality benefits of mammography, and have found that mammograms confer no reduction in mortality from breast cancer or any other cause."
Against that we have three "Mothers of the Year" who disagree with the very people who gave them the awards they received.
I have spent 2015 dealing with prostate cancer and all the attending recommendations associated with a stage 2 diagnosis. My take away: follow your doctor's recommendations with extreme caution. I have no real way of knowing if I am "cured" even if I am "clear." The fact of the matter is surgeons operate and radiologists radiate. That will be their recommendation. The mammogram and the biopsy that might follow are not always, maybe not even usually, definitive. What is needed is the genomics to decipher what the likely outcome of your cancer is in your body. That is coming but it isn't all the way here. Until then, suffer the diagnosis and the attending uncertainty. However I would tend to trust the epidemiology over the physicians.
"Massive studies (90,000 women over 25 years) have examined the morality benefits of mammography, and have found that mammograms confer no reduction in mortality from breast cancer or any other cause."
Against that we have three "Mothers of the Year" who disagree with the very people who gave them the awards they received.
I have spent 2015 dealing with prostate cancer and all the attending recommendations associated with a stage 2 diagnosis. My take away: follow your doctor's recommendations with extreme caution. I have no real way of knowing if I am "cured" even if I am "clear." The fact of the matter is surgeons operate and radiologists radiate. That will be their recommendation. The mammogram and the biopsy that might follow are not always, maybe not even usually, definitive. What is needed is the genomics to decipher what the likely outcome of your cancer is in your body. That is coming but it isn't all the way here. Until then, suffer the diagnosis and the attending uncertainty. However I would tend to trust the epidemiology over the physicians.
12
Have people forgotten the big DCIS front-page article in the NYT just a few weeks ago? That showed that some of these "cancers" may not need treatment at all, similar to the prostrate cancer brouhaha a few years ago.
13
The DCIS article was even worse than this article.
Early in the article, the authors tout their "Mother of the Year" creds. What this has to do with their capabilities as doctors capable of objectively evaluating the evidence isn't entirely clear. Nor does their apparent sincerity and heartfelt devotion toward helping breast cancer patients imply that less emotionally attached scientists and researchers are any less qualified than they are. Indeed, many highly respected and qualified scientists share a view that differs markedly from the authors', otherwise these mammography guidelines wouldn't have been changed.
The authors conclude their article with, "Our goals remain clear: to detect breast cancer as early as possible and reduce the risk of dying from this disease." Of course, the very questions are whether more frequent screening, or screening from a younger age does, in fact, lead to earlier detection of breast cancer, and whether that early detection succeeds in reducing mortality or extending expected survival. And any of those benefits have to be weighed against the various risks associated with earlier and more frequent screening, which are numerous and, in my view, downplayed by the authors.
Dr. David Gorski, a highly respected breast cancer surgeon and researcher, has written extensively on this subject on ScienceBasedMedicine. I would encourage anyone with an interest in a more detailed discussion of the issues and evidence, without the irrelevant appeal to emotion, to read Dr. Gorski's articles.
The authors conclude their article with, "Our goals remain clear: to detect breast cancer as early as possible and reduce the risk of dying from this disease." Of course, the very questions are whether more frequent screening, or screening from a younger age does, in fact, lead to earlier detection of breast cancer, and whether that early detection succeeds in reducing mortality or extending expected survival. And any of those benefits have to be weighed against the various risks associated with earlier and more frequent screening, which are numerous and, in my view, downplayed by the authors.
Dr. David Gorski, a highly respected breast cancer surgeon and researcher, has written extensively on this subject on ScienceBasedMedicine. I would encourage anyone with an interest in a more detailed discussion of the issues and evidence, without the irrelevant appeal to emotion, to read Dr. Gorski's articles.
15
I believe all person or institutions standing to be financially affected by any guideline evaluation should be excluded from the conversation.
10
"Mammography in all age groups, starting at 40 years old, is the only test that has been proven to do exactly this: reduce the risk of dying from breast cancer, by up to 30 percent."
Please could you cite the study where these numbers come from and why it would be more reliable than the study that the American Cancer Society recommendation is based on? Otherwise is just emotional taking.
Please could you cite the study where these numbers come from and why it would be more reliable than the study that the American Cancer Society recommendation is based on? Otherwise is just emotional taking.
17
The American Cancer Society did not conduct a study. They enlisted a panel to analyze 800 previously published studies. These so-called meta-analyses are notoriously fraught with problems. As the authors pointed out, there were no breast cancer specialists included in those conducting the M-A, although an economist was on the panel. This information was available in the article, if you read it.
2
I completely agree with the authors of this article. I am 100% convinced that this "study" and the resultant guidelines were influenced by the greedy insurance companies that do not want to pay for women's mammograms. Yet another attack on women's health.......how many of the people who wrote these "guidelines" are women?????
I have lost 8 friends from breast cancer. 7 of them were under 45. 7 of them had their tumors discovered from mammography and ultrasounds. My other friend was over the age of 55, and if she had waited 2 years for her mammogram, she probably would have died even sooner.
These "guidelines" are a joke. and I'm sure they were funded by insurance companies in some form or another, whether directly or indirectly (and hidden).
I have lost 8 friends from breast cancer. 7 of them were under 45. 7 of them had their tumors discovered from mammography and ultrasounds. My other friend was over the age of 55, and if she had waited 2 years for her mammogram, she probably would have died even sooner.
These "guidelines" are a joke. and I'm sure they were funded by insurance companies in some form or another, whether directly or indirectly (and hidden).
3
Your friends had mammograms, and they died of the diesase anyway. In what universe does this make mammograms lifesaving?
3
It has been said, Mammograms are full of radiation leading to breast cancer. There are other ways to diagnose without harming women such as using thermal infrared imaging. Do your own research and decide .Protect yourself
5
Mammograms deliver radiation and actually can contribute to cancer and other problems. For people with no history, no other cancers, it's just not necessary. And of the people I know who have had mammograms who got breast cancer, none of their cancers were detected on a mammogram- they or their partner felt a lump. I'm not going to subject myself to 20+ years of random radiation for the opportunity to worry and possibly receive disfiguring treatment for a condition that may not exist or may go away on its own. Americans really are obsessed with endless tests. Just because everyone is doing it doesn't make it right. And women like me are right to question and challenge these "preventative" measures.
17
Despite the obvious conflicts of interest here, these physicians are absolutely correct. Even a cursory look at the data for mammograms shows that they detect cancers and save lives for women over 40. There are virtually no serious long term harms from breast biopsies, and certainly no harm even close to leaving a breast cancer undetected for 5 years. Increasing the screening intervals for older patients will also leave cancers undetected for longer periods of time. Both of these policies will result in an increase in deaths from breast cancer.
The main harm that seems avoided in this policy of that of spending too much money. Cutting down on mammograms and unnecessary biopsies will save money. Insurance companies will benefit, overall health costs will decrease somewhat, and cancer deaths will go up. This is yet another example of the greatly decried "death panel." A panel of people who decide how much money can be saved by withholding potentially life saving treatment. Why else would there be an Economist on the panel in the first place?
One thing you can be sure of: insurance companies will very shortly stop paying for these "unnecessary" tests. Poorer patients will stop getting them, and they will start getting breast cancer at marginally higher rates. Rich people will pay for the tests themselves, get their cancers detected earlier and live longer. I thought this was precisely the sort of inequity that Obamacare was supposed to prevent? What did I know?
The main harm that seems avoided in this policy of that of spending too much money. Cutting down on mammograms and unnecessary biopsies will save money. Insurance companies will benefit, overall health costs will decrease somewhat, and cancer deaths will go up. This is yet another example of the greatly decried "death panel." A panel of people who decide how much money can be saved by withholding potentially life saving treatment. Why else would there be an Economist on the panel in the first place?
One thing you can be sure of: insurance companies will very shortly stop paying for these "unnecessary" tests. Poorer patients will stop getting them, and they will start getting breast cancer at marginally higher rates. Rich people will pay for the tests themselves, get their cancers detected earlier and live longer. I thought this was precisely the sort of inequity that Obamacare was supposed to prevent? What did I know?
5
You are missing the bigger picture here and, in the interim, assuming early detection translates into clinically significant, meaningful decreases in mortality and morbidity. The research doesn't support mammograms for those at age 40 in order to decrease mortality, even if selected anecdotal evidence says otherwise. As radiologists and surgeons, you are in the business of tertiary prevention/care. Those of us in public health are in the business of primary and secondary prevention. So while you may know a guy who knows a guy in which an early mammogram saved someone's life, clinical practice recommendations should be based on science and data, not subjective clinical experience.
14
What arrogant pitter patter. The business of primary and secondary prevention? Selected anecdotal evidence was an actual human being, probably (how's that for science and data) a woman, whose malignancy was detected at an early stage because of your so-called tertiary prevention/care efforts.
Those of you in public health use statistics - we all know who uses statistics - to tell whatever story your bosses want you to tell.
Those of you in public health use statistics - we all know who uses statistics - to tell whatever story your bosses want you to tell.
2
One of my best friends was diagnosed with breast cancer in her early 40's. She had a lumpectomy and chemo. She was told she was cancer free but she was not. She died two years later. She was survived by her husband and four children including her then nine year old daughter who served as one of her pallbearers.
Early detection is the key. This age grouping is all wrong. Routine breast exams should be done at each visit to the primary care physician. Mammograms should be done each year. They should not be cut back. Women of all ages need to unite on this. Kudos to the three doctors for writing this.
Early detection is the key. This age grouping is all wrong. Routine breast exams should be done at each visit to the primary care physician. Mammograms should be done each year. They should not be cut back. Women of all ages need to unite on this. Kudos to the three doctors for writing this.
25
Your view is informed by an emotional anecdote, not science and evidence.
2
surfer, as someone who has also lost friends and relatives in similar circumstances, all I can say is, if only early detection were the key, then we would be so much further along than we are. But it is not. Just by way of example: two friends were diagnosed with breast cancer via mammography while still young (before the age of 40). After surgery and chemo and a triumphant pronouncement that the cancer had been removed, they both suffered recurrence in three years later, and there was no magic -- they died before the age of 44. My sister in law had the same thing happen, though she was over 50 at the time of her primary diagnosis. It's unlikely that even earlier detection would have helped any of them. The difference in tumor characteristics that make some breast cancers more lethal than others is largely unknown. Mammography does not help doctors either identify or enhance the treatment of those cancers that are especially deadly. For this reason alone, the mortality rate associated with breast cancer that is not DCIS continues to be stubbornly resistant to amelioration.
2
To assert that "public health experts" are generally in "favor of cutting costs over saving lives" is not only incorrect but seems slanderous. About a quarter of breast cancer can be attributed to unhealthy diet, physical inactivity, alcohol and tobacco use. These risk factors are potentially modifiable by public health interventions, which have their own costs too. If we could address these, the main costs that would be cut would be breast surgeon and breast radiologist salaries.
3
If a quarter of breast cancer outcomes could be modified by public health interventions, then what is the problem? It seems to me public health isn't very effective. What a waste of money.
1
Sing it, sisters! This breast cancer survivor (diagnosed at age 41) agrees -- it's a no brainer.
4
Why is there no simple, inexpensive blood test for breast cancer, or cancer of any type by this time in the history of research on this disease? Clearly, cancer cells have a chemistry which is now well known. I listened to a TED talk about one such test under development. If we can fast track a vaccine for Ebola, we surely can invest the research funds in such a basic test.
4
"A 2014 study that followed more than 7,000 Massachusetts breast cancer patients demonstrated that, sadly, of all the women who died of breast cancer, 65 percent had never had a mammogram and 6 percent hadn’t had one in the preceding two years."
This information is not meaningful at all without the comparable numbers for the women who were diagnosed but didn't die during the time period of the study. And even with those numbers, you still could have a situation where someone who engages in more health-promoting behaviors (healthful diet, exercise, adequate sleep, accesses medical care when needed) is more likely to go for regular screens and is also more likely to survive a fight with breast cancer, unrelated to the fact of having been screened.
This information is not meaningful at all without the comparable numbers for the women who were diagnosed but didn't die during the time period of the study. And even with those numbers, you still could have a situation where someone who engages in more health-promoting behaviors (healthful diet, exercise, adequate sleep, accesses medical care when needed) is more likely to go for regular screens and is also more likely to survive a fight with breast cancer, unrelated to the fact of having been screened.
12
My first mammogram last year at age 40 raised concern that led to a second round of imaging and a breast biopsy. I have dense breasts, and they had no baseline. It was scary and painful, but my grandmother died of breast cancer at 44. I was very willing to go through what I did - and would do it again. The team who handled it was wonderful. I will continue to get a mammogram every year.
1
If you have a family history of breast cancer (or similar risk factors), then, sure, you may need more frequent mammograms starting at a younger age. None of the new recommendations are saying otherwise.
However, the *average* woman (without your particular risk factors) doesn't necessarily need an annual screening starting at age 40, and may not benefit from it.
However, the *average* woman (without your particular risk factors) doesn't necessarily need an annual screening starting at age 40, and may not benefit from it.
1
Early detection is not changing survival rates for women who die from Metastatic breast cancer. Women who caught it 'early' and did Chemo and radiation and lumpectomy or mastectomy and they STILL died from MBC.
Catching it early does nothing to save these women and men.
It has already seeded it's microscopic metastases and will become deadly.
It is all very confusing.
Catching it early does nothing to save these women and men.
It has already seeded it's microscopic metastases and will become deadly.
It is all very confusing.
10
While arguments are persuasive, I hope we all know enough about the science and statistics to know when an author is skirting uncomfortable truths. And while nice to have front line doctors give their say, it's also worthwhile to note the obvious conflict of interest they have toward more business for their clinics.
One misleading fact presented: The authors state a study in which 65% of 7000 breast cancer "Patients" (not fatalities) had never had a mammogram. Only 6% hadn't followed the new guidelines for adults over 55 years of age; the subject of this piece. The author does not break down the ages of these groups. The omission of critical facts does not present an honest assessment of the factors going into the formulation of the Cancer Society's guideline.
One misleading fact presented: The authors state a study in which 65% of 7000 breast cancer "Patients" (not fatalities) had never had a mammogram. Only 6% hadn't followed the new guidelines for adults over 55 years of age; the subject of this piece. The author does not break down the ages of these groups. The omission of critical facts does not present an honest assessment of the factors going into the formulation of the Cancer Society's guideline.
5
What the authors of this article do not understand is politics, which the new guidelines are really about. The politics relates to bending the health care cost curve down, and do so by about a new $15 billion a year. Think about it as 'death panels for women'. The goal remains clear: save money even if it kills a few extra thousand women a year. The 'magic' of government at work, and don't think that the American Cancer Society is not 'government, they get over 70% of their funding from the NIH.
3
I'm pretty sure they understand the politics of the new cancer guidelines.
Please provide some peer-reviewed studies to support that these new recommendations will "kill a few extra thousand women a year".
The whole point is that there is *no evidence* that annual screening actually reduces mortality rates.
The whole point is that there is *no evidence* that annual screening actually reduces mortality rates.
1
With all due respect for your expertise (two radiologists and a breast surgeon), and also with an appreciation of your likely best intentions, the argument presented here is old and so, apparently, is whatever research has informed the subsequent advice.
In 2014, the British Medical Journal reported the most comprehensive set of data on women, mammography and breast cancer, concluding there was no difference in survival rates in women diagnosed with breast cancer, between women who have had regular mammograms and women who have not.
Additionally, there is insufficient evidence about the danger of radiation (however "small" the amount) as potentially harmful.
This is important as every day we learn about the "new" dangers of low-level radiation in the environment as potential cause of cancers of many different varieties.
To this, I might add the abject misery inflicted on women whose
mammograms, now highly sensitive to the point of producing
images, that while not cancer, are then used to subject women to biopsies and their concurrent miseries. Some women who have never developed breast cancer are put through this ringer year after year. This is beneficial?
Add to this, the "unknown" factor of slamming a woman's breast between two plates of glass, and then adding insult to injury, shooting ostensibly "safe levels" of radiation throughout.
We are the keepers of our own bodies. Stop subjecting us to these horrific procedures.
"First, do no harm."
mlm
In 2014, the British Medical Journal reported the most comprehensive set of data on women, mammography and breast cancer, concluding there was no difference in survival rates in women diagnosed with breast cancer, between women who have had regular mammograms and women who have not.
Additionally, there is insufficient evidence about the danger of radiation (however "small" the amount) as potentially harmful.
This is important as every day we learn about the "new" dangers of low-level radiation in the environment as potential cause of cancers of many different varieties.
To this, I might add the abject misery inflicted on women whose
mammograms, now highly sensitive to the point of producing
images, that while not cancer, are then used to subject women to biopsies and their concurrent miseries. Some women who have never developed breast cancer are put through this ringer year after year. This is beneficial?
Add to this, the "unknown" factor of slamming a woman's breast between two plates of glass, and then adding insult to injury, shooting ostensibly "safe levels" of radiation throughout.
We are the keepers of our own bodies. Stop subjecting us to these horrific procedures.
"First, do no harm."
mlm
19
"concluding there was no difference in survival rates..."
This is not ONLY about survival, but about early detection for less assaulting treatment. Sure, living with surgery, chemo, radiation is worth the price for most BC patients, but catching the cancer before all this is necessary is better by ten.
" Stop subjecting us to these horrific procedures."
No one is forcing you to have these procedures.
No one would argue that false positive results are unfortunate, but not nearly as unfortunate as a false negative or an opportunity missed by lack of mammography.
This is not ONLY about survival, but about early detection for less assaulting treatment. Sure, living with surgery, chemo, radiation is worth the price for most BC patients, but catching the cancer before all this is necessary is better by ten.
" Stop subjecting us to these horrific procedures."
No one is forcing you to have these procedures.
No one would argue that false positive results are unfortunate, but not nearly as unfortunate as a false negative or an opportunity missed by lack of mammography.
1
Insurance companies and third party payers will still cover annual mammogram screening starting at age 40 if the doctor orders it. Also, the new ACS guidelines explicitly state that women can request screening begin at age 40 and continue annually after age 55 and doctors should comply with these wishes.
2
Why, if it's not effective? $15 billion a year is a lot of subsidy for a completely fruitless undertaking.
As a surgeon who has treated breast cancer since starting practice in 1990, I agree 100% with the facts stated in this article by these doctors and will continue to recommend screening starting at age 40.
26
Clinical observations, even over the course of many years, are still anecdotes - treatment guidelines must be based on science and data.
3
Why is nobody talking about the cancers caused by the cumulative radiation of mammograms over the decades? I've had a radiologist say to me that radiation was exactly why radiation was not recommended for younger women. Even if the individual dosage per image is small, when one has 4-6 exposures per visit and one visit per year from age 40, across millions of women, the effects must be considerable. Canada has factored this damage into their recommendations. I've never heard it discussed in the states. And now with breast tomography being pushed by all the facilities, the radiation exposure is increasing.
5
I was diagnosed with moderately aggressive invasive ductal carcinoma following my baseline mammogram at age 40. My daughter was 2 1/2 at the time. The tumor was deep, against my breast bone, and both my surgeon and oncologist agreed it would have never been detected by a breast exam. With no family history of breast cancer, I was considered to be "average risk." Because of the mammogram, it was caught early. Had I waited until I was 44 for a mammogram, it would not have been stage 1 at detection. I am grateful for early detection. I know I am only one person, but my life would have been profoundly altered if these new guidelines had been in place when I was 40. It's possible I wouldn't even be here to watch my beautiful daughter grow up. The big question is: How many women like me will be lost with the new guidelines?
31
This is 100% correct.
Next on the list: eradicating the irresponsible dangerous downgrading of DCIS. DCIS all too often is associated with an invasive carcinoma or is a precursor of invasive carcinoma. Those that imagine they can distinguish the "good" from the "bad" are delusional. Worse, DCIS is often diffuse within the breast with apparent skip areas.
Next on the list: eradicating the irresponsible dangerous downgrading of DCIS. DCIS all too often is associated with an invasive carcinoma or is a precursor of invasive carcinoma. Those that imagine they can distinguish the "good" from the "bad" are delusional. Worse, DCIS is often diffuse within the breast with apparent skip areas.
1
With any medical test the doctor should tell the patients that for you given your medical history, these are the advantages for you and these are the disadvantages for you.
And then the doctor and patient should decide on whether the test should be done.
Mammograms save lives. The debate is whether the number of lives saved outweighs the effects of false positives.
I don't know the answer.
The best answer is let the woman in consultation with her doctor make the decision for herself.
And then the doctor and patient should decide on whether the test should be done.
Mammograms save lives. The debate is whether the number of lives saved outweighs the effects of false positives.
I don't know the answer.
The best answer is let the woman in consultation with her doctor make the decision for herself.
1
Don't know why so many are said to have small breast tumors. Could it be that many have these and live decades and end their lives co existing with these cancers , to eventually die of other causes at a ripe old age?
7
My questions: Is survival impacted by detecting cancer when it is microscopic vs. slightly larger if the cancer is slow growing? If the cancer is rapidly growing and likely to be incurable, does detection when it is microscopic vs. slightly larger influence survival time? Or is it just a matter of lead time? Would a careful physical breast exam by a nurse on the alternate of a 2 year mammogram schedule produce the same survival statistics?
5
One third of all breast cancers will never harm the woman who has them. Another third are so deadly, they will kill no matter how early you catch them. Only in the last third does it matter when the breast cancer is detected.
1
Since my risk of dying from breast cancer is way lower than my risk for melanoma I would like to transfer some of the funds from the ineffective mammography screening program to pay for free annual skin exams by a dermatologist. Why do I have to keep subsidizing an ineffective program?
9
How do you know your risks of developing breast cancer are lower than your risk of developing melanoma? You may have a malignant tumor right now and not know it.
1
before we join these lovely life saving Moms of the years in their crusade, let us remember that these "new" recommendations are only new to this particular recommending group, that is now aligning more with the US preventative task force recommendations. The safety net systems and many HMOs like kaiser have adopted these years ago. Are there an increased number of advanced cancer cases in these populations?
7
To quote Upton Sinclair, "It is difficult to get a man to understand something when his job depends on not understanding it."
I had the same feeling about reduced frequency of pap smears until I carefully reviewed the evidence and rationale, and now advocate the new less frequent schedule, despite a significant drop in patient visits.
I had the same feeling about reduced frequency of pap smears until I carefully reviewed the evidence and rationale, and now advocate the new less frequent schedule, despite a significant drop in patient visits.
25
Thank you for being a responsible physician. At the very least, the pap smears don't involve radiation and pain!
This recommendation is based on pharmacoeconomics evaluating the cost of screening the population frequently against the cost of lives lost. Maybe the number of additional lives saved is not huge, but it's huge when it's you or your family. These guidelines will be used to establish reimbursement. Poor women will suffer. Thus begins rationing.
5
Rationing began a long time ago. Poor men and women have been suffering for a long time. ACA made it a little easier for those folks but it's still true. Don't pretend that we haven't been rationing care all along.
1
"Rationing", in one form or another, has existed since the very beginnings of our health care system. Every single health care system in the world uses some type of rationing, including guidelines for (e.g.) how often certain tests or procedures are performed.
That's not a bad thing. Those kinds of guidelines *should* be based on medical evidence, and patients shouldn't be expected to routinely undergo unnecessary tests that they're unlikely to benefit from.
I think the authors (thought obviously well-intentioned) are seriously underplaying the downsides of unnecessary mammograms and biopsies, which include potentially burdensome financial costs, time off from work, etc. To use myself as an example, I have a high deductible health plan, and paying for those unnecessary procedures out of pocket would be a serious financial strain.
That's not a bad thing. Those kinds of guidelines *should* be based on medical evidence, and patients shouldn't be expected to routinely undergo unnecessary tests that they're unlikely to benefit from.
I think the authors (thought obviously well-intentioned) are seriously underplaying the downsides of unnecessary mammograms and biopsies, which include potentially burdensome financial costs, time off from work, etc. To use myself as an example, I have a high deductible health plan, and paying for those unnecessary procedures out of pocket would be a serious financial strain.
12
I'm sorry, but poor women suffer because of lack of insurance! Support the ACA and you will see better results for these poor people as I saw it in the first few months of implementation.
ATTACKS AGAINST WOMEN So you think that the attacks on funding for Planned Parenthood are worthwhile fighting? Then you need to join the fight against the new guidelines for breast cancer screenings.
As a lay person, I must ask why the writers of the article were not consulted? What happened to others in the scientific community who disagree?
Is this a case of trying to equate the Theory of Evolution with Intelligent Design?
Or is it a case of an extremist conspiracy to expand its attacks on women?
Whatever's happening, the American Cancer Society must reopen the debate and review its findings in light of the objections of the experts who wrote this piece. Otherwise they are moving in the direction of those who attack the rights of women.
As a lay person, I must ask why the writers of the article were not consulted? What happened to others in the scientific community who disagree?
Is this a case of trying to equate the Theory of Evolution with Intelligent Design?
Or is it a case of an extremist conspiracy to expand its attacks on women?
Whatever's happening, the American Cancer Society must reopen the debate and review its findings in light of the objections of the experts who wrote this piece. Otherwise they are moving in the direction of those who attack the rights of women.
1
Nope. Disagree. The authors are just three people and the studies they cite aren't even specific. Where do they get their numbers? Face it, this is their business and if fewer women go to their clinics, who is going to pay for the expensive tests and machines?!
1
Evidence-based medicine is not an "attack" on women. Medical recommendations SHOULD be based on the best available evidence and medical consensus. (Which was, in fact, reviewed for these new recommendations).
As a woman, I'd prefer that my doctors base their recommendations on solid science, and not vague intuition or "anecdata". And I'd *really* prefer to avoid unnecessary testing and medical appointments, if medical evidence shows that they're not likely to be of personal benefit to me.
(I must say, the recent announcement that low-risk women can space out Pap smears every three years was the best news I've heard in a long time...)
As a woman, I'd prefer that my doctors base their recommendations on solid science, and not vague intuition or "anecdata". And I'd *really* prefer to avoid unnecessary testing and medical appointments, if medical evidence shows that they're not likely to be of personal benefit to me.
(I must say, the recent announcement that low-risk women can space out Pap smears every three years was the best news I've heard in a long time...)
2
I was 40 years old when I was diagnosed with cancer which was found through a mammogram. I started having mammograms when I was 36 because I'm fibrous and my doctor felt it better safe than sorry. The cancer was stage 2 and I went through chemo and radiation and I've been clean for over 19 years. I don't understand how they think cancer will be detected. In my case, after I was told I had cancer, I could not feel a tumor, so self-exam would not help me. Believe me, I have a mammogram once a year and it is a very uncomfortable experience, but I will go through as often as I have to if it will save my life.
5
My mom is 82 and has had maybe 2-3 mammograms in her entire life. I'm glad. I've had none and not sure if I ever plan to.
I feel torn by this. On my last mammogram (age 43), they saw something that needed additional imaging. After another mammogram and ultrasound, they concluded that it was 'probably benign' (98% certain that it was benign), and would require another ultrasound in six months. I just had the six months follow-up, and they said everything was still same, but that I would require another ultrasound in another six months or I could get a biopsy. I decided on the biopsy because the stress from not knowing--and the fear that I could be making the wrong choice just waiting and watching, was too much. I will have it next week--which will mean that I have had 2 mammograms, 2 ultrasounds, and now the biopsy on this spot. If it turns out it is something bad, I will appreciate the thoroughness. I would not minimize, though, the stressfulness of this process--as well as the significant financial cost. (covered mostly by my insurance but also by me)
8
If your doctors are recommending another ultrasound in six months, and not saying you really need a biopsy now, you probably ought to just go with that. Read up on biopsies (which are actually an independent risk factor for cancer) and you might want to cancel next wee's appointment.
Best of luck to you-
Beware of these priestesses of the Church of Breast Cancer. They live off the offerings of the faithful, especially the mammography fees.
28
I can imagine there are a lot of confused readers listening to health professionals argue this issue back and forth. Which side has a better case? It's actually not hard to understand the arguments and judge for yourself. I suggest reading Chapter 6 of "Overdiagnosed" by Gilbert Welch, which is written for the public. (The entire book is a must-read for anyone over 40 and Dr. Welch is a researcher and nationally recognized expert on medical screenings.) Medical data on screening can't tell us how much money should be spent to save a life. However, the data strongly suggest that small harmless cancers (of many types) are very common. It would be too dangerous to treat all the cancers being found (especially as improved imaging finds even more, and smaller tumors). Most professionals probably agree on these points. The question facing mammograms seems to be: Is it always at least better to discover the tumors and then decide whether to treat or not? Our intuition would say "yes" but the data seems to say "no". Older studies point to benefits of mammograms, but newer, more careful studies designed to really look at this question do not see clear benefits for certain ages. There's a regime where current treatment options do not help enough to show in the data (for women with no symptoms or family history.) Should more mammogram detection be recommended in the later case? What we really need are better ways to tell when a tumor becomes dangerous, and better ways to treat it.
17
These authors are all those who have a financial interest in the outcomes. Science needs to determine procedures, not those who need the income from the procedures. Unfortunately emotion always wins out in medical issues, even if there is no science behind it. As a male, I do not have breasts, but I do note that prostate screening with PSA has not panned out as pushed either.
19
Um, you do have breasts, and male breasts can also develop cancer....
No, George, you actually do have breasts and males can get breast cancer. Look it up.
How does a radiologist become qualified to read mammograms? Is there a difference in how many women are called back based on the experience and training of the radiologist? Is there a recommended threshold number of mammograms a radiologist reads per year to be considered expert? The "harm" factor in the equation used by the USPTF could potentially be mitigated if women could have the information needed to seek out the most expert mammogram readers. What about breast density? Do screening criteria take breast density into account? Should women with dense breasts have an alternate method of screening depending on their risk? Could we please use science to help up make choices instead of emotional appeals and anecdotes?
4
To these three women with hammers, everything looks like a nail. Cancer specialists are the last people who should write screening guidelines.
23
Well on October 15, 2015 Dr. Drossman saved MY life thanks to a mammogram/ultrasound in her practice that picked up a stage one breast cancer that Dr. Drossman biopsied for me. I have them annually (age 71).
What the article does NOT say, but I firmly believe, is that aggregate date that lumps results from small underachieving imaging practices with those from top notch institutions is not the way to illustrate the value of mammography.
We'll see how I make out. Let you know... I'm pretty optimistic. Thank you Schaefer, Schonholz and Drossman (special thanks to Elizabeth Thompson and the technicians as well.
What the article does NOT say, but I firmly believe, is that aggregate date that lumps results from small underachieving imaging practices with those from top notch institutions is not the way to illustrate the value of mammography.
We'll see how I make out. Let you know... I'm pretty optimistic. Thank you Schaefer, Schonholz and Drossman (special thanks to Elizabeth Thompson and the technicians as well.
1
I appreciate this argument. I am an example of a finding that should probably have been monitored, not, biopsied. It was traumatic, to be sure. However, there is no dispute that finding out my lesion is benign is in any way a disadvantage, born from too frequent mammograms. The fact that mammograms lead to findings that can be monitored and not biopsied is another discussion, and I am in such a study at UCSF. That is where advancements are needed, and simply can't be achieved nearly as well without annual mammograms. This recommendation from ACS seems illogical and dangerous.
3
If these three women had been mis-diagnosed with a false-positive result; if these women had unnecessary biopsies, lumpectomies or worse yet--unnecessary mastectomies, we would be reading a completely different editorial.
Personal experiences of the few should not drive medical policies for the majority.
Personal experiences of the few should not drive medical policies for the majority.
20
When you got a hammer, everything looks like a nail. The urologists screamed when the tide turned against screening all the men over ge 50 for prostate cancer. Now the breast cancer screening folks are doing the same.
There will be a fifth grader somewhere in this country who tragically dies of a brain tumor this year. Should my kid get an annual screening brain MRI? (no, in case you are wondering)
There will be a fifth grader somewhere in this country who tragically dies of a brain tumor this year. Should my kid get an annual screening brain MRI? (no, in case you are wondering)
29
If there are scientific reasons to doubt the Cancer Societies recommendations, let's hear them, but the publication of scientifically baseless assertions like those aired in this article only creates needless concern and confusion. The NYT should know better.
17
But then why not start screenings at 35 and do them every six months? Guidelines are arbitrary. The ACS are the ones who originally set the screening age at 40. I would trust the ACS research and deliberations over the emotional response of a few caregivers, and if the ACS is confident of their new guidelines, I support them.
8
Sorry Steve, but I don't think you as a male are qualified to pass judgment in these matters. As for "emotional" discussions by these Drs., let's hear what you have to say when your mother, sister, wife, aunt et al is diagnosed with a breast cancer that could have been prevented by early detection and annual screening.
I'm reading quite a bit of anti-woman sentiment in these comments which, frankly, disturbs and alarms me. In what decade do you live when women's lives are deemed less important or worthy of saving, than those of men? Sign me,
Proud feminist, and cancer free, thanks to
advanced medicine, decent heredity, clean living habits and just plain luck.
I'm reading quite a bit of anti-woman sentiment in these comments which, frankly, disturbs and alarms me. In what decade do you live when women's lives are deemed less important or worthy of saving, than those of men? Sign me,
Proud feminist, and cancer free, thanks to
advanced medicine, decent heredity, clean living habits and just plain luck.
1
This is the usual debate that arises when recommendations are issued based on sound, statistical analysis. Many people show up on the scene with their personal anecdote or story. This is emotion getting in the way of fact.
BUT - I get it. Population-based statistical studies are like casinos. The statistics around the odds in craps are immutable and statistically unquestionable. However, my personal experience when I roll the dice a number of times may be far outside expectation ( 15 "7s" in row).
The personal anecdotes are exactly like my hypothetical casino illustration - outliers. The huge "BUT" here to my anecdote is that dice throwers don't die if the odd don't go their way.
WHAT EVERYBODY MISSES HERE - these are guidelines and recommendations. Nobody is being barred from getting a mammogram. Insurers will, in all likelihood, adjust their reimbursements to reflect the guidelines. However, should a patient ask her doctor for a mammogram outside of the guidelines - she will get one - but at her own cost.
If getting a mammogram more frequently than a person's health-adjusted guideline calls for is so important - pay for it from your own pocket.
BUT - I get it. Population-based statistical studies are like casinos. The statistics around the odds in craps are immutable and statistically unquestionable. However, my personal experience when I roll the dice a number of times may be far outside expectation ( 15 "7s" in row).
The personal anecdotes are exactly like my hypothetical casino illustration - outliers. The huge "BUT" here to my anecdote is that dice throwers don't die if the odd don't go their way.
WHAT EVERYBODY MISSES HERE - these are guidelines and recommendations. Nobody is being barred from getting a mammogram. Insurers will, in all likelihood, adjust their reimbursements to reflect the guidelines. However, should a patient ask her doctor for a mammogram outside of the guidelines - she will get one - but at her own cost.
If getting a mammogram more frequently than a person's health-adjusted guideline calls for is so important - pay for it from your own pocket.
9
Agree, personnel responsibility for one's own health, along with dismantling of monopoly protections for the entire health sector including pharma and medical device companies is needed.
Please document your sources for the statement that mammograms may reduce your risk of dying of breast cancer by 30%. I want to strip the emotion from my decision whether to have a mammogram or not and base it on good and current medical science. I have read voraciously on this subject, but am unable to locate the scientific studies that support this statement.
23
I began reading this article with an open mind. I hoped to gain some insight from the experts. That never happened. Instead, you brought up that 'Mothers of the Year' nonsense and lost all your credibility. Once you were so proud to receive recognition from your colleagues. Then you were crushed when those same colleagues used the current data to update their screening guidelines. Wah wah wah. Are we supposed to feel bad for you three now? Are we supposed to feel betrayed because your colleagues don't agree with you? Your sour grapes has no place in discussion. Its supposed to be about science. As soon as I read that nonsense I knew the rest of your missive wasnt going to be based on nonsense. And I was right. You poo pooed serious issues and minimized women ( anxiety? - really? thats where you chose to go? ), because you couldnt figure out a way to bend science into supporting your point of view. Experts - we expected better from you.
20
Bravo Doctors and thank you! I'm 59 and already had 1 lumpectomy scare.
1
What about the ACS's guideline that one should not have pap smear after 65?
I've seen no one addressing that. Is that new? Is it advisable by these doctors?
I've seen no one addressing that. Is that new? Is it advisable by these doctors?
I have a feeling everything is advisable by these doctors, as long as it benefits them financially.
Wow. Astounding that the ACS is recommending fewer mammograms and "...fewer physical breast exams by doctors entirely." Simply astounding.
The comments themselves are rife with confused definitions - mammogram vs. biopsy, someone wants anesthesia for a mammogram but prefaces their comment with reference to biopsies, confusion about older vs. current diagnostic equipment and techniques, mortality vs. survival, and on and on...
Until everyone is on the same page, using the same definitions, nothing anyone says is valid. ACS, physicians, scientists, patients, cancer patients and survivors and even data crunchers should all sit down together and confirm that they are all talking about the same topic before anyone, including the ACS heads off to a newspaper with the latest screed.
Mammography offers early detection; so do cancer marker blood tests, which are rarely, if ever done prior to a more certain diagnosis of cancer Patients can choose how seriously they value their lives by choosing to have earlier or later diagnostic techniques like mammography. But to restrict that choice and enshrine it in a fixed health plan?
Try finding a facility that will do mammograms. Several physicians in my area say mammograms make no money for the physicians ordering them. So be cautious about accusing radiologists of ordering mammograms for the "money". The age of 40 should be a "gateway" age when a patient can choose to pursue early or later detection, regardless of the ACS.
The comments themselves are rife with confused definitions - mammogram vs. biopsy, someone wants anesthesia for a mammogram but prefaces their comment with reference to biopsies, confusion about older vs. current diagnostic equipment and techniques, mortality vs. survival, and on and on...
Until everyone is on the same page, using the same definitions, nothing anyone says is valid. ACS, physicians, scientists, patients, cancer patients and survivors and even data crunchers should all sit down together and confirm that they are all talking about the same topic before anyone, including the ACS heads off to a newspaper with the latest screed.
Mammography offers early detection; so do cancer marker blood tests, which are rarely, if ever done prior to a more certain diagnosis of cancer Patients can choose how seriously they value their lives by choosing to have earlier or later diagnostic techniques like mammography. But to restrict that choice and enshrine it in a fixed health plan?
Try finding a facility that will do mammograms. Several physicians in my area say mammograms make no money for the physicians ordering them. So be cautious about accusing radiologists of ordering mammograms for the "money". The age of 40 should be a "gateway" age when a patient can choose to pursue early or later detection, regardless of the ACS.
1
Val in Brooklyn, NY to MC in NY, NY
I find this nerve racking to say the least. Thanks for the sense and sanity of your comment, which, right now, is the one that seems spot on to me. And that includes the ACS and the doctors who wrote this opinion page.
My mother and I lost my dear sister this Jan. She died one month before her 50th in Feb. There was no history of breast cancer prior to her getting it and its spreading. We're obviously devastated, but, the confusion you point out makes it worse because--whom do we trust?
I'm trying very hard NOT to lose it. Again, thank YOU--specifically--YOU.
Submitted 10-28-15@2:03 p.m. EST
I find this nerve racking to say the least. Thanks for the sense and sanity of your comment, which, right now, is the one that seems spot on to me. And that includes the ACS and the doctors who wrote this opinion page.
My mother and I lost my dear sister this Jan. She died one month before her 50th in Feb. There was no history of breast cancer prior to her getting it and its spreading. We're obviously devastated, but, the confusion you point out makes it worse because--whom do we trust?
I'm trying very hard NOT to lose it. Again, thank YOU--specifically--YOU.
Submitted 10-28-15@2:03 p.m. EST
Should routine mammography screening at age 40 be based on religious faith or on science? Religion is belief based on unshakable faith even though the claims seem absurd. Scientific claims are believed because they are consistent with facts as we know them. Science claims are always contingent on new facts and "truth " changes as better facts become known. Religious truth is fixed and "revealed by a prophet" precisely because it is untestable and accepted strictly on faith. Faith based belief in the value of mammography need never be tested. So, what facts will the authors ever accept as evidence that their position is incorrect. If there are none, then their claim can not be disproven. Theories and beliefs that cannot be falsified by evidence are matters for Faith not Science.
4
It seems to me that prevention and early detection is cheap medicine compared to surgery and expensive therapies.
2
I survived breast cancer. I had no risk factors, other than being a menopausal 55 year old female. I did not have a lump; I had a flat, spiculated tumor that was not palpable. I had a biopsy, which showed cancerous cells. My annual mammogram provided me the opportunity to get treatment before things got worse. Surely I am not the only woman with this experience. How can an annual mammogram be so controversial? What's the big deal? If this trend to discredit the efficacy of mammograms is an attempt to control costs an analysis of the cost of treating advanced cancer vs. an early stage cancer should be made. Those of us who get to continue living and loving do not appreciate being reduced to a statistical probability that is not in our favor.
7
"...the new guidelines did not include a single surgeon, radiologist or medical oncologist who specializes in the care and treatment of breast cancer"
I find it difficult to take the word of authors with a combined 60 years of experience who think radiologists care for and treat breast cancer patients. News flash: That would be radiation oncologists, NOT radiologists.
I find it difficult to take the word of authors with a combined 60 years of experience who think radiologists care for and treat breast cancer patients. News flash: That would be radiation oncologists, NOT radiologists.
4
The ACS guidelines are, just that: guidelines.
Doctors and patients may still use their judgment. That's a good thing. Also, the guidelines are for women with average risks. If the authors do not think false positives do much harm, it's up to them and their patients to make that call.
In this respect US doctors do better than K-12 teachers, for whom management by numbers has eroded their ability to exercise their own judgment about how to do their jobs.
The story would be different if insurers refused to pay for screenings that doctors recommend.
If that's happening, that would be wrong. If that's happening, then the doctors should tell us about it. But that's not what they write about.
Doctors and patients may still use their judgment. That's a good thing. Also, the guidelines are for women with average risks. If the authors do not think false positives do much harm, it's up to them and their patients to make that call.
In this respect US doctors do better than K-12 teachers, for whom management by numbers has eroded their ability to exercise their own judgment about how to do their jobs.
The story would be different if insurers refused to pay for screenings that doctors recommend.
If that's happening, that would be wrong. If that's happening, then the doctors should tell us about it. But that's not what they write about.
1
Thank you very much for this.
The NYT reported lasts year that a "vast" study of 90,000 showed no difference in outcome between those having mammograms and those who didn't. See "Vast Study Casts Doubts on Value of Mammograms" (http://www.nytimes.com/2014/02/12/health/study-adds-new-doubts-about-val..."It found that the death rates from breast cancer and from all causes were the same in women who got mammograms and those who did not. And the screening had harms: One in five cancers found with mammography and treated was not a threat to the woman’s health and did not need treatment such as chemotherapy, surgery or radiation.").
So the medical tests have no benefit, and may cause harm in many cases. Isn't that the definition of a medical scam?
So the medical tests have no benefit, and may cause harm in many cases. Isn't that the definition of a medical scam?
8
Studies must be done to determine if repeated mammograms are a cause of cancer
5
I hope the NY Times does the right thing and publishes a counterpoint to this potentially damaging, misinforming piece. The most important thing to know about this piece is this: Radiologists and Breast Surgeons are physicians who serve to gain financially by over screening. Its like asking a brake salesman if you should have your brakes checked every year.
These recommendations are not made lightly. Anticipating backlash, I'm sure the ACS and USPTF before them, still err'ed on the side of over-screening in the new recommendations.
We are all scared of dying. But, its okay to be realistic about what we can actually do to prevent it.
These recommendations are not made lightly. Anticipating backlash, I'm sure the ACS and USPTF before them, still err'ed on the side of over-screening in the new recommendations.
We are all scared of dying. But, its okay to be realistic about what we can actually do to prevent it.
16
We have doctors in our family, and friends who are physicians, and though I strongly disagree with the advice here, I have no doubt these physicians are trying to save lives, in what can often be such a slippery slope of evidence.
Just a little jaded in your response, perhaps, to suggest they are in this for the money?
Just a little jaded in your response, perhaps, to suggest they are in this for the money?
1
I've never heard of anyone dying from a mammogram, but I bet that many of us know of people whose breast cancer was caught early by routine testing. The cost of a thousand mammograms has to be cheaper than treatment for a cancer that is diagnosed at a later stage than necessary. The medical economists may have their statistical models, but I don't think they are considering the runaway costs incurred by those with a delayed diagnosis.
2
These doctors probably have good intentions and are committed to the well-being of their patients. But they base the advice in their Op-Ed upon anecdotal information. And, some of their assertions are clearly untrue. The American Cancer Society (ACS) based its recommendations upon a strong base of scientifically conducted studies.
The doctors stated "Mammography in all age groups, starting at 40 years old, is the only test that has been proven to do exactly this: reduce the risk of dying from breast cancer, by up to 30 percent." ACS reports that breast cancer mortality has declined by 34% since 1990. However, only some of the decline can be attributed to early detection via mammography. 7% is due to discontinuation of menopausal hormones. Cigarette smoking, another cause of breast cancer, has decreased significantly. Physical activity and breast feeding have increased, which reduced cancer risk. And, some of the biggest decreases have been due to other forms of prevention and treatment, such as with tamoxifen, surgery, chemotherapy,etc. of breast cancer diagnosed due to symptoms (not mammography). http://www.cancer.org/acs/groups/content/@research/documents/document/ac...
Since they have been so involved with the American Cancer Society, it is surprising that these doctors are not familiar with the extensive set of facts about breast cancer maintained by the ACS.
The doctors stated "Mammography in all age groups, starting at 40 years old, is the only test that has been proven to do exactly this: reduce the risk of dying from breast cancer, by up to 30 percent." ACS reports that breast cancer mortality has declined by 34% since 1990. However, only some of the decline can be attributed to early detection via mammography. 7% is due to discontinuation of menopausal hormones. Cigarette smoking, another cause of breast cancer, has decreased significantly. Physical activity and breast feeding have increased, which reduced cancer risk. And, some of the biggest decreases have been due to other forms of prevention and treatment, such as with tamoxifen, surgery, chemotherapy,etc. of breast cancer diagnosed due to symptoms (not mammography). http://www.cancer.org/acs/groups/content/@research/documents/document/ac...
Since they have been so involved with the American Cancer Society, it is surprising that these doctors are not familiar with the extensive set of facts about breast cancer maintained by the ACS.
10
Mammography saves lives. But the unfortunate truth is that the health care system has demonstrated its even greater investment in charging for continuous tests and procedures. Once you have gotten the public to accept charges for a standard test, you can invent ways to charge for even better, more precise versions of that test--for an even larger fee.
I am sick of the process and have lost my trust in the system, and in the doctors encouraged by hospitals to get more money out of their patients.
I am sick of the process and have lost my trust in the system, and in the doctors encouraged by hospitals to get more money out of their patients.
2
I am a breast cancer survivor. I strongly disagree with the new American Cancer guidelines. First of all, how does one define average risk? As far as I know, I had no close relatives with breast cancer, and no logical or medical reason to think I was at risk. I would have flown under the radar, a small stage 1 cancer, a one centimeter unremarkable spot, undetectable by a breast examination. During my breast cancer treatment, I attended a support group in Palo Alto, CA...and was alarmed at the number of younger women (35-55) who were diagnosed with invasive cancers and undergoing radical treatments. Some had just had their first mammogram. The importance of a timely mammogram is a critical strategy for preventing breast cancer!
To my thinking, false positives and unnecessary biopsies are manageable; it's impossible to imagine discovering a life threatening cancer too late. I wonder if the American Cancer Society has considered the euphoria of an unremarkable mammogram, this feeling of joy eclipses everything else.
To my thinking, false positives and unnecessary biopsies are manageable; it's impossible to imagine discovering a life threatening cancer too late. I wonder if the American Cancer Society has considered the euphoria of an unremarkable mammogram, this feeling of joy eclipses everything else.
2
A little more cynicism is in order, or else there is no end to the barrage of "preventative" testing the American public will be subjected to. Oh, wait- that's already happening.
My mother was diagnosed in 1994 with breast cancer that had spread to several lymph nodes. Her mammogram just months earlier had missed the tumor; she was only saved by her own self-exam when she felt a lump. (Thankfully she is alive and well today.) Although it that is just one anecdote, I know of many others like it from other women. It would be nice to hear these authors stressing the ongoing importance of self-exams somewhere in the midst of this praise for a clearly fallible technology.
9
Nobody seems to have picked up on the fact that "The group is also recommending ending physical breast examinations by doctors entirely" as stated in the first paragraph. With mammograms just every two years, and no breast examinations, how are we to find the aggressive cancers? The ones that kill you without prompt treatment. guess these women are expendable.
13
No. The analysis has been performed and it concludes that the risk of false positives and the harm these will cause outweighs the benefits of finding even an aggressive cancer early. This is simply risk analysis.
I guess the question is: does physical examination actually help "find the aggressive cancers"? Is there medical literature to support that it does?
If there's no evidence to support that it's actually effective, then why keep doing it?
If there's no evidence to support that it's actually effective, then why keep doing it?
My son recently visited a world famous medical clinic for an x-ray of his knee. They x-rayed his shoulder instead.
5
Reading the backgrounds of the authors confirmed my suspicion--two radiologists who stand to gain financially from yearly mammograms.
21
This is such a slur. Do you believe that for every occupation? Or just for medicine? After all, if I call the furnace guy to check the furnaces in my rental property, he might just tell me--and he actually just did-- that there is a problem. He certainly has a financial advantage if he does more work. But I believe he is an honest guy and I believe my doctors are honest doctors.
I'm just another one of those women whose breast cancer was discovered through a routine mammogram. Four different doctors were not able to feel the tumor manually. An ultrasound showed nothing. An MRI and an MRI guided biopsy found it again and determined it was a stage 1 cancer. By the time it would have been found manually, it most likely would have been much larger and may very well have spread to my lymph nodes. Instead it was removed with a lumpectomy and my breasts look and feel normal. I was able to avoid chemo and instead had a short course of radiation. I don't think radiologists get any pleasure from finding suspicious areas because it means more money. I think they take pride in helping to save lives.
I'm just another one of those women whose breast cancer was discovered through a routine mammogram. Four different doctors were not able to feel the tumor manually. An ultrasound showed nothing. An MRI and an MRI guided biopsy found it again and determined it was a stage 1 cancer. By the time it would have been found manually, it most likely would have been much larger and may very well have spread to my lymph nodes. Instead it was removed with a lumpectomy and my breasts look and feel normal. I was able to avoid chemo and instead had a short course of radiation. I don't think radiologists get any pleasure from finding suspicious areas because it means more money. I think they take pride in helping to save lives.
1
The authors completely overlook the harms of overtreatment, which is the biggest downside of mammography (not false positives). How does a woman in her early 40s at average risk of breast cancer -- which means a very small risk -- balance the risk of detecting and treating a cancer that would never cause her harm, vs. the small chance of finding a cancer in time to prevent its spread? That is a question that women and their docs should wrestle with, and statements that proclaim there is one answer for this entire demographic group is ridiculous, no matter what side it advocates.
21
You're spot on! Nobody spells out that overtreatment of tumors that would never cause health issues means surgery, radiation, and/or CHEMOTHERAPY for women who may not need it. The long-term effects of treatment are not benign... increased risk of osteoporosis, possibility of heart damage (cardiomyopathy), increased risk of second cancers,... these are not minor issues.
NY Times readers should know that under the most optimistic of interpretations of data from large clinical trials, you would need to perform annual screening mammography for 20 years in at least 300 women (probably closer to 1000 women) to prevent 1 death from breast cancer. So the overwhelming majority of women who have the test (>99%) will not be helped. But 3 or 4 out of 10 women will experience the worry and inconvenience of a false positive test result. More importantly, many of the cancers detected would not have come to attention or required treatment in the absence of screening. That these "overdiagnosed" cases of cancer exist is hard to imagine, but they are real and it is not currently possible to know which ones are harmless and which ones are harmful--so they all get treated.
Testimonials and personal anecdotes are compelling and sometimes heartbreaking, but they are not sufficient to guide public policy. And do not be fooled into thinking that reducing costs is driving the recommendations. The ACS does not pay for medical care and has nothing to gain (and a lot to lose) by revising their guidelines.
Testimonials and personal anecdotes are compelling and sometimes heartbreaking, but they are not sufficient to guide public policy. And do not be fooled into thinking that reducing costs is driving the recommendations. The ACS does not pay for medical care and has nothing to gain (and a lot to lose) by revising their guidelines.
48
I totally concur
there was no history of breast cancer in my family
went for the yearly mammogram and ultra sound
I was diagnosed with DCIS
It is silly not to take advantage of what we can know medically as there is still so much that we don't know.
there was no history of breast cancer in my family
went for the yearly mammogram and ultra sound
I was diagnosed with DCIS
It is silly not to take advantage of what we can know medically as there is still so much that we don't know.
1
“It is difficult to get a man (or woman) to understand something, when his salary depends on his not understanding it.”
― Upton Sinclair
― Upton Sinclair
17
My dear friend who is dying, right now, of breast cancer, had a mammogram three months before her cancer was detected. That is not unusual but it is also not the issue here. Her story is hers and it does not compare equally to any other woman's. There are different kinds of breast cancer. Mammography screening works well for some kinds of cancers. Breast exams are better for others. That was how my friend's was found, with a self exam. The thing is, we don't know which is true for a particular woman or cancer. And arguing about it on op-ed pages hardly helps women to make good decisions.
In seven years now of watching my friend get diagnosed, get better, remission even, and now have a recurrence of the cancer with the worst possible prognosis, I have learned that breast cancer does not conform to one size fits all ideas. These discussions about guidelines have become nearly useless and women are right to feel as if no one is giving them advice they can use. I will discuss whether to have a yearly mammogram with my own doctor again this year. And again this year, we will both admit we really don't know what is best and my fate belongs to, well, fate. Breast cancer is not a single disease that we can find or treat with single magic bullets. Women need screening, we know that, we can agree on that. Talk about controlling costs or denying coverage dismisses the very real concern women have about this deadly disease.
In seven years now of watching my friend get diagnosed, get better, remission even, and now have a recurrence of the cancer with the worst possible prognosis, I have learned that breast cancer does not conform to one size fits all ideas. These discussions about guidelines have become nearly useless and women are right to feel as if no one is giving them advice they can use. I will discuss whether to have a yearly mammogram with my own doctor again this year. And again this year, we will both admit we really don't know what is best and my fate belongs to, well, fate. Breast cancer is not a single disease that we can find or treat with single magic bullets. Women need screening, we know that, we can agree on that. Talk about controlling costs or denying coverage dismisses the very real concern women have about this deadly disease.
7
Last year I had my first call-back for an ambiguous breast finding. Twice while doing the follow-up ultrasound and repeat mammography a few weeks later, the breast specialty radiologist - despite her commentary with the ultrasound tech that none of the features looked suspicious - offered to do a needle biopsy right then and there "to relieve my anxiety." Sorry, if anyone was anxious in the room it was her, since she subsequently acknowledged the lesion had been present the year before (20-20 hindsight when you know where to look). I went back twice at her requested 4-month intervals (guidelines are for q6 months), and eventually was released back to normal screening by a different breast radiologist. I didn't want a needle biopsy unless the thing was growing or had micro-calcifications, because it was likely to show some sort of ambiguously abnormal cells, plus the lesion was very superficial and under breast fold and I thought there was a chance of making a slow-to-heal wound track to the skin. I'm a watchful waiting person. Not sure what I'll do about my screening interval, and I'll take care of my own physical exams.
4
I recently had abnormal findings on an annual mammogram. I have two sisters, both of whom have had breast cancer. A biopsy was recommended. I did not suffer severe anxiety/stress in anticipation of the biopsy. THe biopsy itself was minimally invasive or painful. I received the results (all findings negative) in only a few days. I have no regrets about the further evaluation, especially given my family history. I believe the risks of false positive findings are being overblown.
8
"The biopsy itself was minimally invasive or painful."
I'm glad to hear it was for you, but that's far from a universal experience-- many women *do* experience significant pain and other issues related to biopsies. (Not to mention the related financial costs, unnecessary anxiety, etc.) False positives and overtreatment do have serious downsides for many people.
I'm glad to hear it was for you, but that's far from a universal experience-- many women *do* experience significant pain and other issues related to biopsies. (Not to mention the related financial costs, unnecessary anxiety, etc.) False positives and overtreatment do have serious downsides for many people.
The American Cancer Society (ACS) guidelines applies to women of "average risk". You are not at average risk due to a family history of breast cancer. So, these guidelines do not apply to you - to start mammography at a later age and end them at advanced age (when remaining life expectancy is less than 10 years).
Read the full report of the ACS and you will likely agree that the revised guidelines are based upon extensive research and thoughtful expert analysis. The Op-Ed by the three doctors, who were very involved with the ACS until it published these guidelines, is based upon anecdotes. Surely they were aware of the extensive research behind the guidelines, but did not provide any counter evidence.
http://jama.jamanetwork.com/article.aspx?articleid=2463262
Read the full report of the ACS and you will likely agree that the revised guidelines are based upon extensive research and thoughtful expert analysis. The Op-Ed by the three doctors, who were very involved with the ACS until it published these guidelines, is based upon anecdotes. Surely they were aware of the extensive research behind the guidelines, but did not provide any counter evidence.
http://jama.jamanetwork.com/article.aspx?articleid=2463262
People calling for more mammograms despite the harm are also generally opposed to research into causes of breast cancer especially for instance toxic compounds that may merit additional gov't regulation. More mammograms is pinkwashing pollution, basically.
8
I wonder why screening guidelines are not stratified by risk factors such as obesity, which markedly increases risk for breast cancer. Just another way in which the one-third of women who are overweight or obese are shortchanged by medical practice.
2
"Today, the overall survival rate for breast cancer in the United States is very close to 90 percent, the highest it has ever been, giving most newly diagnosed patients every reason to be optimistic. Early detection with mammography and better treatment options are both directly responsible for that."
This represents a fundamental misunderstanding of the relationship among screening, treatment and mortality. As treatment options improve, screening actually becomes less important. Screening is much more likely to detect an inconsequential low grade "cancer" with little to no malignant potential, thus artificially inflating the survival rates.
This represents a fundamental misunderstanding of the relationship among screening, treatment and mortality. As treatment options improve, screening actually becomes less important. Screening is much more likely to detect an inconsequential low grade "cancer" with little to no malignant potential, thus artificially inflating the survival rates.
30
There are still women out there aged 50 and above who never had a mammogram in their life. Not because they don't have the means to do so but simply for the lack of a better choice of the word 'lazy'. With this new advice from the American Cancer Society it gives women more reason not to get tested and remain to be complacent. I strongly believe in mammograms. I must say though that every year when I go for the check up, worry and fear of what the results will be lingers until I receive the result. But what a feeling to know that you are clear. Nothing can beat that!
However, see comments relating anecdotes of breast cancers found by self-exam that were missed in mammograms only a few months before. I don't think anyone is ever "in the clear." Keep doing self-exams.
Of course you're going to disagree. All three of you rely on the Cancer Industry to butter your bread - you're not going to advocate doing anything that would go against your own self-interest. Brava! What everyone seems to forget in all this nonsense about what's "right" is that the only person qualified to decide when and how often and how many of any kind of test a person receives is the person receiving it. If I'd been having regular mammograms, I'd be dead, or in much worse shape than I am now. NOT having regular mammograms is what saved me. The only expert I recognize when it comes to making decisions about MY health is ME. This is nothing but self serving twaddle from people who stand to gain.
5
Wondering if you could please explain why you think mammograms would have been harmful for you and if you could share what you believe did, in fact, benefit you.
There is not a single case of a person dying from having repeated mammograms. Before you raise accusations on these experts and see motives behind their actions, it might be worthwhile to look in the mirror and come to terms with your own ignorance.
For every reason any woman who has ever groaned over having one.... pain, inconvenience, cost. Don't you have better things to do with your time? I sure have better things to do with mine. There is evidence that repeated mammograms cause cancer, and spread cancer, in fact. There's even evidence that biopsies spread cancer, but our girls don't mention that, either. In addition, at the time I noticed my cancer, if I'd be having regular mammograms, given that there was no way the cancer could've been detected by a mammogram because of where it was, I would've simply dismissed the lump as nothing. At the time, I had a lot going on in my life and it would've been easy to rest in the false negatives that the mammograms would've given me. What has benefited me tremendously is being clear about what i do and don't find acceptable and not to blindly accept the "standard of care" - just because it IS the standard of care. I have rejected chemotherapy, radiation and all hormone suppressing drugs and have found alternative therapies that don't interfere with my quality of life - in fact, they enhance it - and are a lot cheaper and a lot more fun than anything the Cancer Industry had to offer me.
How about deciding for yourself? If you want to get mammograms, get them. If you don't, then don't.
4
This column fails to address the DCIS issue -- it has been published in the peer reviewed literature since the 1990's that with the advent of screening women for no reason other than age (no family history, no symptoms, no lump), something that would probably have never caused a problem was being treated as "cancer." And yet the name of this pre-cancer still has "Carcinoma" in it, misleading and scaring women. But the medical industrial complex is cashing in on that, so decades letter, no correction in the name.
Further, the premise of this article is that routine screenings save lives, but the statistical evidence simply belies this. See Bleyer and Welch, Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence, New England Journal of Medicine (November 22, 2012).
No, I don't think the advisory panel needed these doctors congratulating themselves on the awards they have won. The panel needed the actual data.
Further, the premise of this article is that routine screenings save lives, but the statistical evidence simply belies this. See Bleyer and Welch, Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence, New England Journal of Medicine (November 22, 2012).
No, I don't think the advisory panel needed these doctors congratulating themselves on the awards they have won. The panel needed the actual data.
15
As for me, I now at age 78 refuse to have those annual mammograms that mash your breasts in torture machines.
I have very dense breast tissurse, as many women do. With the old basic mammogram machines that triggers a retreat test. More pain.
I have remarked to male doctors that how would feel if their most private parts were were similarly being smashed in a vice. They blanched.
My tests were always finally declared fine.
Now there is a less painful test but insurance won't pay for it-- extremely expensive.
I have very dense breast tissurse, as many women do. With the old basic mammogram machines that triggers a retreat test. More pain.
I have remarked to male doctors that how would feel if their most private parts were were similarly being smashed in a vice. They blanched.
My tests were always finally declared fine.
Now there is a less painful test but insurance won't pay for it-- extremely expensive.
10
I have several thoughts after reading the article. The first is that there is always going to be tension between the individual who benefits from screening (the woman who's had a tumor friend who felt that it was helpful) versus the societal benefits. It seems that the societal benefits are rather small, but not zero, and that has a society we need to decide whether or not the expense is worth the benefit. If we do make that decision, then it may create a slippery slope towards screening for all cancers the can be screened for, many with even less benefit than breast cancer. I disagree with those who feel like this is an attack on women's health, as the same kind of decision to decrease screening was made regarding prostate cancer.
I also feel that the take-home message from the Massachusetts a study that the authors quoted is not that that the study supports yearly mammograms, but the conclusion is that getting any mammogram is likely to be more beneficial than getting none. This should lead to a larger public service effort to have women screened at whatever interval is appropriate. It might make more sense to have more women screened it longer intervals, then have fewer women screen more frequently (it is currently the case now.)
I also feel that the take-home message from the Massachusetts a study that the authors quoted is not that that the study supports yearly mammograms, but the conclusion is that getting any mammogram is likely to be more beneficial than getting none. This should lead to a larger public service effort to have women screened at whatever interval is appropriate. It might make more sense to have more women screened it longer intervals, then have fewer women screen more frequently (it is currently the case now.)
4
I was 44 when I was caught in a quagmire of a mammogram in February that was normal and the hard glass feel of 2mm invasive tumor that I found by my thumb-tip in June. I helped to save my life by contacting the facility that took the mammogram in February and we all worked well together through the lumpectomy and local radiation. I am about to turn 50; Aside from that I found that by leaving one state for another, I got kicked around some because I had not engaged in a comprehensive care service in NC (from what was available to me in Kalamazoo, MI at the WMCC), I've not had a bad experience. I'm no longer invincible nor can lay claim to remembering what that means. Without an onco gene test, and without any meds, I am still here. I am free.
To deny any woman a breast exam at least annually is to allow a woman to forget to tend to her own care. I found my hard as glass 2mm lump from the brush of my thumb as I was suiting up to swim laps. Maybe the fluke discovery was emblematic that all our lives are at risk. C lives in us all, let's remember. The American Cancer Society might need to, too.
To deny any woman a breast exam at least annually is to allow a woman to forget to tend to her own care. I found my hard as glass 2mm lump from the brush of my thumb as I was suiting up to swim laps. Maybe the fluke discovery was emblematic that all our lives are at risk. C lives in us all, let's remember. The American Cancer Society might need to, too.
1
These doctors claim that their own anecdotal impressions, rather than evidence, should be the basis for decisions all doctors and women make. "Weird" is the least critical adjective I can think of to describe this argument.
27
A misleading analysis easily uncovered by the author's statistics. One mammogram alone reduces the chances of dying from BC from 65% to 6%. That 6% hadn't had a Mammo in more than two years. No stat is given for those dying of BC who had annual mammos versus every two years, both from age 40 until old age. No one questions the great importance of at least one mammo in all females, starting perhaps, before forty in those with a family history of BC and at least one other sometime later and that alone will reduce the chance of dying of BC by 90%. Annual mammos from age 40 will reduce the MR by 30%. But the most important stat, not given, is the chance of dying from BC in the annual vs. every other year cohorts. I think there is no statistical difference, hence the recommendation for every other year is appropriate although the frequency might need be even less frequent if studied. For sure, the false positives, repeat procedures, surgeries, complications and the added radiation load will be double in the every year vs. the every other year cohorts and the cost will be at least double with no discernible change in the frequency of those dying of BC. Finally, I think its best not to have those MDs with an inherent conflict of interest on the advisory panel.
4
"A 2014 study that followed more than 7,000 Massachusetts breast cancer patients demonstrated that, sadly, of all the women who died of breast cancer, 65 percent had never had a mammogram and 6 percent hadn’t had one in the preceding two years."
And all of these women would have been detected by the new guidelines as well. They basically did not follow the previous guidelines or the current guidelines. It is hard to use them as an argument for more frequent screening.
And all of these women would have been detected by the new guidelines as well. They basically did not follow the previous guidelines or the current guidelines. It is hard to use them as an argument for more frequent screening.
9
I would like to give two examples of women who have been "saved" from breast cancer by early detection without any benefit to either one.
My grandmother was diagnosed with very early localized cancer. She and her doctors decided on a double mastectomy so it could never come back. She recovered well from the surgery. But she died of congestive heart failure after 55 years of smoking, and would have had the same outcome if they never did a mammogram or surgery.
My mother use hormone replacement therapy for over 15 years, and since her mother had cancer she was monitored very very closely. Eventually another early tumor was found and treated with lumpectomy and the "gold standard" chemo and radiation. Unfortunately, either she is unusually sensitive or there was a problem with the radiation dosage and application: she has some damage to a heart valve and her lungs, possibly worsening, and chronic myeloid leukemia (held in check by Tasigna). Death by radiation and chemo side effects used to be even more common, but do still happen. These people don't die of the cancer, but treatment actually shortens their lives.
My grandmother was diagnosed with very early localized cancer. She and her doctors decided on a double mastectomy so it could never come back. She recovered well from the surgery. But she died of congestive heart failure after 55 years of smoking, and would have had the same outcome if they never did a mammogram or surgery.
My mother use hormone replacement therapy for over 15 years, and since her mother had cancer she was monitored very very closely. Eventually another early tumor was found and treated with lumpectomy and the "gold standard" chemo and radiation. Unfortunately, either she is unusually sensitive or there was a problem with the radiation dosage and application: she has some damage to a heart valve and her lungs, possibly worsening, and chronic myeloid leukemia (held in check by Tasigna). Death by radiation and chemo side effects used to be even more common, but do still happen. These people don't die of the cancer, but treatment actually shortens their lives.
21
so if frequent testing saves lives (according to the author) , why not test monthly? or weekly?because the elapsed time is unlikely to change the patients outcome? exactly!
12
I applaud the American Cancer Society for resisting the pressure of the self-interested physicians and other non-profits looking only to maintain their funding profile. The opinion of the op-ed contributor is just that, an opinion; it is not based on statistically relevant data analysis, only anecdotal "evidence". After critically assessing the studies detailing the efficacy of mammograms in not only detecting breast cancer, but more importantly changing the outcome, I decided to forego mammograms entirely until I turned 50 (last year). Although my decision may not be comfortable for all, I strongly encourage all women to divorce their fears and emotions from their analysis of the real data, and to act accordingly.
15
The American Cancer Society’s recommendations to curtail mammograms and eliminate physical examination of breasts at annual doctor visits promotes a standard of care that ultimately will harm women and undermine a woman’s right to be informed about her cancer risks. Additionally, these guidelines will make it more difficult for a woman to get what should be basic diagnostic tests as part of routine care.
Doctors administer the care for which they will be reimbursed and if, based on ACS's guidelines, insurance companies will not authorize or reimburse for a diagnostic test as part of routine care, then the doctor won’t order it, unless there is a high degree of certainty the test will show a positive finding. The paradox is without a mammogram, ultrasound or physical examination of breasts, how is the doctor to deduce that there is a chance the patient has breast cancer? The answer is they can’t and women will be left to do self-exams, but won’t know what they are feeling for thereby increasing greatly the likelihood that they can have cancer that is not diagnosed. The ACS's recommendations are absurd and insulting.
Doctors administer the care for which they will be reimbursed and if, based on ACS's guidelines, insurance companies will not authorize or reimburse for a diagnostic test as part of routine care, then the doctor won’t order it, unless there is a high degree of certainty the test will show a positive finding. The paradox is without a mammogram, ultrasound or physical examination of breasts, how is the doctor to deduce that there is a chance the patient has breast cancer? The answer is they can’t and women will be left to do self-exams, but won’t know what they are feeling for thereby increasing greatly the likelihood that they can have cancer that is not diagnosed. The ACS's recommendations are absurd and insulting.
4
Leave it to two radiologists and a breast surgeon -- who directly benefit economically from increased screening, biopsies, surgeries, and radiation treatment — to decry the new guidelines which are based on actual data, not anecdote. An “overall survival rate of 90%" only means that cancer is generally a slow growing disease; of course, the earlier it’s detected, the longer the survival period after diagnosis. What matters is death rate from breast cancer — and this has barely budged in decades, despite increasing screening. They dismissively write "breast biopsies can be temporarily painful;” my biopsy was much more painful than subsequent surgery. I resent the implication that the inclusion of economists and health experts on the panel resulted “in bias the other way — in favor of cutting costs over saving lives.” They don’t think that their financial interests ever cloud their judgment — resulting in the harms of unnecessary mutilation and pain? Maybe the reason that radiologists, surgeons, and oncologists were omitted from the panel is that they don’t understand science — because that’s not mentioned once in this opinion piece. The guidelines were based on data; if you have data which supports another position, present it, and explain how it supports that position. But don’t flagellate women with fear caused by false and misleading statements, which is what this piece does. It is biased, self-serving, and pure drivel.
32
The esteemed Cochrane Collaboration did a meta analysis of many research studies and concluded that women who get mammograms do not live any longer than women who don't. They looked at all-cause mortality and not just breast cancer. We have to look at the whole person and not individual organs in order to make these decisions.
12
Can the NYT please stop publishing health care advice? This is not a peer reviewed science journal. So it is rather dangerous to see articles here that tell us to have mammograms, not to drink too much water, not to have annual physicals etc.,
Most of the statements made in these articles are not scientific but are rather based on personal feeling or opinion.
However these,not are political or social opinions but rather relate to public health. Could we please leave such pronouncements to scientific organizations such as the Ameran heart association and cancer society?
Most of the statements made in these articles are not scientific but are rather based on personal feeling or opinion.
However these,not are political or social opinions but rather relate to public health. Could we please leave such pronouncements to scientific organizations such as the Ameran heart association and cancer society?
11
Mothers of the Year no less! Well, that clinches it...
For every woman commenting whose annual mammogram finally found a cancer--how many mammograms had you undergone at that point? Five? A dozen? Tenderly bathing your breasts in a nice cozy dose of radiation?
Radiologists and oncologists are vociferous in denying that their diagnostic tools may precipitate or worsen the complex disease process involved in breast cancer.
Every individual story is an anecdote, but how many anecdotes make a pattern? I don't know; I'm not a scientist.
But I do know I would rather prevent disease than detect it. I also know that life has no guarantees or perfect answers. I make my own choices based on what seems appropriate to me, regardless of what the medical profession and government panels may decide.
The time to do something about cancer is long before abnormal cells go haywire. What is your diet? What supplements do you take? How do you manage stress?
Genetics are not cast-iron destiny. Changes in lifestyle can alter the body's complex processes at any age. But the cancer industry does not want you to break free from its grip. I do not want to continue hearing so much about "detection" when the urgent word is "prevention."
For every woman commenting whose annual mammogram finally found a cancer--how many mammograms had you undergone at that point? Five? A dozen? Tenderly bathing your breasts in a nice cozy dose of radiation?
Radiologists and oncologists are vociferous in denying that their diagnostic tools may precipitate or worsen the complex disease process involved in breast cancer.
Every individual story is an anecdote, but how many anecdotes make a pattern? I don't know; I'm not a scientist.
But I do know I would rather prevent disease than detect it. I also know that life has no guarantees or perfect answers. I make my own choices based on what seems appropriate to me, regardless of what the medical profession and government panels may decide.
The time to do something about cancer is long before abnormal cells go haywire. What is your diet? What supplements do you take? How do you manage stress?
Genetics are not cast-iron destiny. Changes in lifestyle can alter the body's complex processes at any age. But the cancer industry does not want you to break free from its grip. I do not want to continue hearing so much about "detection" when the urgent word is "prevention."
11
Thank you for this fine article, particularly pointing out the fact that no breast cancer experts were in the group making final recommendations, but an economist was.
I so appreciate your observation that "In the week since the cancer society issued the new guidelines, we have all encountered patients who said they were grateful that they’d benefited from early detection of breast cancer by mammography. Many expressed concern that their diagnoses would have been delayed under the new guidelines."
I for one don't intend to stop having annual mammograms, because of my age (most cancer cases occur in older women, cystic breasts, and a possible family history of breast cancer (my mother died from metastatic oral cancer too late for definitive biopsy of a breast lump she found a week earlier).
And as a woman, I can tell you I would gladly endure some days of anxiety over a call-back for additional tests and/or biopsy in the interests of catching cancer sooner rather than later. I can't imagine the agony of being diagnosed too late for something that could have been caught earlier.
October is "Breast Cancer Awareness Month". Ironic, isn't it, that of all months, the ACS decides to issue a major change in mammography guidelines that are not only confusing but also not supported by three doctors working in the trenches of breast cancer detection and numerous other medical societies.
I so appreciate your observation that "In the week since the cancer society issued the new guidelines, we have all encountered patients who said they were grateful that they’d benefited from early detection of breast cancer by mammography. Many expressed concern that their diagnoses would have been delayed under the new guidelines."
I for one don't intend to stop having annual mammograms, because of my age (most cancer cases occur in older women, cystic breasts, and a possible family history of breast cancer (my mother died from metastatic oral cancer too late for definitive biopsy of a breast lump she found a week earlier).
And as a woman, I can tell you I would gladly endure some days of anxiety over a call-back for additional tests and/or biopsy in the interests of catching cancer sooner rather than later. I can't imagine the agony of being diagnosed too late for something that could have been caught earlier.
October is "Breast Cancer Awareness Month". Ironic, isn't it, that of all months, the ACS decides to issue a major change in mammography guidelines that are not only confusing but also not supported by three doctors working in the trenches of breast cancer detection and numerous other medical societies.
2
Neither you nor the authors seem to get that the vast majority of "cancers" found through mammography are so small or indolent that they would never have been a threat to the woman's life. Yet, once one is told that they have the Big C, they are frightened into enduring whatever treatment is recommended, including double mastectomies. Of course, these "survivors" are grateful for the early detection. But no one ever told them the truth, all they got was hyped-up fear-mongering. Women should be able to have mammograms if they want them, but those who don't should not be treated as if they are insane and irresponsible.
I agree mammograms are necessary but genetic history and testing need to be accomplished first to determine if some women have a genetic disposition that make radiation mammograms give them an increased risk for breast cancer. I was diagnosed with breast cancer in May after I had found the lump through my own self check. I have undergone surgery and chemo therapy. I completed my chemo on 8 October. I had genetic testing during this process and found that I carry a genetic mutation called ATM. Radiation mammograms for women with ATM increased their risk for breast cancer. All of those yearly mammograms gave me cancer. I cannot receive radiation treatment for my breast cancer due to ATM. I now have to have a bilateral mastectomy. ATM also increases your risk for colon, ovarian, pancreatic and prostate cancers. Radiation for folks like me tip you into the cancer zone. Women should be given other methods of testing such as an ultra sound or MRI. Radiation Mammograms do not always find cancer. Women and men need to have genetic screening before we dose them on a yearly basis with radiation. Like I said, I found my cancer doing a self check. I believe in mammograms but all patients need alternatives to get this done after they are genetically screened.
2
I just want to make sure I have this straight. When it is climate change, if you question the science you are an idiot or worse. When it is vaccine safety, the state of California can pass a law that elimiates any parental choice in the matter and that's ok. But when it is a mammogram, your personal bias should overrule guidelines based on the current science. Is that about right?
And don't get me wrong, I think we should always question science. There's the old saying - half of what science "knows" is likely wrong, and the scientists don't know which half it is. It just irritates me when people use science to stifle debate in one instance, and then ignore science when it doesn't fit their own views.
And don't get me wrong, I think we should always question science. There's the old saying - half of what science "knows" is likely wrong, and the scientists don't know which half it is. It just irritates me when people use science to stifle debate in one instance, and then ignore science when it doesn't fit their own views.
4
There's nothing wrong with "questioning". However, there is no dispute among *reputable* scientists about the existence of climate change or the efficacy of vaccines.
In both areas, there is an overwhelming scientific consensus among people who work in the field, as well as an enormous amount of supporting, peer-reviewed literature.
In both areas, there is an overwhelming scientific consensus among people who work in the field, as well as an enormous amount of supporting, peer-reviewed literature.
I am much less concerned with the risk of false positives than with that introduced by exposure to this level of radiation every year. I wish the authors had addressed this risk, which is much more pertinent than that of false positives when assessing overall risk of cancer.
79
You're right to raise this issue. Typically, articles proclaiming the benefits of mammography do not address the risks of repeated exposure to radiation. We're meant to believe that it is negligible, but where is the evidence? Don't expect any rigorous attempt by the the mammogram "industry" to look for any any negative correlations.
I am a radiologist who has done breast imaging for the last 32 years. The radiation risk conferred by annual mammograms is miniscule and is not a reason to not get a mammogram. This is especially true in women over the age of 40 when breast tissue becomes much less sensitive to the carcinogenic effects of radiation. There has been no evidence of increased breast cancer incidence as a result of yearly mammography. I am a huge believer in mammography screening for breast cancer and have seen many, many patients have aggressive cancers found years before they would have become apparent on physical examination and who have been cured. To the naysayers who say that I only feel this way due to my financial interests, I say "Baloney!" (also recently found to be carcinogenic). As a radiologist, I can make a lot more money a lot more easily by reading CT and MRI full time but I do breast imaging as I find it to be one of the most rewarding things that I can do. I know that I cure cancers!
1
The radiation exposure from mammograms is not that significant.
http://www.radiologyinfo.org/en/info.cfm?pg=safety-xray
The risk is not that pertinent. You are exposed to natural "background" radiation all the time, all the more so when you fly where you get exposed to increase cosmic radiation.
Even something as common as granite counter tops are radioactive, and so are bananas which are great sources of potassium which is in a constant state of radioactive decay.
http://www.radiologyinfo.org/en/info.cfm?pg=safety-xray
The risk is not that pertinent. You are exposed to natural "background" radiation all the time, all the more so when you fly where you get exposed to increase cosmic radiation.
Even something as common as granite counter tops are radioactive, and so are bananas which are great sources of potassium which is in a constant state of radioactive decay.
1
It seems insane to recommend that doctors stop giving routine manual exams. What is lost by taking a minute or two to give an exam? Instead of giving up on manual exams perhaps we should do them as routinely as we check heart, lungs and blood pressure so older women are regularly monitored in a non-invasive, radiation free manner.
A sad commentary on how disconnected practicing physicians can be from the leading edge science, and how illiterate they can be in interpreting basic statistical epidemiology. The latest change in mammogram recommendations is a heartening sign that the medical field can respond to empirical evidence and pull back from overuse of procedures and tests in light of it, despite the overwhelming financial incentives to continue to do those procedures and tests.
11
You will not care for epidemiology or statistics that much, when you or loved one has breast cancer, which could have been detected by a timely mammogram.
Very well said!
I don't doubt that these providers' hearts are in the right places, but I greatly prefer my medical care to be based on accurate data rather than "gut feelings" and personal anecdotes.
And anyone (no matter how caring or careful they are) can be subconsciously influenced by financial incentives. It's disingenuous to pretend that medical providers are somehow immune from this basic human trait.
I don't doubt that these providers' hearts are in the right places, but I greatly prefer my medical care to be based on accurate data rather than "gut feelings" and personal anecdotes.
And anyone (no matter how caring or careful they are) can be subconsciously influenced by financial incentives. It's disingenuous to pretend that medical providers are somehow immune from this basic human trait.
This is a deeply flawed article which doesn't acknowledge many of the recent findings about the efficacy of screening mammography. The most recent Cochrane systematic review on the subject of screening mammogram found no overall or disease-specific mortality benefit to screening mammogram.
Gøtzsche PC, Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database of Systematic Reviews 2013,
Issue 6. Art. No.: CD001877. DOI: 10.1002/14651858.CD001877.pub5
Of the four adequately randomized and controlled trials which have been completed to date, no study has found a mortality benefit (overall or breast cancer specific) for screening mammography.
The authors mention that finding cancers earlier may reduced the extent of operation for detected lesions; however, they neglect the data that screening mammography significantly increases the number of unnecessary procedures for false positive results e.g. mast/lump (1.31 RR, 1.22-1.42 95%CI], as well as radiation [RR 1.24, 1.04-1.49 95%CI]. They also neglect our modern understanding of the biology of breast cancer; namely, that the majority of lesions found by screening are indolent lesions responsive to adjuvant therapy, while high grade lesions often go undetected and do not respond well to treatment when they are.
Mortality benefits proposed for screening are better explained by the introduction of tamoxifen/adjuvant therapy which also occurred around the time the screening program was introduced.
Gøtzsche PC, Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database of Systematic Reviews 2013,
Issue 6. Art. No.: CD001877. DOI: 10.1002/14651858.CD001877.pub5
Of the four adequately randomized and controlled trials which have been completed to date, no study has found a mortality benefit (overall or breast cancer specific) for screening mammography.
The authors mention that finding cancers earlier may reduced the extent of operation for detected lesions; however, they neglect the data that screening mammography significantly increases the number of unnecessary procedures for false positive results e.g. mast/lump (1.31 RR, 1.22-1.42 95%CI], as well as radiation [RR 1.24, 1.04-1.49 95%CI]. They also neglect our modern understanding of the biology of breast cancer; namely, that the majority of lesions found by screening are indolent lesions responsive to adjuvant therapy, while high grade lesions often go undetected and do not respond well to treatment when they are.
Mortality benefits proposed for screening are better explained by the introduction of tamoxifen/adjuvant therapy which also occurred around the time the screening program was introduced.
8
I've had breast cancer twice, the first one detected by a physician screening, which is one of the things the new guidelines discourage, and the second one detected by a routine annual mammogram. They were both small and treatable by lumpectomy and radiation; I did not need chemotherapy either time. I am very grateful for the early detection; I wouldn't have found either one on my own until, probably, much later and would have been subjected to harsher treatment options. I've also had a false positive that necessitated a biopsy, and truly I was not significantly distressed by that experience in the light of the other possibility.
1
They have to pay for these machines somehow!
5
The ACS is offering a public health recommendation based on statistical data. The contrary view is offered by specialists and interventionists who say nothing to refute the statistical findings. Likewise, you have comments from individuals whose lives may have been saved by early intervention. No one likes to think of themselves as a point in a data set but all of us are.
The authors mention in passing the lack of a bottomless pit of medical dollars but that is key to this discussion. From the public health perspective, the vast majority of women will die from something other than breast cancer. Dollars spent on ineffective screening are dollars not available to spend on other tests and interventions that will improve health and reduce mortality to a greater degree.
The authors mention in passing the lack of a bottomless pit of medical dollars but that is key to this discussion. From the public health perspective, the vast majority of women will die from something other than breast cancer. Dollars spent on ineffective screening are dollars not available to spend on other tests and interventions that will improve health and reduce mortality to a greater degree.
9
I hope women listen to this. I always routinely went in for a yearly mammogram. When I was 55 I found myself out of work, with no insurance and so skipped the test. The following year, newly employed, I went in for the test, they found a Stage 3 cancer, 5 cm long with 5 affected lymph nodes. 12 years later with excellent treatment and some luck, it hasn't come back. The Doctors said it had been growing for at least a year and a half. Could this cancer have been caught had I not skipped my annual mammogram. I think probably so. I also find the comments about the authors being motivated by greed to be overly cynical and out of line.
4
The authors make some valid points. everyone wants access to the right test at the right times read by the right Doctor. However, the ACS is using a major study to substantiate their recommendation. In Contrast, the authors are stating that Mammography is the only test proven to reduce the risk of dying from Cancer by 30%. What study are they referencing? The problem is that the taxpayers in the United states are balking about paying more to finance healthcare. Therefore, we need to make complex decisions about where the money is spent. IF a major study demonstrates that there is no need for annual testing which costs Millions of dollars, then the poicy makers are going to take action. If the Authors can demonstrate their point with a major study or prove a flaw in the latest study, then we will all listen. Minus the statistical evidence, we are left with their opinion. While their opinion is informed, it is not a fact. The major study has unveiled new facts.
3
WRONG. It is a cheap shot to accuse scientists who are trying to get the facts straight of trying to reduce costs. False positives can have very negative effects on patients. And the fact that the increased level of screening has discovered many additional cancers, but NOT REDUCED THE MORTALITY RATE demonstrates that widespread testing and the early detection of cancers that may or may not become significant is not as effective had been supposed.
16
The article ends: "Our goals remain clear: to detect breast cancer as early as possible and reduce the risk of dying from this disease. We and our many colleagues who are intimately involved in patient care will continue to recommend to women annual screening mammograms starting at age 40."
Funny, their goals do not include primary reduction of the incidence of cancer through prevention. As long as there is disease, there is treatment and as long as there is treatment, there is payment. And that fact compromises all other considerations and self-serving expressions of service.
This is not meant to judge these three doctors even though they are now mavericks. It is a statement that primary prevention is secondary to diagnosis and treatment which generate income. Stop smoking and cancer rates drop!
When America diverts funds to primary prevention, the need for the present allopathic model will end.
As for the annual mammogram, I was fortunate to know one of the leading mammography advocates, Dr. Philip Strax. He worked with HIP (of NYC) in the early 1970's to do study after study to show that mammography was a viable tool to detect breast cancer early and hence to save lives. Actually the term 'save lives' is an emotional term meant to gather support for all sorts of things. A more real and accurate term would be to postpone death often at terrible financial and personal costs. But no doubt extension of life is often preferred for many reasons.
Primary prevention!
Funny, their goals do not include primary reduction of the incidence of cancer through prevention. As long as there is disease, there is treatment and as long as there is treatment, there is payment. And that fact compromises all other considerations and self-serving expressions of service.
This is not meant to judge these three doctors even though they are now mavericks. It is a statement that primary prevention is secondary to diagnosis and treatment which generate income. Stop smoking and cancer rates drop!
When America diverts funds to primary prevention, the need for the present allopathic model will end.
As for the annual mammogram, I was fortunate to know one of the leading mammography advocates, Dr. Philip Strax. He worked with HIP (of NYC) in the early 1970's to do study after study to show that mammography was a viable tool to detect breast cancer early and hence to save lives. Actually the term 'save lives' is an emotional term meant to gather support for all sorts of things. A more real and accurate term would be to postpone death often at terrible financial and personal costs. But no doubt extension of life is often preferred for many reasons.
Primary prevention!
6
It is beyond ridiculous to state that the American Cancer Society changed its breast cancer screening guidelines in order to cut medical costs, Can we please dispence with this ugly libel?
This editorial contains so many half-truths, lies and twisted "facts" that it would take a very long commentary to address them all. One that really sticks out is the assertion that physicians who deal with breast cancer should issue guidelines for screening mammography. Screening is a primary care issue. Breast cancer doctors are not the ones who sent women for screening. Also, how much credibility would guidelines issued by self-interested parties have?
This editorial contains so many half-truths, lies and twisted "facts" that it would take a very long commentary to address them all. One that really sticks out is the assertion that physicians who deal with breast cancer should issue guidelines for screening mammography. Screening is a primary care issue. Breast cancer doctors are not the ones who sent women for screening. Also, how much credibility would guidelines issued by self-interested parties have?
11
When computers can read mammograms better than radiologists can, I wonder what reason the radiologists will come up with for not eliminating them from the process.
1
They have been trying to do that for decades already, and might succeed in next two decades, but by then science would have moved ahead, and simply identifying morphological differences in a monochrome image will not be enough.
Thank you, ladies, for speaking out. Please continue you important work.
"If you want to know if your house need painting, don't ask the house painter."--Warren Buffet
32
I don't know what your specialty is but I'll bet any amount of money that you would be very insulted if a patient said to you, "I can't trust your analysis of my problem because you get paid for treating me." What's good for your analysis of the geese's opinion is good for my analysis of the gander's.
While I applaud the author's dedication to saving lives I am somewhat taken aback by their decision to completely ignore the overwhelming statistical evidence that supports the ACS' recommendations. While it may seem that less screening would lead to more negative outcomes the data clearly indicates that the opposite is true. Also, the unfounded accusation that the panel's recommendations are driven b4y cost saving measures is, frankly, an uncalled for and unsupported touch of fear mongering.
8
Listening to statisticians, US economy is doing great, unemployment is near 5%, everything is hunky dory and Obamacare is a great success. Statisticians should be the last professionals who should be listened to for making these life and death decisions, not because statistics is a flawed science, but Statisticians and Economists can't be trusted. If you need proof, refer to MIT genius Gruber's testimonies regarding Obamacare.
All women are at risk of breast cancer....no matter the age. Contrary to negative opinions, annual mammograms DO save lives.
1
I should also note that the screening guidelines are most vociferously defended by associations of radiologists, in the face of systematic evidence. This is not surprising, considering that over $8 billion dollars are spent annually on mammography and this practice constitutes one of the largest revenue streams for radiology practices.
Aggregate Cost of Mammography Screening in the United States: Comparison of Current Practice and Advocated Guidelines
Ann Intern Med. 2014;160(3):145-153. doi:10.7326/M13-1217
Anecdotal evidence from patients who believe their "life was saved" by early detection are emotionally charged, but neglect the evidence that these lives were actually saved by the advent of effective chemotherapeutic approaches to these lesions.
In contrast, understanding of highly malignant tumors (e.g. triple negative breast cancer) suggests that these lesions are entirely different entities, they do not arise from pre-existing low grade tumors which can be detected early, and their poor prognosis results from poor response to chemotherapy/radiation and early metastasis.
It is the responsibility of doctors to explain these data to patients, because the notion of screening for low grade lesions is an intuitive one, yet this is a notion that is losing favor in a variety of cancers. In contrast, the practice of screening results in significant harm to patients through unnecessary procedures, without any clear statistical evidence for efficacy.
Aggregate Cost of Mammography Screening in the United States: Comparison of Current Practice and Advocated Guidelines
Ann Intern Med. 2014;160(3):145-153. doi:10.7326/M13-1217
Anecdotal evidence from patients who believe their "life was saved" by early detection are emotionally charged, but neglect the evidence that these lives were actually saved by the advent of effective chemotherapeutic approaches to these lesions.
In contrast, understanding of highly malignant tumors (e.g. triple negative breast cancer) suggests that these lesions are entirely different entities, they do not arise from pre-existing low grade tumors which can be detected early, and their poor prognosis results from poor response to chemotherapy/radiation and early metastasis.
It is the responsibility of doctors to explain these data to patients, because the notion of screening for low grade lesions is an intuitive one, yet this is a notion that is losing favor in a variety of cancers. In contrast, the practice of screening results in significant harm to patients through unnecessary procedures, without any clear statistical evidence for efficacy.
10
This issue reminds me of the issue we men face with Prostate testing. The PSA test is highly unreliable. Ask any Urologist about it, and you'll hear it is all we have to guide us to Biopsy's. If you don't have a invasive test, how in the world would you ever know if you have Cancer. Point is, my observation is, Doctors pay scant attention to guidelines. Physcians practice what hey were taught in Med school.
1
Medicine should be evidence based, not evidence based only when it supports our preconceived biases. The authors need to cite their sources, as large studies seem to contradict their arguments. Breast surgeons, and breast radiologists are unlikely to be able to be objective on this topic. They have obvious financial, and academic conflicts of interest. These American Cancer Society guidelines are based on careful analysis by epidemiologists and public health experts, some of whom are also oncologists.
Even allowing for the unlikely scenario that these three doctors are totally unaffected by conflicting financial and career incentives, their good intentions may be leading them astray. They are invested in their patients, and in treating young women with cancer, they are blinded by their own compassion. Public health is about making the rational decision which will benefit the most people.
We will not beat cancer with screening based on voodoo. We will only succeed in causing more anxiety, unnecessary complications and burn resources that could be better spent elsewhere.
Even allowing for the unlikely scenario that these three doctors are totally unaffected by conflicting financial and career incentives, their good intentions may be leading them astray. They are invested in their patients, and in treating young women with cancer, they are blinded by their own compassion. Public health is about making the rational decision which will benefit the most people.
We will not beat cancer with screening based on voodoo. We will only succeed in causing more anxiety, unnecessary complications and burn resources that could be better spent elsewhere.
6
I think this clarifies one side of the argument.
I accept that early capture of an existing cancer and treatment may not 'save' or extend more lives. But does the treatment that is given earlier result in better quality of life for most women - or for certain groups - undergoing treatment ? There are a lot of personalized reactions among doctors and women who may have seen women diagnosed late, who then required more disfiguring surgeries and harsher treatments.
I am now 68. My mother is 94. I would not like to miss a small bit of cancer because my life expectancy is 20 years plus and I want it to be as active as possible, so I am going to continue with mammograms unless there is a surer method to ruling out breast cancer w/o them. I also - again give age factors - would prefer - if I needed such treatment, to have it earlier rather than later because of my age.
I completely reject the argument that a false positive or need for repeat mammograms is so 'upsetting' as to influence guidelines.
I have absorbed concerns about overtreatment - and not just in breast cancer, and also that often there is no need to rush to action. We will, with continuing research and followup, continue to clarify which treatments are most useful and when. But i don't want insurance carriers to be able, based on the new recommendations, to call the shots and limit access.
I accept that early capture of an existing cancer and treatment may not 'save' or extend more lives. But does the treatment that is given earlier result in better quality of life for most women - or for certain groups - undergoing treatment ? There are a lot of personalized reactions among doctors and women who may have seen women diagnosed late, who then required more disfiguring surgeries and harsher treatments.
I am now 68. My mother is 94. I would not like to miss a small bit of cancer because my life expectancy is 20 years plus and I want it to be as active as possible, so I am going to continue with mammograms unless there is a surer method to ruling out breast cancer w/o them. I also - again give age factors - would prefer - if I needed such treatment, to have it earlier rather than later because of my age.
I completely reject the argument that a false positive or need for repeat mammograms is so 'upsetting' as to influence guidelines.
I have absorbed concerns about overtreatment - and not just in breast cancer, and also that often there is no need to rush to action. We will, with continuing research and followup, continue to clarify which treatments are most useful and when. But i don't want insurance carriers to be able, based on the new recommendations, to call the shots and limit access.
1
This article fails to address the potential risks of earlier and more frequent radiation exposure from annual screening mammograms starting at age 40, compared to those of the new ACS guidelines.
11
I've had exactly one mammogram and have no plans to have another. I've read enough to know that's it's unnecessary at best and has a high probability for false positives. Same with a colonoscopy and I'm not doing that either.
10
Perhaps if you had a mammogram that could not detect a lump in your dense, pre-menopausal breasts even when you could easily feel it, you would question the false sense of security that mammography can provide. As you would hear your story repeated by other women who found lumps before they were 40 who got clean mammograms, you would wonder about the number of women who had treatment delayed because of the failure of the detection method.
No, not data, but a point to consider contrary to all of the women who say that a mammogram hastened treatment. There is no way to count those that mammography resulted in a delay of treatment.
No, not data, but a point to consider contrary to all of the women who say that a mammogram hastened treatment. There is no way to count those that mammography resulted in a delay of treatment.
3
The ACS's guidelines also eliminate the need for doctors to physically examine breasts, which will relieve them of the burden of determining whether a woman’s breasts are dense or not. This is important because laws in five states require doctors to inform women if they have dense breasts. The reason for these laws is to educate women so they can get the right type of diagnostic test as mammography is not the best diagnostic tool for detecting cancer in dense breasted women. The ACS’s new guidelines are essentially an end-run around these laws. The answer is not no testing, but rather better testing.
1
Many states require that women be informed about dense breasts. Radiologists do that too, and the proper way is to automatically recommend MRI for these women.
After calcification was found over twenty years ago (which means I was around 40 years old), I had a surgical biopsy. No cancer was found. I've had an annual ever since. Last year everything was normal. This year calcification was again found in the left breast.
I had a stereotactic biopsy and I was diagnosed with DCIS, grade 2, ER and PR positive . I had a lumpectomy with a Margin Probe, a device which was supposed to enable the surgeon to determine my margins were clear. They were, except for one section that was too close for his comfort and three weeks later I had more tissue removed. This time the scar is significant.
Neither the radiologist nor the oncologist were pushing me for radiation or pill therapy, based on clear margins, localization, size of the DCIS, family history (DNA testing). After doing my own research, I decided on radiation (only), but a shorter course. I will now be monitored with mammograms every six months.
My point? It wasn't there last year, but it was there this year. Would it have been grade 3 a year later? Or, as my surgeon put it, escaped?
I had an Oncotype score of 15% probability of return. The radiologist said look at it as 85% you won't get it. I looked at it as 100 women in one room, 15 of us are going to get it. Those odds were too high for me.
It takes only one migrating cell. Why risk "releasing the Kracken"? BTW, the post mammogram does show some suspicious, but still too small to tell areas.
I had a stereotactic biopsy and I was diagnosed with DCIS, grade 2, ER and PR positive . I had a lumpectomy with a Margin Probe, a device which was supposed to enable the surgeon to determine my margins were clear. They were, except for one section that was too close for his comfort and three weeks later I had more tissue removed. This time the scar is significant.
Neither the radiologist nor the oncologist were pushing me for radiation or pill therapy, based on clear margins, localization, size of the DCIS, family history (DNA testing). After doing my own research, I decided on radiation (only), but a shorter course. I will now be monitored with mammograms every six months.
My point? It wasn't there last year, but it was there this year. Would it have been grade 3 a year later? Or, as my surgeon put it, escaped?
I had an Oncotype score of 15% probability of return. The radiologist said look at it as 85% you won't get it. I looked at it as 100 women in one room, 15 of us are going to get it. Those odds were too high for me.
It takes only one migrating cell. Why risk "releasing the Kracken"? BTW, the post mammogram does show some suspicious, but still too small to tell areas.
The authors also do not comment at all on the effects of the Health Care Reform Act on the "interesting timing" of these guidelines being issued. Perhaps the cost of all those "free" mammograms was higher than the geniuses in Washington anticipated?
I'm surprised and confused by the new guidelines. Basically, what they are saying is that since the mortality is not improved by screening it's ok to detect breast cancer at an advanced stage and make patients go through chemo/radiation/surgery rather than detect it early, most likely just have surgery to remove the lump or mastectomy (depending on type of cancer) just because the patients are going to die at the same time anyways? Is it that patients who had lumpectomies with early diagnosis mostly end up needing chemo/radiation due to microscopic metastasis that grow later on?
1
While the contributors addressed the risks associated with false positives, there is a statistical concern unaddressed with regard to early testing. Since everyone dies at some point, one has to decide what it means to extend life. So, the usual decision is that if the patient lives for some fixed number of years after detection and treatment, such as 10 years, then life has been extended. If a cancer is detected at age 40 and treated and the patient is still living at 50, then that is a success. Now suppose the patient dies at age 52 of something which can be attributed to having breast cancer. If that same patient had been tested later, say at 46, and treated then, the outcome would not count as a success. The same patient lived for the same number of years but because of early testing can be counted as a 'success' with no actual change in outcome.
1
In which the authors identify threats to their career earnings early, with an eye to preventing catastrophe later.
12
I'm alive today thanks to a routine mammogram that I had 10 years ago. Early detection matters. I was diagnosed at Stage 3. Had I been diagnosed earlier, perhaps I wouldn't have lost all of my lymph nodes (I really miss them! Without them, my arm swells up.). Perhaps I wouldn't have had to have so much chemotherapy (eight rounds over 4 months). Perhaps my small tumor (2 cm at diagnosis) wouldn't have morphed from an estrogen-sensitive tumor to a more aggressive HER2+ fueled tumor (which required an additional 1 year of infusions of Herceptin at a $100,000 cost to my insurance). So, yes, early detection matters. But I'm happy to be alive and cured, thanks to one mammogram and one very sharp-eyed radiologist.
2
Digital imaging requires increased levels of radiation, when compared to film. As an RN in an Imaging department, I was regularly called to intervene when the biopsy site bled excessively. While the authors of the piece make some valid points, between the extra exposure and complications of needle biopsies and lumpectomies, there are strong arguments for decreasing the frequency of mammograms in the absence of other factors (such as family history.) A fully informed patient should be able to weigh the pro's and con's and make a decision for herself.
5
Whatever the pros and cons argued for early mammograms, my late wife was diagnosed with breast cancer at the age of 28 by chance. She was applying for a green card and that was part of the process for it. If she hadn't had that test, there was no reason to think she had any kind of growth, and she would have gone many years before it was clear that she had malignant tumors. Given that experience, delaying mammogram testing until later in life could be a fatal error for some.
1
This article serves a useful purpose by warning people to watch out for doctors who present personal opinion and anecdotal experience as if it were fact.
12
Not sure I believe an article written by three women who make big bucks off women getting yearly mammograms....
21
This article would be more convincing if it weren't written by breast radiologists and surgeons, who benefit from a more intense testing regimen. (I don't think they're trying to be deceptive, but perspective inevitably shades opinion.)
13
Hmmm... Two radiologists and a breast surgeon, all of whom may lose income as a result of less screening. A bit of a conflict of interest here don't you think?
20
"Our goals remain clear: to detect breast cancer as early as possible and reduce the risk of dying from this disease." This lofty goal understates another huge and more common benefit of early detection. The earlier cancer is detected, the less awful its treatment protocol and the fewer the lifelong side effects, both physical and emotional. The benefits of early detection far outweigh the hassle of a call back for additional images. Survival should not be the only measure.
I'm currently 39 and going through chemo for stage 1 breast cancer. Being stage one, my chemo protocol does not threaten the same permanent side effects as faced by my later stage peers (permanent nerve damage to hands, feet and eyelids, permanent menopause, lymphedema, damage to eye sight and hearing, PTSD like emotional trauma and paralyzing fear of recurrence, physical disfiguration from radiation). With additional consideration given to these issues associated with later stage diagnosis, I believe the cost benefit analysis is very different.
I'm currently 39 and going through chemo for stage 1 breast cancer. Being stage one, my chemo protocol does not threaten the same permanent side effects as faced by my later stage peers (permanent nerve damage to hands, feet and eyelids, permanent menopause, lymphedema, damage to eye sight and hearing, PTSD like emotional trauma and paralyzing fear of recurrence, physical disfiguration from radiation). With additional consideration given to these issues associated with later stage diagnosis, I believe the cost benefit analysis is very different.
What I don't see here is the observation I have seen elsewhere. Digital mammography is able to detect tumors sooner.
This plays on both sides of the argument. 1) The data gathered to make the guideline changes was based on old style mammograms which were less good at seeing breast changes. 2) Going forward, current use of digital mammograms will give radiologists a better view of seeing smaller tumor they might have missed with the older technology. So, having mammograms every 2 years after age 55 might just be fine since they will see the smaller abnormalities sooner and don't need to rely on a yearly film.
This plays on both sides of the argument. 1) The data gathered to make the guideline changes was based on old style mammograms which were less good at seeing breast changes. 2) Going forward, current use of digital mammograms will give radiologists a better view of seeing smaller tumor they might have missed with the older technology. So, having mammograms every 2 years after age 55 might just be fine since they will see the smaller abnormalities sooner and don't need to rely on a yearly film.
Differences in opinion will not abate, just because the ACS has changed the recommendations in the start and the frequency of mammograms, so to make sense of its value in detecting breast cancer early, and yet, not 'break the bank' by a cost/efficiency ratio. One question, at least in my mind, remains, and that is the fact that mammograms are not the panacea either, given that aggressive carcinomas (those that, though small, already sent metastases at diagnosis, making any local and systemic treatments obsolete for a happy ending) may develop in the interval between the scheduled mammograms. My point, we need better methods to prevent, or at least delay, the development of cancer; and once present, find it at the earliest possible time; that is, before it spreads beyond the breast. Mammograms are fine but far from the ideal for finding the fast killers.
2
The main issue that is missing from this conversation is that of morbidity. Mortality is important, but quality of life is just as important. Early detection improves the chances of having a good quality of life after diagnosis and treatment. That matters A LOT and is rarely discussed.
1
True, Ann; if I were going to have unnecessary treatment, much better to suffer less morbidity.
Healthcare spending isn't infinite. It's a zero-sum game and when you spend money on unneeded procedures you deprive money for other needed procedures.
6
Sigh. When will we understand that mortality is not the only measure of successful cancer treatment.
Cancer for gynecological cancer that is treated with surgery is far less traumatic and life altering than later stage cancer which is treated with surgery and chemo/radiation. Cancer that has spread to the lymph nodes means that the survivor will always have an edge of anxiety that her cancer will come back.
And in more graphic terms, early treatment for gynecological cancers is far less damaging to a woman's sexuality than more invasive treatment for more advanced cases. This is an enormous quality of life issue. If you've never lost your capacity for feeling desire as the result of losing parts of your body, or the emotions which accompany intimacy with a beloved partner, you can't know how deep the grief can be when they are gone.
Real survival from cancer means that your spirit is alive, not just your body.
Cancer for gynecological cancer that is treated with surgery is far less traumatic and life altering than later stage cancer which is treated with surgery and chemo/radiation. Cancer that has spread to the lymph nodes means that the survivor will always have an edge of anxiety that her cancer will come back.
And in more graphic terms, early treatment for gynecological cancers is far less damaging to a woman's sexuality than more invasive treatment for more advanced cases. This is an enormous quality of life issue. If you've never lost your capacity for feeling desire as the result of losing parts of your body, or the emotions which accompany intimacy with a beloved partner, you can't know how deep the grief can be when they are gone.
Real survival from cancer means that your spirit is alive, not just your body.
2
As health care cost continue to rise precipitously with the AHCA, the government must do something to control costs before it's death spiral begins. Insurance companies are partly to blame, however their costs have also increased due to AHCA mandates. While the law may have been passed with good intentions, it is crumbling under the simple fact that it was a bad piece of legislation.
And next year the big hammer drops with the unconstitutionally delayed employer mandate implementation.
And with this mammogram recommendation, amongst others, the Independent Payment Avisry Board (death panel to some) will start making it's recommendations to reduce costs by reducing care. Time for a change.
And next year the big hammer drops with the unconstitutionally delayed employer mandate implementation.
And with this mammogram recommendation, amongst others, the Independent Payment Avisry Board (death panel to some) will start making it's recommendations to reduce costs by reducing care. Time for a change.
2
So much for shared decision making. The authors apparently know how every patient should balance the potential risks and benefits of mammography.
In a practical sense we should all appreciate guidelines that do not agree when the science is uncertain. It gives patients and physicians the leeway to make the decisions that make the most sense for the patient.
In a practical sense we should all appreciate guidelines that do not agree when the science is uncertain. It gives patients and physicians the leeway to make the decisions that make the most sense for the patient.
4
I haven't seen anyone in the comments take the side of a woman like me who had breast cancer (diagnosed at age 58) and am grateful for the tools that helped me to find it early. When you get the diagnosis, the first thing you want to know is how big is the tumor and has it spread to the lymph nodes. I had a particularly aggressive form (triple negative) and any time waiting to find/treat it would have made my situation completely different. I had no family history and never thought it would happen to me. When it did, I was glad that I was diagnosed in time to treat it.
1
The ACS is still recommending mammograms for women who are 58, so the new guidelines would not have impacted you at all.
1
Shellie F, I am sorry about your diagnosis. But there are comments from women like you who have had breast cancer diagnosed; I am one. Though unlike you, I had a huge family history, and was just afraid that this shoe would drop. But I am also a scientist by training, and I am consistently appalled by how little science and data guide the "practice and art" of medicine -- and those two words say it all. I am dismayed by the large number of women unnecessarily "treated" -- in my mind, mutilated and subject to pain and dangerous chemicals -- for no benefit. I wish us both all the best.
1
Doctors demanding the best healthcare possible - especially if others pay (and they get paid to provide it). Everything looks different if you look at the benefits and don't think about the costs.
3
Analogues in the PSA arena. Early & often testing incurs more costs, alarms, angst etc. but if you are the one with a true anomaly, then they (costs et al) are all worth it. The needs of the few outweigh the angst of the many.
2
Breast cancer survival studies have often been misinterpreted to make it seem that mammography is unimportant. The often-cited Canadian study [BMJ 2014;348:g366] actually said the mortality rates were similar ONLY if "adjuvant therapy for breast cancer is freely available.” That is because breast cancers found by mammography were much more likely to be at an earlier stage than those found by discovery of a breast lump. (Average size 1.4 cm [Stage 1] vs 2.1 cm [Stage 2]) and were HALF as likely to have metastasized to lymph nodes (16.5% vs 34.7%). So the mortality rates are similar ONLY if women whose breast cancers are discovered by feeling a lump undergo chemotherapy and/or radiation therapy. This is anything but an unimportant difference. Also, a more recent study in the British Medical Journal [BMJ 2015;351:h4901] found, contrary to assertions in the popular press, "Tumour size and nodal status still have a significant and major influence on overall mortality independent of age and tumour biology in the current era of more conservative surgery and newer systemic (neo-)adjuvant therapies Early stage at detection is vital; surgery is crucial." Quality of life is very important and survival, alone, may be too crude a measure of the importance of early detection and treatment.
5
Actually, AW, newer genomic testing (determining the activities of specific genes, some involved with cancer development) and genetic testing (looking for specific gene mutations which affect cancer outcome) are altering the landscape, for the better. They are beginning to refine pathology -- which includes tumor size, nodal status, and even stage. Some apparently innocuous cancers are actually quite serious, with the reverse perhaps true as well; this has been known for a long time as determined by outcome, but can now be determined early on by these tests, the results of which can help guide treatment decisions. We need much more of these tests, and even better ones.
Unbelievable. The ACS finally gets around to updating their guidelines, potentially reducing countless women's exposure to damaging radiation and unnecessary mutilating procedures, and now the NYT runs this irresponsible Op-Ed. Just unbelievable. One step up and fifty back.....
There is compelling evidence that mammograms detect harmless abnormalities and lead to harmful treatments that do not increase longevity. But fear runs rampant in our culture and the idea of detection trumps reason.
Does anyone really believe the ACS, a century-old institution that has led the way in cancer research and support, would issue recommendations that increase risk?
There is compelling evidence that mammograms detect harmless abnormalities and lead to harmful treatments that do not increase longevity. But fear runs rampant in our culture and the idea of detection trumps reason.
Does anyone really believe the ACS, a century-old institution that has led the way in cancer research and support, would issue recommendations that increase risk?
30
I think that if you don't include experts on a panel such as this, any institution, ACA or any other institution, will almost certainly come up with recommendations that will increase risk. The positions of the authors are supported by solid research. They are clearly more qualified from their extensive experience than an economist and 'public health expert'. It seems many of the commenters here simply take the side of the 'bean counters'. Perhaps you'll have another point of view when you or your wife or mother are afflicted with breast cancer.
"To be sure, breast biopsies can be temporarily painful, but when performed by experienced breast radiologists, the procedure is almost always minimally invasive, requiring only local anesthesia."
I have NEVER been offered anesthesia when having a mammogram, and they are always painful.
I have NEVER been offered anesthesia when having a mammogram, and they are always painful.
28
The writers are referring to breast biopsies, which as invasive surgical procedures involve anesthesia, not to mammograms.
3
A mammogram is not a biopsy. A biopsy is an invasive test where they go into the suspect area (with a needle or an incision) and take cell samples.
1
They said breast biopsies, not mammograms.
2
Full disclosure, my wife is the NYT subscriber. I’m a male radiologist in New Hampshire. I find the literature on the benefits of yearly screening mammography ambiguous. I find it difficult to sort the benefits of screening from advances in treatment. Mammography clearly has utility and a strong role in the diagnosis of breast cancer. However I have often wondered why if yearly screening beginning at age 40 is so critical then why is there not an epidemic of women dying of advanced stage breast cancers in other countries such as the United Kingdom where mammography screening is done every 3 years from age 50 to 70? I don’t believe that is the case. If it were, it would be a highly compelling argument for yearly screening as recommended in this opinion piece.
All that being said, as an accredited facility we follow American College of Radiology guidelines with yearly screening beginning at age 40.
All that being said, as an accredited facility we follow American College of Radiology guidelines with yearly screening beginning at age 40.
112
And what would you say to the family of the patient whose disease wasnt detected early becaase of limited access to mammorgrams. We are not talking about statistics but human lives. My wife was diagnosed with stage 3; she hadnt had a mamogram in several years - the result - 5 year ordeal with chemo/surgery/radiation/tamoxifen. After 5 years it came back; after three more years she was lost. I wouldnt wish my worst enemy to go through what she went through - just to avoid potential false positives. There is no doubt that earlier detection would have saved her life as the lymph nodes transported her cancer throughout her body before detection. And the mammogram - while certainly not perfect - remains the most viable tool for early detection. Yes the future of cancer treatments hold out a lot of hope that by the time my preteen daughter reaches adulthood she wont have to worry about annual mammograms becauase of genetic testing and gene-based therapy. But if anyone asks me - get a mammogram every year
I did that comparison using data available on line for mortality form breast cancer. Older women in England ARE dying at a higher rate than American women of the same age. For exactly this reason - they don't pay for older women to have mammograms. They cheerfully admit it.
1
"For example, women with cancers detected at smaller sizes are much more likely to be able to have a lumpectomy and less aggressive, less disfiguring surgery. In addition, the smaller the cancer, the lower the likelihood is that the disease may have spread to lymph nodes and elsewhere. In turn, this means there is less likelihood of needing aggressive treatment after surgery like chemotherapy and radiation"
I was diagnosed 6 years ago. My tumor was borderline, Stage 1 going on Stage 2 due to size, but I had no lymph nodes involved. I had a lumpectomy but I also had Chemo and Radiation. Now several years ago, I might have had the lumpectomy and that would have been it. I think the above statement is a bit misleading. From what I can tell, having spent time in Chemo suites and in Oncologists offices, the surgery followed by chemo and radiation seems to be the norm. I got a second opinion as well.
The bottom line is that many women will continue to think that the mammogram saved their life, even if the statistics don't bear that out; I have a feeling that perhaps my cancer might have been one that could be left alone (it was not Triple Negative for instance). My surgeon even told me that once researchers have the genomes of breast cancer and some day they will be able to tell what cancers can be left alone and what cancers need the surgery/chemo/radiation. But until then, do the mammagrams!
I was diagnosed 6 years ago. My tumor was borderline, Stage 1 going on Stage 2 due to size, but I had no lymph nodes involved. I had a lumpectomy but I also had Chemo and Radiation. Now several years ago, I might have had the lumpectomy and that would have been it. I think the above statement is a bit misleading. From what I can tell, having spent time in Chemo suites and in Oncologists offices, the surgery followed by chemo and radiation seems to be the norm. I got a second opinion as well.
The bottom line is that many women will continue to think that the mammogram saved their life, even if the statistics don't bear that out; I have a feeling that perhaps my cancer might have been one that could be left alone (it was not Triple Negative for instance). My surgeon even told me that once researchers have the genomes of breast cancer and some day they will be able to tell what cancers can be left alone and what cancers need the surgery/chemo/radiation. But until then, do the mammagrams!
55
A triple negative cancer is harder to treat but not treating a triple positive cancer, which is usually growing very rapidly, will most probably lead to an early death.
1
Not only triple-neg. or HER2+ cancers kill. An ER+ HER2- invasive ductal carcinoma (by far, the most common kind), may or may not be incurable if found beyond its earliest stages. Cytologic and genetic tests like Oncotype DX can determine that, with treatment then tailored to it. But the tumor itself, not the patient’s blood or saliva, gets tested; and for that it must first be detected. The only simple noninvasive ways to detect these tumors are mammography, ultrasound & MRI. (Those who gripe about the cost of mammograms would go apopleptic over a suggestion that all women receive baseline ultrasounds and MRIs--much less annual ones). To the commenter who finds it unacceptably “painful" to get her breast squished between glass plates: honey, the pain of cancer treatment, especially in later stages, makes a mammogram seem like trying on a swimsuit.
You who cite statistical data--do YOU see women with breast cancer? Do YOU or your loved ones have it? Data is abstract and inanimate. My tumor was caught while still small and nonaggressive, treatable without chemo, mutilation or long and full irradiation. It wasn’t there on last year’s mammo, but 1.3cm only a year later. How much bigger had it not been found till next year (and might it have spread)? Must we be told our lives are less important than statistics?
How dare you throw us under the bus in pursuit of cost-effectiveness!!!
You who cite statistical data--do YOU see women with breast cancer? Do YOU or your loved ones have it? Data is abstract and inanimate. My tumor was caught while still small and nonaggressive, treatable without chemo, mutilation or long and full irradiation. It wasn’t there on last year’s mammo, but 1.3cm only a year later. How much bigger had it not been found till next year (and might it have spread)? Must we be told our lives are less important than statistics?
How dare you throw us under the bus in pursuit of cost-effectiveness!!!
1
I am sure that these authors are excellent physicians (whether they are good mothers seems irrelevant to this column). But, like many physicians, they are borderline innumerate. Their grasp on the statistics is weak at best. The arguments they trot out in favor of yearly mammograms are the same ones that have been trotted out for years, and are largely missing the point. For example, this statement is meaningless: "A 2014 study that followed more than 7,000 Massachusetts breast cancer patients demonstrated that, sadly, of all the women who died of breast cancer, 65 percent had never had a mammogram and 6 percent hadn’t had one in the preceding two years."
What we want to know is how many of these deaths could have been prevented by mammograms, and this statistic can't tell us that. It sounds scary while being devoid of useful information. In reality, mammography reduces any individual woman's risk of dying from breast cancer by only 0.05%. Another way to look at this is that 2000 women have to be screened yearly for 10 years to prevent 1 death from breast cancer. This reflects the fact that most of the positive findings caught by mammograms were either never going to be fatal, or were going to be fatal long before a mammogram could detect them. Yes, there is *some* positive effect of mammograms. But mammograms' benefits are vastly oversold. And unfortunately, those who are doing the overselling often are making profits from them.
What we want to know is how many of these deaths could have been prevented by mammograms, and this statistic can't tell us that. It sounds scary while being devoid of useful information. In reality, mammography reduces any individual woman's risk of dying from breast cancer by only 0.05%. Another way to look at this is that 2000 women have to be screened yearly for 10 years to prevent 1 death from breast cancer. This reflects the fact that most of the positive findings caught by mammograms were either never going to be fatal, or were going to be fatal long before a mammogram could detect them. Yes, there is *some* positive effect of mammograms. But mammograms' benefits are vastly oversold. And unfortunately, those who are doing the overselling often are making profits from them.
70
Excellent comment!! Thank you.
1
The issue isn't whether mammograms are helpful. It's whether the resources spent on additional mammograms could be better spent on other illnesses, such as vaccinating children or conducting research into other diseases.
According to the research, it would require annual mammograms for 10 years for 10,000 women aged 40-49 to save five lives. Thus, it is straightforward that shifting resources to other illnesses would save more lives.
http://scienceblogs.com/insolence/2015/07/20/does-mammography-save-lives...
Specifically, in the United States, life expectancy for females is 81.2 years; for males, it's 76.4 years. That difference of 4.8 years. Thus, the resources should be shifted to other groups whose illnesses are less well treated than breast cancer. .
According to the research, it would require annual mammograms for 10 years for 10,000 women aged 40-49 to save five lives. Thus, it is straightforward that shifting resources to other illnesses would save more lives.
http://scienceblogs.com/insolence/2015/07/20/does-mammography-save-lives...
Specifically, in the United States, life expectancy for females is 81.2 years; for males, it's 76.4 years. That difference of 4.8 years. Thus, the resources should be shifted to other groups whose illnesses are less well treated than breast cancer. .
4
Thank you, for such a thoughtful essay! As an oncology social worker, I am extremely concerned that the insurance companies will start to enforce these new guidelines and to paraphrase you, poor women will die. I am always astounded by how these decisions are made! How bizarre, the insurance companies would rather spend hundreds of thousands of dollars on adjuvant therapies and possible end of life care then pay for prevention! Noone likes to be called back by the radiologist for more films, but I would personally go through that (and have) then find myself with metastatic disease. The other strange point is cancer risk increases as we age. These guidelines seem reckless to me. Thanks for advocacy and good work!!
3
peggym2, perhaps you should take some science and statistics courses; then perhaps you would not be so astounded by how these decisions are made. Mammography does not prevent breast cancer. Nor does it prevent death from breast cancer. I worry about your patients, if you bombard them with false information based upon ignorance.
1
If you truly feel that women should have access to yearly mammograms because it is life-saving and agree that reducing the cost burden on insurance companies to obtain this goal would be prudent, then make it a national mandate to stop requiring patients to obtain a prescription from their doctor (saves patient time/money as well as ins co), make radiology studies cash-only, lower the cost to say, $30-$40 per mammogram, $20 extra for additional studies if needed (not having to file a claim will save radiologist time, overhead and improve cash flow), have a national registry for all mammograms (and all radiology studies for that matter) so tracking and comparing previous studies can be done quickly using digital storage and sharing technology (will reduce costs by eliminating need for duplicate studies), and then have the radiologist review the results directly with the patient instead of forcing the patient to review it with their primary care or gyn physician which again would offer cost savings to both sides (patient and insurance)?
5
Cancer diagnostics today rely on far more than 40 year year imaging technologies and biopsies. Indeed far less invasive methods can and are identifying women at risk for various cancers, including forms of breast cancer. The authors fail to recognize that the science is moving forward in leaps and bounds and that, probably by the end of the decade, simple blood tests will be able to detect many cancers by virtue of DNA sequence "signatures". Relying on 20th century technologies for cancer detection will give us 20th century results.
2
Mammography does seem to make women less likely to die of breast cancer, but has never been shown to extend life. That's because women with mammography-detected tumors are much more likely to undergo unnecessary treatments -- treatments that increase the risk of dying from heart disease and other types of cancer.
7
Ah, but Ella, these increased treatments line the pockets of the doctors and their employers. As does screening in the first place. Money for the screening industry, and more patients funneled into breast cancer treatment.
1
I strongly recommend the NYT publish a follow up Opinion on this subject. The authors are very persuasive, and their credentials impressive. But, they fail to mention science's evolving understanding of cancer. We now have reason to fear that we are treating many people who have cancers that are not very dangerous with cancer treatments that are potentially dangerous. These cancers are detected by screening mammography. The lives we are saving may be offset by lives lost to unneeded cancer treatment side effects. I am not an expert on this topic. The NYT should publish an opinion from an medical scientist ( not a clinician who treats breast cancer) who is more knowledgeable that I on this subject for the benefit of its readers who may not read the "comments" section. I almost never do.
Steven Zawilla MD
Family Practitioner
Roseville, CA
Steven Zawilla MD
Family Practitioner
Roseville, CA
68
I think The Times should have required that the authors have been more explicit regarding their financial self interests in more frequent mammograms. Two of them are radiologists who obviously have a financial interest in more frequent mammograms being done as this is how they make their livings and the third an interest in more biopsies being done.
The Op-Ed would have been far more believable if written by experts who have no financial interests in promoting their viewpoints. And if people believe I am being unfair then why does The Times often criticize doctors for promoting medications from companies that pay them.
The Op-Ed would have been far more believable if written by experts who have no financial interests in promoting their viewpoints. And if people believe I am being unfair then why does The Times often criticize doctors for promoting medications from companies that pay them.
28
These doctors are totally financially biased and their recommendations are not based in real science.
18
They are Doctors. Sociology, Religion and Economics likely to not be areas of interest or knowledge. There are strong indications that more procedures, tests and exams are though to be good by doctors. They want to take actions to improve and save the lives of their patients. Given the choice between Doing or Not Doing, they generally will Do. To admit that you do not know what to do, is not a place a Doctor ever wants to be, so there is a strong bias to act. For better or worse.
5
This article rife with what I understand to be incorrect or misleading information. Mammography has not been show to reduce the risk of dying from breast cancer. It has increased number of years alive post-diagnosis, but that's pretty clearly because mammography picks up many indolent cell abnormalities (the misnamed ductal carcinoma in situ), many of which would likely never have become life threatening. In contrast, colonoscopy with polyp removal has led to significantly decreased rates of mortality from colorectal cancer.
30
Colonoscopy is also over-rated and scheduled too much. It too is not the gold standard that practitioners thought it was. Many studies show that those polyps do not become cancer, so there may be no benefits to their removal. Again, follow the money. There is a big infrastructure for that business too. Also, don't under-estimate the chance of getting a disease from instruments that were not sterilized properly.
1
You are so right - I was lucky to have my cancer (two different types in the same breast mind you) detected at a very early stage (it was detected by having annual exams that could be compared by the same doctor who noticed a very small difference -thank you Dr. Barbara Edelstein) . Both were invasive but neither spread to a lymph node. Every doctor I spoke with concurred that it was only a matter of time before the cancer spread - when not if - I avoided chemo and radiation after surgery - I was back to work relatively quickly and within months felt back to normal. From a cost, productivity and ongoing lifestyle perspective early detection and the avoidance of significant post treatment like chemo that clearly causes other issues -there is no way this wasn't the best course of action. Simple math -the cost of 500 mammograms equals the healthcare cost increase of a late stage vs. early stage cancer detection - this is in $ - more importantly the emotional stress and long term impacts to families as a result of a mother/wife suffering and/or dying due to late detection cannot be quantified that simply.
13
As usual, those in the business ignore the studies that show mammography is not the gold standard and doesn't save lives. In many cases it causes a lot of harm. Yes, there are many women who were treated in time to have a good outcome, but what about the women who were treated for cancer they didn't have? It's easy to have good statistics for cures when it includes those the medical profession is treating for breast cancer when in fact, none exists. That is malpractice.
There was an interesting study in Denmark where they compared those women at 65 who had yearly mammography to those who were having their first. The incidence of cancer was the same. According to these doctors, the first timers should have had a large number of cancers found, but they didn't. What does that say about over diagnosis?
There is a large industry built up around mammography which they are not going to give up easily. If women feel more comfortable exposing themselves to yearly radiation that is their choice. The current recommendations are for less scrutiny of the breast which will decrease unnecessary treatments, which is a plus for women. I dodn't expect those in the business to take this lightly, just as some GYNs think that yearly exams and pap tests are still necessary. I am sure the ACS was loath to have to make these recommendations but the statistics were so compelling.
There was an interesting study in Denmark where they compared those women at 65 who had yearly mammography to those who were having their first. The incidence of cancer was the same. According to these doctors, the first timers should have had a large number of cancers found, but they didn't. What does that say about over diagnosis?
There is a large industry built up around mammography which they are not going to give up easily. If women feel more comfortable exposing themselves to yearly radiation that is their choice. The current recommendations are for less scrutiny of the breast which will decrease unnecessary treatments, which is a plus for women. I dodn't expect those in the business to take this lightly, just as some GYNs think that yearly exams and pap tests are still necessary. I am sure the ACS was loath to have to make these recommendations but the statistics were so compelling.
21
So often we confuse the benefit ONE person received from an early mammogram and the benefit large groups of people received.
The same is true of using the PSA test for prostate cancer in men.
If YOU are, or you know, one person who benefits from early detection through early, frequent testing, then you favor early/frequent testing.
If you are a scientist and you find the amount of false positives that put many through the agony of fear and more testing, and look at the total number of lives saved or extended through early testing and find that number insignificant for statistical purposes, you do not favor early/frequent testing.
One life saved versus lives made miserable by mistakes versus the total cost?
I still wanted all the tests possible. At 73 the issue is moot for me since no more mammograms will occur unless I ask. I CAN ask, of course.
The same is true of using the PSA test for prostate cancer in men.
If YOU are, or you know, one person who benefits from early detection through early, frequent testing, then you favor early/frequent testing.
If you are a scientist and you find the amount of false positives that put many through the agony of fear and more testing, and look at the total number of lives saved or extended through early testing and find that number insignificant for statistical purposes, you do not favor early/frequent testing.
One life saved versus lives made miserable by mistakes versus the total cost?
I still wanted all the tests possible. At 73 the issue is moot for me since no more mammograms will occur unless I ask. I CAN ask, of course.
4
I'm an internist with some extra training in epidemiology. I love the genuine concern I see from my radiology and surgery colleagues but it's not see their view as unbiased. As a primary care doctor, I see mostly the normal range of people in the population. As specialists who are referred cancer patients, they see a skewed sample of the population who gets breast cancer so to them it is going to look like breast cancer is lurking around every corner. It is very similar with my urology colleagues and prostate cancer. This is not solely about economics... the United States Preventative Service Task Force, which is one of the most credible societies in medicine has weighed in on the data and mammogram is just not a good screening test. It causes harm and doesn't save lives at the rate of testing being espoused. As a favorite basketball player of mine, Rasheed Wallace, once said, "the ball don't lie". In this case, it is the data that doesn't lie.
249
Dr Sharma
I think you need to get your data straight and stop looking at absolute garbage research like the Canadian mammography study which was done with poor quality equipment, untrained technologists and terrible technical standards as well as biased entry into the study, upon which many epidemiological types base their biased opinions on mammography and its efficacy. Results of this study continue to be published in the New England Journal despite a mountain of criticism from many camps because the public health and epidemiology communities are much more biased on this issue than those of us in the front lines. As a breast radiologist, I do not breast cancer patients referred to me. I find breast cancer on screening mammography in otherwise asymptomatic patients, diagnose them and then refer on to those specialists who will care for them . Does breast cancer lurk behind every corner in my world? Absolutely not. I find 5-7 cancers for every 1000 screening mammograms. The USPSTF is not a credible organization as it has put out guidelines without any input from radiologists, surgeons or oncologists. I do this every day. I save lives, find cancers and don't do harm while I do it. And I don't quote that great medical scholar, Rasheed Wallace, while doing it.
I think you need to get your data straight and stop looking at absolute garbage research like the Canadian mammography study which was done with poor quality equipment, untrained technologists and terrible technical standards as well as biased entry into the study, upon which many epidemiological types base their biased opinions on mammography and its efficacy. Results of this study continue to be published in the New England Journal despite a mountain of criticism from many camps because the public health and epidemiology communities are much more biased on this issue than those of us in the front lines. As a breast radiologist, I do not breast cancer patients referred to me. I find breast cancer on screening mammography in otherwise asymptomatic patients, diagnose them and then refer on to those specialists who will care for them . Does breast cancer lurk behind every corner in my world? Absolutely not. I find 5-7 cancers for every 1000 screening mammograms. The USPSTF is not a credible organization as it has put out guidelines without any input from radiologists, surgeons or oncologists. I do this every day. I save lives, find cancers and don't do harm while I do it. And I don't quote that great medical scholar, Rasheed Wallace, while doing it.
It is unfortunate that such experienced breast radiologists and an academic mastologist have such difficulty understanding or accepting the evidence that previous ACS guidelines led to overscreening and overtreatment.
ACS has lagged other organizations in facing the evidence, but belatedly is moving its recommendations closer to USPSTF and ACP guidelines.
Public health officials, passionate practitioners, and civil society organizations should focus their energies on getting women in the target age range who have never had a mammogram or haven't gone in several years to get one.
Women (and men) in their 30s and 40s would do more to contribute to reducing breast cancer morbidity and mortality by first encouraging their mothers to get a mammogram.
Health professionals should devote more effort to obtaining family histories of breast, ovarian, and other cancers. We need to make genetic counseling, inexpensive genetic panel testing, and targeted non-ionizing radiation surveillance (ultrasounds and MRIs) available to women who are unequivocally at increased risk.
Finally, although intended for the U.S. population, ACS guidelines influence what health professionals do in other countries where the age-adjusted incidence of breast cancer is lower. Public health systems in countries with limited resources need to promulgate screening guidelines appropriate for their breast cancer incidence, so that available screening and diagnostic resources do the most good.
ACS has lagged other organizations in facing the evidence, but belatedly is moving its recommendations closer to USPSTF and ACP guidelines.
Public health officials, passionate practitioners, and civil society organizations should focus their energies on getting women in the target age range who have never had a mammogram or haven't gone in several years to get one.
Women (and men) in their 30s and 40s would do more to contribute to reducing breast cancer morbidity and mortality by first encouraging their mothers to get a mammogram.
Health professionals should devote more effort to obtaining family histories of breast, ovarian, and other cancers. We need to make genetic counseling, inexpensive genetic panel testing, and targeted non-ionizing radiation surveillance (ultrasounds and MRIs) available to women who are unequivocally at increased risk.
Finally, although intended for the U.S. population, ACS guidelines influence what health professionals do in other countries where the age-adjusted incidence of breast cancer is lower. Public health systems in countries with limited resources need to promulgate screening guidelines appropriate for their breast cancer incidence, so that available screening and diagnostic resources do the most good.
9
Happily, I am the recipient of some of America's finest single payer healthcare at the VA. I love my VA doc and she and I have had long conversations about this. The science is perfectly clear, early detection does not extend life. In low risk women, the morbidity and anxiety associated with aggressive screening in no way makes up for the catching early breast "cancers" that may never develop into anything at all except a source of income for the breast cancer industrial complex. No thank you. There's never been a case of breast cancer in my family and I will not support an industry that plays so hard on fear and pinkwashes the reality that if you are poor and have cancer in America, it kills you no matter when you caught it.
10
That could have been my mother speaking. No family history. I'll never get it. She never had a mammogram until she had aggressive breast cancer that eventually killed her. Did you know that the vast majority of women with breast cancer have no family history of it?
There is a third option: Have annual screenings, but instead of using traditional x-ray based mammography, use infrared thermography instead. Unlike x-ray screening technology with its associated hazards and side-effects, IR screening is an effective and non-invasisve alternative.
2
No, that would be making the situation worse, not better. At least mammography has a lot of data to show that its effect is marginal at best (and harmful for many women). Thermography does not have that strength of data behind it. Let's talk about thermography once a 10,000 randomized clinical trial showing its benefit (and safety) has been done. Until then, it is quackery.
2
"while there were medical specialists involved in an advisory group, the panel actually charged with developing the new guidelines did not include a single surgeon, radiologist or medical oncologist who specializes in the care and treatment of breast cancer. Not one".
That statement tells me everything I need to know. Thank you.
That statement tells me everything I need to know. Thank you.
3
Yes, but surgeons, radiologists and medical oncologists don't do epidemiological studies. They are in the trenches, fighting. They don't look up too often to see what the entire population is like with regard to mammography. They don't have time to read those studies--and it probably wouldn't be in their best interest (or of any interest to them) anyway.
2
MIght it just be possible for the "medical community" to offer guidelines which are completely clear, peer-reviewed and accurate? Is that too much to ask? This constant, "well, but..." that streams out of medical organizations of all sorts does nothing but harm people, in real ways - people make skip screenings - and in incalculable ways, as people may simply stop trusting the "experts," since they don't seem to agree on anything!
I think we are at a point where a lot of people don't believe what hospitals and doctors tell them, because they know that they work on a fee-for-service basis, so that every extra x-ray, operation and office visit feeds their bottom line.
I think we are at a point where a lot of people don't believe what hospitals and doctors tell them, because they know that they work on a fee-for-service basis, so that every extra x-ray, operation and office visit feeds their bottom line.
12
The authors do not comment at all on an important rationale behind the new recommendations. Mammography identifies many lesions that will never become aggressive, leading to further testing and treatment. Such "overdiagnosis" leads to high "survival" rates, without actually reducing the rate of breast cancer mortality.
Focusing on breast cancer mortality led to the conclusion that aggressive screening with mammography has not had much impact. In this context, reducing the frequency of testing, which reduces the high rates of false positive results and follow-up testing, seems eminently reasonable.
Focusing on breast cancer mortality led to the conclusion that aggressive screening with mammography has not had much impact. In this context, reducing the frequency of testing, which reduces the high rates of false positive results and follow-up testing, seems eminently reasonable.
126
As I prepare myself for my second round of chemotherapy tomorrow, I consider myself truly, deeply fortunate that a routine mammogram resulted in a follow-up biopsy, which detected a tumor in my breast. No one wants to hear the news that she or he has breast cancer. But not knowing? That's worse.
105
Many women with breast cancer who attribute their lives to having a mammogram have responded to this new policy with this kind of perspective. But the new guidelines do recommend routine mammograms, just not as early or as frequently *for women who are not high risk.* Statistically, the studies show that this practice would have picked up cancer and provided the same survival outcomes that you have experienced.
1
I appreciate your concern. However, the problem you face, like many women before you, is that there is no way of knowing, at the time of diagnosis, whether your breast cancer cells would have ever hurt you, or if you would have died at the age of 90 (with those malignant cells) from a heart attack. That is the concept of overdiagnosis, and it is a very important one.
You may feel like mammography saved your life, but you can't actually know that. And that is precisely the problem.
You may feel like mammography saved your life, but you can't actually know that. And that is precisely the problem.
3
Very persuasive. Thank you.
Women who disagree with the authors are free to start screening later, do it less often, or skip it altogether. However, the change in guidelines will likely affect insurance coverage, limiting choices for all women. Given the composition of the advisory group, it's clear that the change was primarily motivated by efforts to cut costs.
Lastly, I find the argument that callbacks for false positives cause women stress to be particularly infantilizing.
Women who disagree with the authors are free to start screening later, do it less often, or skip it altogether. However, the change in guidelines will likely affect insurance coverage, limiting choices for all women. Given the composition of the advisory group, it's clear that the change was primarily motivated by efforts to cut costs.
Lastly, I find the argument that callbacks for false positives cause women stress to be particularly infantilizing.
35
"Given the composition of the advisory group, it's clear that the change was primarily motivated by efforts to cut costs."
You assertion is unfair and developed without any idea of the deliberations involved. This kind of 'court of public opinion' (read not informed) is half the problem with trying to solve our challenges. You are free to do as you wish, but just making stuff up is not the answer.
You assertion is unfair and developed without any idea of the deliberations involved. This kind of 'court of public opinion' (read not informed) is half the problem with trying to solve our challenges. You are free to do as you wish, but just making stuff up is not the answer.
7
Maybe not callbacks, but unnecessary treatment do cause stress. It is qjuite patronizing on the part of physicians that directly benefit from more screening to assume that all the false positives and unneeded treatments are harmless.
Obviously it is intensely stressful to be told you have cancer and to be treated for it? What if the treatment was never needed? This is the case with a lot of breast cancer, as has been shown in large scale studies. Thus stating that more screening and more treatments are always better is rather self-serving on the part of the authors.
Obviously it is intensely stressful to be told you have cancer and to be treated for it? What if the treatment was never needed? This is the case with a lot of breast cancer, as has been shown in large scale studies. Thus stating that more screening and more treatments are always better is rather self-serving on the part of the authors.
2
I agree. Breast cancer or at least talk of breast cancer is so pervasive, I considered it just a matter of time. Also, because it was DCIS, I didn't have the panic of a woman diagnosed with a tumor (my primary care doctor remarked on how calm I seemed); however, I found it still very hard to make decisions because it was DCIS (as opposed to its a metastatic tumor or a tumor that's going to spread just when, not if, as you put it.) It was the decision-making that made me a little crazy, not the fact that I had it.
I ended up having stress, but it was stress of sorting through conflicting data than my thinking I'm going to die any minute. And, yes, I considered whether or not the treatment I picked (radiation) would cause heart, lung, and even a metastatic cancer later. I did op for a 4 week course (than the routine 6 weeks), which hopefully lessened any side effects from the treatment.
To my mind, I had something that was caught that upped my odds (versus having nothing) of getting something worse down the line. What woman, who has the chance to at least know they have an increased chance of developing a worse form of cancer, not want to know...puddle of goo or not?
According to my DNA (and family history), I shouldn't have gotten squat. But I did anyway, didn't I? And the doctors still can't tell me if the DCIS would have just stayed there or not. After all, it didn't start as a Grade 2 did it? In the end its *our* lives, no one else's.
I ended up having stress, but it was stress of sorting through conflicting data than my thinking I'm going to die any minute. And, yes, I considered whether or not the treatment I picked (radiation) would cause heart, lung, and even a metastatic cancer later. I did op for a 4 week course (than the routine 6 weeks), which hopefully lessened any side effects from the treatment.
To my mind, I had something that was caught that upped my odds (versus having nothing) of getting something worse down the line. What woman, who has the chance to at least know they have an increased chance of developing a worse form of cancer, not want to know...puddle of goo or not?
According to my DNA (and family history), I shouldn't have gotten squat. But I did anyway, didn't I? And the doctors still can't tell me if the DCIS would have just stayed there or not. After all, it didn't start as a Grade 2 did it? In the end its *our* lives, no one else's.
1
I would imagine that a breast Radiologist is the last person to recommend fewer screenings -their livelihood depends of more and more people subjecting themselves to mammograms.
56
Amen. Better a false positive than an undetected Stage 1 cancer that, after two or three years, becomes a Stage 3 or 4. I am still alive because my annual mammogram detected a nasty, aggressive cancer. The previous year's mammogram showed nothing out of the ordinary. This is just one woman's tale but, I've heard variations on this from women friends all over the world--many, many times in the last year.
124
No - you very well may be alive because your particular cancer was probably not going to kill you whether you found it when you did or earlier. That is part of the point of this recommendation.
1
In the end it was other women's stories and a European study that compared doing something, doing a little something, and doing absolutely nothing that showed doing something had significant better results that made me opt for radiation.
1
My story is similar to your's, Irene. I had a normal mammo one year and the next year I had an abnormal one. One tumor was found during a biopsy, the second, less than 1mm from my chest wall, was found during my mastectomy. I was fortunate to have an aggressive surgeon. But if I had had to wait another year, there was no doubt that my lymph nodes would have been affected and who knows what else. I consider myself to be extremely lucky to have had the doctor that I did. That was in 1999, and I have had no further problems. Knock wood!
1
These drs. consider the benefits but not the costs. It is easy to argue for any intervention when you do this. I'm not saying they're obviously wrong; just that they are entirely unconvincing here.
Obviously the new guidelines are going to be bad for business for these three. I can't help but wonder if that is motivating their concern, or at least biasing sound judgement. It also probably provides a reason for their not being such a person on the board that made the decision to change the rules---would you have an auto industry exec decide what the standard for fuel emissions should be? You don't need to know how to perform a surgery to evaluate its effectiveness.
Obviously the new guidelines are going to be bad for business for these three. I can't help but wonder if that is motivating their concern, or at least biasing sound judgement. It also probably provides a reason for their not being such a person on the board that made the decision to change the rules---would you have an auto industry exec decide what the standard for fuel emissions should be? You don't need to know how to perform a surgery to evaluate its effectiveness.
32
Do these authors have any financial stake in women getting frequent mammograms?
22
Their business depends on it! The reasoning for recommending fewer mammograms was that it leads to unnecessary and risky procedures----which are performed by specialists such as these docs!
2
Massive studies (90,000 women over 25 years) have examined the morality benefits of mammography, and have found that mammograms confer no reduction in mortality from breast cancer or any other cause:
http://www.nytimes.com/2014/02/12/health/study-adds-new-doubts-about-val...
I don't know where the authors got their data that mammograms "reduce the risk of dying from breast cancer, by up to 30 percent." Perhaps they'd like to cite to their source for this claim? Was it a small study from many years ago, before tamoxifen was developed? Does it simply compare different countries without any further analysis (a textbook definition of the ecological fallacy)?
Cancer obviously is an emotional topic, but this is all the more reason for us to focus on data -- big studies conducted over many years. We should also note carefully that the authors of this article make money by diagnosing and treating breast cancer, and that they get paid whether their diagnoses and treatments provide actual benefit or not.
E. Wong
Master of Public Health, Harvard University, 2013
http://www.nytimes.com/2014/02/12/health/study-adds-new-doubts-about-val...
I don't know where the authors got their data that mammograms "reduce the risk of dying from breast cancer, by up to 30 percent." Perhaps they'd like to cite to their source for this claim? Was it a small study from many years ago, before tamoxifen was developed? Does it simply compare different countries without any further analysis (a textbook definition of the ecological fallacy)?
Cancer obviously is an emotional topic, but this is all the more reason for us to focus on data -- big studies conducted over many years. We should also note carefully that the authors of this article make money by diagnosing and treating breast cancer, and that they get paid whether their diagnoses and treatments provide actual benefit or not.
E. Wong
Master of Public Health, Harvard University, 2013
485
I do not understand why you think early detection is not suppose to save lives. It certainly saved mine. I am not a statistical round off error. I am a human being!
3
This is exactly correct. No one disputes that mammograms discover tumors earlier than manual manipulation, but there is absolutely no difference in longevity between the two. This 30 percent "zombie" figure just keeps reappearing, and only proves how few people understand how to read a statistical analysis.
We need to stop perpetuating a test that has resulted in unnecessary treatment for far too many women.
We need to stop perpetuating a test that has resulted in unnecessary treatment for far too many women.
10
Have you actually read these papers?
I've read almost every study done on this topic. Most of those studies, conducted over many years, were based on film data, not digital data. Would you want your diagnoses based on X-rays when CT scans could prevent either missing a cancer or ensuring that there wasn't one? I don't think so. Well, mammogram recommendations based on film data are just as silly.
I've read almost every study done on this topic. Most of those studies, conducted over many years, were based on film data, not digital data. Would you want your diagnoses based on X-rays when CT scans could prevent either missing a cancer or ensuring that there wasn't one? I don't think so. Well, mammogram recommendations based on film data are just as silly.
2
So if you look at the specialties of the physicains writing this article, it is pretty clear that they are probably not unbiased in their opinions. In fact, radiologists have the most to loose from the new guidelines, and surgeons, who perform a lot of the biopsies that turn out to be false alarms, the second most. At least surgeons are involved with the patient in discussing the findings of the biopsies from the false positive mammograms. The radiologists, however, never really have to deal with the anxious patients beforehand, or some of the angry patients after.
And in my 20 year career in Internal Medicine, the guidelines have never advised annual screening starting at age 40. The recommendation was for a mammogram every 2 years starting at 40 and then annually at age 50. The breast tissue of many women in their 40's is too dense for mammography to provide an accurate interpretation of any abnormalities seen.
So the new recommendations really aren't solely about cost, as the authors seem to suggest, though it certainly will impact their bottom line. I think women should wait until more clinicians/specialists involved in breast cancer care weigh in and then have a conversation with their personal physician to weigh the pros and cons of the new guidelines and make the decision appropriate for their individual situation.
And in my 20 year career in Internal Medicine, the guidelines have never advised annual screening starting at age 40. The recommendation was for a mammogram every 2 years starting at 40 and then annually at age 50. The breast tissue of many women in their 40's is too dense for mammography to provide an accurate interpretation of any abnormalities seen.
So the new recommendations really aren't solely about cost, as the authors seem to suggest, though it certainly will impact their bottom line. I think women should wait until more clinicians/specialists involved in breast cancer care weigh in and then have a conversation with their personal physician to weigh the pros and cons of the new guidelines and make the decision appropriate for their individual situation.
41
Interesting that every time I have seen an article decrying the now numerous studies from unbiased, learned institutions giving reasons for fewer mammograms, they are written by breast radiologists or oncologists? Could it possibly have to do with their easy income from these procedures?
80
Mothers of the Year? Frankly, I'm not impressed with the title or the title holders' cherry picked arguments.
The fact is you would have to screen 1,000 forty year old women every year for ten years in order to "save" one woman's life. You are far more likely to be overdiagnsed and overtreated for a breast cancer that never would have harmed you than you are to have your life "saved." This is one of the leading reasons why the US has the world's highest per capita healthcare expenses but the worst healthcare expenses in the developed world.
The fact is you would have to screen 1,000 forty year old women every year for ten years in order to "save" one woman's life. You are far more likely to be overdiagnsed and overtreated for a breast cancer that never would have harmed you than you are to have your life "saved." This is one of the leading reasons why the US has the world's highest per capita healthcare expenses but the worst healthcare expenses in the developed world.
195
Perhaps if your life had been saved, as mine was, by early detection of a very aggressive cancer, you would feel differently.
77
And what if the one "saved" woman is you? (8 years ago it was me.)Or your sister? Or your daughter? Still willing to play the odds?
12
@madrona: I'm glad you had a good outcome. This should not affect the way you look at these new guidelines. Really good studies show no better outcomes for breast cancer with early and annual screening. It is thus extremely unlikely that your "life was saved" by the old recommendations. Furthermore, and much more uncomfortably, studies show that tens of thousands women diagnosed with breast cancer and who went through chemo and radiation and who identify as cancer survivors *never needed to do so* because their cancer was either a false positive or in a category unlikely to progress. The "pink ribbon" movement has encouraged heavy identification with breast cancer survivorship in a way that may be obscuring clear-eyed discussion about this issue.
22
Overemphazising false positives? My wife had a false positive, the doctor scared her half to death. Which is basically what doctors do.
Sorry you two sound to me more like people protecting a revenue stream than anything else.
The one thing I know for sure. After her false positive my wife has said she would never put herself in that position again.
Sorry you two sound to me more like people protecting a revenue stream than anything else.
The one thing I know for sure. After her false positive my wife has said she would never put herself in that position again.
130
Then again, after 8 years of annual mammograms with NO breast cancer family history, a tumor was found at age 48. So small I didn't have any lymph node involvement. So small that after a lumpectomy, and 3 weeks of Mon-Fri radiation before work I did not need IV chemotherapy. It's been 8 years. I don't know what the future holds but I am grateful for annual mammogram. Your wife has a choice and must live with the consequences of her choice.
2
I feel for your wife, my experience was quite the same. My doctor wasted no time giving me a mammogram at 36 (with no history of cancer, really?) but took his sweet time telling me my positive test was false. 9 weeks I waited to find out my status - never, never again!
1
sandis, neither you nor Mike Melcher's wife know the consequences of your choices -- except as statistical probabilities. You cannot tell in advance what your particular outcome will be. But I wish the both of you the best, and I think that Mike Melcher's wife has made a good sound decision. If she detects a lump herself that is cancer, she can be treated at that time, with no apparent deleterious effect on her outcome.
4
A well written article, although coming from breast radiologists and surgeons, this interventionist attitude is to be expected. What the authors of this article fail to mention is the ACS/USPSTF recommendation that screening recommendations be individualized to reflect a woman't values and preferences. Of course, until such time when good risk assessment tools are widely available to patients and their physicians, emotional factors will continue to play a big role in the decision to screen aggressively or not.
14
Radiologists are against fewer mammograms? There's a shocker. Let the science govern. Plus, in my experience, no one except the patient is looking out for the cumulative effects of radiation - because no doctor ever got sued for ordering 1 more mammogram, CT, x-ray, etc. - it'll be years before any effect, it's cumulative, and no way to prove any one test caused anything - even if statistically, it does lead to increased risk.
146
Thank you! Is this funded by insurance companies? Because who is benefiting from this guideline. And the cost of treatment is so much more than the cost of prevention. Physical exam is unnecessary? Are they kidding?
Were there any medical minds working on this guideline?
Were there any medical minds working on this guideline?
21
And you don't think the authors of this article, and other doctors like them, are benefiting from MORE mammography? Everyone's making money here and nobody's argument, on either side, is altruistic, I promise you.
5
The authors of this op-ed benefit from the old guidelines. And the cost of prevention screening increased the costs of treatment overall0, especially if the screening (which it does) causes treatment of lesions that would have never required treatment.
3
I'm convinced. Thank you for putting patients above economics.
15
Au contraire: if you're a breast radiologist (as are two of the authors), the economics of continuing frequent mammograms are very much in your favor. In our (perversely incentivized) health care system, you earn money as a physician by charging for procedures; what this means is that if you are a breast radiologist, every mammogram is money in the bank. I'm not saying the authors' motives can be cynically reduced to economics, but they are prominent figures in a specialty that benefits enormously from frequent mammography. That is why impartial data is important in making determinations like this, and this article is scant on it.
5
Two of these three writers are radiologists who presumably profit off of mammograms, so the idea that they are putting patients above economics isn't convincing. They may have the purest intent and be completely right, but they are hardly putting their economic interests at risk with their assertions.
2
Performing medically unnecessary tests (that individuals will likely never benefit from) is not "putting patients first".
You have to factor in the downsides of false positives and over-treatment-- e.g., unnecessary out-of-pocket costs, unnecessary anxiety, unnecessary (and potentially painful) biopsies, etc.
You have to factor in the downsides of false positives and over-treatment-- e.g., unnecessary out-of-pocket costs, unnecessary anxiety, unnecessary (and potentially painful) biopsies, etc.
All these authors work either in radiology or breast cancer treatment. It's an ugly fact that incentives matter, and those individuals whose careers may be impacted by this prudent change in guidelines will naturally argue against it. Notice though, that they are unable to argue against the data, which shows definitively that despite the increase in diagnoses, breast cancer mortality has failed to decline.
309
Actually, in the US, per capita breast cancer deaths HAVE declined, from 31.4 per 100,000 women in 1975 to 21.3 in 2012. (http://seer.cancer.gov/statfacts/html/ld/breast.html)
The million dollar question, though, is how much of this decline is from a) better screening 2) better treatment or 3) increased prevention.
The million dollar question, though, is how much of this decline is from a) better screening 2) better treatment or 3) increased prevention.
4
Breast cancer mortality has definitely declined over the past 20 years. The American Cancer Society publishes an annual report on breast cancer statistics. It is available here (mortality figures on page 7 of the report):
http://www.cancer.org/acs/groups/content/@research/documents/document/ac...
This shows a decrease in breast cancer death rates in almost all ethnic groups (Native American being the exception).
http://www.cancer.org/acs/groups/content/@research/documents/document/ac...
This shows a decrease in breast cancer death rates in almost all ethnic groups (Native American being the exception).
The implication of "incentives matter"--that the views of professional cancer caregivers are biased by self-interest--is dumber even than the moral hazard argument against universal health insurance. There is absolutely no chance that oncologists will lack for work any time soon, no matter what the ACS recommends, so caregivers have no incentive to recommend testing for personal gain. It is much more likely that the cost-benefit analysts on the panel were operating on the false premise that testing that does not directly reduce mortality is responsible for our runaway health care costs. The truth is that we have the world's most expensive health care because we are the only advanced nation stupid enough to leave health care in the hands of the free market.
1
To whole point is that early screening and treatment in the vast majority of women does not extend the life of a women who has breast cancer. In other words they die at the same time as they would have without early screening and intervention. The same women with cancer for example if she had early screening and early treatment lives ten year and dies at the age of fifty let's say, if she did not have early screening and early intervention lives five years will still die at the age of fifty. Maybe I am wrong but wasn't that the gist of the logic?
47
You are right, but using death statistics is wrong. Here's why: A woman who has not been screened for a while is found to have cancer, which has of course progressed during that time. Now there will be more severe surgery and probably chemo, which is debilitating. She and her family may be bankrupted, since many people lack good coverage. She may lose her job, since many people do not have safe jobs. And she has suffered a lot. After 5 years of survival, they count this outcome as a success: she didn't die yet! That is how the statistics work. Count up all this against a simple screening exam. The problem is not too much screening, but too little. The problem behind that one, is that medicine, including screening, is overpriced in this country. The doctors who wrote this column, of course, never mention that.
2
99percent, you are wrong, and OYSHEZELIG is correct: the problem is too much screening. But perhaps you are being sarcastic.
1
This opinion appears to be entirely that, not based upon any specific scientific study demonstrating better outcomes over a large population with higher levels of screening.
18
Thank you! I questioned the new standards at my recent mammogram and was told pretty much the same as was written in this article. Personally, I will continue to have yearly exams until there is another reliable method of detection.
10
Asking people whose customer you are, whose incomes depend on testing customers, if you should come in less frequently may not be the way to get an objective answer.
1
Follow the money. Is it cheaper in the long run to avoid the up front costs of finding breast cancer early? I suspect it is. And everyone knows that you can deny women rights and access to health and not have a problem politically because we have so few women in office who complain loudly. So "unladylike," you know.
15
... we have so few women in office (period),
Thank you for this important rebuttal to the new guidelines. A close friend has twice benefitted from annual mammograms in that they caught her cancer - yes, two times. My mother-in-law died from Stage 4 breast cancer after it had metastasized into her spine; I don't think she'd ever had a mammogram in her life. These tests save lives. It would be nice if the insurance and health care industries could find another place to make their advised cuts in services.
17
I am sorry about your mother-in-law's cancer - it sounds like she may have suffered greatly. Did she develop breast cancer before she turned 50? The issue that was addressed by this article is whether to have biannual mammograms between 40 and 50.
5
Thank you for this well written essay. I was lucky to have had a mammogram that detected a highly malignant cancer at the age of 64. If the new guide lines had be in place the cancer would not have been detected until it was too late to treat. There was no lump and the sonogram was negative. I know many women who have had mastectomies and not one of them has regretted their decision. If the new guide lines are put in place the death rate for cancer will increase. Almost 40 million mammograms are currently performed per year. Even if only 1 in 2000 mammograms are positive this translates into a huge number of woman and 80% of the detected tumors are malignant, not in situ.
13
Thank you for not letting this attack on women's healthcare go unnoticed. The only parties who will gain are insurers who will argue that they no longer need to pay for screening this segment of women.
15
You don't think these so-called "Mothers of the Year" will gain financially from recommending more mammography? How do you think THEY make a living? Let's keep the feminism out of this, shall we?
4
I don't understand some of the points made in this article. Why does it matter that the authors are "Mothers of the Year"? trading on warm and fuzzy maternal imagery I suppose. I am not looking for a "Mother of the Year," but rather "Scientists of the Year," who can find answers. Why the scary language about colonoscopies? This is irresponsible language that could scare people away from the procedure. And why is it such a concern that more money may be spent to address larger cancers down the road? Plenty is already being spent on diagnostics. And insurance doesn't cover all of the facilities fees and other extras costs that patients are forced to bear NOW to address all of the false positives. When are we going to get some real answers and not just these competing viewpoints?
99
What the science in its current state is saying is (1) the breast cancers that need to be treated are the aggressive ones, (2) mammography is not better than other means of detection, notably self examination, (3) the aggressive life-threatening breast cancers are a small (less than 10%) percentage of those detected and treated under the heretofore standard of extensive use of frequent mammography, and (4) many of the non-aggressive cancers do not require the immediate and intensive level of treatment they are currently given.
6
With so many different recommendations, my main takeaway is that women can use their own best judgment. I have friends who are more comfortable getting lots of check-ups. I prefer to space my check-ups out -- try to live a healthy life and respond to any problems, but otherwise, every couple of years for a check-up is fine by me. I'm in no rush for my next mammogram. It would appear that my friends and I can all find medical experts who will back our preferences. Good. Let's support women making their own choices about their own bodies.
21
Thank you for this very sane and realistic view on why it is important to make mammograms an important part of one's health care. Surely the cost of healthcare will skyrocket if we don't have access to screenings. But the insurance companies won't suffer! As guidelines shift away from preventative care, the insurance companies escape having to pay for it, leaving us to pick up the tab. Then more people will be in treatment for end stage cancers. The insurance companies win there too! I wonder how many men were on the advisory board. Men get breast cancer too, after all. But most people think of breast cancer as strictly a woman's health issue...
8
Too much preventative screening also causes health care costs to skyrocket. Treatment of cancers and (treating the side effects of such treatments) that would never kill someone is expensive.
11
Like all disease in America, breast cancer is big business so it doesn't surprise me that a breast radiologist supports annual mammograms starting at age 40. According to a study published in the NYTimes in 2014, "It found that the death rates from breast cancer and from all causes were the same in women who got mammograms and those who did not."
http://www.nytimes.com/2014/02/12/health/study-adds-new-doubts-about-val...
http://www.nytimes.com/2014/02/12/health/study-adds-new-doubts-about-val...
71
Not one mention of "real" data to support their claims that screening mammography actually saves lives. The article is all opinion and anecdotes with the exception of one statistic (30% percent reduction in mortality...four decade old data since refuted). They also fail to mention the serious toll of treating many thousands of women with mammographically diagnosed breast cancer who would have never died of their disease.
111
Perhaps early mammography does not save lives but it does improve the odds that we will catch the cancer earlier which will mitigate the need for more radical surgery and chemo which is devastating to patients and their families. I think the metric should focus on better patient outcomes and quality of life after diagnosis rather than just life expectancy. Anyone who agrees with these new recommendations has surely never faced a diagnosis of breast cancer.
1
On the contrary, @Engles - what we are finding is that women are getting invasive tests and treatments that they wouldn't have gotten *at all* without mammography because they didn't need to get them in the first place (because the cancer would never have spread).
10
No, Engles, you are wrong, and Robert Gendler is correct. I agree with these recommendations -- and yes, I have been diagnosed with and treated for breast cancer. So you are wrong again. All of the women I know who have been diagnosed with and treated for breast cancer found it themselves. My sister is an example of an aggressive breast cancer found 8 months after a "clean" mammogram -- and she found it herself. Some early cancers have already metastasized; it's not clear how effective early treatment is. I hope you find better information on which to base your own treatment decisions.
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Brava! And as a cancer survivor who had suspicious though negative findings both before and after my diagnosis , I want to emphasize the fact that the studies used by the ACS tend to emphatically overestimate the degree of pain and suffering from a false positive, yet dramatically undervalue the impact of an advanced cancer diagnosis.
Also not emphasized enough by the authors is that the ACS recommendations are based on data from much older radiological equipment. Every study that concludes that mammogram screening has no benefit has included data from older mammography equipment (including film imaging) that is - by my estimate - three generations old. Imagine basing a recommendation on equipment that was 20 years old! In contrast, every study that concludes that mammography has immense benefits has been careful to use data from the latest equipment, in most cases digital mammography. Bottom line - as equipment improves, as does the sensitivity and specificity of the technique.
Yet even now, we have more advances in mammography, including Digital Tomosynthesis. This creates a three-dimensional image of the breast. The best analogy is that Standard Digital Mammography is to Digital Tomosynthesis the way a standard X-ray is to a CT scan.
It is ironic that as technological advances have made mammography an even more accurate diagnostic tool, the medical societies are reducing its ability to be used to save lives and reduce late stage cancers.
Also not emphasized enough by the authors is that the ACS recommendations are based on data from much older radiological equipment. Every study that concludes that mammogram screening has no benefit has included data from older mammography equipment (including film imaging) that is - by my estimate - three generations old. Imagine basing a recommendation on equipment that was 20 years old! In contrast, every study that concludes that mammography has immense benefits has been careful to use data from the latest equipment, in most cases digital mammography. Bottom line - as equipment improves, as does the sensitivity and specificity of the technique.
Yet even now, we have more advances in mammography, including Digital Tomosynthesis. This creates a three-dimensional image of the breast. The best analogy is that Standard Digital Mammography is to Digital Tomosynthesis the way a standard X-ray is to a CT scan.
It is ironic that as technological advances have made mammography an even more accurate diagnostic tool, the medical societies are reducing its ability to be used to save lives and reduce late stage cancers.
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I am now 71, in what is often considered breast cancer prime, and I had a 'suspicious' mammogram in April, a needle biposy in May and a lumpectomy in June, after 30 years of nary a shadow in a mammogram. That yearly mammogram probably saved me from far more medical intervention and therapy, or worse. Perhaps we need to have "Yearly Mammogram" marches!!!
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The controversy is not about what 71-year-old women should do, but whether 40 year old women should get mammograms. As you point out, these are not women in "breast cancer prime."
Stay well, Susan.
Stay well, Susan.
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Physicians should be guided by science, not the anxiety of their patients.
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The authors don't come out and say it, but we need to know if these new recommendations are being pushed by health insurance companies. Now we need investigative reporting on this.
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Indeed. Follow the money.
I had a call-back mammogram, with tomosynthesis this summer that gave the all-clear. But two people dear to me had call-backs that uncovered stage 2 cancer. Those call backs saved their lives.
My insurance company refused to pay for my second mammogram. How many women will skip the 2nd mammogram if it costs hundreds of dollars? How many cancers will be missed? Would the insurance company prefer to pay $60k per chemo round instead of $1k for a mammogram?
I had a call-back mammogram, with tomosynthesis this summer that gave the all-clear. But two people dear to me had call-backs that uncovered stage 2 cancer. Those call backs saved their lives.
My insurance company refused to pay for my second mammogram. How many women will skip the 2nd mammogram if it costs hundreds of dollars? How many cancers will be missed? Would the insurance company prefer to pay $60k per chemo round instead of $1k for a mammogram?
2
This is a very good point. There needs to be some balance here. Women who want mammograms should be able to get them affordably, especially if they are at known risk. No woman who might benefit from a mammogram should be denied one by an ensurer But it sounds like we need more fact- and evidence-based information to inform and empower women to make their own choices. We're getting too many anecdotes and interested opinions. I am also very concerned about women who have mammograms that turn up something suspicious but who want to adopt a "watchful waiting" strategy being hounded into further unnecessary scans and biopsies by doctors and insurance companies.
3
Their jobs are at stake. What would you expect them to say?
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