Experts question motives of mammogram guidelines

RightinNYC · Nov 16, 2009

Experts question motives of mammogram guidelines | Health | Reuters

Cancer experts fear new U.S. breast imaging guidelines that recommend against routine screening mammograms for women in their 40s may have their roots in the current drive in Washington to reform healthcare.

...

* Dr Carol Lee, chairwoman of the American College of Radiology Breast Imaging Commission, said she fears insurers -- both private and public -- will use them to pare back health costs.

"These new recommendations seem to reflect a conscious decision to ration care," Lee said in a statement.

She said since the onset of regular mammogram screening in 1990, the death rate from breast cancer, which had been unchanged for the preceding 50 years, has decreased by 30 percent.

* Dr Len Lichtenfeld, deputy chief medical officer of the American Cancer Society, said the influential group will not change recommendations for routine mammograms for women starting at age 40.

...

* Lichtenfeld and other doctors are worried that insurance companies and government insurers will seize on the recommendations as a way to control rising health costs.

"What is going to happen is insurers are going to say, 'The U.S. Preventive Services Task Force doesn't support screening. We're not going to pay for it,'" said Dr Daniel Kopans, professor of radiology at Harvard Medical School and a senior radiologist at Massachusetts General Hospital in Boston.

"There were no new data to assess. One has to wonder why these new guidelines are being promulgated at a time when healthcare is under discussion and I am afraid their decision is related to saving money rather than saving lives," Kopans said.

I'm all for cutting back on care that isn't cost-efficient, but the timing of this move really does make you wonder whether the new guidelines were influenced by something other than science.

jackalope · Nov 16, 2009

RightinNYC said:
Experts question motives of mammogram guidelines | Health | Reuters

I'm all for cutting back on care that isn't cost-efficient, but the timing of this move really does make you wonder whether the new guidelines were influenced by something other than science.

If there was no new data to assess, as the article stated, then yes, it does make you wonder whether the new guidelines were promulgated for a reason other than science.

1069 · Nov 16, 2009

As far as I know, this recommendation has been in the works for some time.
For the past several years at least, there's been no consensus within the medical community on when mammograms should start.
There are a couple of issues here:

1. Each mammogram raises one's risk of cancer slightly.

2. Breast cancer under age 50 is rare.

3. Before menopause, mammograms are unlikely to detect cancer, because there is a lot of fibroid tissue in pre-menopausal breasts that makes it difficult if not impossible to detect tumors with a mammogram.

So, these ideas have been kicked around for some time. The debate has been going on for years.
I think a lot of experts in the field are now beginning to lean more toward routine mammograms only after age 50.
That does not mean no mammograms ever for women under 50.
It just means that it depends upon the circumstances.
For many women under 50, mammograms would be of little benefit, and the slight risk these women incurred from undergoing mammograms unnecessarily would not be justified.

I personally do not plan to have my first mammogram until I'm 50.

jackalope · Nov 17, 2009

Pretty interesting, Ten.

RightinNYC · Nov 17, 2009

1069 said:
As far as I know, this recommendation has been in the works for some time.
For the past several years at least, there's been no consensus within the medical community on when mammograms should start.
There are a couple of issues here:

1. Each mammogram raises one's risk of cancer slightly.

2. Breast cancer under age 50 is rare.

3. Before menopause, mammograms are unlikely to detect cancer, because there is a lot of fibroid tissue in pre-menopausal breasts that makes it difficult if not impossible to detect tumors with a mammogram.

So, these ideas have been kicked around for some time. The debate has been going on for years.
I think a lot of experts in the field are now beginning to lean more toward routine mammograms only after age 50.
That does not mean no mammograms ever for women under 50.
It just means that it depends upon the circumstances.
For many women under 50, mammograms would be of little benefit, and the slight risk these women incurred from undergoing mammograms unnecessarily would not be justified.

I personally do not plan to have my first mammogram until I'm 50.

More info from the report:

Over all, the report says, the modest benefit of mammograms — reducing the breast cancer death rate by 15 percent — must be weighed against the harms. And those harms loom larger for women in their 40s, who are 60 percent more likely to experience them than women 50 and older but are less likely to have breast cancer, skewing the risk-benefit equation. The task force concluded that one cancer death is prevented for every 1,904 women age 40 to 49 who are screened for 10 years, compared with one death for every 1,339 women age 50 to 74, and one death for every 377 women age 60 to 69.

It appears that it's unquestioned that mammograms prevent cancer deaths. The task force apparently concluded that the benefits of saving 1 death per 1,339 women outweighed the costs/risks of the procedure, but saving 1 death per 1,904 women is not enough.

But the new guidelines are expected to alter the grading system for health plans, which are used as a marketing tool. Grades are issued by the National Committee for Quality Assurance, a private nonprofit organization, and one measure is the percentage of patients getting mammograms every one to two years starting at age 40.

That will change, said Margaret E. O’Kane, the group’s president, who said it would start grading plans on the number of women over 50 getting mammograms every two years.

The message for most women, said Dr. Karla Kerlikowske, a professor in the department of medicine, epidemiology and biostatistics at the University of California, San Francisco, is to forgo routine mammograms if they are in their 40s.

http://www.nytimes.com/2009/11/17/health/17cancer.html

Just doing some (very) rough calculations:

There are 22 million women between the ages of 40-49. Currently, approximately 65% of women in this age group (14.3 million) get regular mammograms. Using the above numbers, that means that over the 10 year screening period, 7,510 deaths are prevented because of those mammograms.

1069 · Nov 17, 2009

It appears that it's unquestioned that mammograms prevent cancer deaths. The task force apparently concluded that the benefits of saving 1 death per 1,339 women outweighed the costs/risks of the procedure, but saving 1 death per 1,904 women is not enough.

That's not the issue.
The issue is that mammograms raise the risk of breast cancer slightly; each consecutive mammogram raises it more.
Routine mammograms on all women beginning at age 40 may well cause more than "1 death per 1339 women". It might cause 2 or 3 deaths per thousand, for all we know.
If so, recommending that routine mammograms not begin until age 50 is saving lives.

Who GETS breast cancer more often?
Affluent white women. Read the national stats.
Who do you think is most likely to begin early routine mammograms?
Gee, I dunno... could it be affluent white women? :doh

RightinNYC · Nov 17, 2009

1069 said:
That's not the issue.
The issue is that mammograms raise the risk of breast cancer slightly; each consecutive mammogram raises it more.

I don't think there's actually conclusive evidence to support this. The closest thing I've found is a study saying that mammograms may increase the risk of breast cancer in women with the BRCA gene.

Routine mammograms on all women beginning at age 40 may well cause more than "1 death per 1339 women". It might cause 2 or 3 deaths per thousand, for all we know.
If so, recommending that routine mammograms not begin until age 50 is saving lives.

Presumably the panel took that into account when it "concluded that one cancer death is prevented for every 1,904 women age 40 to 49 who are screened for 10 years, compared with one death for every 1,339 women age 50 to 74, and one death for every 377 women age 60 to 69."

If the risk were anywhere near as large as you're suggesting, it wouldn't make sense for the procedure to be worthwhile to save 1/1,339 but not 1/1,904. Furthermore, since the panel excludes women with the BRCA gene from its new guidelines, I don't see how this proposal will affect them at all.

1069 · Nov 17, 2009

I don't think there's actually conclusive evidence to support this. The closest thing I've found is a study saying that mammograms may increase the risk of breast cancer in women with the BRCA gene.

A mammogram is an x-ray of the breast.
"Routine" annual mammograms beginning at age 40 means that by the time a woman's 50, she's had that breast x-rayed ten times.
By the time she's 70, thirty or more times.
It's a x-ray, for cripe sake. "No conclusive evidence"?
Are you f'ing kidding me? :doh:lol:
Each mammogram exposes the breast to more radiation; the effect is cumulative.

American · Nov 17, 2009

1069 said:
As far as I know, this recommendation has been in the works for some time.
For the past several years at least, there's been no consensus within the medical community on when mammograms should start.
There are a couple of issues here:

1. Each mammogram raises one's risk of cancer slightly.

2. Breast cancer under age 50 is rare.

3. Before menopause, mammograms are unlikely to detect cancer, because there is a lot of fibroid tissue in pre-menopausal breasts that makes it difficult if not impossible to detect tumors with a mammogram.

So, these ideas have been kicked around for some time. The debate has been going on for years.
I think a lot of experts in the field are now beginning to lean more toward routine mammograms only after age 50.
That does not mean no mammograms ever for women under 50.
It just means that it depends upon the circumstances.
For many women under 50, mammograms would be of little benefit, and the slight risk these women incurred from undergoing mammograms unnecessarily would not be justified.

I personally do not plan to have my first mammogram until I'm 50.

I plan to offer breast exams for free to help lower healthcare costs. :mrgreen:

Kal'Stang · Nov 17, 2009

The OP's link didn't mention it but here's another one that does...

For years, mammograms have been recommended every year or two for women beginning at age 40. The new report from the U.S. Preventive Services Task Force, issued Monday night, now says women this age should simply talk to their doctors about the benefits and risks. The group also says there's no benefit to performing breast self-exams. The recommendations, which help shape how doctors practice, don't affect women at high risk, such as those with strong family histories of cancer.

USA Today

I wish that all the news sites that I've seen talk about this would explain the part in bold more. I can see no reason what so ever for them to be saying the part in bold.

RightinNYC · Nov 17, 2009

1069 said:
A mammogram is an x-ray of the breast.
"Routine" annual mammograms beginning at age 40 means that by the time a woman's 50, she's had that breast x-rayed ten times.
By the time she's 70, thirty or more times.
It's a x-ray, for cripe sake. "No conclusive evidence"?
Are you f'ing kidding me? :doh:lol:
Each mammogram exposes the breast to more radiation; the effect is cumulative.

If you drip water into a bucket 30 times in a row, does that mean you can wash your car with what you've got in there? Or is the number of times you add water less important than the actual amount of water you've put in there?

Again, if it's so mind bogglingly obvious, how come there aren't any scientific studies conclusively showing that mammograms cause breast cancer?

Aunt Spiker · Nov 17, 2009

RightinNYC said:
If you drip water into a bucket 30 times in a row, does that mean you can wash your car with what you've got in there? Or is the number of times you add water less important than the actual amount of water you've put in there?

Again, if it's so mind bogglingly obvious, how come there aren't any scientific studies conclusively showing that mammograms cause breast cancer?

There's no way to know, honestl y- if someone gets routine mammograms and is exposed to that radiation - and then later developes breast cancer - there *might* be a link or they're *might* not be a link.

I think it's such a delicate issue that the process of finding out for sure would be quite time consuming, challenging if at all possible - you're dealing with the unknowns. . .there's no way of telling the difference between some cancers caused by radiation and their naturally-occuring forms.

I think, then, that presuming that breast cancer might be caused by overexposure to that type of radiation is a safe medium.

http://www.boloji.com/wfs3/wfs337.htm

RightinNYC · Nov 17, 2009

Aunt Spiker said:
There's no way to know, honestl y- if someone gets routine mammograms and is exposed to that radiation - and then later developes breast cancer - there *might* be a link or they're *might* not be a link.

I think it's such a delicate issue that the process of finding out for sure would be quite time consuming, challenging if at all possible - you're dealing with the unknowns. . .there's no way of telling the difference between some cancers caused by radiation and their naturally-occuring forms.

I think, then, that presuming that breast cancer might be caused by overexposure to that type of radiation is a safe medium.

Radiation Causes Breast Cancer by Stephanie Hiller

There's absolutely a way to know - conduct a scientific study. So far, no study has proven a link.

You're free to err on the side of caution as it relates to your own personal choices, but when it comes to setting policy for the nation, we should be looking at scientific facts.

Aunt Spiker · Nov 17, 2009

RightinNYC said:
There's absolutely a way to know - conduct a scientific study. So far, no study has proven a link.

You're free to err on the side of caution as it relates to your own personal choices, but when it comes to setting policy for the nation, we should be looking at scientific facts.

Lack of a study doesn't mean there's not a legitimate concern - but mammograms aren't mandatory. I'll never be getting one, that's for sure.
Heck, even things that have had countless studies turn around all the time - "don't eat before bed, eat before bed" "don't wear pantyhose while pregnant, do wear pantyhose while pregnant" ... study study study, evidence evidence evidence. . . .and it all conflicts.

But this all points back around to the government being involved in healthcare, period - and why it shouldn't be doing it.

aps · Nov 17, 2009

RightinNYC said:
Experts question motives of mammogram guidelines | Health | Reuters

I'm all for cutting back on care that isn't cost-efficient, but the timing of this move really does make you wonder whether the new guidelines were influenced by something other than science.

This is on MSNBC's home page. When I saw it last night, I though, "Huh?" I agree. WTH is going on with this?

Aunt Spiker · Nov 17, 2009

aps said:
This is on MSNBC's home page. When I saw it last night, I though, "Huh?" I agree. WTH is going on with this?

*gasp* noooo.
MSNBC reporting something thta's against hte president's prerogative - my my pigs fly.

*poking*

LiveUninhibited · Nov 17, 2009

RightinNYC said:
Presumably the panel took that into account when it "concluded that one cancer death is prevented for every 1,904 women age 40 to 49 who are screened for 10 years, compared with one death for every 1,339 women age 50 to 74, and one death for every 377 women age 60 to 69."

If the risk were anywhere near as large as you're suggesting, it wouldn't make sense for the procedure to be worthwhile to save 1/1,339 but not 1/1,904. Furthermore, since the panel excludes women with the BRCA gene from its new guidelines, I don't see how this proposal will affect them at all.

It is known that the younger you are, the more likely radiation exposure is to be harmful, both in terms of susceptibility and the likelihood of the cancer to come soon enough to make a difference in lifespan. This is a major reason they do not do the screening before 40, and since the two highest quality trials found no mortality benefit given current practices, it does make sense to cut out the 40-50 range. Screening for breast cancer with mammography

Another thing this systematic review highlights is that the trials are biased by the fact that cause of death, e.g. origin of the cancer, is more likely to be known with screening. Furthermore:

Screening is likely to reduce breast cancer mortality. As the effect was lowest in the adequately randomised trials, a reasonable estimate is a 15% reduction corresponding to an absolute risk reduction of 0.05%. Screening led to 30% overdiagnosis and overtreatment, or an absolute risk increase of 0.5%. This means that for every 2000 women invited for screening throughout 10 years, one will have her life prolonged and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress for many months because of false positive findings. It is thus not clear whether screening does more good than harm. To help ensure that the women are fully informed of both benefits and harms before they decide whether or not to attend screening, we have written an evidence-based leaflet for lay people that is available in several languages on Nordic Cochrane Centre.

People often forget that overtreatment is a risk in medicine. More medicine is not always better medicine.

bowerbird · Nov 17, 2009

1069 said:
As far as I know, this recommendation has been in the works for some time.
For the past several years at least, there's been no consensus within the medical community on when mammograms should start.
There are a couple of issues here:

1. Each mammogram raises one's risk of cancer slightly.

2. Breast cancer under age 50 is rare.

3. Before menopause, mammograms are unlikely to detect cancer, because there is a lot of fibroid tissue in pre-menopausal breasts that makes it difficult if not impossible to detect tumors with a mammogram.

So, these ideas have been kicked around for some time. The debate has been going on for years.
I think a lot of experts in the field are now beginning to lean more toward routine mammograms only after age 50.
That does not mean no mammograms ever for women under 50.
It just means that it depends upon the circumstances.
For many women under 50, mammograms would be of little benefit, and the slight risk these women incurred from undergoing mammograms unnecessarily would not be justified.

I personally do not plan to have my first mammogram until I'm 50.

Mammograms are free here and only done routinely after age fifty for all the reasons you quoted.

underdog334 · Nov 17, 2009

The reccommendation was based on a cost-benefit analysis,which means that the panel had to arrive at the dollar value of a woman's life. I wonder what that value was. I notice on the EPA website that a human life is valued at around $5 Million. Folks,here's your death panel in action. I'm wondering do different races have different rates of breast cancer? If so,why no outcry over the racism of this decision?

apdst · Nov 17, 2009

The rationing begins.

MyOwnDrum · Nov 17, 2009

RightinNYC said:
Experts question motives of mammogram guidelines | Health | Reuters

I'm all for cutting back on care that isn't cost-efficient, but the timing of this move really does make you wonder whether the new guidelines were influenced by something other than science.

I feel that doctors order a lot of expensive diagnostics on flimsy grounds just because they are there. Not sure specifically on the mammogram.

Case in point: Three years ago, a doctor told me I now have a heart murmur. I'm having no symptoms of decreased cardiac output. Since that time 2 other doctors have heard the murmur and recommend a baseline echocardiogram, which is an ultrasound of the heart that measures mechanical function of each chamber of the heart and the heart valves, and overall cardiac output.

I work on a per diem basis in a hospital by choice so I can have maximum flexibility and control over my schedule. This means that I don't receive any health insurance through my work, but instead buy a policy with a $3000 deductible, 6 office visits a year, yearly checkup. A friend of mine with a similar policy and a heart murmur did get an echocardiogram and it cost $700.

Yesterday at work I asked my favorite cardiologist for advise on my situation. He said he would listen to my heart and we could have the echo tech do a quickie unofficial echo if needed. He listened to my heart murmur and said that you can barely hear it and that I definitely don't need an echo done.

This just proves to me that a lot of doctors are ordering expensive diagnostics, most likely to cover their asses, and also because they are there and insurance will pay.

Partisan · Nov 17, 2009

MyOwnDrum said:
I feel that doctors order a lot of expensive diagnostics on flimsy grounds just because they are there. Not sure specifically on the mammogram.

Case in point: Three years ago, a doctor told me I now have a heart murmur. I'm having no symptoms of decreased cardiac output. Since that time 2 other doctors have heard the murmur and recommend a baseline echocardiogram, which is an ultrasound of the heart that measures mechanical function of each chamber of the heart and the heart valves, and overall cardiac output.

I work on a per diem basis in a hospital by choice so I can have maximum flexibility and control over my schedule. This means that I don't receive any health insurance through my work, but instead buy a policy with a $3000 deductible, 6 office visits a year, yearly checkup. A friend of mine with a similar policy and a heart murmur did get an echocardiogram and it cost $700.

Yesterday at work I asked my favorite cardiologist for advise on my situation. He said he would listen to my heart and we could have the echo tech do a quickie unofficial echo if needed. He listened to my heart murmur and said that you can barely hear it and that I definitely don't need an echo done.

This just proves to me that a lot of doctors are ordering expensive diagnostics, most likely to cover their asses, and also because they are there and insurance will pay.

This is it, exactly....
They need those tests to bump up the bottom line....
This is no different than drug reps whining when their drug is taken off the preferred prescription list.....
I find it hard to believe that Obama is dictating health policy to the CDC...
I'm sure the recommendation for someone who has a history of breast cancer in their family would be different....
The health care providers see it as ten years of revenue shot to hell, nothing more.....

bowerbird · Nov 17, 2009

underdog334 said:
The reccommendation was based on a cost-benefit analysis,which means that the panel had to arrive at the dollar value of a woman's life. I wonder what that value was. I notice on the EPA website that a human life is valued at around $5 Million. Folks,here's your death panel in action. I'm wondering do different races have different rates of breast cancer? If so,why no outcry over the racism of this decision?

No, it was based on what is done elsewhere and what is standard practice elsewhere.

It is not stopping women from having mammograms - just saying these are the ones we should concentrate on

Mach · Nov 17, 2009

RightinNYC said:
There's absolutely a way to know - conduct a scientific study. So far, no study has proven a link.

You're free to err on the side of caution as it relates to your own personal choices, but when it comes to setting policy for the nation, we should be looking at scientific facts.

Proven links and facts are not part of science really, that may be the mistake in thinking that.
Science is falsifiable. Science as it concerns medicine is so primitve in terms of certainty that it's a terribly difficult job to promote national guildelins on health, and the understanding is that the guidlines will change relatively frequently.

That's just how it is. Same with prostate exams, this isn't just breast cancer. Same with eating fat (learned fat from trans fat vs sat vs unsat), etc.

Guidelines are what they are. Nothing beats discussing it, in an informed manner with your doctor(s). That's what the guidlines now prompt. Not "regular screening", but "consult with your doctor", because the pros are not significant enough. That could reverse in a few years with new information or new thinkers. But that's what science does. The alternative is God did it, just pray
Between false positives, causing cancer, exacerbating existing cancer, biopsy risks, and no real help in terms of mortality (recalling news reports from memory here), it made sense to pull back on "suggested every year starting at 40".

Jackboot · Nov 17, 2009

I know I sound like a broken record, but this is what happens when the government forces itself in to the free market. :shrug:

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