Sunday, December 2, 2012

Mammograms Overdiagnose Breast Cancer - Let the Games Begin!

Breast news is booming.  Mammography is in the news again. We have legions of breast lobbyists that have agendas that are far beyond the true medical value of mammography.  Even legislators have entered the mammographic arena in a clumsy effort to show their pro-women bona fides.  Politicians should not practice medicine.  It’s absurd that they try to do so when they can’t even perform their own jobs competently.



In 2010, the government overturned its own panel the United States Preventive Services Task Force (USPSTF), in response to an outcry from politicians and mammo-cheerleaders. The USPSTF is not anti-mammogram, and neither am I. I’m pro medical evidence. Mammogram enthusiasts often champion positions that are beyond the science.  Beyond the Kool Aid drinkers, there are billions of dollars at stake here.  Medical evidence is massaged by companies who manufacture conventional and emerging imaging breast techniques and by radiologists who interpret the studies.  If you're a player in the Mammogram Industrial Complex, and a major study threatens your livelihood, predict the reaction.  Here are some sample press releases.
  • The study is irreparably flawed
  • The study is a right wing conspiracy
  • The job killing study will shift more jobs overseas
  • The male study investigators want mammography to fail so they can divert research money to prevent prostate cancer
Let me preempt the argument that I am holier than thou with respect to my implication that radiologists may be tainted by a conflict of interest.
  • Gastroenterologists perform too many colonoscopies
  • Colonoscopy is a clumsy tool for colon cancer prevention
  • Colonoscopy advocates primarily rely on polyp removal as evidence of its worth, which is a surrogate marker of uncertain value.
Hopefully, the above statements will support my credibility.
The truth is that mammography, even in its most optimistic light, isn’t the lifesaver that the public believes.  Indeed, some experts opine that women who undergo mammography do not enjoy a mortality advantage, although they may suffer fewer breast cancer fatalities and complications.  While this is a worthy outcome, it is clearly a limited benefit. 
The November 22,2012 New England Journal of Medicine article strongly suggested that millions of women have been overdiagnosed with breast cancer, meaning identifying cancers that would not have progressed or would have been detected later without posing more danger to these women. 
Advances in breast cancer treatment may exaggerate the benefits of mammographic detection.  In other words, a breast cancer survivor might wrongly credit the mammogram as her savior rather than the treatment.
Overdiagnosis of cancer should be regarded a disease itself.  These women undergo unnecessary surgeries, chemotherapy and radiation, which can have profound and lifelong effects on them and their families. It is also costing us a fortune. It is not a fair and balanced approach to showcase women who have been saved without acknowledging the harm that mammography causes  Shockingly, the American College of Radiology issued a statement calling the study ‘deeply flawed an misleading’.  Any conflict of interest here?
It is easy to deepen our cynicism when those who support or attack a view have a personal interest that coincides with their position. 
The medical and political establishments do not reverse course easily.  We have known for years that prostatespecific antigen (PSA) is deeply flawed and harmful. Look how long it took to disarm its advocates, many of whom were urologists who believed in PSA with religious zeal.  Every one of them honestly believed that this test had saved men’s lives.  I do not dispute this contention.  How many men, however, were gravely harmed by treatment of prostate cancer that would have never threatened them?  Isn’t this worthy of some consideration?
Patients need to know the medical evidence that supports our medical advice.  When there isn’t evidence, or the evidence is conflicting, we physicians need to disclose this, and patients should interrogate us directly on these issues.  I welcome this dialogue in my office.
The public has an exaggerated view of the benefits of mammography. For instance, I suspect that most ordinary folks believe that mammography prevents breast cancer, which is completely false and was never its intent. 
The vexing issue for patients is whom can they trust to offer them candid and unvarnished advice?  I believe in truth. It’s not enough in medicine to believe that something is true because we want it to be or because it serves our own interest. 
Have any women Whistleblower readers been counseled about the hazards of mammography by their physicians?  If not, then was your decision to proceed truly informed?  Aren’t your breasts worth knowing the whole story?

4 comments:

Anonymous said...

If I were to rank-order those whose best interests are protected by mammography, I'd put patients near the bottom of the list.

I had my first mammogram shortly after age 40 at one of the nation's fine teaching hospitals. Shortly after the images were taken, a radiologist walked into the exam room and started talking about the need for for me to follow up with an ultrasound, then another mammogram. I asked what was wrong and wasn't given a clear answer aside from 'this is your first one, so we have to be sure'. I followed up with the ultrasound, which found nothing; however, I was told that I should get another mammogram 6 months later, which I refused to do. No matter who I spoke to at the hospital, my repeated question of why I needed it was never answered directly, but was always responded to with that similar 'we need to be sure' retort, including from my primary care doc who was located at the same hospital. (However, she backed down when I cited concern about radiation exposure.) The entire experience seemed like a colossal exercise in due diligence from the legal or risk management department, all of which caused me a lot of stress and anxiety and the time.

I ended up switching to a doctor afilliated with a different hospital and did have a mammogram 2.5 years after the first one, which was normal. But in the time between these two mammograms, I received fairly regular reminders of my need to get a mammogram -- from my insurance company. Not only did I get postcards and letters, but also periodic robocalls from the plan's headquarters. I'm fairly sure that their concern had less to do with breast health than they did to ensure a high HEDIS score for the health plan on mammography.

In addition to my own experience, seeing two women I know go through treatment for "stage zero" breast cancer gives me a lot of pause, too. Both were advised to get aggressive treatment because it's better to be safe than sorry. Is this providing patients with options, or minimizing litigation risk?

Michael Kirsch, M.D. said...

I think you should write your own blog! Appreciate your comments.

Anonymous said...

When I saw the 11-22-12 article in NEJM on overdiagnosis of breast cancer I could hardly wait to read it. I did not find the results surprising. It validated what I concluded several years ago from my own awful experiences. Every time I had a mammogram I was called to come back, and sometimes was also followed up with an ultrasound. This process in itself was frightening and stressful. Each time the conclusion, after all of the exams were finished was "you just have fibrocystic breasts - don't worry". Well it is hard not to worry through the whole process and afterward wonder if one technician did a better job of obtaining films then another one and/or if one radiologist was more accomplished at interpreting the results, so which conclusion was really correct. Was there really "something" to worry about or not???

No one ever told me there were any risks to mammograms - only benefits.
I really don't think I experienced any benefits - just lots of pain and discomfort - the exam itself is horrible - and lots of stress.
I have not had a mammogram for several years and have no intention of having another one unless I find something suspicious when doing a self exam.
Women (as a group) really need to be better advocates for themselves so we get the treatments we do truly need and not a lot of treatments that we do not.

David Bend said...

I appreciate that you said: "Patients need to know the medical evidence that supports our medical advice.". I think it is very important for the patient to be educated on what happens to their bodies. When my wife was learning about mammography in Chandler, AZ, the physicians did a very good job with educating her.
Thank you for writing your extensive post, My wife and I enjoyed reading it!

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