Sunday, February 16, 2014

Mammograms Under Fire in New Study: Trash the Study?

Sometimes, we play a little politics on this blog.  I am a student of current events and enjoy following the dysfunction and absurdities in American politics.  To paraphrase the legendary former British Prime Minister, ‘never has so little been done by so many to benefit so few’.

Legendary Former British Prime Minister

Which of the following recent events is the most politically charged?
  • Speaker of the House John Boehner passed a clean extension of the debt limit without conditions. (Nothing like a colossal failure on this issue months ago to guide the speaker today.)
  •  Obamacare received its 27th extension, another ‘tweak’.
  • A new study questions the value of mammography. 
Readers know how skeptical I am about medical dogma.  When I was an intern a quarter century ago, I didn’t grasp why routine measurement of Prostate Specific Antigen (PSA) was standard medical practice since it was true back then that more men were harmed than helped by its use.

A recent study in the prestigious British Medical Journal (BMJ) has concluded that mammography does not save lives.  This study will become political dynamite as breast cancer is as much a political issue in this country as it is a medical subject.  Remember Mammogate?

I have no agenda here beyond a search for the truth.  I favor any reasonable endeavor that will prevent disease, treat illness effectively and deliver comfort.  If persuasive scientific information informs us that a medical treatment or test is not effective or is harmful, our reaction should not be to attack the test as flawed. We should also note if the criticizers have a personal stake in the test’s survival.   When colonoscopy is supplanted by a better test – which it will be – gastroenterologists will need to separate our own interest from the public interest, in accordance with our professional ethical standards and the oath that we all took. 

This new view on the old breast test mammography emerged from a randomized trial, which is a rigorous method of scientific study.  Ninety thousand women participated.  When there are a large number of subjects in a medical study, it strengthens the conclusions for mathematical reasons. This is why investigators strive to recruit a large number of patients in their studies.   The BMJ study concluded that women who underwent mammograms had the same death rate from breast cancer as women who only underwent breast examinations.   Additionally, ‘non-invasive’ mammography led to unnecessary invasion on many women.  Twenty percent of cancers found were felt not to be a medical threat and yet led to surgery and other unpleasant treatments.

Even when prior mammography data is viewed in its most optimistic light, the benefit to an individual woman is extremely modest.  This point is so often misunderstood by even an informed public.  When a study performed on a large population shows a 10% benefit, for example, the benefit to an individual participant may be trivial.  This is why headlines such as, “New Drug Strengthens Bone Density by 20%”, are so deceptive.  Patients need to know what the benefit of a particular treatment is for them, not for a large study group.

Get ready for the Mammography Zealots to mobilize for their three pronged approach: Pitchforks, Placards and Protests!

My question for them is do they want to save mammography or save women?


Third News said...

Twenty percent of cancers found were felt not to be a medical threat and yet led to surgery and other unpleasant treatments.

Without knowing further data, this statement is irrelevant. Did these patients opt for aggressive treatment because their cancer was a familial disease? Most women and men who are inflicted pursue their treatment based on the best information related to their own circumstances.

Anonymous said...

This statement isn't irrelevant, Third News, particularly in view of other relevant studies showing that overdiagnosis is large and it routinely leads to invasive treatments, harming healthy women (read "The Mammogram Myth" by Rolf Hefti).

Barbara said...

Most women gasp when I tell them I've never had a mammogram. Yep. At 71, and having survived this long completely intact, I am a living fossil who has never felt the need for a mammogram because 1) breast cancer does not exist anywhere in my family tree, and 2) irradiation really isn't all that good for the human body and I don't do it unless absolutely necessary, and 3) I never drank the Kool-Ade, er...took the HRT. That's right, a toughed-out, miserable but healthy menopause, and no, I have not been surgically castrated, either. My belief about HRT has always been that if you fool Mother Nature too much, she will turn around to bite you. I watched far too many friends and neighbors die, have mastectomies or lumpectomies and chemo/radiation, and they all got their mammograms religiously. The numbers of them that I knew personally were statistically aberrant they were so high. Save the boobs - no more HRT!
I vote instead for DNA studies to see who is at risk.

Anonymous said...

mammograms saves lives ; what else is any better? Your last comment on the board recertification scam was years ago; care to comment on the new yearly Maintenance of Certification for ABIM and the other medical specialties? Do you feel victimized by a corporate the testing company forcing you to buy their dubious product or face economic loss? The conspiracy from ABMS/ABIM and the testing prep courses/materials sold by ACP, medical schools , all this is a certfication industry complex that will harm real working MD's. It is a corporate assumption of governmental power without any due process. Check out websites like Change Board certification and the AMerican Assoc PHysicians Surgeons ; it exposes this abuse . The time to fight back is now.

Anonymous said...

Well, I'm 63 and I have had ONE mammogram - a diagnostic mammogram years ago because of brief shooting pains in one breast. I'm not going to ignore a symptom or a lump, but I'm damned if I'm going to go hunting for something like DCIS that might never trouble me. That's just asking for trouble.

Michael Kirsch, M.D. said...

Wondering if Third News has reflected on his initial comment. Mammography is but one example, in my view, of overdiagnosis leading to overtreatment.

Michael Kirsch, M.D. said...

For some unknown reason, Third News's comment did not post. Here it is with my response below:

I have not yet read the mammogram study but over-diagnosis/over-treatment became the responsibility of the physician upon the contrahented suretyship.

As for my original comments, they reflect that I've only known younger women (under the recommended mammogram age) who were diagnosed, and followed what they deemed to be the best personal option.

Angelina Jolie's prophylactic double mastectomy may have encouraged women to become overly aggressive in their treatments but if I had her BRCA gene mutation, I'd consider her choice.

If/when a celebrity makes a procedure 'trendy', it is still the sponsion's responsibility to ensure appropriate medical care.

Angelina had BRCA issues, which is distinct from screening mammography. Many medical practices and procedures are considered established dogma often without supportive medical evidence. Habit and belief are not efficacy.

Third News said...

Angelina had BRCA issues, which is distinct from screening mammography. Many medical practices and procedures are considered established dogma often without supportive medical evidence. Habit and belief are not efficacy.

Unfortunately, absent of HTML blockquoting, it may be difficult to distinguish my comment from your reply above.

Since we are both not privy to AJ's medical records, you are just playing a coddum . We both have no idea if Jolie had hormonally-induced lumps, false-positive mammograms, and so on, before Jolie's BRCA results convinced her to take this as yet unproven step.

"without supportive medical evidence"...Yes, but if a patient decides that they want to be essentially a test subject, it should be their liberty to do so.

BTW, Philipp Bozzini wants his endoscope back -the Vienna Medical Society disapproved of his tool when he invented it, and tried it out without supportive medical evidence.

puja shaha said...
This comment has been removed by a blog administrator.
Michael Kirsch, M.D. said...

@TN, Thanks for the comment. Forgive me, once again for my technical inadequacy. Two inquiries:
(1) If a patient wants to serve as a test subject, as you support, who should pay for this? The patient? the rest of us? The drug company?
(2)Knowing what you now know, do you support widespread use of mammography for all women at age 50 at yearly intervals because you are persuaded that this is cost effective and that the benefits exceed the risks? A focused response is requested.

Third News said...

1. Though your concern is the economic consequence, the case I am familiar with was a breast cancer patient who sought treatment in the medical tourism industry, and payed cash. As you well know, outside of trials, and off-label drugs, this premise does not apply here

2. I have not read the study and not to calumniate the BMJ but "prestigious" preceding an institution is all too often reflective of past performance and writer's verbigeration ;-)

Again, my opinion is limited to respecting the patient's choices on medical care -inclusive of yearly mammography.

I thought this was interesting:

Michael Kirsch, M.D. said...

@TN, thanks for the comment. I reviewed the link you provided, which is sponsored by a health care institution, which may have a self-serving reason to dispute the BMJ study. My own blog has no possible commercial bias.

I agree that the adjective prestigious is trite, but in fact, the BMJ is one of the most respected journals out there.

With regard to "Again, my opinion is limited to respecting the patient's choices on medical care -inclusive of yearly mammography", I do not think that patients should have free choice for any and all medical care that someone else pays for. Indeed, this is once of the core reasons why we spend gazillions of someone else's money and health care that doesn't heal.

Third News said...

It is an irony that you cement your opinion here as I have just read your article "The High Cost of Health Care: A Personal Confession".

Are you also a politician?

Michael Kirsch, M.D. said...

I'm not a politician, but I play one on the blog...

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