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?
If I were to rank-order those whose best interests are protected by mammography, I'd put patients near the bottom of the list.
ReplyDeleteI 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?
I think you should write your own blog! Appreciate your comments.
ReplyDeleteWhen 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???
ReplyDeleteNo 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.
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.
ReplyDeleteThank you for writing your extensive post, My wife and I enjoyed reading it!