Save the boobies under attack

[merithyn]

As a woman approaching her 40th birthday, I'm now completely confused. Do I self-examine? Do I get a mammogram? Do I just sit around and hope? 

http://www.fox6now.com/news/nationworld/chi-mammograms-nov17,0,5164993.story

An influential group's new recommendations about mammograms for younger women set off a furious debate Monday that left women without clear guidance about how best to protect their health.

The U.S. Preventive Services Task Force, a government-sponsored group whose work is closely followed by doctors and insurance companies, is now advising that healthy women in their 40s may not need routine breast screening.

Mammograms help save lives, but they also can be unreliable, identifying benign growths as cancerous, missing other tumors that are malignant and sometimes leading to medical interventions of questionable benefit.

For younger women at low risk of the disease, the benefits are not large enough to endorse routine mammograms, the task force said in materials published Monday in the Annals of Internal Medicine. Instead, 40-something women should make individual decisions after weighing the pros and cons, the group said.

"No one is saying that women should not be screened in their 40s," said Dr. Diana Petitti, vice chair of the task force. "We're saying there needs to be a discussion between women and their doctors."

The task force also advised women 50 and older to get mammograms every two years instead of every year, and said evidence isn't sufficient to determine a course of action for women 75 and older.

Breast cancer specialists immediately denounced the new recommendations, warning that they could undermine advances in detecting and treating breast cancer early. Deaths from breast cancer have dropped 30 percent since 1990.

"This will be disastrous for women's health," said Dr. Daniel Kopans, senior radiologist in the breast imaging division at Massachusetts General Hospital.

"It's arrogant and irresponsible," said Dr. Robert Schmidt, a professor of radiology at the University of Chicago Medical Center. "It's wrong to keep changing recommendations and give conflicting messages to women."

Underscoring divisions over the issue, both the American Cancer Society and the National Cancer Institute said they would not follow in the task force's footsteps. Both organizations recommend routine mammograms for women starting at age 40.

After a review of the evidence, "we see no reason at this point to alter our guidelines," said Dr. Len Lichtenfeld, the cancer society's deputy medical officer.

"It is very confusing," said Careese Anderson, 48, of Chicago, who has been getting annual mammograms at the University of Chicago for eight years. "You hear one thing all these years, and it's scary when they start saying something else."

Evaluating the scientific evidence on the benefits of mammograms has challenged experts for more than 15 years. Eight "gold standard" medical trials have assessed the impact of mammography on breast cancer deaths, but most of the studies have significant flaws, experts say.

Fundamentally, the difference of opinion comes down to "a judgment call" about potential benefits and harms, Petitti said -- a call that doctors will also need to make when talking to patients.

"Our breast cancer group will review this very carefully," said Dr. William Gradishar, an oncologist who directs the breast cancer program at Northwestern University's Feinberg School of Medicine.

A new scientific analysis and modeling study published Monday along with the new recommendations found that women in their 40s who were offered the opportunity to get mammograms were 15 percent less likely to die of breast cancer than those who weren't.

That's an important advantage, but it needs to be seen in context. The risk that a 40-year-old woman will die of breast cancer in the next 10 years is very small -- just 0.19 percent, according to data from the National Cancer Institute. (Over an entire lifetime, the risk rises to 2.86 percent.) And the risk that a woman of 40 will be diagnosed with invasive breast cancer before her 50th birthday is 1.44 percent.

Most women vastly overestimate these risks, research shows.

Meanwhile, the chance of "false positive" results (which signal cancer but turn out to be incorrect) is 60 percent higher in 40-something women than in women in their 50s, in part because younger women's breasts are denser and harder to evaluate. Rates of over-diagnosis -- the detection of cancerous lesions that would never become life-threatening -- can run as high as 10 percent, the analysis said.

These false alarms expose many women to extra medical tests and procedures, which can be expensive and anxiety-producing, without yielding clear health benefits.

One statistic the new analysis doesn't detail is how many women in their 40s might die of cancer if they decided to forgo screening until they turned 50.

"Until I know how many cancers we're going to wait to pick up at a later age and a later clinical stage, I'll be screening annually," said Dr. Therese Bevers, professor of clinical cancer prevention at M.D. Anderson Cancer Center in Houston.

The new task force recommendations give little guidance to women in their mid-70s and their 80s, saying only that evidence isn't sufficient to make a recommendation. Doctors say they'll continue offering mammograms to older women who are in good health.

"If I see someone who's vibrant and vigorous at age 78 and who may live another 10 years, yes, I'm going to lean in favor of screening," said Gradishar of Northwestern.

"I'm entitled to the same course of action that any 40-year-old would take," said Ann Coan, 79, of Oak Lawn, who is awaiting results from her latest mammogram. "They can get breast cancer; I can get breast cancer too. Who can tell me my life isn't as important as theirs?"

The task force also recommends against breast self-examinations, saying teaching women how to perform them doesn't save lives and isn't necessary. Instead, experts say, women should make a point of noticing any changes in their breasts in the course of daily activities.

Whether the new mammography recommendations will change medical practice or impact insurance coverage remains unclear. They "won't change what I do and I hope it won't change what other people do," said Dr. David Dershaw, director of breast imaging at Memorial Sloan-Kettering Cancer Center in New York City.

"It may be more expensive to find each breast cancer for women in their 40s, but if you look at productive years of life saved, they're substantial," he said.

Financial cost did not enter into the task force's analysis, Petitti said.

[HisMajestyBOB]

More people die from heart disease; keep your heart in good condition first.

[Maximus]

I recommend daily examinations.

[Caliga]

I recommend daily examinations.

[Jos Theelen]

What risk do you find worse?
That you have breast cancer, but they didn't find it, because you didn't want an investigation?
That they investigate you and tell you have breast cancer, while in reality you haven't?

[merithyn]

You forgot the cost of the mammogram that is likely not going to be covered by insurance now that this report has come out.

I'm not in danger of breast cancer, per se (no family members with it), but since I've had ovarian cancer, I'm at a greater risk than the average woman. Add to that the hysterectomy, and voila! Danger, Will Robinson! Danger!

[DontSayBanana]

You forgot the cost of the mammogram that is likely not going to be covered by insurance now that this report has come out.

I'm not in danger of breast cancer, per se (no family members with it), but since I've had ovarian cancer, I'm at a greater risk than the average woman. Add to that the hysterectomy, and voila! Danger, Will Robinson! Danger!

Let's hold off on the Chicken Little-esque panic for a bit- sure, USPSTF is a heavy hitter, but the American Cancer Society and the National Cancer Institute are both extremely powerful and telling USPSTF where they can stick it; I doubt we're going to see significant changes in breast exam coverage as a result of this opinion alone.

[merithyn]

Let's hold off on the Chicken Little-esque panic for a bit- sure, USPSTF is a heavy hitter, but the American Cancer Society and the National Cancer Institute are both extremely powerful and telling USPSTF where they can stick it; I doubt we're going to see significant changes in breast exam coverage as a result of this opinion alone.

The U.S. Preventive Services Task Force, a government-sponsored group whose work is closely followed by doctors and insurance companies, is now advising that healthy women in their 40s may not need routine breast screening.

I have little respect for the insurance companies decision on these things. It's not a chicken-little response.

[HisMajestyBOB]

I recommend daily examinations.

Languish can help. Always good to have a second (or third, or fourth...) opinion. 

[Jos Theelen]

You forgot the cost of the mammogram that is likely not going to be covered by insurance now that this report has come out.

I'm not in danger of breast cancer, per se (no family members with it), but since I've had ovarian cancer, I'm at a greater risk than the average woman. Add to that the hysterectomy, and voila! Danger, Will Robinson! Danger!

Sorry, I am a European. We don't have that healthcare system, I don't have to worry about those things.

Maybe you should do it, but less regular. Certainly when the risks are greater.

BTW: your remark suggest that this report could be publiced to reduce health-care spending.

[DontSayBanana]

I have little respect for the insurance companies decision on these things. It's not a chicken-little response.

The work is closely followed, yeah, but they hardly have unilateral authority.  ACS and NCI are more publicly visible entities, so one of the worst business decisions an insurer could make is to refuse breast exam coverage against the recommendation of either.

Also, there's still the fact that there are whole clinics who almost solely work with breast cancer prevention.  If the insurers suddenly start tightening the purse-strings on exams, they'll also come up against angry doctors whose businesses suddenly tanked.

[BVN]

(...) younger women's breasts are denser and harder (...)

That was the only thing of interest in the article... 

[Berkut]

I think results like this are rather amusing.

It is funny how impossible it is to have a rational discourse about any of this. If you ever suggest that maybe a course of action that will cost less, but result in some number of deaths is the right course of action, you are getting to get roasted for being such a callous prick.

The only acceptable answer is "ZOMG WE MUST HAVE EXAMS FOR EVERYONE NO MATTER THE COST!!!" So much of what is "important" in medicine is based on completely emotive responses, rather than simple and dispassionate evaluations of risks and costs.

Kind of funny Meri that you would champion this, while at the same time you laugh off vaccinations. A bit inconsistent there in your decisions about what preventative measures should be taken. Vaccinations are a lot cheaper, and prevent a illness that is MUCH more likely than breast cancer in women in their 40s.

[Berkut]

I have little respect for the insurance companies decision on these things. It's not a chicken-little response.

If the science says that the risk of breast cancer in women in their 40s does not justify the costs and risks associated with mammograms at some particular rate, then the insurance companies should most certainly not cover those exams.

Of course, this will never happen, because everyone will wear their pink bows or whatever, but it is what SHOULD happen.

[Martinus]

I think results like this are rather amusing.

It is funny how impossible it is to have a rational discourse about any of this. If you ever suggest that maybe a course of action that will cost less, but result in some number of deaths is the right course of action, you are getting to get roasted for being such a callous prick.

Once you start reasoning like this, euthanasia of the undesirables becomes a valid option.

After all, if you believe it's sensible to save money on prevention, why not save on the actual treatment? A child born with a debilitating disease that requires a life-time life support is unlikely to be worth it in financial terms - he or she will never get contribute to the society in a way that will exceed the costs of keeping such treatment going. Likewise, treating pensioners for any diseases really doesn't make sense either.

So yes, you are a callous prick. But then we knew that already.