There's no way this complex issue can be covered in one post, but thankfully there have been some really thoughtful pieces written by others that we can pull from. For example, my own comments led to this headline on the AtlanticWire: Politics Beats Science in Cancer Screening Debate, featuring a terrific piece by Kevin Sack in the NY Times (Screening Debate Reveals Culture Clash in Medicine), comments by Ezra Klein (WaPo), Arthur Caplan (MSNBC), and David Dayen (Firedoglake). The author of the AtlanticWire piece jumps to the heart of the issue and writes:
According to the panel, the timing of the new pap smear guidelines is entirely coincidental. But politicians — already taking steps to distance themselves from the obviously unpopular mammography guidelines — seemed wary Friday. The anger from women, doctors, and advocacy groups over the relaxed screening guidelines is revealing, pundits say. They argue that it reveals a divide between the hard science of cancer screening and the explosive, personal politics of health.
Kevin Sack's piece adds something to the debate in the form of a graphic showing that mammogram utilization has fallen recently in other age groups, and that a steady bit more than 60% of women 40-49 get yearly mammograms (for those interested, a state by state table is here.)
Presumably for the 40% that don't get yearly mammograms, this represents no change. But the recommendations have been presented to younger women as if something important is being taken away from them, rather than what the panel actually said: that the experts suggest that they cannot determine whether yearly mammograms in that age group for low risk women are helpful or harmful and that the best thing to do is discuss it with your own doctor.
The balance of benefits and potential harms, therefore, grows more favorable as women age. The precise age at which the potential benefits of mammography justify the possible harms is a subjective choice. The USPSTF did not find sufficient evidence to specify the optimal screening interval for women aged 40-49.
That, of course, assumes you have a doctor, and that's where the interface between health reform and this topic is most obvious.
As to what the risk is from breast cancer, and why the recommendations were changed away from "just do them", this St. Louis Post-Dispatch piece notes:
The British Medical Journal published an article to help people understand the risk in simple terms.
It means that if 1,000 women don't get mammograms, we can expect four of them to end up dying of breast cancer. If all 1,000 women do get regular mammograms, three will still die of breast cancer.
No matter the odds, many doctors and patients say any life saved is worth everyone getting the mammograms.
"We're all in agreement that this is not the best tool, but does that mean we should take the next step and not screen at all?" said Dr. Burton Needles, medical director of the cancer center at St. John's Mercy Medical Center in St. Louis. "Most of us who treat patients with cancer feel that the benefits still outweigh the risks of screening."
For more details, Kossack charliehall (biostatistician) wrote this more detailed diary on studies available through the Cochrane database, and noted the same result as above: women in the screening group were just as likely to die as women in the no-screening group.
Given that kind of information, the panel suggested individualized care over rote screening for everyone. And on the topic of relying on routine breast self-exam, which was another recommendation from the panel, Orac (pseudonym of a practicing surgeon from ScienceBlog's Respectful Insolence) notes:
The USPSTF's recommendation not to teach breast self-examination (BSE) is another point of controversy. Despite a lot of enthusiasm for the practice, Cochrane Reviews and other evidence have failed to find convincing evidence that routine regular BSE saves lives. I wish it were otherwise, but it appears not to be, even though there are compelling anecdotes out there of women who did find a lump on BSE and it turned out to be cancer. Unfortunately, overall, the evidence to support BSE is weak. On the other hand, even the Cochrane Collaboration, which I have in the past sometimes accused of methodolatry and "nihilism" with respect to screening concluded:
Some women will continue with breast self-examination or will wish to be taught the technique. We suggest that the lack of supporting evidence from the two major studies should be discussed with these women to enable them to make an informed decision. Women should, however, be aware of any breast changes. It is possible that increased breast awareness may have contributed to the decrease in mortality from breast cancer that has been noted in some countries. Women should, therefore, be encouraged to seek medical advice if they detect any change in their breasts that may be breast cancer.
Indeed, on a purely practical level, I see nothing wrong with women being taught to be aware of how their breasts normally feel and to bring to a physician's attention any changes that concern them and still encourage that, but there really is no good evidence to support BSE.
To add to that, Our Bodies Ourselves (Boston Women’s Health Book Collective) wrote that the case against screening is not new:
New government guidelines recommending that women start screening for breast cancer at age 50 instead of 40 set off a round of criticism this week and caused much confusion for women who for years have been told that early detection saves lives.
But a number of women’s health organizations, including Our Bodies Ourselves, the National Women’s Health Network and Breast Cancer Action, for years have warned that regular mammograms do not necessarily decrease a women’s risk of death. Premenopausal women in particular are urged to consider the risks and benefits.
In fact, the NWHN issued a position paper in 1993 recommending against screening mammography for pre-menopausal women. It was a very controversial position at the time — even more so than now. The breast cancer advocacy movement was in its infancy and efforts were focused on getting Medicare and insurance companies to cover mammograms. What the NWHN found — and other groups have since concurred — is that the potential harm from screening can outweigh the benefits for premenopausal women.
The above statement is important for several reasons. This is not a male view of the world superimposed on women. It's also not a view suddenly brought into the discussion by those wanting to focus on cost and cost alone. it predates this health bill, and it predates cost control discussions in the House and Senate, and in the Obama administration. More from Our Bodies Ourselves:
I don’t believe the new guidelines are politically motivated, nor are they "patronizing" to women simply because they call into question the stress related to biopsies and false positive results. Rather, the guidelines provide a useful framework for helping each of us to decide when is the best time to begin screenings and the intervals at which they should be repeated.
Personal health remains just that: personal. Note what the World Health Organization has to add on BSE:
There is no evidence on the effect of screening through breast self-examination (BSE). However, the practice of BSE has been seen to empower women, taking responsibility for their own health. Therefore, BSE is recommend for raising awareness among women at risk rather than as a screening method.
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So what do you do when you feel you are sitting on data that contradicts the status quo? How do you convey that information to the public? It's not like there's nothing written on the topic. Recognizing the political and social impact of the guidelines is a must, and failure to do so is a mistake, one that science and government types seem to make a lot. These particular guidelines won't be implemented immediately in any case. Physicians and the public still need to read and accept them. The likelihood of any such thing happening, or participatory and reasoned dialog occurring with the public with the current political atmosphere, is nil (now, those are odds we can all understand.) But if the recommendations make sense, further supporting data will present itself and the discussion will go on.
Note that none of the above has anything to do with insurance companies. That's a side issue, more likely to be settled in the health reform debate than with these recommendations. But if Republicans want to make an issue of this (and they will), they are going to have to make an issue of evidence-based medicine.
Evidence-based medicine (EBM) aims to apply the best available evidence gained from the scientific method to medical decision making. It seeks to assess the quality of evidence of the risks and benefits of treatments (including lack of treatment).
EBM recognizes that many aspects of medical care depend on individual factors such as quality- and value-of-life judgments, which are only partially subject to scientific methods. EBM, however, seeks to clarify those parts of medical practice that are in principle subject to scientific methods and to apply these methods to ensure the best prediction of outcomes in medical treatment, even as debate continues about which outcomes are desirable.
Our own Christopher Hughes recently wrote a diary on evidence-based vs anecdotal medicine.
"Experience," or anecdote, is sometimes helpful in medicine, but often harmful, because we physicians often internalize our experience into hard rules about treating patients. This often leads us down dangerous paths.
Evidence based medicine is long overdue counterweight to this kind of medical practice. EBM, when evidence is available, makes us think hard about our practices: Are we doing this because that's the way we've always done it, or because we have scientific research to back up our decisions?
That is the future of medicine. These guidelines will stand or fall on their merit, but given the fact that the US is 19th of 19 in preventable deaths, the way we do things is going to have to change. And that may mean recognizing when cancer screening is helpful and useful (colonoscopy) and when it's not (Pap smears before age 21.) And it may also mean allowing ourselves to debate the issue without accusing each other of trying to kill women. Personally speaking, I really haven't tried to kill any women all this week, and I don't intend to start this weekend. But if we don't discuss this, we won't make any progress on preventable deaths. And that, my friends, is progress that has to happen.
For the meantime, I am sorely tempted to suggest that if you want people to get mammograms, tell them they can't, and if you want to get people not to get flu shots, tell them they have to.