New Mammogram Guidelines Are Causing Confusion, But Here’s Why They Make Sense

@Kristen, one might equally say that the evidence was just not that compelling to warrant the earlier recommendation of annual mammos.

3 months, 3 weeks ago by Dana on Wordpress

“How is it conscionable to advocate that early stage cancers not be treated when there are many, many women who have them and later face a deadly recurrence?”

Breast cancer is more than one disease. There are different types of breast cancer and not all of them require the same treatment. It is not clear that we are making any difference by treating breast cancer diagnosed between 40-49. Those cancers that are not aggressive were never going to spread so we don’t really cure them. Those cancers that are aggressive appear to spread despite the standard treatment.

People often insist that it is worth any amount of money to save one life, but that’s not really what we believe. If we were to lower the speed limit on highways to 35 mph, we could save thousands, maybe tens of thousands of lives, yet we don’t do it. Why? Because it is too inconvenient, and costs too much time.

When it comes to making guidelines for large populations, the lines we draw are always somewhat arbitrary. Though people claim to be outraged at dropping the recommendation for yearly mammograms in women aged 40-49, why aren’t they clamoring that the recommendations should be extended to yearly mammograms for women aged 30-39? If they truly believed, as they claim that they do, that it is worth any amount of money to save one life, they should be insisting on screening for women aged 30-39 since breast cancer can occur in that group, too.

There’s nothing special about whole numbers that end in 0. Why not recommend yearly screening women aged 28-39? For that matter, there’s nothing special about yearly intervals. Why aren’t they recommending screening for all women every 6 months instead of every 12 months? Surely we could save a few more lives that way, too.

The fact is that we are forced to make relatively arbitrary policy decisions when it comes to safety issues of any kind. We are always forced to balance benefits and costs. We don’t really believe that it is worth any amount of money to save even one life. We don’t even believe that it is worth getting to our destination a little later to save thousands of lives lost on the highway each year.

That’s why the outrage over rationing is entirely misplaced. If by rationing people mean considering cost when making safety decisions, we ration every day in many ways. We live in the real world, and in the real world there is not unlimited money. A dollar spent on mammograms is a dollar not spent on another form of healthcare that may have a much better benefit to cost ratio. It is not rationing to suggest that some money spent on mammograms might be better spent elsewhere. It is merely common sense. ... See all content Hide content

3 months, 4 weeks ago by Amy Tuteur, MD on Wordpress

I STRONGLY agree with Kristin Harris and take issue with Dr. Amy Tuter’s points.

“The scientific evidence shows that up to 20% of early stage breast cancers detected in women aged 40-49 would go away by themselves. In the rest, there doesn’t seem to be much benefit to treating them aggressively because they do not behave aggressively.”

I had a non-agressive stage 1 BC diagnosed a few months ago at my 39th birthday after my second mamogram. I never felt a thing, but the mass was a little beyond DCIS by the time it was found.

How would we know if my tumor would have gone away by itself? We have no way of knowing right now. So, do nothing about it and hope you’re in the 20%. Come on, that’s crazy. This is my life.

“There does not seem to much benefit to treating them aggressively because they do not behave aggressively.”

Is lumpectomy, radiation & tamoxifen considered aggressive treatment? I agree with Kristen. I am glad I had good health insurance and was able to get that kind of treatment. How would we know if it MIGHT behave aggressively? Again, no way to know. None at all. So, do nothing? With a stage 1 tumor? That would be insane. Unless someone could guarantee me that the tumor would go away or not grow at all, I HAD to do something. We KNOW that guarantee does not now exist, maybe in the future, but until then do nothing??? Really??? This seems like quite a glib position for a physician to take.

I will have MRIs & breast ultra-sounds for a while. Do I like this? No, but I also know several women my age with aggressive BC, and this seems like a small price to pay for my health. I hate that i had this diagnosis, but hate more that women my age are dying of this disease and there is not enough research going on about WHY so many more young women are getting this disease.

With the change in the recommendations, it’s just a matter of time until the insurance companies stop paying for mamograms etc. for women in their 40s. Women who should get the tests or want them WILL be denied. That is for sure.

IS THAT PROGRESS FOR WOMEN? ... See all content Hide content

3 months, 4 weeks ago by Shura on Wordpress

@gglockner Another women's health group defends new guidelines: http://bit.ly/5i7uGY

4 months ago by petedanko on Twitter

Why the new gov't recommendations for breast cancer screening make sense: http://tiny.cc/JniCa

4 months ago by bethfully123 on Twitter

Thanks @RitaRubin @wileycnm @Bobinska for retweets on mammogram guidelines http://bit.ly/4yCHE

4 months ago by JudyOBOS on Twitter

Rj, I think you misunderstanding the responses. I think everyone favors being on the safe side and having tests. Some Doctors here seem very cavalier with people lives and peice of mind but want to pound the statitics home. My wife was glad to have her cancer treated aggressively and put it behind, there is no way (given that no data spoken here is 100%) that she would have lived with the cancer based on someones theories and statitstics. How could we expect anyone to do that? Amy, I am still waiting for your response to Kristen\’s post. ... See all content Hide content

4 months ago by Dennis on Wordpress

for those of you saying that the new mammography guidelines are racist, please read this http://tiny.cc/AkRFV please think for a sec

4 months ago by randijames on Twitter

Amy – thanks for your reply. I did *extensive* research when I was first diagnosed and never found that scientific evidence which you reference. In addition to exhaustive medical journal research on my own, I also interviewed three oncologists, two surgeons, and two radiation oncologists. Most of them told me it would be highly risky to “watch” my cancer and potentially unethical to even do a study that would simply “watch” cancer that was in my breast. I would embrace reading that evidence you reference that conclusively shows that up to 20% of early stage breast cancers detected in women aged 40-49 would go away on its own. That is the exact type of evidence I was looking for, but could not find. My cancer was aggressive, and the research I did find indicated that many cancers in women of younger ages tended to be more aggressive.

Due to the high level of research I did before undergoing any treatment, I was not filled with fear, anxiety during or after treatment. I was empowered and had a sense I was more in control of my disease.

The one article of research you reference was not regarding age 40-49 breast cancer cases. One study is not enough. Please provide any other sources. Thanks! ... See all content Hide content

4 months ago by Kristen Harris on Wordpress

“The scientific evidence shows that up to 20% of early stage breast cancers detected in women aged 40-49 would go away by themselves. In the rest, there doesn’t seem to be much benefit to treating them aggressively because they do not behave aggressively.”

Cite source please. I’m curious how this is known, especially for the relatively younger women.

4 months ago by Tammy on Wordpress

“The cancer was early stage, so I could have a successful lumpectomy, radiation treatment, and now will have the added protection of taking tamoxifen for the next five years. I firmly believe in my case, if we would have been following these recommendations, my prognosis and anxiety would be much worse.”

But that’s not what the scientific evidence shows.

The scientific evidence shows that up to 20% of early stage breast cancers detected in women aged 40-49 would go away by themselves. In the rest, there doesn’t seem to be much benefit to treating them aggressively because they do not behave aggressively.

In some ways, that’s even more distressing information than the change in mammography guidelines. It means that thousands of women have undergone unnecessary biopsies, unnecessary surgeries and unnecessary chemo and radiation, not to mention unnecessary anxiety and fear. We didn’t cure these women. We treated many of them even though they didn’t need it and then took credit for what would have happened anyway. ... See all content Hide content

4 months ago by Amy Tuteur, MD on Wordpress

When I heard about the US Preventive Services Task Force mammography recommendations, I had two thoughts. The first was that these recommendations are old, not new, but people keep ignoring them for political reasons. The second was that the Republicans would exploit these recommendations to claim that the Obama administration was attempting to ration healthcare. What I hadn’t counted on was that the politically motivated claim of rationing would resonate with so many women despite its complete lack of factual support.

It was not a stretch to envision the Republicans trying to exploit these recommendations for political purposes. After all, they are not constrained by the truth. The same people who fabricated the idea of “death panels” were not going to be able to resist the idea of “breast panels” convened to deprive women of what breast cancer surgeon Dr. Susan Love aptly and humorously disparages as “a right to be radiated.”

The beauty of a lie, particularly a big lie, is that if you say it often enough, people will begin to believe it. Even though death panels never existed; even though they were a complete fabrication of Sarah Palin and Republican operatives, they struck a chord in the American public. Republicans implied, or even stated, that Barack Obama wants to kills you to save money for the US government.

So American women were primed to ascribed nefarious motivations to the new recommendations: the timing of the recommendations is supposedly suspect, the fact that the president is a Democrat is supposedly not coincidental, the mere idea of saving money by applying scientific evidence is merely a cover up for rationing.

But the timing is not suspect; the recommendations have been proposed repeatedly over the past decade. The identity of the president is coincidental; the same recommendations were proposed under George W. Bush. Saving money by applying scientific evidence is not rationing; no one is being deprived of medically beneficial care. Anyone who wants to have a mammogram can get one; you simply have to pay for it if it’s not medically indicated.

The irony is that everyone claims to favor “evidence based medicine.” Well, this is what evidence based medicine looks like. The scientific evidence does not justify routine yearly mammograms for women aged 40-49. But instead of opting for evidence based medicine, the American public seems to favor fear based, politically motivated medicine. ... See all content Hide content

4 months ago by Amy Tuteur, MD on Wordpress

I must say that I am troubled by these new recommendations, perhaps because they come so close to my mother’s breast cancer diagnosis. Her cancer is so small that it was found on a mammogram, and so we are lucky. However, I was also troubled by your explanation that cancers basically break down into three categories:

“Women are constantly being told “early detection saves lives ,” but in reality we know some breast cancers, by the time they’re found, cannot be treated. Other cancers will never be life-threatening, and some will respond to currently available treatments.”

My mother’s cancer is the dreaded triple negative, and so would that put her in the “cannot be treated” category? So why bother screening? And perhaps I should forgo any screening even though I am now at high risk, because the type of cancer I am genetically more likely to get in the next ten to twenty years is untreatable and their for I should resign my self to inevitable death?

I know you don’t mean to say that, I know these guidelines don’t mean to say that. However, suggesting that the 10% possibility of a faulty mammogram or the inconvenience of a negative biopsy is more important then catching a breast cancer early is disingenuous. I would have loved my mom’s biopsy to be negative, but instead I’m at least happy that we caught it early enough to give her a chance at beating it. ... See all content Hide content

4 months ago by Myra on Wordpress

Thanks for the great article, OBOS. From a historical perspective, much of anxiety and uncertainty is a product of screening procedures that have led the medical profession to view the breast as a “precancerous organ” (this phrase comes from Robert Aronowitz book, _Unnatural History_).

4 months ago by Knitting Clio on Wordpress

Here's our take on the new mammogram guidelines and why, despite the confusion, they make a lot of sense: http://bit.ly/4yCHE

4 months ago by JudyOBOS on Twitter

@Angie_Coiro Fantastic! So glad you're delving into the topic. Our Bodies Our Selves has a great post up about this http://bit.ly/at9lp

4 months ago by rebecca_f on Twitter

I am an epidemiologist and understand why this ADVISORY TASK FORCE (not the government itself) reached these conclusions. Nevertheless, I think that the RECOMMENDATIONS (not guidelines) are wrong and are patronizing. My mother died from breast cancer so the recommendations, if upped into guidelines and effecting health insurance coverage for mammograms for women between the ages of 40 and 49 would not have effected me. I had yearly mammograms, had to have repeat mammograms on several occasions, and once nearly had a biopsy due to a self-identified breast lump; it was a cyst and collapse the night before the scheduled biopsy. Those things made me very anxious. But finding out that it was a false alarm was so wonderful that it made up for the anxiety. I cannot imagine any woman thinking that it is worse to have anxiety and a repeat mammogram or even a biopsy than delaying treatment for actual breast cancer. Women have a lot of causes for anxiety in their lives. this is minor compared to many other things that cause us to be anxious. Unwanted pregnancies are one of them! The US Preventive Services Task Force recommendations are based on a lack of understanding of the terror that breast cancer represents for American women. It was also tone deaf. And terribly mistimed, coming out in the midst of discussion, and lots of rumors and misinformation about what is being considered for health care reform in this country. I am afraid that it has already done terrible damage to that so important process. In addition, the only television discussion I heard about the mammogram recommendation was on CCN’s “situation room” while I was eating lunch yesterday. A member of the US Preventive Services Task Force, spoke in favor. A breast cancer survivor had already spoken vehemently against them. I am a nurse (and midwife) and know that there are a lot of brilliant nurses, and she had a PhD. But she is a nurse at a nursing education program in Georgia. She wasn’t bad, but she wasn’t good. She really just repeated the recommendations. The Task Force should have been represented by an MD epidemiologist, such as Dianna Petitti. When you have a chance to go on national television to make your case, you have to cave to the general population’s belief that anyone who is not an MD is a lesser authority on anything having to do with disease. I hope that the Task Force will withdraw its recommendation and study it further.

Judith Rooks ... See all content Hide content

4 months ago by Judith Rooks on Wordpress

Thank you, thank you, thank you for such a thoughtful and comprehensive review of this very important topic. I have been distressed at the inaccurate and frankly irresponsible journalism with regard to the new recommendations. The most important thing is that women need to talk with their physicians and do what is best in their individual circumstances.

4 months ago by Chukwuma on Wordpress

I am a BC survivor. Diagnosed at 48 years old, I found a lump, the mammogram substanciated that.

The science discussed in this post makes sense BUT — my breast cancer was either one that would never be life threatening or one that would response to today’s known treatments. I do not know which kind mine was but it was obviously one of those as I am still alife with no symptoms .

Now I wonder, if I had not found the lump, had not had the mammogram see it, and it was the kind of breast cancer that would respond to treatment, how would I have known I had it and needed that kind of treatment?

If a cancer resides in a woman’s breast and it is not felt because we are no longer encouraged to do a self exam and it is no longer screeened how will it now be detected and how will this woman’s life we saved?

I know that we need better screening methods, better ways to find out what kind of cancer exist but waht do we do in the meantime to find breast cancers? ... See all content Hide content

4 months ago by jan on Wordpress

thank for posting this. I’ve been wanting to read a thoughtful & scientifically-based response to the new guidelines.

4 months ago by Stephanie on Wordpress