XX Factor: the blog

Screen Less

Emily B, I agree with you that it’s really unfortunate that the conclusion that we don’t need to routinely do mammograms until 50, instead of aparking a national, rational discussion about the advisability of “screening and prevention,” has become the harbinger that we’re all going to live under British health care rationing. The debate over whether we benefit from searching for early cancers is not new, and no wonder the public is so confused. This is like the “no fat” to “no carbs” pendulum swings on official diet recommendation. First we’re told looking early for breast cancer is the way to save lives; now we’re told look too early and often and we mostly finds lumps that are benign. Barack Obama has said that improved detection and prevention under his health care plan will lead to Americans being healthier, but this government task force on mammograms raises questions about what that means and whether it works. And now the administration, when confronted by evidence that we should do less, realizes it can’t take that political hit. As Steve Pearlstein writes, this is not good news for our ability to contain costs.

There’s no way to take the politics out of health care. But instead of seeing this debate as something sinister, we all would benefit from constant reexamination by the medical profession of its recommendations about how we should be examined. A few years ago, CT scans were supposed to revolutionize lung cancer treatment. Finally, we had a technology that would discover these tumors before they became deadly. But it turned out the screening didn’t save lives, it picked up tumors that wouldn’t have progressed. So this wasn’t a matter of “anxiety,” as in the false-positive mammogram. This meant people were being treated for a cancer that would have just sat there had it not been found.

In the mammogram debate, we are mostly hearing from the women who are angry and fearful that their annual mammogram will be taken away. But I wish that in my 40s my doctor hadn’t lectured me every year that I was overdue for a mammogram, and instead we’d been able to discuss when it made sense to start and how often I should have one.

Photograph of mammogram by John Foxx/Stockbyte/Getty Creative Images.

Tags: breast cancer, health care reform, mammograms

Emily Yoffe is Slate's Dear Prudence and Human Guinea Pig (emilyyoffe@hotmail.com)

Comments

Sister with aggressive breast cancer

By: im1 | Mon, 11/23/2009 - 12:28

If your sister is diagnosed with aggressive breast cancer (especially at a young age) you are no longer in a low risk category, you are in a high risk category and the only screen after 50, every 2 years guidelines do not apply.

nonsense

By: patron002 | Sun, 11/22/2009 - 19:31

You can complain about how this was made political, but it was made political by democrats not republicans.Democrats are the ones claiming that prevention is more important than treatment. Well, panels like this one will decide what should be covered. Its interesting that they chose this time to make that decision I will admit, either they are against the change in health care or very foolish indeed. There is no other way to take that decision but as a direct preview of what healthcare under Obama will look, true or not.

Beware the Cancer Genie

By: Biotunes | Sat, 11/21/2009 - 20:27

Amester,
Part of the problem with this issue is that people like you who needed treatment are confusing routine screening with testing people who are symptomatic, as you were. The panel's recommendations have nothing to do with women who have found a lump - like you and me - they only have to do with looking for cancer in healthy women who have no symptoms. That seems to have been a big point of confusion contributing to animosity in this debate. It is also not about "rationing" because again, this is the screening of healthy people, not a decision that affects someone who is already sick.

For far too long, the fact that many, many cancers are treated that will never progress into a noticeable disease has been swept under the rug by the pro-screening lobby (which shamefully includes the American College of Radiologists, who have a blatant conflict of interest). As you know, having cancer is stressful, exhausting, expensive, and scary. You and I had clear-cut cases that needed treatment. Women with only DCIS do not. But once the "cancer genie" is out of the bottle, treatment is assumed to be the only option, for several reasons.

Although money and the morality of how it is spent is certainly an issue to do with this debate (e.g. how many mammograms for healthy women in their 40's will pay for someone without insurance to have a surgery they need to survive?) the report was not focused on cost, except in the sense that there is a significant non-monetary cost associated with screening, and we need to include that information in our decision about whether or not to screen. It is simple cost-benefit analysis - which you can't do accurately without knowing the risks as well as benefits.

"Mostly"? "Appropriate"?

By: Amester | Sat, 11/21/2009 - 18:11

"Mostly" finding lumps that are benign and "appropriate" risk factors are easy words to throw around when you're outside of the cancer circle. I found a lump via self exam at age 34, shortly after I stopped nursing my 10-month-old son. I was told that because I was "so young", had just been breastfeeding, and was extremely healthy, it was surely nothing and to wait a few months to see what happened before getting any screening. I am not a paranoid person by nature but I insisted that it be checked and (say it with me) it was cancer - triple negative and Nottingham grade 9. In layman's terms, that means uber-aggressive and impossible to treat with any adjuvant therapies outside of surgery, chemo and radiation (no medication options such as Herceptin or Tamoxifen). I chose a bilateral mastectomy (which occurred the day before my son's first birthday - I had a total of 15 hours in the hospital, but that's a whole 'nother rant) and four months of chemo even though my lymph nodes were clear because we had no other defense.

One year later, my 44 year old sister had a mammogram - she had skipped hers the year I was diagnosed - and (say it with me) she had stage II, triple negative, Nottingham 3 cancer.

Please tell me, with all of the talk that self exams are unnecessary and mammograms are overdone, how would my sister and I have fared under the "new" guidelines? Sure, we were in the minority for risk factors, cancer type, etc. but damn, we still count. Exceptions abound, but we still count.

Decisions like this cannot and should not be made out of hand and only with an eye toward majorities and percentages.

Mammography

By: peggylsanders | Sat, 11/21/2009 - 15:31

While I realize that Slate is about politics, there's something missing this discussion of screening. I believe that this debate should be about women's health and not health care politics. I think that there are sincere and critical concerns from women who know the cost of breast cancer -- and it's not just about politics.

I did, in fact, look at the study itself online. The blaring absence in the study was any discussion about the benefits of early detection on the extreme nature of treatment for the disease. It may in fact be true that mortality rates are not significantly improved by early detection. Putting aside for the moment that it matters greatly to the one in 1,900 who is saved by screening, I noted that there is no evaluation about reducing the extreme impact of treatment on women with breast cancer. What I mean by that is -- I recently recovered from breast cancer myself. My tumor was detected During my routine mammogram (which followed by ultrasound and biopsy -- then MRI, etc prior to starting treatment). My tumor was not detectable by physical examination, even after my doctors knew where it was. And before I started treatment, the doctors were very thorough in determining that the tumor was in fact cancerous.

My tumor was at Stage IIA. Because of the timing of detection, my treatment involved a lumpectomy, chemo and radiation. When I was diagnosed, there was a trace of cancer in a lymph node in my breast tissues -- but none in the lymph nodes under my arm. I did not have to have a bunch of lymph nodes removed, and as a result I don't suffer with lymphedema as many cancer survivors do. The good news is that I am cancer free, I have no lymphedema and I have most of my breast. So when we talk about the benefits of screening, early detection and treatment, let's not forget that we're not just talking about mortality.

Also it would be interesting to compare the costs of early treatment versus the cost of treating later stage breast cancer. I'm going to assume (with no proof) that a lumpectomy is cheaper, faster, and easier to recover from than a mastectomy. I know I was back at work within two weeks of my operation.

Another part of this debate very definitely should be -- if mammography isn't good enough to justify the cost or the "anxiety", let's get a better test. Until we have one, should we really be throwing away the one we have?

Finally, I need to protest the idea that we can limit our screening to "high risk" women. High risk is a misnomer when one is discussing breast cancer. Everyone talks about family history as evidence of high risk -- but only 5-10% of the women who get breast cancer have a family history. I didn't have any of the risk factors that everyone mentions. I don't have a family history, I never took birth control or hormone replacement therapy, I never smoked, and okay so I'm a little overweight. My diagnosis seemingly came out of nowhere and my doctors told me that the highest risk factor for breast cancer is being female. When we can identify high risk factors for breast cancer, then maybe I would change my mind. Again, until then, why throw out what has worked?

In fact, in Britain

By: _Nancy_ | Mon, 11/23/2009 - 15:20

routine screening is on the rise. If you talk to GP's who are already struggling to cope with their work load, they will tell you that most of the people screened will have nothing or will have a scare that turns out to be nothing wasting time, effort and energy. It might create the illusion of improving health but it probably just leads to a morbid preoccupation with it. We're not preempting disease, we are making a pathology of ordinary life - that's why so many otherwise healthy people are walking around with vaguely defined syndromes and disorders and why so many long discredited alternative therapies enjoy so much popularity.

How much better would it be to spend the resources currently spent on meaningless screening into perfecting how we understand what screening it appropriate to which individual and when?