A very brief post about the breast cancer screening recommendations

I am running late and have to go pick up the Critter at the sitter's, so I'm going to make this post very, very brief and to the point.

To everyone who has seized upon the new recommendations regarding breast cancer screening, and is making a fuss about it -- stop. Just stop. Particularly if you are scoring political points because of it. This was a scientific recommendation based upon evaluation of the data, of the costs incurred (not just monetary, but also in terms of radiation absorbed, surgeries endured, etc.) by unnecessary follow-up for benign lesions, and the number of lives that are actually saved by the current practice of mammography. Scientists may debate the data, and may disagree about the conclusions. It is well out of my area of specialty, and thus I have no business commenting on the actual merits of the recommendations. I am neither a gynecologist nor breast surgeon, and do not treat patients for breast cancer. However, as a practicing physician, I am familiar with recommendations of this kind. They come down the pike every now and then, are sometimes controversial, and have nothing at all to do with the President, the Congress or health care reform.

This was a scientific recommendation based upon evaluation of the data. Spinning it for political purposes is ridiculous and addle-brained. Any assertion to the contrary is wrong, full stop.


  1. Dan, back in May of 09 the CDC got all itchy about a slight downward trend in mammogram screening. Now the USPSTF recommends skipping routine mammograms util 50, while the American Cancer Society and American College of Obstetricians and Gynecologists disagree. And ISTR Barry Big-Ears telling us increased prevention would decrease costs.

    So tell me, who is better equipped to know? The CDC, the ACS, and the Ob-Gyns -- or some independent task force funded by the Feds who need to cut costs? Cui Bono? I think this is NOT something that we should just STFU about. You have no way of knowing that this has "nothing to do with the President, the Congress or health care reform." That's your assertion, unsupported by any real analysis. I hope the CDC, ACS, and the guy at Harvard Medical (Daniel Kopans) take a close look at the evidence and reasoning of the panel. If we are going to have the Feds running healthcare, then we should demand transparency and explanations for these "recommendations."

  2. The CDC, ACS, etc. are free to dispute the findings. That is what scientific bodies do, and how scientific consensus is reached. But federal panels of this kind are formed regularly to investigate practices such as this, and to hold forth that this is some kind of cost-cutting conspiracy is inane. The question of when, how and how often women should be screened for breast cancer is very old, and there are plenty of OB/gyns who are fully in support of the new recommendations. My assertions come from years of reading the recommendations of similar task forces. Where do yours come from?

    Your calling the President "Barry Big-Ears" is something I would expect from a truculent 7th-grader, and makes you seem incredibly petty and juvenile.

  3. The acronyms do dispute the findings, along with the named Harvard doc. It will be interesting to see how this plays out.

    Regarding scientific consensus, I can only agree with the physician and author Michael Chrichton in his speech Aliens Cause Global Warming:

    Let's be clear: the work of science has nothing whatever to do with consensus. Consensus is the business of politics. Science, on the contrary, requires only one investigator who happens to be right, which means that he or she has results that are verifiable by reference to the real world. In science consensus is irrelevant. What is relevant is reproducible results. The greatest scientists in history are great precisely because they broke with the consensus.

    You appeal to medical consensus but like scientific consensus, I imagine what medical consensus means is "we don't really have enough data to make a convincing case, because if we did, no one would speak of consensus."

    Regarding assertions, I'm not making any. I observe that your assertion is justified by appeal to authority, which is fine if somewhat weak. And I question the appeal to authority, not that I think you are deceptive, but to ask you to consider if you might be mistaken in this particular case. Is it possible that you could be mistaken? If so, how would you know? What I see is you and the USPSTF on oen side, and the ACS, CDC, a Harvard professor, and the College of Ob-Gyn on the other. I think it quite reasonable to question your appeal to authority with an appeal to authority of my own. I honestly don't know which side is correct. I am interested in how this disagreement is resolved.

    You don't like Barry Big-Ears? OK, I'll retire it.

  4. John, I believe we are arguing past each other. Let me try to be more clear.

    I am not endorsing the recommendations of the task force. I think it remains an open question whether the recommendations re: screening are for the best, and I think it is entirely appropriate for the various bodies you cite to debate them. I am not appealing to the authority of the task force, and do not bow to recommendations from on high in my own practice if I don't agree with them. (Not so long ago, some august body or another made recommendations about the care of overweight children, including a recommendation that overweight children be started on lipid-lowering agents as young as (IIRC) nine years old. It will be a cold day in hell before I consider starting a 9-year-old on Lipitor.) I don't argue that even medical/scientific consensus is necessarily correct. History is full of examples of the prevailing scientific consensus being dead wrong. FWIW, I know a very smart man (who may or may not be related to me) who has studied the pertinent science and questions anthropogenic global warming, and has managed to make me agnostic on the issue. So, in summary, I am not arguing that the recommendations be accepted because they come from a federal task force, that they are correct, or that any resulting consensus is necessarily correct.

    What I AM arguing is that this is not part of some nefarious "ObamaCare" plot to cut funding for a vital service. If anything, it is patently obvious that the Obama administration is falling all over itself to reassure people it won't cut funding, and clearly would not have wanted such an unpopular report to be released at such a crucial time in the health care debate. It is obvious that the White House is not orchestrating anything having to do with this task force, just like it hasn't been behind the myriad other task forces that have made various recommendations for lo these many years.


  5. Yes, we seem to be in violent agreement about the consensus.

    However, by telling people to stop with the politicial observations, you do not seem to realize that these kinds of recommendations are exactly what Mr. Obama meant by the "difficult conversation" we'd have as a nation. I'm not going to stand by while some acronym "task force" made up of ivory tower types tells my wife what is best for her, or me what is best for me. I'll find a doctor I trust, and get a second or third opinion if I feel it wise. I don't want the effing Congress deciding what is permissible and what is not based on this year's budget. I mean, can a "recommendation" for reduced screening for prostate cancer be far behind? Old guys get it, they usually die before the cancer woudl kill them, and frankly, the treatment is expensive, not always successful, and tests produce false positives. The gain to the individual isn't worth the cost to society. There is your damn death panel in spades.

    In fact, Dr. Sanjay Gupta apparently tore someone on the USPSTF a new orifice during a CNN interview about the mammogram guidelines. Dr. Gupta was good enough to be offered the Surgeon General slot by Pres. Obama, so I don't think he's an ideologue hack. Let's have that difficult conversation without attempts to shush the critics of CongressCare.

  6. John, I fear your perception of how recommendations of this sort are made and received is making it difficult to have a constructive conversation.

  7. Dr. Dan, I think I have a pretty good handle on how task force recommendations come into being, and how one should evalute them from a professional POV. I've served on task forces developing professional standards, albeit not in medicine. So I'm well aware of how easily political pressures can sway the analysis and interpretation of data, but somehow I'm getting the sense that you aren't that aware of this all-too-human phenomenon.

    Perhaps you might address the substance of my part of the conversation, to wit, that task force recommendations affect patient and physician options -- as ACOG points out, this recommendation will make routine mammography an uncovered procedure for some patients. ACOG also points out that the USPSTF already recommends against **teaching** Breast Self-Examination to women! Despite this, ACOG's recommendations remain unchanged (teach BSE and offer counsel mammograms for the < 50 set).

    Now, once we have been placed in the tender mercies of CongressCare, spelling out precisely what must be in qualifying coverage, is it possible that the beancounters at CongressCare will put the ixnay on mammograms and **teaching** BSE, regardless of individual physicians' judgement? Can you imagine this might somehow be motivated by costs and budget concerns? And can you imagine the aforementioned beancounters testifying before Congress -- "hey, we are just going along with the Settled Science. It is for the greater good." Can you imagine that? I can. In fact, I can imagine more. I can imagine physicians who actually teach BSE or perform routine mammograms would be vulnerable to lawsuits -- we all know the current Congress isn't ever going to protect physicians from lawyers, damn the costs, because Democratic leaders have said so and the Senate bill guts States' ability to pass tort reform.

    And also, I can imagine pediatricians will not be exempt from these kinds of things. Welcome to the brave new world of medicine, brought to you by the Most Ethical, Most Transparent, Smartest, Most Caring Congress and Administration Evah.

  8. http://scienceblogs.com/insolence/2009/11/really_rethinking_breast_cancer_screenin.php

  9. I quote from the blog post above:

    The USPSTF found fair evidence that women who have screening mammography die of breast cancer less frequently than women who do not have it

    Well, there ya go. Sorry about that, Elizabeth, you and your fellow non-males will have to take one for the team.

    but the benefits minus the harms are small for women aged 40 to 49.

    Can't have that, can we? Just a small gain. Only a small number of families will need to go through the heartbreak of a mother, a sister, a wife dying a painful and preventable death if we adopt these recommendations. But hey, who cares if we manage to save a few dollars? Bend the cost curve, baby.

    Now I understand Dr. Gupta's anger at the USPSTF better than before.

  10. @ Gadfly

    If you're assuming all decision-making occurs discretely and independently, then sure, you're correct.

    However, the question, "Is the benefit worth the cost" is a legitimate question if what you're talking about is net effectiveness of a collection of actions inside a domain.

    Sure, it sucks to be one of the rare people who would have had their breast cancer caught. It's also great to be one of the ones who would have been diagnosed with a false positive and wasn't. Neither of those represents an entire picture.

    Most importantly, if we're talking about a finite bucket from which funds are drawn, we then have the question: do we lose more lives if we cut breast cancer screening and *put those saved funds into developing antivirals* (or some other procedure/drug/etc.) or do we save more lives?

    Because every medical procedure costs money, and there's a finite amount of money to spend on medical procedures, and spending millions on what is statistically a relatively unnecessary procedure when we could be spending those funds on a relatively necessary procedure is irresponsible.

    Yes, if someone wants to spend their own funds getting a mammogram, okay, knock yourself out. I don't think anyone is seriously considering removing independent action here. But if you're talking about the best use of funds (either at the governmental level or even at an organizational level), that's an unrealistic goal.

    This is functionally equivalent to the, "It doesn't matter what it costs, if it prevents one terrorist attack it's worth it" frame of mind.

  11. padraig, I completely agree that cost-benefit is a legitimate issue. And I completely agree that we have finite resources, and so must spend them as carefully as we can. I disagree that my dissent is the functional equivalent of the cost-doesn't-matter claim.

    Two points. First, this started when Dr. D asked people to stop drawing political conclusions. I absolutely think we should talk about the political consequences, because this is the "difficult conversation" that Pres. Obama brought up in the context of medical recommendations and reform. How *do* we decide which treatments give us the best bang/buck ratio? The USPSTF example is a great starting point. I have seen ZERO cost/benefit data from USPSTF, or from opponents for that matter. I'd really like to be in that discussion if we have CongressCare, because I'm ponying up the moolah.

    Second, this "recommendation" came as if floating down from the heavens. No discussion, no running it by the obvious parties (CDC, ACS for starters). I'm personally not going to stand for that kind of arrogrance without raising a stink and asking questions. And I think it reasonable to expect answers. For instance, exactly how much do we save per death from ending yearly 40-49 mammograms? What if we did biannual, what would be the savings per death? And why are BSEs so ineffective? Inquiring minds want to know!

    Because it more than sucks to be one of those preventable cancer deaths. It sucks to be a son, a daughter, a husband, a friend of one of those who die, and it sucks for a very, very long time. I want to know what I'm getting as a society for what I'm giving up.

  12. I checked, and the USPSTF didn't make this recommendation based on economics (supposedly). The decided it is OK for women to die based on straight up statistics, as best I can tell. If that is indeed true, they all ought to be told their services won't be needed anymore. I'm sure HHS can find some people with better qualifications who won't ignore the Hippocratic Oath.

  13. Dan, I've ignored all the comments to comment on your original post...I agree. It seems that if a scientific body says "if you're at risk, by all means, do diagnostic tests early, but if you're not, there isn't *as much reason as we used to think* to begin so early" it seems reasonable to check their math, and discuss with your personal physician. It seems as though the major freaking out is misplaced. Nobody is saying you can't have or shouldn't get this really really painful procedure. If you need it or suspect anything or think it would make you feel better, they seem to say, please, by all means, carry on with your excruciating test. Further, if you're not in a risk group and would rather avoid terrible pain, we think it might be okay to wait a few more years because this particular form of cancer, the number five killer of women (way, way, way behind heart disease), doesn't generally show up this early in your life. Generally. Get the test if you want or need it, but you don't have to start if you and your doc agree you don't need to yet.
    Why is that a political football? Oh, right. When a woman and her physician discuss anything, politicians need to get their heads in up to the shoulders.