Attacking routine mammograms, again

[question everything]

Study questions value of mammography screening

http://articles.latimes.com/2012/nov/21/science/la-sci-breast-cancer-screening-20121122

(snip)

The report, published Thursday in the New England Journal of Medicine, argues that the increase in breast cancer survival rates over the last few decades is due mostly to improved therapies and not screenings, which are intended to flag tumors when they are small and most susceptible to treatment. Instead, the widespread use of mammograms now results in the overdiagnosis of breast cancer in roughly 70,000 patients each year, needlessly exposing those women to the cost and trauma of treatment, the authors wrote.

===

So let's see: increase cancer survival is due to better therapies, however, how would you start therapy if you cannot find the tumor, first? And wouldn't it be better if you find the tumor in an earlier stage?

[still_one]

1. fuck them. I know several people who are here today because of mammograms

[skepticscott]

5. And how many people do you know

who have suffered detrimental side effects from needless surgery, prompted by an overreaction to the results of early screening?

[still_one]

6. The 5 people I know are what matter to me. This is just bs cost cutting crap. It saves lives.

As far as unnecessary surgeries, they do a biopsy first before any surgery to confirm, and unless it is a complete incompetent, biopsies are very safe.

As far as undo stress, having cancer spread is undo stress

Its the same garbage in California why they say you don't need seat belts in School Busses, because it has been shown not be be effective. It is all about money

[skepticscott]

9. Well, that's very generous of you

I suppose if was going to take $100 million dollars each to save the lives of the five people you know, you'd be fine with that, even if it would cost the lives of hundreds or thousands of other people.

And yes, like it or not, it IS about money. Money is not an unlimited resource, and the people who provide medical care need and deserve to be paid. People like you seem to think that health care resources are or should be a bottomless well, but they aren't. Every dollar and every minute spent on one person is a dollar or minute that can't be spent on another person, and sooner or later, people will die from that lack. I'm sure if it's someone you don't know, you wouldn't give a shit but the people who care about THEM, do.

In the end, effective health care is about providing the most care to the most people with the limited resources available. It is not about spending money without limits to save or prolong every life in every way possible. The latter is insanity, no matter how good the thought makes you feel.

[still_one]

11. Mammography saves lives period, and it is a heck of a lot more than 5 lives of people I know

[skepticscott]

17. That's your answer?

Just to restate the same claim, as if repeating it made it more true? Would you care to justify your claim that money and cost-cutting shouldn't matter in health care?

And to answer the question you dodged above:

"How many people do you know who have suffered detrimental side effects from needless surgery, prompted by an overreaction to the results of early screening?"

It's not justification enough to simply say that some people's lives were saved by a certain medical practice or procedure, without taking into account ALL of the consequences (not just the happy ones) to EVERYONE who underwent it.

[still_one]

18. The benefits are are listed in numerous studies. Nobody forces you to have a mammogram. Insurance

Companies would have no problem abiding by your request

Post #4 lists one such study

There are a lot more if you care to search which evaluate the risks verses the rewards, and for the demographic where mammograms are recommended it saves lives

The bottom line is that I have seen numerous studies and evidence reflecting one view, and you have a different opinion

and if you read the link from the OP Dr. Kopans and others disagree vehemently with the studies conclusions. Your choice, believe what you want.

There are articles that have come out in recent years saying colonoscopies, Pap smears, Psa show no benefit. I also disagree with those assessments also.

[skepticscott]

25. Saying that no one "forces you to have a mammogram"

is a rather silly justification, when the woman's health community is blanketed with dire advice that it is foolish and dangerous not to.

[still_one]

26. ok, have a good day

[Dorian Gray]

38. Are you

arguing against mammograms for aging women as a dangerous and unnecessary medical practice?

I'm trying to get your point here.

[Dorian Gray]

37. none

[sense]

2. Women are needlessly exposed to radiation

due to the many, many mammograms now recommended, increasing their likelihood of getting breast cancer. I've known many women who've unnecessarily had extra mammograms and/or breast cancer treatment due to being told that their mammograms found something, when, in fact, there was nothing. Unnecessary stress and extra radiation and treatments.

http://www.cochrane.dk/research/Screening%20for%20breast%20cancer,%20CD001877.pdf

Authors’ conclusions
Screening is likely to reduce breast cancer mortality. As the effect was lowest in the adequately randomised trials, a reasonable estimate is a 15% reduction corresponding to an absolute risk reduction of 0.05%. Screening led to 30% overdiagnosis and overtreatment, or an absolute risk increase of 0.5%. This means that for every 2000 women invited for screening throughout 10 years, one will have her life prolonged and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress for many months because of false positive findings. It is thus not clear whether screening does more good than harm. To help ensure that the women are fully informed of both benefits and harms before they decide whether or not to attend screening, we have written an evidence-based leaflet for lay people that is available in several languages on www.cochrane.dk.

http://www.preventcancer.com/patients/mammography/ijhs_mammography.htm

Question everything, especially the things that are highly profitable.

[question everything]

13. You don't get breast cancer treatment because of mammography

You will have a needle biopsy to determine whether there are cancerous cells and what type. In many cases, if they are DCIS - no treatment will be given. I am not aware of "false positive" biopsy. False positive mammography, yes, this is why you get called for a second mammography that will concentrate on the suspicious area. Perhaps also MRI and ultrasound.

Yes, I am biased against men who conduct these type of studies, who probably have never treated breast cancer in their lives, only look at numbers and churn statistics. Would they come with the same recommendations for their wives? daughters?

[sense]

28. Yes, many women do get breast cancer treatment

for things that would never have developed into anything harmful. There are also false positives and all of the extra diagnostics that women have because their mammograms are said to show something that's actually nothing are harmful and stressful.

From the New England Journal of Medicine study:

"If it is indeed true that DCIS, other abnormal breast findings, as well as clinically confirmed invasive breast cancer, either remain benign or regress when left untreated, the entire breast cancer industry, which is already deeply mired in cause-marketing conflicts of interest, must radically reform itself, or face massive financial and ethical liabilities vis-à-vis outdated and no longer “evidence-based” practices.

Another serious problem with mammography (and there are dozens of them) not addressed in this latest research finding concerns the unique carcinogenicity of the x-rays the technology employs. We now know that the 30 kVp radiation, colloquially known as “low energy” x-rays, are between 300-400% more carcinogenic than the “higher energy” radiation given off by atomic bomb blasts (200 kVp or higher).[vi] Present day radiation risk models used to assess the known breast cancer risk associated with mammography against the purported benefits do not take into this profound discrepancy. In fact, these models were developed before DNA was even discovered."

[Peace Patriot]

3. I suspect that it's just more cost-cutting for private insurance corps and gov't medical programs.

I have to admit, I worry about the radiation. But that's a different issue (risk vs benefit). These on-going cutbacks in preventive care are very worrisome. Not long ago, it was prostate screening, with all the corp media touting "studies" saying it wasn't necessary and didn't save lives. I know that isn't true. I know somebody whose life was saved by prostate screening. What's next? Prenatal care? Pap smears? We've lost dental care for the poor in California anyway. Bad teeth/gums are a very serious health hazard and CAN be prevented by visits to the dentist. But that's a luxury we don't want the poor to be coddled with!

I don't know what's more disgusting, that medical care is conditioned in any way by cost, or the sneaky role played by the media and our corporate-run government in cutting back medical care, while there is all the money in the world for drone bombers and all the latest military and security "toys" and saturation bombing of commercial TV with obnoxious campaign ads.

I gotta laugh at this (what else is there to do?): "...needlessly exposing those women to the cost and trauma of treatment, the authors wrote." Right. As if anybody running this horrible medical care system gives a damn about the "cost and trauma" to its victims! That ain't what they're whining about, believe me.

Do you think this is a Doctors vs Radiologists War? All that money should go into doctors' fees rather than mammograms?

Something's not right about this, probably my first guess: sneaky cost-cutting. In the Obama-care system, most women wouldn't be paying out of pocket for mammograms, IF the mammograms were deemed essential to preventive care. Preventive care would be included in the insurance, as it is with Medicare. Maybe a co-pay, but not the bulk of the cost. So WHOSE costs are being reduced?

One thing is certain: It is NOT driven by concern about patient trauma, nor cost to patients. The Medical Gods are happy to inflict trauma when it suits them--that is, when it's highly profitable or when they're just covering their asses or when they have kickback arrangements (unnecessary tests and consultations, f.i.). And they are more than happy to inflict ruinous costs on patients, most of them. How about the trauma of THAT? Seeing your medical bills? Medicine has become such a racket...

[question everything]

14. Yes, there is room for cost cutting

A senior in his/her 90s who is terminal, does not need life savings operations. We need to accept dying as a normal part of life. I suspect that in previous generations, when people were born and died at home surrounded by family members, dying was accepted, perhaps even welcomed. But now we cannot even die with dignity - those of us who want to.

[newfie11]

4. Having been a mammographer for 40 years I can tell you it does save lives

The reason women are called back and nothing is found is because the radiologists needs additional specialized picture or pictures of an area that has either changed from her last mammo or looks suspicious. Without doing the additional views the radiologist is extremely limited on how to proceed. Many times it is nothing and by doing a spot film, a different angle film , or ultrasound the patient can be told if this is a concern or normal breast tissue.

Breast tissue can change from year to year due to age/hormones/estrogen/medications and change the look of the imaged breast.

Yes a mammogram does involve radiation and that is one of the reasons we do not like to do mammos on young women.

Frankly it is the patient's choice. If you don't want one then don't get it. It is your body and if your doctor doesn't like it find another.

Also make sure you go to a mammo facility doing a large number of mammos. A doctor reading 5-10 a day will not have the expertise of one reading 20-50 a day.

http://www.breastcancer.org/research-news/20110628

A very large, long-term Swedish study found that women who had regular screening mammograms were 31% less likely to die of breast cancer over nearly 30 years compared to women who didn't get regular screening mammograms.

more at link above

[still_one]

7. Exactly. First of all unless their is a family history it is recommended for women over 50.

However, the big problem is density, and if the breast is too dense other means should be used, and that is where I think insurance companies would resist, which is unfortunate.

[newfie11]

8. ACS guidelines are starting mammos for women starting at 40 HOWEVER

not all women have dense breast at a younger age and there are 60 year olds with fibrocystic breast tissue due to HRT. Digital mammography has helped tremendously in imaging dense breasts. Digital is a little higher in radiation but the image can be manipulated to give more information without doing another exposure.

Breast cancer in a premenopausal woman can be a very aggressive creature. Many women develop breast cancer and have no family history.

The ONLY other thing of value besides mammography is MRI and yes it is very expensive and can but not always require a contrast injection (into arm not breast).
MRI is a tool but it does not replace mammography. Ultrasound cannot be used for screening. It also is an aid with mammography.

I would have a hard time believing any woman (insurance aside) would find a doctor to order ONLY MRI/US as a screening tool for breast cancer.

http://www.breastcancer.org/symptoms/testing/types/mri/screening

[still_one]

10. Excellent information

[hedgehog]

12. I have two questions:

1. Does mammography find anomalies that will never become metastatic cancer, and are we treating those anomalies needlessly?

2. Does finding an aggressive tumor earlier with mammography actually make a difference in survival rate?


There was a time when every kid had a tonsillectomy sooner or later. Now, tonsillectomies are done only if absolutely needed. Sometimes changing a medical protocol does save money, but the overarching reason is to provide better overall patient care!

[newfie11]

15. There is a vast difference between tonsillectomy and breast cancer

answer
#1.I assume your referring to DCIS. This is something the patient and doctor need to decide. Because this cancer has not spread outside of the ducts is no guarantee it won't as time goes by. I remember a teaching lecture I attended for physicians on mammography. A patient had a mammo done and it showed calcification's. The radiologists thought it was "different" looking and had her come back for a 6 month follow up. Nothing had changed. So she returned for a routine mammo the following year and all looked the same. This continued for 5 years but on the 6th year the calcification's were gone. Life is good no cancer right. The 7th year she returned for a routine mammo and the entire breast was full of very suspicious calcification's indicating breast cancer. It turned out to be breast cancer on biopsy.
My point is how do you decide what will never become invasive cancer? DCIS is in situ but there is no guarantee it will not continue to grow into invasive breast cancer. No one can guarantee that. This is up to the patient to have all the knowledge and make her/his decision on how to proceed.
http://www.ductalcarcinoma-info.com/2009/landinge.php?gid=OC008&?a=a&assoc=Google&keyword=dcis

#2. YOU BET!!!! If found early enough, the type of cancer, and the age of the patient. I must say that some cancers are not seen until they are huge and big enough to feel. These in younger women are very dangerous and aggressive. Not removing a cancer because you don't think it makes a difference is a death sentence and a miserable one. Now with doing sentinel node mapping so much more information is available.

Mammography is an art and it takes a great deal of training in reading the images. All I can say is go to the very best place you can, discuss the findings with your doctor if needed, educate yourself on what the results indicate, and make an educated decision.

It is your body and if you don't believe DCIS is a problem and willing to live with it then do.

[question everything]

19. Thank you. We both posted at the same time

with similar responses but yours is a lot more comprehensive and based on personal and professional knowledge.

[hedgehog]

20. Everything you have to say makes perfect sense -

but - for a while it made perfect sense that the way to treat breast cancer was to irradiate the entire body, then do a bone marrow transplant. Except - that method didn't save lives. I am willing to withhold judgment on this issue. It's possible that early detection and treatment is the way to go. It's also possible that statistical analysis is showing that mammography is catching cancers by coincidence and is not really making a difference in survival rates.

[newfie11]

21. Where did you hear about irradiating the whole body?

That is news to me for breast cancer?

[hedgehog]

22. here's what I was referring to:

http://theincidentaleconomist.com/wordpress/the-rise-and-fall-of-bone-marrow-transplantation-for-breast-cancer-a-tragic-success-story/

http://www.webmd.com/cancer/bone-marrow-transplants-stem-cell-transplants-cancer-treatment?page=2

http://www.nejm.org/doi/full/10.1056/NEJMbkrev58584

i was incorrect - the treatment involved massive chemo, not massive radiation .

The third reference reminded me of another "obvious" treatment that turned out not to be true - the use of hormone replacement therapy in menopausal women.

I don't know if mammography is useful, useful under a different set of protocols (age groups, risk groups etc) or a mirage. I just am not willing to dismiss discussion of the usefulness of mammography out of hand. As with all medical practices, we need to avoid basing our conclusions on anecdote.

[hedgehog]

23. here's a good roundup of the type of info I've been looking at:

"You can't expect from mammography what it cannot do. Screening is not prevention. We're not going to screen our way to a cure."

"It's just not true to say that 'if you get a mammogram, all will be well.'

A recent study indicates that most stage II and III breast cancers actually turn up clinically, between normal planned screens.


"Most women with screen-detected breast cancer have not had their life saved by screening. They are instead either diagnosed early (with no effect on their mortality) or overdiagnosed."






http://www.happyhealthylonglife.com/happy_healthy_long_life/mammography/

[newfie11]

27. I don't believe anyone has said mammography screening can cure breast cancer.

The links you mention are lightweights. If you really want to study anyone in mammography try László Tabár, M.D.
This man know more about mammography than anyone alive.
http://www.breastcanceranswers.com/category/laszlo-tabar/

or read this and the links at the bottom.

http://www.ncbi.nlm.nih.gov/m/pubmed/20356942/

Anyone can make claims for or against mammography but studies prove the results. Good studies with radiologists and techs that know what their doing. As far as vit D I have no idea. Take it if you want.

I think I have covered as much as possible and at this point it is like beating a dead horse. So we will have to agree to disagree I am afraid. I am through with this post.

[question everything]

16. Answers

(I am not a medical professional, so others may add or correct still)

1. Yes. DCIS -Ductal Carcinoma in Situ is considered stage 0, not cancer but with the potential to develop to one. I believe that in these cases there are no treatments, perhaps some radiation, and certainly a close follow up.

2. Yes. if you treat with surgery, chemotherapy and radiation, also hormonal treatments if the tumors have receptors to estrogen and/or progesterone and/or HER2 - these directed treatments will increase the survival rates.

It would have been nice if these statisticians - I doubt that they've ever treatment a breast cancer patient - also looked at the statistics that give survival rates based on the tumor.

Now, you have to better define aggressive tumor. You may have a stage 1 - less than 2 cm in diameter and minimal or no spread to the lymph nodes - but the cancer will be considered aggressive if the cells show fast division (grade 3) and/or if there are receptors to HER2 growth factor. The latter can now be treated with the drug Herceptin.

[hedgehog]

24. Thinking it over - here's a wild speculation -

there are glimmers that serum levels of Vitamin D may be a predictor of breast cancer mortality rates -

http://www.direct-ms.org/pdf/VitDNonAuto/Breast%20serumSBMB2747.pdf

What if instead of getting mammograms to find cancer , it turns out that checking Vitamin D levels to prevent cancer is the way to go?

[Sgent]

29. Because we have no idea

if low levels of Vitamin D indicate a cause, or an effect. Vitamin E was thought to be a miracle supplement, until it was discovered that those who take it have higher mortality rates.

[hedgehog]

30. I was offering this topic as an area to be investigated mainly to point out that by

focusing on mammography we are accepting the status quo. The focus should be on preventing cancer.

[question everything]

31. Don't confuse association with identification

Let's say that, indeed, lower levels of Vitamin D are associated with breast cancer. Again, associated, not causing. That paper that you cited talks about 50% lower risk. This means that the other 50% can still get breast cancer even with high level of D.

But either way, say you have a very low level of D - 10ng/ml. What, then? Will you go ahead and subject the women to double mastectomy? Of course not. You will perform a mammography to find any suspicious area and if you do, you will perform a needle biopsy.

And I will refer again to the original comment. The fact is that level of death from breast cancer has declined in this country as the level of routine mammography has increased. If any woman chooses to skip it, it is her decision. Sadly, many of us know of women who skipped routine mammography, either forgot or assumed that they lived "right." And when the cancer was found, it has already advanced.

[hedgehog]

32. Let me try to make a summary of my points -

" The fact is that level of death from breast cancer has declined in this country as the level of routine mammography has increased"

Is that causation of correlation?

Here are the questions I think need to be answered:

1. Are we actually improving the survival rate by finding cancers early via mammography?

2. For a given type of breast cancer, what is the difference in rate of success between patients diagnosed by mammography versus finding a lump?

3. Are we finding cancers with mammography and treating them, when if we had never spotted them, the immune system would have resolved?

4. Is there a change in how women react when they find a lump? What I'm asking is this - how many women in the past would have hidden their cancer until it was too late to treat? How many women today go to a doctor immediately if they spot an issue?

What I object to is the knee jerk reaction that any suggestion that the protocol for mammography is based on cost cutting measures only. If mammography is useful, we need to ensure that every woman has access. If it is a mirage, we need to know that also.

We need to follow the medical evidence regardless of where it takes us. If mammography is not as useful a tool as we thought, we need to move on.

[Tumbulu]

33. Excellent points and questions

I have them myself.

And why not reduce the number of mammograms to what the Europeans recommend- one every three years?

[hedgehog]

34. It all goes back to the numbers - either we believe in accurate statistics

or we believe in anecdote. If we go by the fact that someone we know was diagnosed via mammography and therefore mammography is vital, we might as well recall that someone we know swears that her cancer was cured with crystals.

[question everything]

35. The difference between real cases and statistics

Personally, I've never trusted statistics when it comes to medicine. Pharmaceutical companies conduct studies and if the stats are not good enough to make the product profitable, they will abandon the study. But what about those statistical insignificant patients who do benefit? who actually feel like they've got a new lease of life?

There are millions of cases of women whose cancer was discovered by mammography and were treated. Are you going to tell these women that they should forgo treatment because their cancer is not aggressive enough? And, how, exactly, do you, or the authors of the study, even know which one is aggressive? And at what level of confidence?

About mammography vs. finding lumps. I know a woman whose cancer was right below her nipple. No one could feel it, it was discovered with mammography. Was considered stage 1. But... it had receptor to HER2 - a nasty growth factor that makes cancers more aggressive and prone to return.

What would you tell this woman? That she should not have had her mammography? Wait for another year or two until the tumor grew enough to be felt and, perhaps, spread to the lymph nodes and beyond?

I think that it is very easy to sit on a high perch and preach to others what they should and should not do with their lives.

As you earlier noted - tonsillectomy was considered advisable. And measuring feet via X-rays was routine in a shoe store. And lobotomy to help the mentally ill, the depressed and the epileptics.

So these statisticians who, as I've said, have never seen a cancer patient in their lives can play with their stats. For the rest of us, we will continue the road that has proven to us, to family and friends, to be a life saver.

Personally, I am disheartened that in a place like DU some choose to be judgmental instead of compassionate.

[leftyladyfrommo]

36. I don't do tests any more.

If I am sick I go in. If I have symptoms I go in.

I'm afraid I don't have much faith in the medical profession any more. Besides, I have to pay for everything myself. No money for stuff like that.