New mammogram guidelines raise questions

Discussion in 'Politics, Religion, Social Issues' started by MacNut, Nov 17, 2009.

  1. MacNut macrumors Core

    MacNut

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    #1
    http://www.msnbc.msn.com/id/33973665/ns/health-womens_health/?ns=health-womens_health

    I don't understand how less mammograms will help anybody.
     
  2. harperjones99 macrumors 6502

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    #2
    It's obviously about saving money for insurance companies and the government, not what is good for us. The same thing happened with prostate tests like PSA. If they can call it the "standard" to have it less or later they can get away with not covering it.
     
  3. savoirfaire macrumors 6502

    savoirfaire

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    #3
    Oh, come on, there's a difference between doing something to save money for insurance companies and doing something that also happens to save money for insurance companies. Medicine is a constantly evolving science. There are a lot of things that doctors do that may not have proven benefit. Sometimes, subsequent studies end up proving that a particular treatment or screening test does NOT save lives. Digitalis, for example, was widely used for heart failure until a large study in 2005 demonstrated that people don't live any longer whether they are given digitalis or a placebo.

    I think it is pretty clear that not everyone should get PSA and prostate exams. A lot of prostate cancers are so slow-growing that men end up dying from heart attacks or other things instead of from the prostate cancer. If you had your prostate removed because of a high PSA and couldn't maintain an erection afterwards (a very common result of these surgeries), wouldn't you be mad as hell if you found out afterwards that the prostate cancer would never have caused you any problems if you just left it alone?

    Screening for breast cancer has similar potential pitfalls. The concerns that were raised include that there are always a significant number of false positives that lead to unnecessary surgery and that some women have breast tumors that are slow-growing and do not warrant aggressive treatment. Doctors are always trying to strike a balance between picking up early cases of disease to save lives and being too aggressive and putting patients through unnecessary testing or procedures. Over time the pendulum will have a tendency to swing a little bit one way or the other.

    I won't be surprised if insurance companies spin the results of the task force recommendations in order to avoid paying for mammograms in some patients, but don't accuse the doctors on the panel of prioritizing the best interests of Big Insurance over those of their patients.
     
  4. MacNut thread starter macrumors Core

    MacNut

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    #4
    The problem with cutting back the tests is that younger women that might get breast cancer between 30-40 won't be treated so more younger women would die because they cut back on the tests.
     
  5. jmann macrumors 604

    jmann

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    #5
    How is the harm greater with starting testing in the 40s? I don't like this. *pushes dislike button*
     
  6. savoirfaire macrumors 6502

    savoirfaire

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    #6
    Well, going by that logic, why not screen young women who might get breast cancer between the ages of 20 and 30? If we don't screen them, more younger women would die because they cut back on the tests. What about between the ages of 10 and 20? Maybe all the 20- and 30-somethings on these forums should get PSAs and prostate exams to make sure they don't die from prostate cancer. It's obviously not as clear cut as some people are making it out to be.

    The likelihood of breast cancer increases as a woman gets older. The hard part is figuring out where the ideal cut off is.

    Sorry for not multi-quoting, but I didn't see your response. Your question is very valid. Rather that becoming a windbag, I will point you to some very recent controversy out of the UK where people were criticizing their government for not being clear enough about the risks of breast cancer screening. Those individuals and you guys here are all expressing valid concerns. It just goes to show that there are risks and benefits to EVERYTHING and there is probably no such thing as an IDEAL cut-off point for screening.
     
  7. MacNut thread starter macrumors Core

    MacNut

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    #7
    If the system we have now is working fine why change it. We are trying to improve healthcare in this country not make it worse.
     
  8. savoirfaire macrumors 6502

    savoirfaire

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    #8
    Is the system we have now working fine? Is there no room for improvement? Is trying to reduce the amount of unnecessary radiation exposure, unnecessary surgery, and unnecessary chemotherapy in women who are at lower risk the same as making healthcare worse? Don't just read the headlines - it is still recommended that young women who have risk factors such as a family history of breast cancer undergo screening. They just increased the cut-off at which they recommend screening for ALL women.

    Again, the concern that there will be cases of breast cancer missed in younger women is a valid one, but try not to pass judgment before learning the data on which the recommendations are being made.
     
  9. harperjones99 macrumors 6502

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    #9
    I am guessing you are a doctor or have some personal interest here? Sorry if not but you seemed to take it very personally and created something out of my words. I didn't say a thing about the docs involved and was talking about the insurance companies, you pulled that out of nowhere...but since you brought it up:

    Have you never seen doctors being wined and dined by drug reps? The prescribe certain meds, use certain products, recommend certain facilities all the time because of these relationships. In fact there is a group of doctors who have sworn off any dealing with these reps because they find it unsavory...but this is not the majority. Doctors are as easily manipulated and motivated by greed as anyone and if you think they are all out for your best interest only you haven't known many. I am not saying they are all evil or anything crazy so don't get all worked up about it but dismissing money as a motivation for a lot of what goes on in medicine is a mistake. Both Breast and Prostate cancers are very real threats. The only reason to NOT test for them is to save money. You seem to think ignorance would be bliss in many cases...after all you MIGHT not have unnecessary surgery if you don't know you have cancer right? Nonsense.
     
  10. savoirfaire macrumors 6502

    savoirfaire

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    #10
    Don't worry, I have absolutely no personal or professional connection to any of this (EDIT: actually, I take that back, my mother has been treated for breast cancer) but obviously the whole issue of health care has been a hot button topic. I apologize if I misconstrued what you said, but since the new recommendations were put forth by the US Preventative Services Task Force which is composed entirely of doctors and nurses, when you say the new recommendations are "obviously about saving money for insurance companies and the government," that would mean that the doctors and nurses on the task force made their recommendations to save money for insurance companies and the government and "not what is good for us".

    I totally agree that the pharmaceutical industry has had more influence than they should on health care in the US, and there are definitely doctors who are "on the take". But it is also true that doctors who sit on these Task Forces are held to a higher standard than your local family doctor. In order to be on this particular task force, there can be no substantial conflicts of interest, and any potential conflicts of interest have to be stated up front. Sure, a couple of the members of the task force (their names and positions are publicly available) may be hiding stuff on their resumes, but hard to believe that a couple of rogue doctors/nurses would be able to steer the recommendations of the entire group of 16.

    I am also trying to point out that your argument that the only reason not to test someone for breast/prostate cancer is to save money is not at all true. I'm curious how old you are and whether you are getting a rectal exam and a colonoscopy every year just to make sure you don't have cancer, but it's none of my business. I think if anything, doctors have too much of an incentive to OVERtest. Feel like buying an expensive sports car? Send a few more patients for MRIs to boost your profits, why not? In your case, you would probably thank the doctor for being extra cautious with you, right? Of course ignorance is not bliss, but you don't seem to acknowledge that there is any downside to screening tests. If I may ask, do you have a teenage daughter, and is she getting screened for breast cancer every year? I've read about some women who developed breast cancer in their 20's. I don't know why doctors aren't screening them. Seems like they're being too stingy with their tests to me.
     
  11. eawmp1 macrumors 601

    eawmp1

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    #11
    The problem with SCREENING tests is that you take asymptomatic populations and look for a disease with the thought that early detection can improve outcomes. Screening low risk populations for a specific disease result in low yield of return. And this also means many more false positive tests resulting in unnecessary anxiety and further costly testing (both in terms of financial and possible medical complications). In addition, exposure to radiation increases with every mammogram.

    Many studies have looked at this and only after age 50 is there any consensus that whole population mammography screening cost/benefit ratio is positive. Targeted screening (if genetic/social high risk factors) may better identify who/when/how often individuals should be screened.

    NO screening test can ever catch all disease. Mammography does not detect 10-15% of PALPABLE masses. Unfortunately, most laypeople do not have the ability to digest/interpret the mass of information we have and make a logical individual decision. This issue is a huge gray area in medicine. Unfortunately, most naive people will hear this latest guideline for mass screening and think rationing and conspiracy.
     
  12. savoirfaire macrumors 6502

    savoirfaire

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    #12
    I think it's also important to note that these are general recommendations, not rules that are written in stone. Ultimately, each individual woman and her doctor need to discuss her specific situation and to decide what the best screening plan should be. Hopefully, the insurance companies won't use this as an excuse to deny coverage for services (I doubt they would be so bold). Besides, this is only one group's recommendations. Others still recommend annual screening starting at the age of 40. Unfortunately, it just goes to show that there is no such thing as "the right answer".
     
  13. harperjones99 macrumors 6502

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    #13
    I don't think anyone here truly wants anyone to suffer. But I think if a test even detects 5% of cases that would go unnoticed without it...then unless there is a better test that detects more that test is worth it. If you were one of those 5% or your wife or daughter or mother was you would think much differently unless you are just a cold, selfish individual.

    It is very easy to talk about "rational" costs etc when you are not the one going to die because someone thought it wasn't worth it. Nobody lying in a hospital bed in pain will agree with you that it's not worth it.

    One of the most "right" answers is to bring down the ridiculous costs of tests, treatments and services. They are only so high because of the pure greed of many industries. Insurance companies are one of the worst. You cannot reconcile profit and lives no matter how much you try...and people charging 100 dollars for 5 dollars worth of chemicals or litmus paper is evil no matter how you try to paint it.
     
  14. savoirfaire macrumors 6502

    savoirfaire

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    #14
    Harper, you are absolutely right, which is why the decision is ultimately up to the individual and their doctor. These task forces don't determine treatment, but they do offer guidelines for primary care doctors who aren't able to keep up to date with all the new data that comes out. You still neglect to mention the risks, though. You only bring up the 5% possibility of benefit (or whatever the number actually is). In your case, obviously being aggressive about screening is the right thing to do, and I sincerely hope that none of your family members end up undergoing breast biopsies or lumpectomies or have any complications related to the surgeries. Believe it or not, there are women who ended up with infections or disfigured breasts due to procedures for what turned out to be benign, and none of those people lying in a hospital bed in pain will agree with you that it's always worth it. Let's face it, not all women want what you want for your family members. Thank goodness we live in a free country, no?
     
  15. harperjones99 macrumors 6502

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    #15
    You seem to have this idea that screening equals unneeded surgery. There is a step between having test results and choosing surgery. But the first step is information. NOT having tests is not the solution to unneeded surgery. This idea that its better to not test so that you might not CHOOSE to have surgery is ridiculous.

    Bad surgery is caused by bad doctors (and there are plenty of them)...not screening.

    Your idea is akin to sticking your head in the sand and pretending it might not be there.
     
  16. Xfujinon macrumors 6502

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    #16
    I quoted this answer because it contains the truth as supported by the science. To that effect, screening tests applied to an otherwise healthy population must have very high sensitivities and specificities in order to translate statistically into reduction in DALYs (Disability Adjusted Lift Years, meaning time spent sick, suffering, or dead). Research time and again has supported that screening women under 50 does not make much statistical sense because on the whole of it, no significant changes are made to the statistical bottom line: no additional lives were saved, or morbidity averted, by changing the statistical parameters of the testing population.

    Since no test is perfect, and the likelihood of detecting tumors that warrant intervention (read this sentence carefully) in this age category is very small, the additional costs are not warranted by the outcomes.

    Now, anecdotally, some people will go berserk because they'll pull some story out about a "35 year old woman whose life was saved by the screening!". Well, that is a complex and loaded statement to make; while some people will have their tumors detected this way, the overwhelming majority do not. Ambiguity abounds in the interpretation of the 35-50 year old women's mammogram, especially with overlying fibrocystic changes and the complexities of younger women's anatomy (fiber:fat ratio complicates detailed analysis). This argument can be applied to testicular cancer, bone cancer, prostate cancer, heck even an occult uterine fibroid that just may not be leiomyoma but something more sinister. Screening is exactly that: a screen of a population to narrow down who needs more involved treatment for the purposes of saving lives.

    Here's an analogy they taught us in medical school. Really think about this:

    Heart disease is very common, about 33% of people die from it. So, let's say based on the evidence that 25% of people over the age of 50 have some coronary artery disease. So, if we treat 1000 people over 50 with coronary artery disease with a drug (say, Plaavix or even aspirin), how many people will NOT die of a heart attack/stroke because of the treatment, compared to a group of 1000 people over 50 with the same disease but no treatment? If out of 1000 people, 100 lives are saved, it is a ratio of about 1:10, meaning of 10 people treated, one person treated will have their disease averted (i.e. saving their life, perhaps). This is oversimplified, but you get the idea. If it costs 10 cents, we need to spend one dollar to effectively "save" one person, so about 10 times the cost for the person's life saved.

    Now lets take a really rare disease, like Pheochromocytoma (tumor of the adrenal medulla). About 1 in 3 million people get a Pheochromocytoma, so if we look the population of the USA, about 304 million people, then about 100 of these people will get Pheochromocytoma. Lets say we have a drug that will save 10 of these 100 people. How many do we have to treat in the population with this drug to save 10 lives? Everybody! All 300 million people would need to be treated. Even if this drug cost one dollar, that's 300 million dollars to save the lives of 10 people, about 30 million a head, and about 10x what most people make in a lifetime. Who pays that?

    This is, again, somewhat of a statistical oversimplification, but it does the trick. Mammograms, office consults, rad consults, the X-ray machines, technicians, they all COST MONEY. How many people do we need to subject to these costs under the age of 40 relative to the amount of effective treatments rendered? The science affirms that, if you raise the age to 50, no significant difference is seen in terms of "lives saved", "crises averted", and so forth.

    While this may seem cold, calculating, and unfeeling, it is the fundamental basis of how evidence-based medicine works to be develop treatment guidelines that work for all people. It is stupendously easy for one person to indignantly state "yeah, well, I'm different, so this doesn't apply to me!" whereas it is unbelievably complicated to develop effective treatment regimens for a population.

    Anyway, there are some good articles out there concerning this topic, but since I am taking finals I can't locate them in PubMed right this moment. Google will do your dirty work if you wish.

    Take care, get a checkup every year to keep your body tuned up! Head things off at the pass, and what not.
     
  17. savoirfaire macrumors 6502

    savoirfaire

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    #17
    You know what? I think I will just walk away from this discussion, if that's ok with you. Again, I wish the best for you and your family members. To each his/her own.
     
  18. MattSepeta macrumors 65816

    MattSepeta

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    #18
    Wrong buddy

    "They are only so high because of the pure greed of many industries. Insurance companies are one of the worst. You cannot reconcile profit and lives no matter how much you try...and people charging 100 dollars for 5 dollars worth of chemicals or litmus paper is evil no matter how you try to paint it. "

    Nope. Wrong. Incorrect.

    1. Industry does not set prices. Consumers set prices. you can chalk it up all you want, but it always boils down to this: If you don't like the price, don't pay it.

    2. Insurance (Health, at least) Companies are NOT the greedy, profiteering people-haters that the leftist media makes them out to be. Look up insurance companies Net Profits. I am working and dont have the time to find the articles again, but if I recall correctly, one of the biggest names in insurance was only making 3% yearly profit. Something along those lines.
    It was significantly less profit than the auto, home, or theft insurance industry pulls in.

    3. "charging 100 dollars for 5 dollars worth of chemicals or litmus paper is evil" -Nope. Having the litmus paper tests and not making them available would be evil. Again, if that price is too steep for you, than don't pay it.
    Keep in mind that these "evil" corporations are staffed by people. People that need to put food on the table, and roofs over heads.


    Besides, if we are not in it for the profit, why are we in it? I know I'm sure as hell not working for the good of everybody else. I work soley for the good of me and mine. But I guess I'm just an ass-hole conservative, so what do I know? :rolleyes:
     
  19. kavika411 macrumors 6502a

    kavika411

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    #19
    Interesting thread. It may get super-charge of responses if it is moved over to the PRSI forum. Just a thought.
     
  20. harperjones99 macrumors 6502

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    #20
    Let's see you put your money where your mouth is if you ever have a serious medical condition and the price for care is too high. Anyone can be ruined by such things and no matter how secure you think your life is right now all it takes is one big issue to wipe that attitude right off your face. I do not wish suffering on you but I do wish you could see the actual implication of what you claim because attitudes like yours are part of the problem with keeping things as they are.

    Comparing medical needs to consumer shopping is stupid. Patients do not drive the cost of medical care like consumer goods. Nobody WANTS to pay the ridiculously inflated prices they just don't have a choice.

    I am on the conservative side of a lot of my beliefs as well but I have never met anyone who could live the things you claim (like if you think the price is to high don't pay it)...everyone changes their attitude when THEY are the one in pain and struggling. They often say they wouldn't but they always do. I know you will disagree...and I also know that if you are ever unfortunate to be in that position of suffering you will say "damn he was right".
     
  21. TK2K macrumors 6502

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    #21
    This is honestly just another case of the all too common occurrence of the injustice of a patriarchal society. I know, i sound like a nutter, but honestly it is. we live in a male dominated society, and the choice tat it is not 'worth it' to protect women from breast cancer is an example of the value our society places on women. We don't hear these recommendations about prostate cancer, but that is an equally expensive test with an equal number of false positives.
     
  22. alFR macrumors 68020

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    #22
    Er, actually you do - there is an increasing body of evidence that suggests that PSA screening for men is undesirable as it generates a substantial number of false positives and unnecessary treatment, just as there is evidence that screening too early for breast cancer has the same outcome. This is leading to a lot of debate as to whether PSA screening should be carried on or not.

    Please read post 17, which is a pretty good summary of where the evidence for breast cancer screening is at the moment and why this recommendation was made. While you're at it google for "number needed to treat" and "number needed to harm" and have a read.

    Alternatively, don't let logic and science based on the two largest clinical studies ever done on breast cancer get in the way of a good torch and pitchfork-wielding crusade and carry on. ;)
     
  23. mkrishnan Moderator emeritus

    mkrishnan

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    #23
    Are you joking or serious? I'm not sure if this is meant to be a parody of someone else's post? :confused:

    These recommendations came out for prostate screenings before they came out for breast cancer screenings. This same discussion has been in the news for months and months about prostate cancer screenings, for much the same reason.

    Yes, there are cost basis issues involved in testing people for disease. Anyone who tells you that cost should never be an issue in healthcare lives in a fantasy world. However, these recommendations came out primarily in response to research that clearly showed that women (and men, in the round before them, since, once again, this has been a topic of discussion with respect to prostate cancer for well over a year now) were unnecessarily undergoing invasive and sometimes dangerous procedures, sometimes with serious side effects, and many of them were not at risk.

    While there are economic and political issues that abound in this question, the basic issue here is not the efficacy of the tests -- the tests work fine. It's that we just don't understand cancer very well. The masses that these tests identified, we've always assumed to be invariably progressive and therefore justifying aggressive, early intervention. However, that's not the case. Some of them progress very slowly. Others disappear without any kind of oncological intervention.

    I'm not saying that this is not a political issue. But I can tell you that this isn't something that some politician or insurance industry person dreamt up of a few days ago... we've been talking about this issue in the context of discussing cancer within healthcare for some time. These studies have been coming out for a few years now.
     
  24. harperjones99 macrumors 6502

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    #24
    If a high PSA is the only thing you are using to indicate surgery then you are an idiot and so is your doctor. This idea we should not do some tests because of false positives is ludicrous. Are you willing to sentence the people who these tests DO save to death? That is what you will be doing if you say don't do the tests at all because sometimes they are false and people have unneeded care. Stop having the tests and some people will die because it goes undetected...this makes as much sense as zero tolerance policies. The reason there is a movement to stop some screenings is purely profit driven...if it was about what was "good" they would champion the tests because of the people they DO save and educate people on making decisions based on more than a single point of information.

    It really makes as much sense as saying we should take seat belts out of cars because once in a while someone gets trapped and dies because of their seat belt...and this does happen sometimes and sucks. If you fear this don't wear it....but don't try to make it cost more for others who want to wear one (which is what making screenings non standard will do...make them uncovered and cost people more who want them). There is an easy way to deal with this if you are worried about false results driving bad care...don't have the test yourself.

    Use common sense and base your decisions on more than ONE test that does sometimes produce false positives....goes for any disease.
     
  25. eawmp1 macrumors 601

    eawmp1

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    #25
    Wow...just wow. The failure of logic here (as well as the inappropriate analogy) reinforces why uninformed laypersons should not set public policy.
     

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