Girl, you have too much Faith in Medicine

[I started working on this last night and ran out of steam -- I then awoke to a front page New York Times story dealing with new recommendations on cervical cancer screening-- this is going to take a lot of people's paranoia level up to eleven, not to mention the full-on wingnut exploitation sure to follow.] 

It was interesting to see the reaction to the recommendations of the U.S. Preventive Services Task Force regarding breast cancer screening.  In a nutshell, the study cast doubt on the efficacy of annual mammograms for women between the ages of 40 and 50 who are not at an elevated risk for breast cancer.  The study concluded that routine annual screening in this age group was not cost effective and should be deferred until women reached the age of 50.  The study found that mammography did result in lives saved, but weighed this unfavorably against the cost of such widespread screening, the psychological stress associated with the numerous false positives in the tests, and the unnecessary biopsies and other procedures resulting from those false positives.

This conclusion prompted genuine outrage in many circles, some of the opportunistic and political variety (yes, I am looking at you Republicans), but much from people who strongly feel that this is bad advice that reflects a warped sense of cost and benefits. The reaction has been especially strong in segments of the women's community, where it seems to be viewed as trivialization of women's health and lives.  (I was laughing at one commenter who claimed that they would never do this with prostate cancer, but as I discuss below, exactly that sort of recommendation has come out regarding certain prostate cancer screening.) The authors of the recommendation appear baffled by the firestorm that has greeted their recommendation.  The people who do this kind of work are generally doctors and nurses with either masters in public health or PhDs.  They are not typically front line practitioners, but rather study reviewers and number crunchers.  Their approach to these issues is a dispassionate statistical analysis that looks at overall outcomes and costs and weighs them in a way that may strike many as cold and even inhuman.  I understand that reaction -- my layman's limited scrutiny of the study left me with the feeling that the call was closer than the Task Force let on.   

Interestingly, a similar study for screening for prostate cancer did not generate nearly as much attention. Part of that seems to me to be an accident of timing -- health care reform is clearly the subtext to this, even if the studies' releases are coincidental.  Not to engage in gender essentialism, but I think this may have to do with the fact that men are always comfortable with a recommendation that reinforces our tendency toward denial in these kinds of matters -- oh the test is no good -- great, I'll skip it.  (Or maybe I'm just projecting.)

I do think the people who are upset with the studies need to take a deep breath and look at all of them anew.  They tell us a couple of things that are worth noting, even if you ultimately conclude that personally you are going to get all of the screening you can.  The first and most obvious -- and in some ways the least persuasive to many people -- is that all of this screening is really expensive.  Really expensive.  And raises the obvious question of whether our health care dollars could be more effectively deployed.  [In the case of pap smears for women under 21, doctors detect one to two cases of cervical cancer per one million 15 to 19-year old girls screened.]  But the bigger point to me is that the results of these tests are not always (please forgive the pun) so benign.  People are not only put through a great deal of stress due to erroneous readings of these results, which I suppose we can live with, but are subject to additional invasive tests -- biopsies, fine needle aspirations, and actual treatment for cancers that may not be a danger to them.  

Ultimately though, I think the largest point is that all of our emphasis on screening, prevention, and early treatment are to some degree faith-based talismans, ways to ward off our understandable fears.  The reality is that our tools in screening for many kinds of cancer remain relatively crude despite their great expense and they cannot prevent the disease from occurring. In the end, we continue to confront our own vulnerability and mortality, things that can't be tested away.  

I have added this link, at Jim Benton's recommendation, to an excellent blog post by a real doctor rather than a juris doctor on this issue.

Comments

[big bad wolf]

your mortality.

gail collins had an interesting column in the times yesterday. http://www.nytimes.com/2009/11/19/opinion/19collins.html?_r=1

[Sir Charles]

bbw,

I meant to reference that too. I particularly liked her line about everything in life being fodder for a column.

[Prup (aka Jim Benton)]

Sir C: For other reasons entirely I have been arguing that the political blogosphere should be more familiar with the Skeptical blogosphere. However, in this case, one of the most prominent, perhaps the most prominent Skepticla blogger -- and moderator of the Skeptical blogosphere is "Orac." His real name is one of the worst kept secrets on the net, but as a matter of courtesy -- he is, in a way, my 'blog father' though this is another way I'm a bastard -- I don't use it. However, he is one of the more prominent clinical and academic oncologists on the East Coast.

He has, for obvious reasons, been discussing the new standards recently, most prominently yesterday in a post that is long even for him. (In checking the reference, I discover he has a further post today, specifically dealing with the Republican/Paranoid Party's myths on the subject. Haven't read it, but can recommend it sight unseen, as I would a legal comment from you, Sir C.)

I will not, nor could I, summarize an article that is long even for him, but I can give a couple of highlights and a brief explanation of some confusing points. But please -- and this is particularly directed at our female members/commenters -- read the whole thing and the second article he links to in the first paragraph.

First, this refers to asymptomatic women with no family history only. If there is any specific reason to get yourself checked out, DO IT! (Sorry for the amount of HTML I'm using, but for this i think it is necessary.)

Second, this is for women between the ages of 40-50, above 50, get checked out regularly.

Third, for sound reasons that he explains, 'regularly' should be every TWO years, not every year.

(There is also a statement about self-examination that he disputes, for what seem to me to be sensible reasons, but IANAD, to put it mildly.)

He neither supports nor opposes the changes -- though he does criticize 'a society I am a member of' for an over-hysterical response -- but explains the basis they were made on and leaves it to the reader to make up her own mind. (If any of you have read him, this fact alone will demonstrate how complicated the question is. He usually has no difficulty in making definite -- and definitive -- statements.)

So I would seriously suggest anyone here read this article, the one linked to, and today's piece before dashing off a quick response to this statement. I will say this, that I have never found him to make a factual statement that is inaccurate or sloppy.

[big bad wolf]

i liked that line too. i think she has a very nice way of humorously leavening serious matters to create perspective while still treating matters as serious. she doesn't write the typical here's-your-answer opinion column, but she doesn't shy away from the issues either.

[Prup (aka Jim Benton)]

OUCH!!! I was responding to the statement on BREAST cancer screening -- fast reading after 4 hours sleep and an incredibly rough day yesterday and 'seeing what you expect to see instead of what's there.' I am sure Orac will be covering this as well -- and will report if I spot it first -- but I was talking about the wrong thing.

BLUSH!!

[low-tech cyclist]

Not to engage in gender essentialism, but I think this may have to do with the fact that men are always comfortable with a recommendation that reinforces our tendency toward denial in these kinds of matters -- oh the test is no good -- great, I'll skip it. (Or maybe I'm just projecting.)

I don't think you're projecting - I know too many guys who would rather avoid the doctor than find out they've got a health problem.

But it's also true that we don't labor under the history that women do of having their health issues being taken less seriously by the medical profession - of diseases affecting primarily women getting too little study, of men being regarded as the normative patients for diseases that affected both sexes more equally, but differently.

Whether the recommendation is justified or not, the result of that history is that the recommendation that women not be given mammograms between the ages of 40 and 50 sends an unintended signal of "hey, it's a women's disease, getting timely information about it isn't that important." So I don't blame women for being suspicious and angry.

[Sir Charles]

l-t c,

It is worth noting that the Task Force in this case consisted of 16 medical professionals, the break down of which was nine men and seven women. It seems to me that the study shows a rather careful analysis of the problems at issue and is in no way an attempt to minimize the seriousness of what is at issue.

One can disagree with the calculus reached by the panel, but I think there is a danger in importing too much "history" into responses to this sort of thing.

[Prup (aka Jim Benton)]

l-tc:
I think it is just the headlines that send this message. If someone reads the actual report, or a factual discussion of it, they will see that this is actually 'sending a signal' that 'it's about time women weren't being put through unnecessary procedures automatically' and in fact is very much pro-women.

[Prup (aka Jim Benton)]

Minor point but -- again from Orac, today's piece in fact --

But Ned Calonge, who chairs the 16-member panel, defended the recommendations and denied that cost or the debate over health-care reform played any role in the decision. "Cost just isn't a consideration when the task force deliberates," said Calonge, who is also the chief medical officer for the Colorado Department of Public Health and Environment. Twelve of the task force members were seated during the Bush administration, and the remaining four were chosen before President George W. Bush left office, he said.

Again, please read the post I linked to above.

[Sir Charles]

Jim,

I liked that post a great deal and have added a link to it.

[kathy a.]

there is a cultural overlay with breast cancer specifically that might be driving some of the outrage. breast cancer is the sexy cancer, the cute cancer, the pink cancer, the cancer everyone supports. you may have noticed a bergillion pink products in october, breast cancer awareness month -- marketers go absolutely nuts, but their idea is to sell more, and i simply do not believe that buying a pink bicycle seat or pink vacuum cleaner or pink spatula or food with pink on the packaging does much to advance diagnosis and treatment. breast cancer action has a "think before you pink" campaign. http://thinkbeforeyoupink.org/

i personally think that the new recommendations make sense for women who are not at high risk. on the one hand, there are a LOT of mammogram findings that result in invasive procedures and even false positive diagnoses. each of my 3 sisters and me has had biopsies that turned out to be benign. a friend was told she had cancer; she found others to take over a class she was teaching, and was scheduled for a radical masectomy by the time they decided it was not malignant. and on the other hand, annual screenings are not very good at catching very aggressive cancers early.

strange developments and high risk are reasons to be more aggressive with screening/investigation. i have had 3 rounds of mammography plus 2 ultrasounds this year, to follow something suspicious after i learned that my sister has an aggressive breast cancer. her diagnosis bumped the rest of us into the high risk category. there is a pretty fair amount of anxiety and discomfort involved even with these non-invasive procedures.

[it didn't help that the last time, i got sent to a brand-new really posh breast cancer center instead of the outpatient imaging place. artwork, artful tiling and woodwork, plaques for donors, meditation rooms, sounds of waterfalls, soft bathrobes embroidered with the name of the center, etc. as a matter of fact, the place pissed me off because it is located in a city with a lot of poverty and a lot of uninsured people, and i kept wondering how many poor women could get mammograms they need for the amount they spent on decor. maybe teh donors prefer to contribute to decor.]

my sister with cancer is absolutely livid about the new guidelines. however, annual screening did not catch her cancer. she found a lump and followed up, between regular screens. her type of cancer is aggressive, fast to grow and spread. it is also relatively rare. she's entitled to be emotional on the subject, since she has the fucking cancer. but emotion is not a good basis for public health recommendations.

and public health recommendations are just that: broad recommendations, not the decisions that might be made and justified in an individual circumstance.

[Nicholas Beaudrot]

It's even worse than you say. The report doesn't conclude that Mammogramms aren't cost effective from age 40-50, it concludes they aren't effective. There just aren't many people who are surviving today because we caught a stage I growth at age 43 who wouldn't survive if we caught the same stage I or stage IIb growth at age 50.

In the UK, mammograms begin at age 50-53, and occur once every 3 years. The recommendations don't even go that far.

[Sir Charles]

kathy,

I'm very sorry to hear about your sister. And I completely understand how emotional this issue is -- especially among people who feel that their lives have been saved by mammography. It's pretty hard to view such a compelling life circumstance as a mere data point.

The whole health care for the affluent thing is pretty disturbing -- and so not an isolated occurrence.

I hate to be cynical about this sort of thing, but there is, as you point out, huge money in the breast cancer-medical-charitable complex. I can't help but view the objections of the American College of Radiologists with a slightly jaundiced eye.

In the end, I understand people's concerns about this sort of thing -- it's very jarring to have your assumptions completely undermined by the same medical establishment that confidenty told you that the prior path was the way to go. But we have to accept that medicine is an uncertain art and that this sort of thing is going to be a continuing phenomenon.

Obviously we all wish you the best in the concerns facing you.

[Prup (aka Jim Benton)]

kathy: my sympathies as well. My wife's parents are doing well and about to celebrate their 64th Anniversary, but both her siblings have different forms of cancer (as does her sister's wife -- that's one reason I know the Canadian health care system works, because they live in Vancouver). So far they are doing well, but it is always scary. Can't say I'll pray for you without being a liar or a hypocrite, but if there is anything in 'positive energy' there's a big dose heading you and your sister's way.

[Prup (aka Jim Benton)]

In re Republican despicability, President Obama's 'close friend' Tom Coburn might have set a new record. (From Steve Benen.)

[Yesterday], Oklahoma Republican Sen. Tom Coburn, who is a physician and staunchly opposed to this legislation, suggested on the Senate floor that a woman would be taxed if she had breast reconstruction surgery following cancer.

"In this bill is a 5% tax on cosmetic surgery," Coburn said. "Just yesterday -- the day before yesterday, U.S. preventive task forces, services, recommended because it's not cost effective that women under 50 not get mammograms unless they have risk factors. Well, you tell that to the thousands of women who were diagnosed with breast cancer lat last -- last year under 50 with a mammogram. You tell them it's not cost effective. Also in this bill is a 5% tax on the breast reconstruction surgery after they had a mastectomy. They're going to tax having your breast rebuilt after your breast is taken off because it is elective plastic surgery. It is elective cosmetic surgery. We're going to have a tax on it because we've taxed elective cosmetic surgery. We're in trouble as a nation because we've taken our eye off the ball."

And since his Senatorial partner is James Inhofe, he is still the saner and more honest of the two. What IS IT with Oklahoma?

[kathy a.]

aw, thanks for the good thoughts! no praying necessary, since i don't do that either.

so far, my sister is doing fine. she was diagnosed at stage II, had surgery and chemo and radiation, which all went well; her work was accomodating; her treatment was covered; her hair is back and really looks good. the fucking cancer didn't get farther because she found something weird and went in. as we all should [and should be able to do].

a brother-in-law also had prostate cancer diagnosed last year; that also was not caught with a regular screening, but because he noticed symptoms and went to the doctor about them. he's also fine! his cancer was caught early, and his prognosis is great.

my sister's prognosis? a little more complicated. hers is rare, and it is fast-growing. it is a type not receptive to treatment with common hormonal therapies, like tamoxifan, which is why she got the full round of surgery, chemo, and radiation. if it comes back, that is probably very bad news.

so, here is where i make my pitch for sharing medical history with immediate family members. it's important.
my sister's cancer diagnosis means that my sisters and i are are higher risk, and so is my daughter, and any descendants need to know, too.

it also means that our people need to be cautious about hormonal interventions, because of her particular fucking cancer. for example, even though i do not want supplemental hormones for perimenopause symptoms like the freaking hot flashes from hell, my doctor told me flat out that she would refuse to prescribe them, because of the risk knowing my sister's diagnosis. [triple negative, is what they call it.]

as for my own mams -- 3 mams plus 2 sonograms over 9 months showed no changes, and nothing suspicious enough for anyone to even suggest a biopsy. they want me back in a few months "just in case." i'm not deciding quite yet.

[kathy a.]

prup, i can't really follow what he is saying. is he arguing against breast reconstruction? or the tax because it's a tax? or what?

there is a difference between breast implants or butt lifts on an elective basis, and reconstruction of an injured body part. what kind of moron lumps those together? he cannot be seriously arguing that taxing breast augmentation hurts women who can't get mammograms when they need them, can he? sheesh.

[Sir Charles]

Coburn is a disingenuous piece of shit. Under federal law (the Women's Cancer Rights Act -- those of you lucky enough to have employer sponsored insurance should get a notice about this every year), reconstructive surgery after a mastectomy must be covered by all group health plans as medically necessary.

[kathy a.]

crap, i really try not to use the word "moron." it is an insulting term. apologies for comparing those friends and family who need to try harder -- whom i admire greatly -- with privileged people who are mean and willfully ignorant, condescending, and misleading.

there is hardly anything nastier than using a particular example of misfortune [breast cancer surgery] in a false way [reconstruction is "cosmetic" surgery] to advance a political agenda based on fear, so as to deny some millions access to health care. i'm curious about coburn's views on reconstruction and rehabilitation for military personnel blown up in the war. i'm betting he isn't arguing that artificial limbs or burn treatments/reconstruction are cosmetic and liable to be taxed.