Screening Mammography: Making Well Women Sick

                In December 2009, the U.S. Preventive Services Task Force recommended that women between the ages of 50 and 74 be screened for breast cancer once every two years rather than once every year.  It also recommended against routine screening of women younger than 50 and older than 74.

                Almost immediately after the recommendations were made public, there was a large outcry against them.  I was surprised that so many people were able to decide so quickly that the recommendations were wrong.  To me it seemed there hadn’t been enough time to learn about and evaluate the evidence upon which the Task Force based its recommendations.  Since women and their doctors are now in the midst of making decisions about when and how frequently women should be screened and because I don’t want women to make uninformed decisions about their health care, I decided to devote this and the next couple of postings to providing the information I think they will need.

                 The U.S. Preventive Services Task Force is a panel made up of primary care providers (e.g., internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health care specialists) who are not only experts in prevention but also experts in understanding and interpreting evidence-based medicine.  In the case of breast screening that would include scientific results important for evaluating how effective screening mammography is.  The members of the panel are independent; they are not part of the Federal government.  Plus, financial cost is not taken into consideration; it plays no part in determining the panel’s recommendations.  But human cost does.

                The Task Force will not recommend a service such as mammography screening unless its benefits outweigh its harms.  Just being able to identify breast cancer in women is not good enough.  Why? Because of the tens of thousands of women who are screened for breast cancer every year the vast majority are well.  And although we tend to evaluate doctors in terms of how good they are at making people who are sick well, it’s just as important to keep in mind that they’re also not supposed to make people who are well sick. So the questions boil down to these: What are the harms of screening women younger than 50 and older than 74? What are the harms of screening once a year? How do they occur? And how do they outweigh the benefits?

                The harms of screening mammography come from two sources: (1) incorrect diagnoses by radiologists reading and interpreting mammograms and (2) the inadequacy and carcinogenic properties of the mammography technology itself.  My next postings will cover how incorrect diagnoses occur, the steps radiologists take to reduce the number of incorrect diagnoses, whether adding computer-aided-detection to mammography reduces the risk of incorrect diagnoses, the harms associated with incorrect diagnoses, and the steps women can take to reduce their risk of being incorrectly diagnosed.

Introduction

I named this blog "Patient Power" because:

                1) I’m discouraged about how expensive health care is in the United States;

                2) I’m angry that so much money is spent on health care that’s clearly inadequate;

                3) I’m worried that at all levels of government our elected representatives seem to have no clue about how to control health care costs except in ways that would make health care even worse for most of us;

         and 4) I hope that by transferring to you my knowledge about how the health care system operates in the United States, you will be able not only to make more informed and better decisions about your own health care and the health care of your family and friends, but also about what must be changed so that we all can have better healthcare at lower costs.

 In later postings, I’ll be writing about (not necessarily in the following order):

                1) Conflicts of interest, what they are and how they influence the behavior of doctors, our health and the costs of medical care;

                2) The fallacy of small doses and what it means for your health;

                3) What scientists now believe about how solid cancers develop and what that means about current and possible future methods of cancer detection;

                4) The controversy over the effectiveness of mammograms, including computer aided detection, and breast self-examination;

                5) The possible demise of the large pharmaceutical companies (aka “Big Pharma”), how it came about and what it means for the development of “individualized medicine;”

                6) Large drug trials, why they evolved, their costs, what their results mean, possible alternatives and the roles played by doctors;

                7) The importance of generic drug manufacturers;

         And 8) how the Food and Drug Administration makes its decisions and what seems to influence the decisions it does make.

Finally, in terms of evaluating my postings I think it’s important to know four things about me:

                1) I’ve been living with active breast cancer for the past fifteen years. I learned most of what I know about the practice of medicine in the United States during my quest to determine what treatments would be best for me;

                2) I’m a clinical and an experimental psychologist. My training included learning how to design and statistically analyze experiments involving human participants---training that has proved to be valuable for understanding and evaluating experiments in medicine since they, too, use human participants;

                3) my politics are progressive.  I believe social, political, and economic reform should come through the state.  However, I also believe progressivism only works well in a democracy when the electorate is able to make informed decisions.

         And 4) most of the examples I use will be coming from the two areas of health care I know the most about: breast cancer and psychology/psychiatry.