It's about time the medical profession began taking seriously the costs as well as the debatable benefits of annual mammograms for women over 40 (among other routine screening procedures). If the controversial new set of guidelines constitutes rationing, it may be one form of rationing that's overdue; the challenge is for women who consider "clean" mammograms clean bills of health to recognize that their value is limited, partly by the ability of doctors to interpret them.
I've been a little lax about obeying the annual mammogram mandate for some years, since reluctantly submitting to a biopsy because of an anomaly in a hard to read film. "It doesn't look evil," an oncologist assured me, and nothing that looked evil was revealed subsequently by two ultra sounds and an MRI. Against my instincts (and the judgment of one radiologist who advised a series of follow-up mammograms), I was eventually persuaded to undergo a needle biopsy -- an unpleasant procedure that entailed an overnight hospital stay (of which I have no memory, thanks to some wonderful drugs). "In Europe, they wouldn't operate; their protocols are different," the surgeon acknowledged, when I discussed my doubts about our protocols with him.
This sorry experience was, however, an education in medical decision making: the clinicians advising me (a radiologist, oncologist, and internist) were compassionate, generous with their time, focused on my welfare, and honest about what they didn't know. But an additional radiologist consulted for a second opinion insisted that he could enable a meaningful biopsy, and his insistence inevitably drove the process. My strong belief that he was mainly invested in proving an ability to locate cancers that others couldn't, was no match for the advice of other cautious, trustworthy doctors disinclined to dismiss the claims of a respected radiologist. But they weren't patients, exposed to the boundless egoism exhibited by him and his hospital superior: "Let's hope we're right," the department head said, taking my hand and feigning concern, after I agreed to the biopsy. "Let's hope you're wrong and I don't have cancer," I replied.
The biopsy was negative, but it didn't mean that I didn't have cancer: it meant that tissue extracted in what may have been a meaningless operation was benign -- which is not to say I wasn't relieved. But along with relief, I gained an understanding that yearly screenings and even biopsies can offer no guarantees of being cancer-free. So I wonder how many women will welcome the new recommendations for fewer mammograms, perhaps greeting them with a silent "I told you so," and how many will continue the yearly screening regimen, with its false positives and, perhaps, even falser sense of security.
(Photo: Scott Meis Photography/Flickr)
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Wendy Kaminer
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I live in Mexico, in an area not populated with a lot of Americans but indeed populated with quite a lot of good doctors. I had delayed getting a mammogram for three years after moving here, even under present recommendations, clearly too long. When I finally got up my nerve, the first thing out of the radiologist's mouth was, "You're an American? I thought Americans were compulsive about getting annual mammograms." He was a very good radiologist with a reputation outside our area. He had the very latest equipment.
Here's how it goes here. A nurse takes the pictures. Since it is digital equipment, the images are immediately available and appear on a screen in front of the patient. Then the doctor comes in. He does a manual exam as he is looking at the images. He explains what he sees, and he explains what you see that worries you. He also does an ultrasound. And talks about that while he does it. Very interesting, very educational, very thorough. I did not have anything requiring further follow-up at that time. He did recomend another one in a year, but then I am sixty six,and there are things one can keep an eye on.
I paid for it. I could have gone through the national health program, but there is a waiting list for that, and once I'd made up my mind, I figured I'd better go through with it. The visit cost around $100.00. I'll go this doctor again. I've been spoiled.
Open communication between doctor and patient here in our area is more reassuring than any number of extra or unneeded tests. In the US, mammograms were strange and scary experiences. Sometimes getting one was like being on an assembly line. At other times, with a nervous or hyper-careful radiologist, extra mammograms were ordered. I never saw the doctor ordering them. I never saw the mammogram film nor the report nor had it explained specifically to me. Knowing they weren't perfect, of course I wanted one every year: if they missed something last time (and who's to say they didn't), at least maybe they'd capture it the next time before it was too late.
As a high-risk woman (mother, grandmother, great-grandmother), I have been having mammograms since I was forty. It was the one thing I was faithful about when it came to health care. I had one needle biopsy over fifteen years ago, probably one of the most unpleasant experiences imaginable. In June 2007 I had my annual mammogram and got an all clear. It was such a relief. Six weeks later, I found a little lump. It turned out I had stage 3A breast cancer, a rather large tumor. I asked my oncologist how this could be and she informed me that the rate of false NEGATIVES for mammograms is 10%! This information is never shared or at least I never heard of it. Add this to the huge number of false positives and the value of mammograms as a diagnostic device really becomes more questionable.
What I found more confusing about the panel's recommendations had to do with self-examination. So many of the women who end up with breast cancer, like me, find the abnormality themselves.
BTW, Wendy, I agree with the assembly line and scary nature of the whole mammogram procedure and the lack of meaningful feedback. But that has a lot to do with the impersonal nature of American health care.
Well, at least from now on, my mammograms will only cost half as much
I'm confused too. At age 20, I had a lumpectomy, which was benign. Diagnosis of "cystic breasts" (later called fibrocystic breast disease) led to four decades of annual mammograms and at least a dozen needle aspirations (fluid removed from the cysts) -- all benign. Now it's appears I never was at higher risk for breast cancer (great), but have probably over-radiated my breasts and subjected myself to unnecessary discomfort and expense. It all seemed to make sense at the time, but never did any doctor or technician suggest that maybe the original diagnosis needed revisiting.
Just wait until somebody you love has annual exams and is diagnosed at an early stage. I know. I've lived through it. The joy of one life saved infinitely outweighs nattering about how much a needle biopsy is "one of the most unpleasant experiences imaginable." Having breast cancer, even at an early stage, is a lot worse. Having breast cancer that was not caught in time must be unimaginably worse.
But hey, it's your life -- don't bother with tests if you don't want to. Just don't try taking them away from people who are more conscientious than you.
Here's a thought experiment. Imagine if this Medical Task Force report had been delivered under the Bush Administration.
I know at least 5 women who had breast cancer diagnosed before they were 50. I am married to one of them. Maybe it is more economical that they should die. Thanks.
TCrosse,
What does the Bush Admin have to do with any of this? The studies that the Task Force reviewed were conducted in the last four years both in the US and Europe. Perhaps a few of the studies were funded by the NHS under Bush.
Don't conflate the hysteria of the current health debate with a review of medical studies and literature of the last x amount of years.
In your wife's case, did she suspect the breast lump during a self-exam or was she completely surprised by a mammogram's results?
Of the friends that I know who had breast cancer pre-50 and post-50, most of them had family members with a history of cancer and were diagnosed with breast cancer by a self-exam or other methods first and the mammogram as a secondary confirmation diagnosis.
As a woman who comes with a family, on both sides, with no cancer history and who has made a concerted effort to stay on top of my personal health, I was angry this fall when I received a letter from my health insurance that they would drop me if I did not go get a mammogram. I am 41 with no family history of cancer and I was forced to get an unnecessary radiation screening. Result: no cancer and extra radiation.
From my perspective, I would have preferred that my doctor and health insurance had listened to me that I felt a mammogram was unnecessary and put me at risk. I even quoted the studies (pre-Task Force) to my doctor and was not listened to. From your & your wife's perspective, you may be very happy to have a mammogram and have it covered by your health care.
I don't like Industrial One Size Fits None Health Care and I am sure you don't either, but we have it now in our current system, regardless of Mr. Bush or Mr. Obama.