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The Mammogram Guideline Kerfuffle

19 November 2009

Yes. So, who wasn’t surprised earlier this week, when we here in the US first heard about the U.S. Preventive Services Task Force’s reversal on yearly mammograms and monthly self-exams?

Since then I have read one article (and many of the reader comments) and listened to part of one radio show on the topic, and here are my first thoughts.

Things I believe:
• This report did not have appropriate PR in place when it was released (especially because it reversed long-held recommendations).
• The usefulness of self-exams has been overplayed by the medical community.
I believe in the ability of science to review information with an unemotional eye.
• I have not heard that breast cancer deaths are significantly higher in Europe and Canada; and I know that British guidelines are for less frequent mammograms, starting later.
• New, similar, recommendations have recently been made for prostate cancer, so it is not surprising that a fresh look resulted in such changes to mammogram guidelines.
• The idea of cancer terrifies most, if not all, of us, and our first instinct is to attack it with the most aggressive measures possible.
• We take the effects of accumulated radiation much too lightly in our society (and I think back to how much radiation I was dosed with last year, and I think: how naive my post was!).

I do not believe:
• …that this is a ploy to disenfranchise women during an economic downturn (this is when I stopped listening to the radio show, when they let a caller say this — these reports take a long time to put together, so for liberal and fair NPR to allow such fear-mongering was irresponsible).
• …that because currently doctors do not take the time to sit and discuss personalized risk factors with patients, we should just continue to dose millions of women with extraneous radiation (a reason for continuing yearly mammograms that Dr. Weiss used in the radio conversation).
• …that the reasoning behind stopping self exams has convinced me yet (sure, they may not make a big difference if you are going in for mammograms every year, but if we push those back to every two years, they may play a more useful role).

Sadly, the chair of the Task Force, Dr. Calonge, is not a great speaker (clearly a researcher with little bedside manner) and the statistician who supervised the data crunching, Dr. Miglioretti, sounded terrified to be speaking on air. And sadly, Dr. Weiss was much too invested in this personally to come across as anything but a fearmongering reactionary.

What most people seem to overlook is that these are recommendations, not dicta in a one-size-fits-all command. If a woman has family history of breast cancer, if she works in a high-risk field or has had high exposure to unhealthy levels of radiation, or if she has had questionable scans in the past, then of course she may choose to continue with yearly mammograms (remember the x-ray issue though — a lump may be the devil you see, but radiation is certainly a devil we don’t see).

I had my first mammogram last fall, and had just last week received a letter reminding me to schedule my yearly mammogram. But if you recall, they had me redo one side — five times. I felt lots of anxiety about the whole situation, and even after I was given the “all clear” it still made me feel like I had dodged a bullet.

Because I have no other risk factors, and because I am young, I have chosen to sit back and wait for the time being, see how all this falls out — but make a concerted effort to remember my self-exams.

What have you or the women in your life elected to do at this time?

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6 Comments leave one →
  1. 19 November 2009 7:28 pm

    Well, PI, my beloved spouse is not a fearmongering reactionary, and his response to this panel’s recommendations was,”They’re positioning for insurance companies to not pay for mammograms before age 50.” My first thoughts, too. He is a rational smart business person, and caught the direction this was taking immediately.
    I myself have found two lumps through self examination, and had them removed and checked out. Biopsy analysis showed they were benign, but let me tell ya, you find lumps, you are not inclined to ignore them. One of my dearest friends was diagnosed with breast cancer BEFORE she was 50 years old; she got a double mastectomy as a precaution, and hasn’t looked back.
    I have had mammograms every year since I turned 40. I just turned 59 last week. Our fairly cautious insurance provider, Group Health Cooperative, a local HMO, has insisted on this schedule.
    Think about this: Insurance companies are always looking for ways to cheap out and not cover people. What better group to fuck over than generally nonreproducing women? You notice them not covering Viagra?

    • Peaceable Imperatrix permalink*
      19 November 2009 9:08 pm

      I think I’ll have more to respond to after I let things percolate for a while, but I did want to clarify this: I did not mean to imply that anyone who disagreed with the Task Force was a fearmongering reactionary, only Dr Weiss on the radio program. Her vehemence was difficult to ignore, and her arguments seemed to come more from emotion than reason. I hope not to stoop to painting everyone who disagrees with me (well, except perhaps for Palinesque “real Americans”) with too broad a brush!

  2. 20 November 2009 8:26 am

    Isabelita, I had the same first thought, too: that the new guidelines would give insurance companies increased rationale for not covered mammograms before 50. I know that supporters of the new guidelines point out that they are merely recommendations and that women who want or need or feel they need mammograms before 50 can continue to get them. But if insurance companies align their coverage policies with the new guidelines, I am sure that many women will be unable to afford these tests. That’s what concerns me here.

    Personally, I remain unsquished for now. Because of my family history, ethnic background, and age, early testing hasn’t been recommended for me. When I hit 40 in a couple of years it will be interested to see what they tell me then.

  3. Cateling permalink
    20 November 2009 9:02 am

    Is there a forthcoming reaction to the new recommendations for pap smears?

    http://www.nytimes.com/2009/11/20/health/20pap.html?_r=1&hp

  4. Peaceable Imperatrix permalink*
    20 November 2009 4:48 pm

    Cate: Aaargh! Like I said, terrible PR management. (but thanks for the link)

    But back to mammos for a minute. I think the argument against the new recommendations conflates two different things: there is independent science (which this Task Force is) which is a nonemotional look at the data, and there is the distrust of insurance companies. These new guidelines should in NO WAY be influenced by what insurance companies might do with the information — I would much rather have straight talk from science that to never be able to believe what it says.

    As to the business of the insurance industry: we paint them as an Evil Empire, and although it is often the case, it can’t always be the case that they are purely evil, because those of us who have insurance thank the gods above and below when we do need it (otherwise, I’d have to ask you all to put your money where your feelings were and pull out of any insurance coverage you may have).

    And sure, it’s easy to say that if the guidelines change, then insurance companies may not cover yearly mammos any more — but they are in it for the profit, so if this guideline turns out to be incorrect, then they will lose lots of money when they are called upon to pay for the further-developed, more difficult to get rid of, full-on breast cancer (they wouldn’t stop covering breast cancer treatment, only yearly mammos — we can agree on that, right?). I don’t think they’d see it as a good business model to just ignore preventative care that works.

    Now, my British readership has dwindled, and I would so love to get some international input, but here is what I found on the UK National Health Service Web site: “The NHS Breast Screening Programme provides free breast screening every three years for all women in the UK aged 50 and over. ” Do you see that? Every THREE years, starting for women aged 50 (to 53, see the link). Do women in the UK have a statistically significant higher risk of death from breast cancer? I’d like to know, but as I said in the post, I doubt it.

    Also, they have the following question and answer on the page: “Why are women under 50 not invited? Women under 50 are not currently offered routine screening. This is because film mammograms are not as effective in pre-menopausal women. as the density of the breast tissue makes it more difficult to detect problems, and also because the incidence of breast cancer is lower in this age group. ” You see? It can’t be the US insurance industry, because other countries have come to this conclusion independently.

    Lastly, as I mentioned in the post, just a few months ago new guidelines were put out about prostate cancer screening. This same Task Force came out against screening for men over 75 (but are any of you thinking that they are trying to fuck over the generally nonreproducing men which make up this group?), and did not find any convincing evidence either for or against screening in younger men. As we learn more about diseases, we will change how we treat them. We used to cut off limbs at the earliest sign of danger — now we don’t. I just consider this the next step in fine-tuning how we screen for certain cancers.

    I found this AP list useful in seeing the recommendations from different groups for various cancer screenings.

    Now, I await the next round of conversation. 🙂

  5. Peaceable Imperatrix permalink*
    20 November 2009 4:49 pm

    Oops! here’s the link for the NHS site:

    http://www.cancerscreening.nhs.uk/breastscreen/

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