Last week, leading experts correctly challenged long held practices in women's health. Despite the evidence, doctors and patients, as well as political and community leaders hotly debated these recommendations. My heart sank when Kathleen Sebelius, Director of Health and Human Services (HHS) weighed in and suggested that women ignore the recommendations and continue doing what they have been doing. I was astounded.
Ask any good surgeon or physician (preferably one who does not own a diagnostic machine) and we can all tell you nightmare stories about patients who have been hurt (sometimes severely) by overzealous screening and unnecessary interventions. Still, it is hard to stop something that you have been trained to do or advocate.
I still shudder, when I hear colleagues suggesting that women should perform clinical breast exams each month. We have known for over a decade that teaching women to examine themselves once a month does not prevent or improve detection of breast cancer. It does lead to more biopsies, surgeries, and anxiety (with increased cost and no benefit). The evidence against breast self exams is strong and robust. Women who identify lumps should still contact their doctors, but performing planned screening in the shower every month is simply ineffective and harmful.
Yet it's hard to stop something your doctor told you to do 30 years ago. It's also hard to stop telling patients something you learned in medical school 20 years ago. All of these recommendations represented our best advice at the time. Fortunately, we continue to learn and grow, and so must our advice.
The recommendations announced last week by the US Preventive Services Task Force (USPSTF) and the American College of Obstetrics & Gynecology (ACOG) that women reduce the number of mammograms and pap smears they receive were both founded in strong science and empiric evidence. Unfortunately, the USPSTF article reads like Greek to most non-physicians and non-statisticians.
Its critically important to realize that the men and women who develop these guidelines have no "skin in the game." They do not benefit from reducing the number of mammograms or pap smears. They're not heartless bureaucrats trying to save a few dollars. Both the USPSTF and ACOG are composed of physicians and scientists whose only motivation is to improve the health and wellness of women nationwide. Being invited onto the USPSTF or ACOG Practice Committee is a huge honor. These are our best and brightest. They strive to determine what is best for our patients, our community, and our loved ones.
Back to the reaction of Secretary Sebelius: When the captain of the ship ignores the engineer's suggestion regarding engine maintenance, it's a problem. The USPSTF is sponsored and funded by the HHS. By ignoring their recommendations on mammography, the Secretary demonstrated why the federal government has been unable to rein in health care costs: Even when testing is found to be more harmful than beneficial, our leaders and some in the media still demand more tests.
The current health reform bills have done little to change the incentives and drivers of increased health care costs. When good evidence suggests that increased testing provides no benefit, we should stop such testing. Meanwhile, as health care costs continue to grow, it crowds out money for other important areas, like education. Can we really demand medical tests that our experts suggest are unhelpful, while we increase class size in schools and cut funding to schools and our teachers?
These problems are connected. Sometimes good intentions can do more harm than good. The trust between a doctor and patient is sacred and doctors still need the ability to make individualized decisions given a patient's unique medical history. However, when it comes to standard protocols and recommendations, we must act based on the best evidence, weighing not only the benefit, but also the cost and potential for harm from a given test or treatment.
The next time a friend goes under anesthesia for a stressful, painful but benign breast biopsy, or the next time a young woman has a preterm delivery after part of her cervix was removed for an abnormal pap smear she had at age 20 (most of which resolve with time), I hope we remember that sometimes in medicine, less is truly more.
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INCLUDING PROSTATE AND LUNG, ETC.
WHERE ARE THE REVISED GUIDLINES FOR THOSE SCREENINGS?
And, Nothing is more OVERZEALOUS than the infatuation with Erectile dysfunction medications.
Where are the revised guidelines on THAT?
But they must appreciate how baffling their recommendations seem to the rank and file American, and how stupid the timing of these recommendations are, right in the middle of the health insurance reform debate. Many of us also know people who did get a lump caught "early" through screening, so these new recommendations seem a bit odd. If you are one of the small number of people who DOES benefit from routine breast cancer exams and mammograms from 40 onward, I guess the good doctors are telling us that, statistically speaking, your life isn't worth saving,and your kids can make do without a mother?
...and were very careful not to mention that more than 2000 people were saved by airbags.
So, which is more important: The 200 people who will die from airbags or the 2000 people who will be saved?
No generalized medical program will ever be perfect for everybody in every situation. As every doctor involved in this has said: Talk to your doctor and if the two of you find something unusual, then by all means have it investigated. But, there is a difference between watching your own health and simply doing something "routine" because the guidelines say so.
If the "routine" process winds up with more people being harmed than helped, is it really controversial to recommend stopping that "routine" process?
Suppose the "routine" process was to surgically remove the breast, send it through a detection machine, and then surgically reattach it. Is that really something we should recommend for everyone every year? Mammograms are not trivial. Biopsies are not without risk. We should continually re-examine our processes to make sure they are really helping.
Sebelius was right to do what she did. The government needs to alow women to get annual mammograms before the age of fifty if their family history dictates it. If she had gone along with the new recommendations - prompted, incidentally, by old research - the government would remove the mammogram-before-50 coverage out of the public option (hoping it passes) and Medicare. She is protesting those of us with histories of breast cancer in our families.
Both my mother and grandmother are breast cancer survivors. I'm 46 and got tested earlier this year for the first time. I will be getting tested next year, too.
And the bit about encouraging women NOT to do self-examinations is crazy. We know our bodies and should trust our instincts if we think something is wrong, no matter what age we are.
Better to be safe than sorry.
Nowhere in the report does it say not to have a mammogram. Instead, it says that routine mammography before the age of 50 isn't helpful. By your logic, why should we stop at 40? Why not 30? 20? Shouldn't all women get mammograms starting at menarche? If you understand that there's a reason why we don't do them for 22-year-olds as a matter of course, then you can understand why it might not be the best thing for a 44-year-old, either.
Talk to your doctor. Are there other factors involved? History of breast cancer in the family? Other symptoms that are indicative?
You seem to think that mammography and the resulting post-test treatment are trivial and benign.
What are the overall consequences for doing a "laser excision of the transformation zone" at age 20 ?
Will she be spared further abnormalities if she does not change her lifestyle - medicine does not know
Will she be able to carry a pregancy term - if not then why not - medicine does not know
Will she run into problems with pelvic pain at 5-10 years - medicine does not know.
As for the consequences of HPV vaccination - it is alleged to "prevent" CIN 2 in a proportion of cases - We have no population-based trials about the incidence of cancer - they would take 25 years. But the propaganda from BIG PHARMA is "vaccination prevents cancer" - scientific tat !
We do not have answers to these questions.
I say that as a woman who has had a scare in her forties, with an ultra sound and a biopsy. I say that also as a woman who lost a friend in her forties to breast cancer 5 years ago, another friend in her forties to breast cancer 7 years ago, and has a friend in her forties who is undergoing chemotherapy for breast cancer as we speak.
What are we supposed to do to find the breast cancers that will kill 600 additional American women each and every year? Their lives matter.
Asking for answers,
Heather
I'm reminded of the "debate" regarding air bags. CNN when they were still doing "Talkback Live!" had an episode about it and brought forward people who had been injured by airbags who were adamant that they be allowed to remove or disable them. They put forward the statistics that 200 people were injured by airbags every year...
...and were very careful not to mention that more than 2000 people were saved by airbags.
So, which is more important: The 200 people who will die from airbags or the 2000 people who will be saved?
No generalized medical program will ever be perfect for everybody in every situation. As every doctor involved in this has said: Talk to your doctor and if the two of you find something unusual, then by all means have it investigated. But, there is a difference between watching your own health and simply doing something "routine" because the guidelines say so.
If the "routine" process winds up with more people being harmed than helped, is it really controversial to recommend stopping that "routine" process?
Suppose the "routine" process was to surgically remove the breast, send it through a detection machine, and then surgically reattach it. Is that really something we should recommend for everyone every year? Mammograms are not trivial. Biopsies are not without risk. We should continually re-examine our processes to make sure they are really helping.
I'll take a captain who pauses to reflect on matters of life and death. Research is not conducted in a vacuum and that done by the USPSTSF is no exception. Looking at this issue is necessary and could result in better ways to detect breast cancer. But just as our president is taking his time deciding whether to put the lives of young men and women in danger, Secretary Sebelius should take the time needed to protect the health of women. "What's the rush?" women ask. "Why two major cutbacks for women in one week?"
Even if the research is without flaws, which is never the case, communicating the results in a manner that serves patients' needs is as important as doing the research in the first place. If you understand research and statistics, the study is not "Greek" at all, and there is much room for discussion and time for further research before putting the lives of women at risk. It isn't that women can't change. They aren't that stupid. It's that they expect to hear good reasons before they're asked to jump.
Dr. Reardon also blogs at www.bardscove.com
The task force wasn't being callous, they were making recommendations based on research and logic. Mammograms don't prevent deaths. They just postpone them. If you want a life of unnecessary medical procedures and fear, that's up to you. Please don't wish it on others with your fearmongering.
The problem is that we have been brainwashed to believe that more is always better when it comes to medical tests and procedures. We should be open-minded when hearing the recommendations of this committee, and apply them rationally to our own personal situation.
I disagree with your statement that "for every woman who's been through a scare or unnecessary biopsy there's at least one other whose life has been saved or extended by early detection." That is the point of this article and the committee's statement, that all of this screening and cutting does do more harm than good.
He says that
"performing planned screening in the shower every month (i.e. self-exam) is simply ineffective and harmful."
If this is the case then why does he suggest that "Women who identify lumps should still contact their doctors.." This suggests that self-exam can lead be extremely important; otherwise, why would he suggest that women contact their physician to report their findings?