Mammograms, Reconsidered

A long-term study published this week found that mammograms don’t increase women’s odds of surviving breast cancer:


The University of Toronto study split a group of 89,835 women in two. Half of them got mammograms, and half did not. After 25 years, the rate of death from breast cancer was the same in both groups. Some of the women who underwent mammograms ended up with unnecessary treatment.


The research is well done and will influence a global conversation. Dr. Richard Wender, chief of cancer control for the American Cancer Society, said an expert panel will factor this research into new guidelines to be released within the year. Until then, current recommendations stand.


Moreover, they can actually be harmful:


The BMJ study calculated that 22 percent — more than 1 in 5 — breast cancers diagnosed by a screening mammogram represented an overdiagnosis. These were breast cancers that did not need treatment, and the women who received these diagnoses needlessly underwent treatments that could damage their hearts, spur endometrial cancer or cause long-lasting pain and swelling. …



These treatments are totally worth it if it means that you avoid dying from the cancer. But if they’re aimed at curing a cancer that was never going to become deadly, then what early diagnosis has actually done is made a healthy person sick. I think it’s safe to say that no one wants that. Treatments and awareness about breast cancer seem to have created most of the improvements in breast cancer outcomes, and we should celebrate those accomplishments.


Still, Kate Pickert says regular mammograms are likely here to stay:


Otis Brawley, chief medical officer for the ACS, has been outspoken about the downside of various types of cancer screening, arguing that benefits are often over-stated. But even he points out that the ACS examined the ongoing Canadian study when the group last updated its breast cancer screening guidelines seven years ago and concluded that annual mammograms for women over 40 were still warranted. (Findings from the study back then were similar to those published this week.) The ACS will take a fresh look at the research on mammography this year and may change its recommendations, but there’s no guarantee.


Cohn gets Ezekiel Emanuel’s take:


“There will never be a truly definitive mammogram study,” says Emanuel, who was longtime head of the National Institutes of Health Bioethics Department and is now a vice provost at the University of Pennsylvania. “You’re in this circle where you will never resolve the issue. You need a long timeline to get the best results, but in that time span the technology always improves—and people will always say, well, this is based on old technology so it’s not so relevant anymore.”


Aaron Carroll adds:


If you’re not going to be swayed at all by a randomized controlled trial of 90,000 women with 25 year follow up, excellent compliance, and damn good methods, it might be time to consider that there’s really no study at all that will make you change your mind.


John Horgan thinks it’s up to patients to stop demanding expensive, ineffective medical tests:


[U]ltimately, the responsibility for ending the testing epidemic comes down to consumers, who too often submit to—and even demand–tests that have negligible value. Our fear of cancer, in particular, seems to make us irrational. When faced with evidence that PSA tests and mammograms save very few lives, especially considering their risks and costs, many people say, in effect, “I don’t care. I don’t want to be that one person in a million who dies of cancer because I didn’t get tested.” Until this attitude changes, the medical-testing epidemic won’t end.


But Leah Libresco sympathizes with patients:


It’s tempting to be skeptical whenever a medical recommendation is reversed. If the last thing they told us was wrong, why should we trust them again? However, health care has changed since the advent of mammography. The old studies on the benefits of mammography weren’t necessarily wrong, just out of date. As awareness of breast cancer has increased, self-screenings have begun to do the work of mammography. As cancer drugs have improved, it’s no longer critical to identify diseases at their earliest stages to be able to survive.


But for a patient, who just hears conflicting recommendations, and not a discussion of research methods or the history of medicine, it’s hard not to come away with a sense of unease.



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Published on February 13, 2014 16:42
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