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Thursday, December 13, 2012

Mammogram screening: reconsidering the wisdom of saying 'no'

An article was published in the New England Journal of Medicine questioning the utility of mammogram screening for prevention of death from breast cancer. The authors were research professor Archie Bleyer, MD, at Oregon Health and Sciences University in Portland, an oncologist who was chief of pediatrics at MD Anderson Cancer Center, and H. Gilbert Welch MD, MPH, a professor at Dartmouth Medical School.

The article examines the ability of mammograms to prevent late stage breast cancer by diagnosing and treating breast cancer early as a result of detection by mammograms. They found that mammograms do detect lots of breast cancer, but when we compare women during the years 2006-2008 when mammogram screening was widely practiced to women during the years 1976-1978, there was no difference in the incidence of the really nasty breast cancers, ones that had spread beyond the regional lymph nodes, and only a small decrease in the less nasty but still significant regionally metastatic cancers. Many, many women were treated for breast cancer but only a few were saved from dying of late stage disease with mammogram screening.

Their evaluation was carefully done, making assumptions about the increase in rates of breast cancer over time that were designed to make the results of having a mammogram more favorable. They concluded, somewhat generously, that "Women should recognize that our study does not answer the question 'Should I be screened for breast cancer?' However, they can rest assured that the question has more than one right answer."

Mammograms are X-rays of breast tissue and were first introduced by a German surgeon named Albert Salomon in 1913 when he examined mastectomy specimens with X-rays. Mammograms were used rarely before 1978 when widespread use of mammography was introduced in an attempt to identify and treat breast cancer early to reduce mortality and morbidity.

The procedure has been controversial since 1978. The first objections regarded the danger of radiation to the breast. A mammogram is performed by squashing a breast between two plates and passing X-rays through it. A digital mammogram detects the X-rays with digital detectors and creates an image on a computer monitor. A film mammogram creates an actual negative on a piece of photographic film. These techniques are equally sensitive, but digital machines are replacing film machines due to the overall convenience of storage and communication of images. The dose of X-rays with a typical digital mammogram is 3.9 milligrays, the same as for a film mammogram, and about 4 times the radiation dose of a chest X-ray. It is a small dose and is probably not a significant danger.

After initial worry about radiation, very reasonable concerns remained about the quality of mammograms and mammogram readings. In 1992 the Mammography Quality Standards Act was passed to assure that facilities that performed mammograms were accredited by the FDA to be of adequate quality.

Mammograms are very big business. I can't find out how big, but if there are about 40 million women between the ages of 50 and 75, and half of those get mammograms at a cost of $100. That would be $4 billion spent on mammograms alone, not to mention repeat mammograms and other technology to further identify actual breast cancer. If I am off by a factor of 4, that's still $1 billion. It is a big deal to write an article questioning the utility of this test. Any move away from a recommendation of yearly mammograms starting at age 40 or 50 is met with outrage. Still, articles and studies continue to demonstrate that the benefit of screening mammography is limited.

Norway has been extensively studied with regard to mammogram screening because they keep excellent records and have had a staggered approach to universal mammogram screening for women. Over the last 20 years multiple studies have come out of Norway suggesting that breast cancer is overdiagnosed by mammogram.

Overdiagnosis is what happens when we find a breast cancer that would never have caused harm if it had not been detected. Some cancers do not kill people and are probably taken care of by a healthy immune system. In an article published last April, a study group evaluated the data and estimated that, of all the breast cancers diagnosed, about a quarter of them would never have caused harm. This week's article concurred, but suggested that number may be as many as 30% and that over a million women have been diagnosed with breast cancer since the inception of screening who would never have been affected had they not had mammograms.

But, one might ask, is it really a big deal to be diagnosed with breast cancer that would not have hurt or killed you? Yes. It is actually a very big deal. The British Medical Journal reported that 50% of women were depressed in the year after they were diagnosed with early breast cancer, the type of breast cancer most likely to be overdiagnosed.

But we don't really need studies to tell us this information. It is clear after treating women with breast cancer that they are profoundly affected by this diagnosis, feeling ugly, self-conscious, maimed. Treatment complications include disfigurement, chemotherapy side effects, infection, chronic pain, to say nothing of astronomical monetary costs.

Still, breast cancer kills, and fewer people die of it now that mammogram screening has become standard. How do we explain this? Some of it is due to mammograms. We are detecting lots of breast cancer early. Some of it we should be detecting early and some we should not. Still, some early breast cancers would have become late, bad, killer breast cancers. The study published this week suggests that there are not many of these, but there are definitely some.

The treatment of breast cancer has also gotten much better. People who used to die of metastatic breast cancer now remain on chemotherapy and remain in remission for many years, and some are cured. It is undoubtedly because of the huge increase in breast cancer awareness that therapy has improved, and likely the million women who were overdiagnosed were important in helping to pioneer excellent treatment.

What is a woman to do? What is a doctor to do? I think it might be good to start with recognizing that a decision not to do mammogram screening is not tantamount to a death wish. We give women who reject the recommendation for regular mammograms a really hard time, and that is neither fair nor evidence-based. Mammograms are quite good for evaluating lumps, especially in older women. They are also good for giving peace of mind, since a negative mammogram suggests (but does not prove) that a woman does not have breast cancer.

There may be a subset of women, those at particularly high risk of cancer for instance, who would be very wise to have regular mammograms. There may be technology that can help us identify which breast cancers need treatment and which do not. Tests that detect more breast cancers, such as MRI and PET scanning may not be particularly helpful in this situation unless they can reassure us that some breast cancers are of no significance.

If we accept that medical resources should be limited, we might look at places where money now used for universal mammogram screening of women might be more effectively spent.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health care so expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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