Thursday, January 10, 2013
Mammograms over-diagnose breast cancer. Let the games begin!
Breast news is booming. Mammography is in the news again. We have legions of breast lobbyists that have agendas that are far beyond the true medical value of mammography. Even legislators have entered the mammographic arena in a clumsy effort to show their pro-women bona fides. Politicians should not practice medicine. It's absurd that they try to do so when they can't even perform their own jobs competently.
In 2010, the government overturned its own panel the U.S. Preventive Services Task Force (USPSTF), in response to an outcry from politicians and mammo-cheerleaders.
The USPSTF is not anti-mammogram, and neither am I. I'm pro medical evidence. Mammogram enthusiasts often champion positions that are beyond the science. Beyond the Kool-Aid drinkers, there are billions of dollars at stake here. Medical evidence is massaged by companies who manufacture conventional and emerging imaging breast techniques and by radiologists who interpret the studies.
If you're a player in the Mammogram Industrial Complex, and a major study threatens your livelihood, predict the reaction. Here are some sample press releases.
--The study is irreparably flawed.
--The study is a right wing conspiracy.
--The job killing study will shift more jobs overseas.
--The male study investigators want mammography to fail so they can divert research money to prevent prostate cancer.
Let me preempt the argument that I am holier-than-thou with respect to my implication that radiologists may be tainted by a conflict of interest.
--Gastroenterologists perform too many colonoscopies.
--Colonoscopy is a clumsy tool for colon cancer prevention.
--Colonoscopy advocates primarily rely on polyp removal as evidence of its worth, which is a surrogate marker of uncertain value.
Hopefully, the above statements will support my credibility.
The truth is that mammography, even in its most optimistic light, isn't the lifesaver that the public believes. Indeed, some experts opine that women who undergo mammography do not enjoy a mortality advantage, although they may suffer fewer breast cancer fatalities and complications. While this is a worthy outcome, it is clearly a limited benefit.
The Nov. 22, 2012 New England Journal of Medicine article strongly suggested that millions of women have been over-diagnosed with breast cancer, meaning identifying cancers that would not have progressed or would have been detected later without posing more danger to these women.
Advances in breast cancer treatment may exaggerate the benefits of mammographic detection. In other words, a breast cancer survivor might wrongly credit the mammogram as her savior rather than the treatment.
Over-diagnosis of cancer should be regarded a disease itself. These women undergo unnecessary surgeries, chemotherapy and radiation, which can have profound and lifelong effects on them and their families. It is also costing us a fortune. It is not a fair and balanced approach to showcase women who have been saved without acknowledging the harm that mammography causes. Shockingly, the American College of Radiology issued a statement calling the study "deeply flawed and misleading." Any conflict of interest here?
It is easy to deepen our cynicism when those who support or attack a view have a personal interest that coincides with their position.
The medical and political establishments do not reverse course easily. We have known for years that prostate-specific antigen (PSA) is deeply flawed and harmful. Look how long it took to disarm its advocates, many of whom were urologists who believed in PSA with religious zeal. Every one of them honestly believed that this test had saved men's lives. I do not dispute this contention. How many men, however, were gravely harmed by treatment of prostate cancer that would have never threatened them? Isn't this worthy of some consideration?
Patients need to know the medical evidence that supports our medical advice. When there isn't evidence, or the evidence is conflicting, we physicians need to disclose this, and patients should interrogate us directly on these issues. I welcome this dialogue in my office.
The public has an exaggerated view of the benefits of mammography. For instance, I suspect that most ordinary folks believe that mammography prevents breast cancer, which is completely false and was never its intent.
The vexing issue for patients is whom can they trust to offer them candid and unvarnished advice? I believe in truth. It's not enough in medicine to believe that something is true because we want it to be or because it serves our own interest.
Have any women Whistleblower readers been counseled about the hazards of mammography by their physicians? If not, then was your decision to proceed truly informed? Aren't your breasts worth knowing the whole story?
This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who 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.
Labels: colonoscopy, evidence-based medicine, guest post, health care cost, less is more, mammography, MD Whistleblower, Michael Kirsch, politics, prostate cancer, PSA
posted by Michael Kirsch, MD at
11:00 AM
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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.
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.
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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