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.
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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.
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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 Iowa City, IA, 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).
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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.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
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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.
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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.
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.
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.
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.
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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.
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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.
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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.
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The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.