Wednesday, March 12, 2014
Mammograms don't help, and the dog that didn't bark in the night
In the short story “Silver Blaze” by Sir Arthur Conan Doyle, Sherlock Holmes remarks that it was very curious that when a race horse disappeared and its trainer appeared to have been murdered, the dog was not heard to bark. Dogs are supposed to bark when odd things happen in the night. If they don’t, it means something.
Today Reuters commented upon the most recent article in a series over several years showing evidence that mammograms do not reduce death from breast cancer. Although this is not actually a new finding, it is still big news in the U.S. where the wisdom of having regular mammograms is rarely questioned.
In my junk e-mail folder I get commentary on the most influential news from medical meetings and journals from organizations such as Medscape and Internal Medicine News, organizations primarily funded by drug and device manufacturers, but also by other aspects of the business of medicine. These organizations successfully take it upon themselves to educate physicians via e-mail communications and throwaway journals. Most of us would never believe information directly given us by companies that make a profit off of our activities, but we still read the headlines and article links these news services put in front of us. This means that those companies have a powerful influence on what medical news physicians read. There was no mention of this new article by these proprietary news organizations, despite the fact that it was headline news at Reuters and the New York Times.
The Canadian Breast Cancer Research Initiative and 9 other primarily cancer research organizations funded this study, published this week in BMJ. It looked at nearly 50,000 women ages 40-59, half of them randomized to be offered yearly mammograms and half to clinical breast exams alone. These 2 groups were followed for 25 years to look for differences in mortality from breast cancer. There was no difference in mortality. If doctors paid attention to this, it would follow that we would not universally recommend mammograms at all. There may be subsets of women who will benefit from mammogram screening, but it may also be that bad breast cancers kill people, and discovering them a little bit earlier by mammograms rather than when they can be felt on a clinical exam, and removing them just that little bit earlier doesn’t change this.
So why the spotty news coverage? I saw the Reuters article on Google News, as a top story, then researched the actual study a bit, then went back to find the article on Google News and it was gone. It was replaced by a study that said that removing both breasts if you have the BRCA breast cancer gene mutation saves lives, even if one of those breasts has no cancer. I had to go to my history to find the Reuters article again. It was nowhere on Google News. Suppressing a story like this until people with a stake in the outcome have their official responses polished may have a profound effect on maintaining the multi-billion dollar revenue associated with regular screening mammograms.
Am I being a paranoid conspiracy theorist? Perhaps. But I am hearing a strange lack of anything about how maybe we don’t need to be doing mammograms.
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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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
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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.
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, 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.
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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 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.
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.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
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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.
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Other blogs of note:
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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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