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New Mammogram Guidelines

What's even more bizarre about this flurry of news is these are not really new guidelines. Neither are the guidelines new about the frequency of Pap smears which also made the news.
 
rockinkt said:
I always laugh when people talk about cost/benefit in health care in such cold and calculating ways.
Why? Because do you honestly think that when their mother/wife/daughter is in a stage of cancer that is less than positive for the calculated successful survival rate they will heroically console everybody with their statistics saying that it is best that they should just get on and die because it will save everybody money? :boggled:
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The thing is this is not a question about money, but the costs to peoples lives. So it is not asking how much you would spend, but how many people you would hurt, for something that might be of no benefit.
 
ponderingturtle said:
The thing is this is not a question about money, but the costs to peoples lives. So it is not asking how much you would spend, but how many people you would hurt, for something that might be of no benefit.
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Indeed, this is, I think, a sincere and sober recommendation about a reasonable question, but I still have some doubts about how some of these comparisons are made. How can you (can you at all?) reconcile cost to a life with cost of a life, and how generalize it if the people affected cannot agree on what that balance might be?
 
Jorghnassen said:
Google is your friend. Again, fewer screenings are recommended because overtreatment is harmful, especially to women who may want to have children in the future. Here the potential harms are more clear cut.
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It seems reasonable enough, especially in the case of people who have tested clear for a long time, and are not in a high risk group, but then we read that the problem here is not (as is in part the problem in mammograms) the danger of the test itself, but the danger of overtreatment based on questionable results, in particular the presence of HPV. Isn't the problem one of overtreatment, rather than overtesting?

Imagine I live in a place where giant scorpions are common. I make it a practice to check my bed for scorpions every night before retiring. It's very rare to find one, but once every couple of years or so I do, and finding it saves me from death by scorpion bites. Unfortunately, because my eyesight is bad and I'm too stubborn to put on my glasses, I occasionally mistake the cat for a scorpion and shoot it instead. I shoot several cats a year. This causes great suffering and marital discord, as well as bloody linen, until an epidemiologist is called in. He makes a recommendation that I inspect the bed only every other night. Sure enough, the number of cat shootings has decreased by a dramatic 50 percent in under a year. So far I have also not been bitten by a scorpion, so the solution is perfect!
 
bruto said:
Indeed, this is, I think, a sincere and sober recommendation about a reasonable question, but I still have some doubts about how some of these comparisons are made. How can you (can you at all?) reconcile cost to a life with cost of a life, and how generalize it if the people affected cannot agree on what that balance might be?
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Sure, but it also seems that early detection is not as important as it was thought, because the cancer starts to spread while it is very small. So it becomes questionable when is a life saved?
 
bruto said:
Imagine I live in a place where giant scorpions are common. I make it a practice to check my bed for scorpions every night before retiring. It's very rare to find one, but once every couple of years or so I do, and finding it saves me from death by scorpion bites. Unfortunately, because my eyesight is bad and I'm too stubborn to put on my glasses, I occasionally mistake the cat for a scorpion and shoot it instead. I shoot several cats a year. This causes great suffering and marital discord, as well as bloody linen, until an epidemiologist is called in. He makes a recommendation that I inspect the bed only every other night. Sure enough, the number of cat shootings has decreased by a dramatic 50 percent in under a year. So far I have also not been bitten by a scorpion, so the solution is perfect!
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Really really bad analogy. For one thing failure to detect is not death, it will be detected later. So first it needs to be shown that early detection is vital in this cancer.
 
Again, pap smears are recommended every three years or five years depending on age group in the UK and starting at 25. It seems there is some sort of general tendency towards more frequent screening/ preventative measures in the US.
Since different countries have such different guidelines I would have thought camparisons could be useful in weighing costs versus benefits.
 
Elaedith said:
Again, pap smears are recommended every three years or five years depending on age group in the UK and starting at 25. It seems there is some sort of general tendency towards more frequent screening/ preventative measures in the US.Since different countries have such different guidelines I would have thought camparisons could be useful in weighing costs versus benefits.
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Hmmm, I wonder why that could be? What could be the incentive to perform lots of expensive procedures on healthy people?
 
ponderingturtle said:
Really really bad analogy. For one thing failure to detect is not death, it will be detected later. So first it needs to be shown that early detection is vital in this cancer.
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Certainly, if early detection is not an issue, or if the cancers are so slow growing that one need test less frequently, then by all means, do it less frequently. I would have no quarrel with that if that were the reason given. But this is not the argument I'm seeing for the change. The argument I'm seeing for the change is that doctors are over-treating for questionable test results. To reiterate, bolded in case this point is not clear enough, the argument I am seeing is not that there is no benefit to more frequent testing, but that the harm from overtreatment outweighs it. It seems ridiculous to me that this should be the argument against the tests rather than against the way they are treated, even if it makes a sort of epidemiological sense.

Of course, though, if you don't need the test so often because more frequent tests do no good even when handled right, then by all means, recommend less frequent tests for that reason. I have no problem with that idea. When I was told after my colonoscopy to come back in ten years, I was happy enough. My wife, at 54, has cut her mammograms to once every two years as well, because she has a good history and low risk. No argument there. Just don't tell me that the best way to handle inept reading of tests is to skip the tests.
 
This is basically an argument over where the threshold should be set on the ROC curve, and is very subjective.

Some women may be very stressed by any thought of developing breast cancer and would prefer to risk having potentially pointless and harmful treatment than risk more severe disease later. Other women may prefer to only undergo treatment when there is a higher probability that they do have actual disease. The former group of women will want mammograms more frequently (i.e. less specific) than the latter group.

In "socialised" medicine another consideration is whether a particular threshold delivers value for money. I.e., the setting of the threshold which results in the best compromise between the proportion of the women with actual breast cancer being treated and the proportion of the women without cancer not being treated.
 
Elaedith said:
Again, pap smears are recommended every three years or five years depending on age group in the UK and starting at 25. It seems there is some sort of general tendency towards more frequent screening/ preventative measures in the US.
Since different countries have such different guidelines I would have thought camparisons could be useful in weighing costs versus benefits.
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UK only start at 50. Only risk groups start earlier!
 
Darth Rotor said:
Could it be defensive medicine, fear of a lawsuit? :confused:
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Sure, but there is the uncomfortable role of money as well. Doctors are very reluctant to discuss this.

But there is this truth as well. If there is one person doing say cataract surgeries they use 20/200 as the standard, if there are 2 it is 20/80 and three 20/50.

More treatment is not always better treatment, even for tests like this.
 
bruto said:
Certainly, if early detection is not an issue, or if the cancers are so slow growing that one need test less frequently, then by all means, do it less frequently. I would have no quarrel with that if that were the reason given. But this is not the argument I'm seeing for the change. The argument I'm seeing for the change is that doctors are over-treating for questionable test results. To reiterate, bolded in case this point is not clear enough, the argument I am seeing is not that there is no benefit to more frequent testing, but that the harm from overtreatment outweighs it. It seems ridiculous to me that this should be the argument against the tests rather than against the way they are treated, even if it makes a sort of epidemiological sense.
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The thing is that it is always a case of balance. There there might be a benefit to testing every month, but the costs in terms of harm to peoples lives. So the question is how much benefit is there and how much cost.

The argument is that there is limited benefit to these tests and a real harm to them.

Like with self exams it is found that they were not helpful, women notice lumps in their breasts the way people notice lumps in other portions of their anatomies.
Just don't tell me that the best way to handle inept reading of tests is to skip the tests.
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A false positive is not necessarily a result of the doctor being inept.
 
ponderingturtle said:
The thing is that it is always a case of balance. There there might be a benefit to testing every month, but the costs in terms of harm to peoples lives. So the question is how much benefit is there and how much cost.

The argument is that there is limited benefit to these tests and a real harm to them.

Like with self exams it is found that they were not helpful, women notice lumps in their breasts the way people notice lumps in other portions of their anatomies.


A false positive is not necessarily a result of the doctor being inept.
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I don't think you are understanding my point here. What you say may well be true in many tests, but as far as what I have read about the pap guidelines, it is not a matter of false positives, or harm from the tests themselves. It is a matter that certain true positives, in particular those caused by HPV, are leading women to be treated who might otherwise have managed to shake the infection within a year. The guideline is based on the expectation of over-treatment. And the solution put forth is to skip the test, but is that a rational approach to the problem? If a certain percentage of the women getting the test will test positive and be overtreated, there's little to be gained by deferring the error for a year. It's true that fewer women per year will be harmed, simply because there will be half as many tests, and presumably if a woman who has HPV but the ability to get over it unaided happens to go through the entire process in a non-testing year, she'll dodge the harm, but if she gets it at any other time, there's no reason here to expect she won't be over-treated just the same as before, because the cause of the harm is not really being addressed. In the meantime, a person who has something more serious will lose a year of early detection.

I understand the balance problem, I think, but a person is not a population, and a plan that reduces the number of persons harmed in a given period may look good, but if it does not also reduce the likelihood of an individual being harmed, it's a hollow victory.
 
Sarah Palin has an opinion on this!

Now, tonight, more disconcerting news – the New York Times reports of new guidelines to scale back cervical cancer screenings. The recommendation from the American College of Obstetricians and Gynecologists comes on the heels of another recommendation to limit breast cancer screenings with mammograms. There are many questions unanswered for me, but one which immediately comes to mind is whether costs have anything to do with these recommendations. The current health care debate elicits great concern because of its introduction of socialized medicine in America and the inevitable rationed care. We need to carefully watch this debate as it coincides with Capitol Hill’s debate and determine whether we are witnessing the early stages of that rationed care before the Senate bill is rushed through as well.

Another question is why these women-focused cancers are seemingly receiving substandard attention at a time when proactive health and fitness should be the message. Every woman should encourage rigorous debate to ensure that our collective voices are heard. We are paying attention to Washington’s health care proposals, and we want to hear what helps patients the most.
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Reaction to Palin here

OTOH, despite what Obama has said in the past about finding out scientifically what works and what doesn't, the administration isn't pushing back against the uproar. In fact it took them only a day or two to distance themselves from these findings. Kind of craven, no? People can agree with that stuff in the abstract, but not when it comes to their own sacred cows.
 
What we really want to understand is

1. Why are doctors/scientists recommending less tests?

If I have the money is it worth my while to get tested every year starting at age 30? If they are recommending less testing there must be some risk/benefit tradeoff. But what is the risk of getting tested, it doesnt make sense and has not been made clear.

2. What is the risk of getting tested. (besides the cost and time it takes?)
 
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