1/3/10

Opinions

A dear friend recently asked me what I thought of the recommendations recently published by the U.S. Preventive Services Task Force, regarding how soon and how often women should get mammograms, and whether they should be encouraged & taught by their doctors to do regular self-exams. A reasonable report on this can be found at the New York Times website, here.

My friend thought that I would be outraged, but my response is perhaps more measured.

First of all, in case you haven't read this before, understand that my cancer was missed by a mammogram taken nearly three years ago - it was probably very small at that time, and snugged up against my chest wall, beneath a great deal of breast tissue. I found my primary tumor in November of 2008 during my own routine self-exam; it was 3cm at that point, which is not small, but even then the doctors/radiologists had a great deal of trouble finding it via palpation, and could not image it well in either x-ray or ultrasound.

Unfortunately, by the time I found my particularly aggressive cancer, it had metastasized to Stage IV and was incurable. Had I found it earlier, my life (if not my breasts) might have been saved, and I would now be looking forward to many years of celebrating milestones with my son and perhaps even holding grandchildren in my arms.

Which brings us to the current change in USPSTF recommendations to the government. There are three recommendations in particular which apply here:

~ That regular mammogram screenings begin at age 50, rather than at 40.

~ That mammograms be done every 2 years, rather than every year.

~ That doctors stop teaching/encouraging women to do regular self-examinations.

The recommendations are largely based on their conclusion that the 'modest' 15% death reduction benefit of the current recommendations re mammograms is overbalanced by the anxiety and expense brought about by 'unnecessary' testing (including biopsies) of tumors that don't turn out to be deadly.

Now, they don't recommend this lowering of testing guidelines for women who are at high risk through either genetics or extensive chest-wall radiation. But of course, 70-80% of women who are diagnosed with breast cancer don't have a significant risk factor for the disease.

Now, I don't know that 15% is a small enough number to figure that it's an acceptable loss - certainly it is not an acceptable loss to that 15% and their families.

I also find their logic questionable in terms of which age groups should be tested. From the NYT article:

"The task force concluded that one cancer death is prevented for every 1,904 women age 40 to 49 who are screened for 10 years, compared with one death for every 1,339 women age 50 to 59..."

That number soars to one in 377 for women aged 60-69. So if one looks at it completely objectively, with the concerns raised by the USPSTF in justification of their adjusted recommendations, it makes absolutely no sense to recommend that mammograms begin at age 50. The difference between one in 1,904 and one in 1,339 is just not all that significant. If one takes the supposed expense and risks into account, and takes the USPSTF's arguments at face value, a recommendation that mammograms begin at age 60 makes much more sense.

One might suspect that the recommendations to start at 50 were based on political/public relations concerns, rather than on either logic or concern for women's health.

I'm just saying...

On the other hand, there is little doubt that frequent scans could cause cancer to grow in tissue that otherwise might stay healthy. There is a risk to having scans every year from age 40 on. If you think you might potentially live to see age 75, for instance, that is 35 sets of x-rays to your chest for that one issue alone. And if there are questions about any of those x-rays, and you end up having CT, PET scans, MRI's, etc, that's a significant raise in radiation levels.

So I guess I think that women between the ages of 40 and 50 should have the right to talk to their doctors and be informed of both the potential benefits and the risks of mammography. And then they should have the right to choose which risk seems more reasonable to take in their opinion. Informed choice is always the best option, wherever possible.

As for self-examination: I see no credible excuse for this recent recommendation, and this is where my measured response ends. Self-examination is something that can be easily taught, is free of charge, is free of medical risks, and if started early in life is likely to cause very little anxiety in and of itself. In fact, if taught early enough, it might help young girls become more familiar with their bodies as they change, which could very well relieve as much anxiety as it might cause. Yes, it may send a few people in for mammograms who might otherwise not have bothered, but in most cases this would not result in frequent scans, and I suspect that in a reasonable number of cases it might be a life-saving thing.

And to paraphrase our dear Dr. Franklin, A Life Saved Is A Life Earned... a life that is valued highly by a significant number of us, whether we count in the Statistics or not.

3 comments:

Glorious Hats said...

Well written and thoughtful response. So the good news Eileen, is your brain is very clear, your words wise, and your wit intact.

Really support the idea of "informed choice" - doing what is right for the individual in her circumstances. Not rote action or inaction for a group.

Did they look at the cost of "late treatment" to balance it against the cost of early detection? All the chemo, counseling, oncology dr, nutrition, hospitalization, other dr costs of treatment of aggressive CA, not to mention the loss of the inflicted person as a wage earner, supporter of others.

As always you bring up challenging and difficult to discuss issues with grace.

Hang tough,
Jane

Carrie K said...

That's the most helpful thing I've seen on the subject.

Polly Andersen said...

I've been feeling my sex organs since I was 6 and I think every girl should be in touch with her boobs, and all the other part of her body!!! It's only natural. Ya gotta know your own bod.