The Journal of the American Medical Association (JAMA) published a short article on screening mammograms that included a spiffy infographic on the benefits vs. the harms.
Looking at the graphic I can easily see that if 10,000 50-year-old women are screened, 10 will be “saved”, but 940 will undergo an unnecessary biopsy and 57 will be overdiagnosed. (For copyright reasons I can’t reprint the graphic here, but you can view see it yourself by clicking on the above link.)
The author of the article explains:
Another possible harm of screening is overdiagnosis. This means finding something on a mammogram that is breast cancer or has a chance of becoming breast cancer, but is such a low-risk type of tumor that it would never have caused any health problems if left alone. Instead, because it was found on mammogram, standard cancer treatment, such as surgery and radiation therapy, is recommended. In cases of overdiagnosis, these treatments are unnecessary and costly and can have both physical and psychological side effects. It is difficult to know exactly how often overdiagnosis happens, but some studies estimate that 1 in 5 breast cancers found on mammograms are overdiagnosed and lead to unnecessary treatment.
Of course, if you are the patient with the abnormal mammogram and the diagnosis of cancer, even a low-risk cancer, it’s very difficult to choose to do nothing.
Related post: “The Treatment Trap”
On his blog Common Sense Family Doctor, Kenny Lin, MD, writes this about the JAMA article:
Just as a gambler rarely hits the jackpot in Vegas, a patient who undergoes cancer screening is rarely the lucky one whose life is extended from the test, and much more likely to figuratively lose his or her shirt. Common harms of screening include false positive results, risks associated with subsequent diagnostic procedures, and possible unnecessary treatment (and associated side effects) for “cancer” that looks dangerous under the microscope but is actually destined to never cause health problems.
Obamacare requires insurance companies to pay for yearly screening mammograms for all women over the age of 40. The American Cancer Society also recommends the broad guideline of annual mammograms from the age of 40.
The US Preventive Services Task Force (USPSTF), however, recommends screening mammograms every other year for women 50 and over, and not past the age of 75.
Despite current evidence showing that the benefit of annual screening mammograms is iffy, at best, most physicians still recommend them to their patients. Why? Because screening mammography is a HUGE business in this country. Since the early 1980s we have been conditioned to think the annual mammogram is a life saver. “Breast Health” specialty clinics staffed with “breast specialist” radiologists and surgeons abound.
In general, mass screenings and one-size-fits-all medicine is easy, fast and profitable.
Mammograms are a useful tool when used wisely. For myself, I would rather have a discussion with my doctor and discuss the evidence-based benefits and harms, my personal risk factors (age, family history, etc.), and my personal comfort level and then make an informed decision that suits my health care goals (if it ain’t broke, don’t fix it).
But lengthy discussions aren’t supported by our system anymore, as one journalist recounts:
A few days after my 40th birthday, I had a routine appointment with my gynecologist. As she turned to leave the exam room, she handed me a slip of paper without saying a word. It was a prescription for a mammogram.
“Wait — you’re not going to discuss this with me?” I asked. I knew that the U.S. Preventive Services Task Force (USPSTF) had advised that for women in their 40s, the decision to start mammography should be an individual one, based on family history and a patient’s values.
“I am discussing it. I’m telling you to get a mammogram,” she replied. When I asked her why, she told me because it could save my life.
What she neglected to tell me is that a mammogram was, in my case, more likely to hurt than help me. Few doctors take the time to mention the risks of mammography — especially, the danger of overdiagnosis — that a mammogram might lead a patient to get needled, sliced, zapped with radiation and possibly treated with tamoxifen, a drug that increases risk of uterine cancer, for a breast lesion that wasn’t life-threatening in the first place.
Her experience is unfortunately typical. Have you ever had a physician use the phrase “Because it will save your life?” It reminds me of all the times I, as a parent, said “Because I told you to.” It’s a good way to end a conversation, but it shouldn’t be part of a patient-doctor dialogue.
Related post: “When Doctors Don’t Listen”
If we are serious in this country about reducing health care costs, and improving overall health, we have to question the widely-held belief that annual screening mammograms for all women over the age of 40 is safe and cost-effective.