What mammography says about the practice of Medicine…

If you read one article that explains where we are going in Medicine, read this one.

Few procedures have been more entrenched in the dogma of Medical practice than mammograms. In our climate of political correctness and right-think, it would define heretical to suggest a procedure that detects breast cancer–an important killer of women–at an earlier stage doesn’t change outcomes.

Until now.

But here is the message:

What was isn’t always what is. Things change. Knowledge and evidence should always trump right-think.

It seems to me that the more sure medical people are about something, the more likely it is to be proven wrong.

There was…

  • Low-fat food to prevent obesity and heart disease.
  • Hormone-replacement therapy for post-menopausal women.
  • Widespread PSA screening for prostate cancer.
  • Screening stress tests for heart disease.
  • Non-statin cholesterol lowing medicines.
  • Placing coronary stents and thinking doing so reduces the risk of heart attack.

And soon to fall from medical right think…(My predictions)

  • Internal Cardiac Defibrillators for those with just low-ejection fraction. Look for better predictors of those who will benefit from the invasive and burdensome strategy of implanting an ICD.
  • Giving 80+ year-old patients more than four medicines.
  • Titration of medicine to achieve ideal cholesterol levels.

Good medical practice has one enemy–a never event of all never events.

Hubris.

JMM

8 comments

  1. Hi John. GREAT post. I thought you were leading up to a prediction that advocating screening mammography for all was one of your predictions …. but since you didn’t – perhaps you should add it.

    Perhaps we should also add NOT treating (anticoagulating) most of the pulmonary emboli that are found – for the same reason not to screen all women with mammography (for the same reason not to screen all men with PSAs) – namely that all of these entities are associated with gross OVERDIAGNOSIS.

    The article you suggest for reading in your 1st sentence was written by Dr. Gil Welch who I’ve corresponded with to congratulate him on what I feel is perhaps the BEST medical book I have read. It is called “Overdiagnosis” – available in hard copy & kindle. It is a short and sweet – easy to read – and appropriate book not only for ALL medical providers (of any specialty) – but one I’ve recommended to all medical students, nurses and intelligent patients wanting to partake in shared decision making. The premise is simple- breast and prostate cancer can clearly be terrible diseases for those unfortunate to develop malignant aggressive tumors of those organs. But many men and women die with (not of) cancerous cells in the breast and prostate- and this apparently occurs much more often than we previously realized. Because of early “detection” of cancers in these areas that would not have ever harmed the patient – it looks like “survival times” are increased when in fact these individuals now become patients, undergo all sorts of tests and procedures with potential for harm yet don’t benefit at all. Clearly – some patients DO benefit from early detection – but not nearly as many as had been previously thought.

    Better and better CT scanners being done for patients with symptoms less and less likely to be truly due to “PE” has resulted in more “overdiagnosis”- as prognosis for many of these low-risk patients without real “PE symptoms” is excellent without need for anticoagulation despite the finding of small abnormalities on chest CT …

    Back to screening – Patients SHOULD be included in the decision-making process and allowed option not to get screened as a perfectly reasonable approach.

    THANKS again for your excellent post!

    1. Thank you Ken.

      Never make a well patient sick. This is the thing. Of course we want to protect and treat our patients skillfully. What Dr Welch and you say so eloquently is that in the process we must always be mindful of making them worse. That’s why I love your last sentence, which emphasizes the participation of patients in the decision-making process.

      Screening is particularly thorny because of the many conflicts: first, that we are dealing with well people; second, doctors and industry are financially incented to do tests and procedures–not just for direct compensation but also for the future riches that come with disease-state creation.

      If there can be a sliver of hope from the gloom of mandated EMR, one might be the ability to study the outcomes of what we actually do to people. Imagine how much sooner we would have discovered this important data on mammography? Meaningful real-world data is one of the the elixirs of good medical practice.

  2. When I was diagnosed with advanced stage breast cancer in 2004 the company I work for asked a local hospital to bring over the mobile mammography bus to offer screening to my co-workers. One of the women who decided to receive the screening is a very good friend of mine. She was found to have a .03 cc malignancy that was treated with a lumpectomy, an outpatient procedure. She requested and received radiation treatments to insure that all cancer cells were gone even though her surgeon felt that it was unnecessary. In all she missed 4 days of work for her treatments. On the other hand, I had grade 3, stage 3, highly aggressive cancer. I did 12 rounds of three very potent chemotherapy drugs, had a modified radical mastectomy and 6 weeks of radiation treatment, all of which were necessary to my healing. I was poisoned, disfigured and burned, it was brutal. My treatments lasted eight months and I was out of work all of them and more. Thats why I find it curious that Dr. Welch should liken the treatment for pneumonia to that of breast cancer.
    “As treatment improves, the benefit of screening diminishes. Think about it: because we can treat most patients who develop pneumonia, there’s little benefit to trying to detect pneumonia early. That’s why we don’t screen for pneumonia.” The treatment for breast cancer have not improved significantly enough to warrent that kind of comparison.

    Recently, in light of such attacks on mammogram screenings, I had a conversation with Susan. I asked her if she felt that she’d been overdiagnosed or if she would have done anything differently. She said no, if she would do anything differently she would have opted for a mastectomy instead of radiation. I asked her why and she said “Because it’s cancer and no one can tell me that it wouldn’t have advanced.”

    Truthfully, Susan and I have both survived eight years. Susan is fairly confident that her cancer will not return. I will never have that confidence. Even eight years out, there is still a 25% chance that my cancer will return. With psa and mammograms, it’s cancer, you want to find it early. If you think you may be misdiagnosed you can always wait 3 or 6 months and test again. But, it is cancer that you are watching for.

    1. @Lisa – THANK YOU for disclosing details of your personal ordeal. You bring up MANY excellent points to which there is no single answer.

      I am curious (if I may ask) whether your cancer was detected as a pure screening mammography done on a totally asymptomatic person without any lump – or whether you had a lump (that either you or your doctor found) and then got mammography.

      IF in fact your had no lump at all and your cancer was detected by routine “screening” mammography – then you are very lucky indeed that such screening was done, as it unquestionably saved your life. Yours was a highly aggressive cancer that fortunately responded to intensive treatment. Had it not been detected – you would have died.

      If on the other hand – a lump was found and then mammography was done – it is again indeed fortunate that you underwent intensive treatment that undoubtedly saved your life – but then it would not be a life saved by “screening mammography”. There is universal agreement that once a breast lump of uncertain etiology is detected – that the patient should be worked up and followed by an expert (usually a surgeon with expertise in breast cancer).

      On the other hand – we do not know what would have happened with Susan had she not been screened by mammography. All I believe Dr. Welch is saying – is that just like in prostate cancer – there is a significant percentage of women with breast cancer (many more than previously thought) who would not die of that breast cancer (and might never even know about it) had they not been screened.

      That said – IF someone told me I had breast or prostate cancer – I would do exactly as you and Susan did, namely undergo intensive treatment and follow-up. The problem is that we do NOT yet know which of those cancers will become problematic (and life-threatening) vs those that will not …. It does appear – that for both breast and prostate cancer – the numbers of patients who are screened and who are subject to procedures/adverse effects far outweigh the number who actually benefit from treatment. But,”n=1″ – so if you are the one whose life is saved – then all of the risk was “worth it”. If on the other hand – you are one who develops impotence, incontinence, and/or the fear and worry after being told you have cancer (with biopsies, lumpectomies, etc.) – then maybe it is not worth it.

      It is not an “all or none” – and the patient should be involved in the decision-making process for them to decide IF doing screening is or is not something they want to undergo – realizing precisely what the potential for benefit AND the potential for harm is.

      THANK YOU again for sharing your story. I am happy your outcome thus far has been good and wish you the very best.

      1. I’d had a screening mammogram done 18 months prior to finding a rather large lump while showering. The screening mammogram allowed my doctors to understand the agressiveness of my cancer.

        Thank you for eloquently pointing out what Susan said with her answer to my questions. We do not know which cancers will remain in place and which will become invasive and metastasize.

        Believe me, I do understand the harm the treatments that Susan and I took can do. I’m living with many of them; Susan is too. Still, I know this allowed me the time to raise my child. It’s less clear with Susan, but she isn’t sorry that she had the mammogram. She still feels the choice was worth it.

        Thank you for eloquently stating what we know.

        1. Lisa – In your case I agree with you that it WAS helpful to know that your screening mammogram done 18 months earlier was normal – as this clearly indicated that the large lump you then felt was rapidly growing. N=1 – which means that regardless of whether screening mammograms are more helpful than not in large populations – for you the screening mammogram that you did provided helpful information for determining your treatment plan. Thank you again for sharing the details of your case with others.

  3. I would add to your list, stress testing. Automatic, yearly stress tests/echo’s/etc… without changes in symptoms.

    Also, I’d like to see that stents are never used unless someone is having an acute myocardial infarction. Since there is no benefit and clear harms of angio, the stent and a year-lifetime of clopidogrel, that would certainly be helpful.

    Lisa brings up a good point that I believe Dr. Welch and Dr. Otis Brawley bring up as well. As we try to bring a rational approach to screening, those that have been “saved” by screening (by “saved” I mean a cancer was overdiagnosed), they become quite strong advocates of screening, touting themselves of how well screening works and how it saved their life. No one wants to believe that all of the treatment, side-effects and appointments were for naught.

    Strong post.

  4. I’m a medical oncologist. My uncle is a urologist. Neither of us has ever had a PSA test. Neither of us ever intends to get a PSA test.

    Why?

    If you get a PSA test, there’s a Russian roulette chance that you’ll end up with multiple trans-rectal needle biopsies of the prostate. If you get the needle biopsies, there’s a Russian roulette chance that you’ll end up getting your prostate whacked out. If you get your prostate whacked out, there’s about a 1/3 to 1/2 chance that you’ll end up with sexual dysfunction and/or urinary incontinence. And a vanishingly small chance that the entire exercise will end up saving your life (possibly 1 life saved out of 1,500 men screened; compared to dozens with serious complications).

    The truth is that, for prostate cancer, the disease comes in two flavors. The “live with it” flavor and the “die of it” flavor. Patients with the former flavor don’t need to have their prostates whacked out. Patients with the latter flavor aren’t helped by having their prostates whacked out.

    So getting PSA test would serve no purpose, other than to vex my spirit with worry, were my PSA found to be elevated. Since I have no intention of getting a biopsy, absent any symptoms, what would be the point in getting tested?

    As time goes on, evidence seems to be emerging that breast cancer may share some of the above properties, with respect to risk:benefit ratio of screening.

    – Larry Weisenthal/Huntington Beach CA

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