New Mammogram Guidelines

[Puppycow]

So, these new mammogram guidelines came out and apparantly they are very controversial. On my way to work I was listening a radio program about it, and the doctor who was speaking for the people who wrote the new guidelines was viciously attacked, with all kinds of nasty aspersions thrown at her. It was a clear-cut case of shooting the messenger. All they did is look at the evidence from population studies to see if the benefits of yearly mammograms were outweighing the risks, and the data showed that it's arguable that the benefits outweigh the risks for women in their 40s and that every two years rather than every year might be better for older women. They didn't say not to get mammograms, but to discuss it with your doctor. For reporting what the evidence is, they have subjected to a lot of abuse. It's a real shame. One one side is the cold hard data, and on the other are personal experiences.

I know that Obama has suggested that America could save a lot of money on healthcare by studying what works and what doesn't, but this episode suggests that people aren't going to care what the data says if you have some actual real people come out and say "treatment X saved my life, so you know where you stuff that data of yours."

[Ivor the Engineer]

Similar news today in the UK about £3000/month cancer treatment for terminally ill. NICE, based on the guidelines it has been given, ruled that it was not cost effective.

http://news.bbc.co.uk/1/hi/health/8367614.stm

Quote:

Liver cancer drug 'too expensive'

A drug that can prolong the lives of patients with advanced liver cancer has been rejected for use in the NHS in England, Wales and Northern Ireland.

The National Institute for Health and Clinical Excellence (NICE) said the cost of Nexavar - about £3,000 a month - was "simply too high".

But Macmillan Cancer Support said the decision was "a scandal".

More than 3,000 people are diagnosed with liver cancer every year in the UK and their prognosis is generally poor.

Only about 20% of patients are alive one year after diagnosis, dropping to just 5% after five years.

...emotional guff...

Nexavar - also known as sorafenib - had already been rejected in Scotland, despite studies showing it could extend the life of a liver cancer patient by up to six months.

'Devastating disease'

The Scottish Medicines Consortium ruled that "the manufacturer's justification of the treatment's cost in relation to its benefit was not sufficient to gain acceptance".

Andrew Dillon, chief executive of NICE, agreed: "The price being asked by [the manufacturer] Bayer is simply too high to justify using NHS money which could be spent on better value cancer treatments."

And the group's clinical and public health director, Peter Littlejohns, added the drug was considered "just too expensive" by its advisory committees.

...

[Jorghnassen]

I'm not surprised by the new recommendations or the reactions. Cancer (breast cancer in particular) is always a very emotional issue, so new evidence that goes against conventional wisdom is more often decried and attacked than rationally examined. People have personal experience with cancer which is always sad, scary and often traumatic, so it clouds their judgement when thinking of the bigger picture. Detection bias, false positives and limited ressources are all immaterial from the individual point of view.

[jasonpatterson]

My response to these people would be, why do they think 40 is the right number in the first place? Why not 30? If 30, why not 20? Puberty? When do THEY think that the cost/benefit plays out? Do they understand that this is an x-ray as well, that there is some actual risk (small though it might be) associated with getting it?

For crying out loud, I can't freaking buy toilet paper without a freaking pink ribbon on it anymore, but these people are all moaning about how women are being mistreated and nobody cares about breast cancer. Give me an effing break.

Sorry, but from the moment I heard about the 'controversial' new guidelines and all the associated, completely uninformed whining that went with it, this has been burrowing further and further under my skin. I really hate people.

[Silly Green Monkey]

I find it curious that health bureaucrats in Colorado plan to ignore the new guidelines. Never mind that evidence in medicine, I guess?

[Professor Yaffle]

Its all because there aren't any charities representing the interests of people who have suffered from a false alarm through screening and had to have the stress of investigations, only to turn out not to have the illness.

[jasonpatterson]

This is just the sort of post that JREFers hate, because I have no supporting evidence or even names to back it up, but on some idiotic daytime show (Today or something similar) there was a woman who was the head of a major breast cancer organization (and also a doctor, as I recall.) She said that when the guidelines were set originally, it had only been put at 40 because Congress passed a resolution that told whoever set said guidelines that they weren't good enough and to try again. This makes little or no sense now that I read it, but the gist was that the original guidelines weren't based on anything more than political pressure. I didn't check her story, and I don't care enough about this to do so, but it was vaguely interesting.

Wow, talk about a crappy post.

[Tiktaalik]

Several posts up over at Scienceblogs including:http://scienceblogs.com/insolence/20...r_screenin.php

[Elaedith]

In the UK it is once every three years from age 50.

[Kestrel]

Originally Posted by Silly Green Monkey

I find it curious that health bureaucrats in Colorado plan to ignore the new guidelines. Never mind that evidence in medicine, I guess?

People often believe things that are not supported by science. Especially something like "get a mammogram if you are over 40" that has been repeated for years. Even people with medical degrees fall into this trap. For example, it's not hard to find doctors that tell their patients to drink eight glasses of water a day.

[rockinkt]

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?

[jasonpatterson]

Originally Posted by rockinkt

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?

This has absolutely nothing to do with the topic that's being discussed though. We're not talking about a person who has advanced cancer being denied treatment, we're talking about a diagnostic exam that exposes people to not insignificant amounts of radiation that is done unnecessarily early and often.

[Beerina]

Originally Posted by Silly Green Monkey

I find it curious that health bureaucrats in Colorado plan to ignore the new guidelines. Never mind that evidence in medicine, I guess?

It, like all of socialized medicine, is about politics.

Haven't you figured that out, yet?




On the radio today, NPR had some woman who was like, I'm getting it anyway, my mom died of breast cancer at 56 and my aunt at 46.

Well, ya, you would be one of those who would be recommended to start it early.


I had an interesting non-medical experience with people at work yesterday. Sometimes I forget how...unaware?...most people are of things.


And these things of course:

1. Cost aside, what is the dividing line between the average woman where she'd be more likely to find a tumor and be saved vs. more likely to induce cancer by having screenings? Presumably one could have more frequent ones the older you got to reflect the shifting probabilities as you age.

2. Could "government money" to pay for these be better diverted to research for it, with more bang for the buck, saving-of-life-wise?

[Niggle]

My concern would be the number of insurance companies who would look at these guidelines and say, "Oh, look! We don't have to cover mammograms on anyone until they're over 50!" Then, even if you're in one of the high-risk groups, it takes your doctor getting an official act of Congress to make them believe it and pay for the stupid test.

[casebro]

Looking at the Nexavar cite above, the total cost per liver cancer patient for one year of treatment would be (3000 pounds/month, 12 months, pounds to dollars) about $70,000. No mention of associated costs- tests, visits, etc. So lets say $100,000 to take six months longer to die. That is $16,000 per month of death delayed. Six additional months of being deathly ill- I watched my brother die of cancer. Chemo kicks your ass too, in addition to the cancer. It's not like $16,000 would have bought him a month of youthful life.

So no, the cost/benefit in some therapies is quite easily negative.

[Silly Green Monkey]

Insurance groups have already gone on record as intending to continue to cover mammograms. Somehow that rated front page mentions.

[bruto]

I've been listening a bit to this debate, and it's interesting to me that both sides are so convinced they're right, and so convinced that they're unbiased, and rational in their position, and it makes me wonder if perhaps they are both right in their own way, but thinking differently about it.

I should preface this with the statement that I'm no statistician or epidemiologist, and know only what I've heard so far on some radio programs and debates.

I haven't seen the studies that the recommendation is based on, but it appears, from what I've heard, that the result is based on a relatively simple balancing of benefit versus harm, for a relatively large population. Perhaps this is not the case, but it appears that they've taken a virtual scale, and in one pan they put the benefit (you don't die of an undiagnosed cancer), and in the other pan they've put a whole panoply of possible negative consequences. So, for a population of n patients, if more are harmed than helped, you say it's not a good bargain.

What I don't see here is how they have weighed harm. {Edited to add: they did try to emphasize that the financial consequences were not weighed in this study.} The obvious negative consequence if you need a mammogram is that you will die of cancer, which is a horrible, terminal, drastic consequence, at least in most people's opinion. Does the study weigh only equivalent negatives, or does it, as its advocates at least appear to be saying, bundle all the negatives as a cumulative "harm," including consequences which, while nasty enough, are not singly equivalent to a painful death from cancer? Again, I'm not sure how they're weighing this all, but on one NPR program I was listening to, one of the persons responsible for the study appeared to be referring to a large list of negatives including stress and inconvenience, as well as unnecessary biopsies and mastectomies. Obviously some of these consequences are heavy, and even fatal, but some are not. It did not appear from what I heard that the advocates of the new study are balancing deaths against deaths, but rather that they're making a judgment of relative harm. Even if that judgment is wise and impartial and well considered, it's debatable.

The second thing I don't know is whether the study used matched pairs, or whether it's a general population study. From what I've heard so far, it's a population study. I don't know what rules were applied for inclusion in the study. While that may be perfectly adequate to weigh overall benefits for a population of getting a procedure, unless the subset of the population matches one's own circumstances, it's of far less value in making a personal decision about the same thing. To pick an obvious random example, if a certain percentage of the negative consequences of the test were related to diabetes or heart disease, or some other condition, then obviously a person without these conditions would see different odds. Or to pick another example, if some of the consequences were due to poor medical judgment on the part of doctors, a person who has a really good doctor with a proven record of good judgment has a different decision to make. I don't know how the study has taken these factors into account, but suspect that if it did not use fairly careful matching, at least some of these factors will have been omitted, and if that is true, then it would be a poor basis for individual decision making, and a poor basis for any policy that drives or enables individual decision making, no matter how valid it is as an actuarial reference.

[fls]

Originally Posted by bruto

The second thing I don't know is whether the study used matched pairs, or whether it's a general population study. From what I've heard so far, it's a population study.

What study are you talking about?

Linda

[Jorghnassen]

The big issue here is that the mantra that early detection saves lives is not necessarily true. The other thing is that there simply isn't an objective way to set a screening guideline. You'll have to assign different weights to a large number of factors and try to optimize under some set of rules that are all subjective to some degree. Should we focus on breast cancer when its mortality rate has been going down while lung cancer mortality rates have been increasing among women? Detection and prevention there could save lives too...

[bruto]

Originally Posted by fls

What study are you talking about?

Linda

According to what I heard, the new guidelines were based on a population study, but it appears from further searching that it was a meta-study, if that term can apply, based on a number of studies.

Washington Post says this:

Quote:

To conduct the review, Heidi D. Nelson of the Oregon Health & Science University in Portland led an analysis of data from more than 40 studies, including a new British study involving more than 160,000 women and data collected from more than 600,000 women in the United States.

Without knowing a bit more about how the various risk factors in such a large sample were evaluated, I do wonder how relevant the results are to an individual's decision.

[Skeptic Ginger]

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.

[ponderingturtle]

Originally Posted by rockinkt

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?

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.

[bruto]

Originally Posted by ponderingturtle

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.

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?

[wicked_ways]

Originally Posted by skeptigirl

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.

skeptigirl, what are the new guidelines about the frequency of pap smears?
i hear nothing about this.

[Jorghnassen]

Originally Posted by wicked_ways

skeptigirl, what are the new guidelines about the frequency of pap smears?
i hear nothing about this.

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.

[bruto]

Originally Posted by Jorghnassen

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.

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!

[ponderingturtle]

Originally Posted by bruto

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?

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?

[ponderingturtle]

Originally Posted by bruto

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!

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.

[Elaedith]

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.

[Ivor the Engineer]

Originally Posted by Elaedith

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.

Hmmm, I wonder why that could be? What could be the incentive to perform lots of expensive procedures on healthy people?

[Darth Rotor]

Originally Posted by Ivor the Engineer

Hmmm, I wonder why that could be? What could be the incentive to perform lots of expensive procedures on healthy people?

Could it be defensive medicine, fear of a lawsuit?

[Ivor the Engineer]

Originally Posted by Darth Rotor

Could it be defensive medicine, fear of a lawsuit?

Those as well.

But the one I was thinking of is the one which makes sceptics throw insults at you for assuming medical profesionals behave as rational agents.

[bruto]

Originally Posted by ponderingturtle

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.

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.

[Ivor the Engineer]

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.

[shandyjan]

Originally Posted by Elaedith

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.

UK only start at 50. Only risk groups start earlier!

[ponderingturtle]

Originally Posted by Darth Rotor

Could it be defensive medicine, fear of a lawsuit?

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.

[ponderingturtle]

Originally Posted by bruto

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.

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.

Quote:

Just don't tell me that the best way to handle inept reading of tests is to skip the tests.

A false positive is not necessarily a result of the doctor being inept.

[bruto]

Originally Posted by ponderingturtle

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.

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.

[Puppycow]

Sarah Palin has an opinion on this!

Quote:

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.

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.

[Elf Grinder 3000]

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?)