Slightly OT: U. S. Preventive Services Task Force and Mammography
Francis A. Miniter
Mammography and I have listened to a lengthy NPR interview
with one of the scientists making the report. I don't know
who appointed this independent panel or when, but the
analysis seems like a standard Republican cost-benefit
analysis. "What rate of death is acceptable?" The
following web page fails to answer the question:
http://www.ahrq.gov/clinic/uspstfab.htm
Looking at the report itself, the Results section in the
Summary of Evidence
http://www.ahrq.gov/clinic/3rduspstf/Breastcancer/bcscrnsum1.htm#results
contains the following:
----------------------------------
In our meta-analysis, excluding the Edinburgh trial, the
summary relative risk was 0.85 (CrI, 0.73 to 0.99) after 14
years of observation, with a number needed to screen of
1,792 (CrI, 764 to 10,540) to prevent one death from breast
cancer. Some might argue that the Canadian study should be
excluded in calculating the number needed to invite to
screen because its participants were prescreened volunteers
who may have differed from the general population. When the
Canadian study was excluded, the summary relative risk was
0.80 (CrI, 0.67 to 0.96) and the number needed to invite to
screen was 1,385 (CrI, 659 to 6,060). Figure 1 (22 KB) shows
an increasing screening benefit among this age group with a
longer period of observation.
----------------------------------
Meanwhile as to women 50 or over, routine examination of 838
women would save one life. That is deemed acceptable.
As a result, they came to the following recommendations:
---------------------------------
# The U.S. Preventive Services Task Force (USPSTF)
recommends screening mammography, with or without clinical
breast examination (CBE), every 1-2 years for women aged 40
and older.
Rating: B recommendation.
Rationale: The USPSTF found fair evidence that mammography
screening every 12-33 months significantly reduces mortality
from breast cancer. Evidence is strongest for women aged
50-69, the age group generally included in screening trials.
For women aged 40-49, the evidence that screening
mammography reduces mortality from breast cancer is weaker,
and the absolute benefit of mammography is smaller, than it
is for older women. Most, but not all, studies indicate a
mortality benefit for women undergoing mammography at ages
40-49, but the delay in observed benefit in women younger
than 50 makes it difficult to determine the incremental
benefit of beginning screening at age 40 rather than at age 50.
The absolute benefit is smaller because the incidence of
breast cancer is lower among women in their 40s than it is
among older women. The USPSTF concluded that the evidence is
also generalizable to women aged 70 and older (who face a
higher absolute risk for breast cancer) if their life
expectancy is not compromised by comorbid disease. The
absolute probability of benefits of regular mammography
increase along a continuum with age, whereas the likelihood
of harms from screening (false-positive results and
unnecessary anxiety, biopsies, and cost) diminish from ages
40-70. The balance of benefits and potential harms,
therefore, grows more favorable as women age. The precise
age at which the potential benefits of mammography justify
the possible harms is a subjective choice. The USPSTF did
not find sufficient evidence to specify the optimal
screening interval for women aged 40-49 (go to Clinical
Considerations).
---------------------------------
This is not exactly the way that the evidence has been
presented in the news.
Taking the 1: 1385 ratio of lives saved to women screened on
an annual basis, we get something like the following. That
would be 13,850 exams over 10 years to save one life. There
are 150,000,000 women in the US., so over 10 years, a guess
at the number of women who are 40 - 49 is about 30,000,000 ,
so the overall benefit would be 21,600 lives saved over ten
years, or about 2,200 per year. That to me seems to be a
lot and to have a lot of value.
--
Francis A. Miniter
Oscuramente
libros, laminas, llaves
siguen mi suerte.
Jorge Luis Borges, La Cifra Haiku, 6
Cece
wrote:
> I have taken a look at the report of the USPSTF on
> Mammography and I have listened to a lengthy NPR interview
> with one of the scientists making the report. I don't know
> who appointed this independent panel or when, but the
> analysis seems like a standard Republican cost-benefit
> analysis. "What rate of death is acceptable?" The
> following web page fails to answer the question:http://www.ahrq.gov/clinic/uspstfab.htm
>
> Looking at the report itself, the Results section in the
The panel has been around since 1984. It (currently) has no
oncologists. This study was outsourced. The recommendations are most
definitely not Republican in origin or leaning. Have you watched the
discussions of it on Good Morning, America, ABC Nightly News, The
View, and practically everything else? An ABC medical advisor/
consultant says that he knows one of the doctors on the panel and that
there was no political anything involved with this (and if you believe
that...). Elisabeth Hasselbeck, The View's conservative, did a little
research and learned that in one state this is already what insurance
will pay for -- and that state has the highest mortality rate for
breast cancer. Which state? Utah.
This, folks, is ObamaCare!
Jr@Ease
and Weary, Over Many a Quaint and Curious Forgotten Post, s/he wrote:
--------------------------------------------------------------
>
>This is not exactly the way that the evidence has been
>presented in the news.
>
>Taking the 1: 1385 ratio of lives saved to women screened on
>an annual basis, we get something like the following. That
>would be 13,850 exams over 10 years to save one life. There
>are 150,000,000 women in the US., so over 10 years, a guess
>at the number of women who are 40 - 49 is about 30,000,000 ,
>so the overall benefit would be 21,600 lives saved over ten
>years, or about 2,200 per year. That to me seems to be a
>lot and to have a lot of value.
There was an Op Ed in today's NY Times that essentially concluded that
they would have to do 1900 mammograms every year for 10 years to save
1 life, with a resultant 1000 false positives and the effect that
would have onn those 1000 women. My personal reaction was, if we're
going to allow a woman to die to save 1000 women from the procedure
attendant with the false positives, who gets to tell that woman she
has to die?
John P
Francis A. Miniter
This study had to have been commissioned by a previous
administration, and had to be mostly complete when Obama
took office. He is not the author, nor is this in any way
related to the two Health Care plans working their way
through Congress. Or can you cite to a particular provision
of either that dovetails with this study?
Annie C
"Francis A. Miniter" <fami...@comcast.net> wrote in message
news:he718b$p66$1...@news.eternal-september.org...
> Cece wrote:
>>
>> The panel has been around since 1984. It (currently) has no
>> oncologists. This study was outsourced. The recommendations are most
>> definitely not Republican in origin or leaning. Have you watched the
>> discussions of it on Good Morning, America, ABC Nightly News, The
>> View, and practically everything else? An ABC medical advisor/
>> consultant says that he knows one of the doctors on the panel and that
>> there was no political anything involved with this (and if you believe
>> that...). Elisabeth Hasselbeck, The View's conservative, did a little
>> research and learned that in one state this is already what insurance
>> will pay for -- and that state has the highest mortality rate for
>> breast cancer. Which state? Utah.
>>
>> This, folks, is ObamaCare!
>
> This study had to have been commissioned by a previous administration, and
> had to be mostly complete when Obama took office. He is not the author,
> nor is this in any way related to the two Health Care plans working their
> way through Congress. Or can you cite to a particular provision of either
> that dovetails with this study?
>
> --
> Francis A. Miniter
Another thing too is that it not a new study, but a "study of studies." You
might find this video** of interest too. Not a single oncologist or breast
cancer specialist was on this panel, all meetings were secret, and 3 of the
panelists are (surprise!) from the insurance industry...
Dr Bazell and Rep. Debbie Schultz (breast cancer survivor) on Chris Matthews
last night. Look for the "need for mammograms may slow" video. **
http://www.msnbc.msn.com/id/3036697/#34049252
Annie
Francis A. Miniter
P.S. Utah is Republican country.
P.P.S. This task force had to have placed an economic value
on the life of a 40 - 49 year old woman, since this was more
a study in economics than medicine. I wonder what that
value is?
Cece
>
> - Show quoted text -
Whoever came up with it, it is not the Republican Party. I've been to
two Republican meetings this week, one regular women's club and one
town hall -- and everybody there was against this thing. But this is
what Pelosi/Reid Care will bring! What, we can't attach Obama's name
until he's signed it? As if he weren't agreeing with Pelosi and Reid
on this?
Where in the Constitution, pray tell, is there any authorization for
the federal government to have anything to do with healthcare or
health insurance?
Pogonip
>>
>
> P.S. Utah is Republican country.
>
> P.P.S. This task force had to have placed an economic value on the life
> of a 40 - 49 year old woman, since this was more a study in economics
> than medicine. I wonder what that value is?
>
Then it's all good because the woman will spend eternity on a planet
with her husband, who can become a god, and she will be eternally
pregnant with spirit babies, thus fulfilling her destiny.
<g, d & r>
--
Joanne
stitches @ singerlady.reno.nv.us.earth.milky-way.com
http://members.tripod.com/~bernardschopen/
Joan in GB-W
"Cece" <ceceliaa...@yahoo.com> wrote in message
news:61ed7d60-e0c8-4b76...@o10g2000yqa.googlegroups.com...
Whoever came up with it, it is not the Republican Party. I've been to
two Republican meetings this week, one regular women's club and one
town hall -- and everybody there was against this thing. But this is
what Pelosi/Reid Care will bring! What, we can't attach Obama's name
until he's signed it? As if he weren't agreeing with Pelosi and Reid
on this?
Where in the Constitution, pray tell, is there any authorization for
the federal government to have anything to do with healthcare or
health insurance
-----------------------------------------------
I hope your Republican club and committee don't let the facts get in the way
of their conclusions.
http://blog.taragana.com/health/2009/11/18/hhs-secretary-mammograms-still-vital-federal-policy-unchanged-by-panel-recommendations-15880/
Regarding your second paragraph, I would hope that the same club and
committee and yourself step forward when the time comes (if you are not at
that age yet) to stand up for your convictions and refuse to accept
Medicare.
Joan
Francis A. Miniter
As I said before,you cannot find one provision of either
piece of legislation that supports your belief.
Francis A. Miniter
I had missed the second paragraph. Thank you. A fine response.
Mary
> "Cece" <ceceliaarmstr...@yahoo.com> wrote in message
>
> news:61ed7d60-e0c8-4b76...@o10g2000yqa.googlegroups.com...
>
> Whoever came up with it, it is not the Republican Party. I've been to
> two Republican meetings this week, one regular women's club and one
> town hall -- and everybody there was against this thing. But this is
> what Pelosi/Reid Care will bring! What, we can't attach Obama's name
> until he's signed it? As if he weren't agreeing with Pelosi and Reid
> on this?
>
> Where in the Constitution, pray tell, is there any authorization for
> the federal government to have anything to do with healthcare or
> health insurance
> -----------------------------------------------
>
> I hope your Republican club and committee don't let the facts get in the way
>
> Regarding your second paragraph, I would hope that the same club and
> committee and yourself step forward when the time comes (if you are not at
> that age yet) to stand up for your convictions and refuse to accept
> Medicare.
>
> Joan
You go, Joan.
Mary
Mary
No kidding. This is a highly treatable cancer, IF you catch it early
enough. Reducing the chances that the cancer will be diagnosed early
enough to be treated successfully is callous at best.
Mary
Pogonip
>
> No kidding. This is a highly treatable cancer, IF you catch it early
> enough. Reducing the chances that the cancer will be diagnosed early
> enough to be treated successfully is callous at best.
>
> Mary
There has been discussion for some time now about how effective the
old-fashioned x-ray mammograms really are. Apparently, the newer scans
are far more accurate and have fewer false positives and false
negatives. But are more expensive. There's also some question about
how effective it is to scan everyone. If one patient has no history, no
blood relatives with the same or similar cancer, do they need to have
screenings as frequently as someone with a history and/or relatives?
Then there is the whole thing with "self-examination" which has always
been iffy, but highly promoted.
ell...@webtv.net
save 1000 women from the procedure attendant with the false positives,
who gets to tell that woman she has to die?
John P>>
Mammograms are not compulsory, John, so I think this is kind of a "straw
man."
Ellen
Janet
> Mary wrote:
>>
>> No kidding. This is a highly treatable cancer, IF you catch it early
>> enough. Reducing the chances that the cancer will be diagnosed early
>> enough to be treated successfully is callous at best.
>>
>> Mary
>
> There has been discussion for some time now about how effective the
> old-fashioned x-ray mammograms really are. Apparently, the newer
> scans are far more accurate and have fewer false positives and false
> negatives. But are more expensive. There's also some question about
> how effective it is to scan everyone. If one patient has no history,
> no blood relatives with the same or similar cancer, do they need to
> have screenings as frequently as someone with a history and/or
> relatives? Then there is the whole thing with "self-examination"
> which has always been iffy, but highly promoted.
I read something in The New Yorker seseveral years ago that said that
"treatability" of breast cancer is really dependent on the agressiveness
(ie, growth rate) of the tumor. Period.
There was a huge outcry and negative reaction from people who wanted to
believe that ALL breast cancers could be treated successfully if "caught
early enough."
Mary
> I read something in The New Yorker seseveral years ago that said that
> "treatability" of breast cancer is really dependent on the agressiveness
> (ie, growth rate) of the tumor. Period.
Really? The stage at which you diagnose it doesn't matter? That seems
counterintuitive.
> There was a huge outcry and negative reaction from people who wanted to
> believe that ALL breast cancers could be treated successfully if "caught
> early enough."
>
Well, that doesn't surprise me. People want to be able to believe in
treatment. I don't think there's any cancer that can be said to be 100%
treatable, whether caught early or not.
Mary
ELF
<snip>
> Taking the 1: 1385 ratio of lives saved to women screened on an annual
> basis, we get something like the following. That would be 13,850 exams
> over 10 years to save one life. There are 150,000,000 women in the US.,
> so over 10 years, a guess at the number of women who are 40 - 49 is
> about 30,000,000 , so the overall benefit would be 21,600 lives saved
> over ten years, or about 2,200 per year. That to me seems to be a lot
> and to have a lot of value.
>
>
http://scienceblogs.com/goodmath/2009/11/the_balance_of_screening_tests.php#more
--
"We live in the interface between radioactive molten rock and hard
vaccum and we worry about safety." --Chris Hunt in alt.sysadmin.recovery
ELF
> No kidding. This is a highly treatable cancer, IF you catch it early
> enough. Reducing the chances that the cancer will be diagnosed early
> enough to be treated successfully is callous at best.
>
> Mary
http://scienceblogs.com/goodmath/2009/11/the_balance_of_screening_tests.php#more
Isn't that simple.
Pam K
To me, a woman who was diagnosed with early-stage BC 2 years ago, there is more
to this than mortality rates.
Cancer is never a one-size-fits-all, especially breast cancer. The fact that a
mammogram found my BC doesn't mean that my life was saved - no one really knows
if my BC would have grown to an advanced stage. I treated it like the cancer it
was, had surgery, radiation & will be on the anti-hormonal Tamoxifen for another
4 years. What that mammogram and its discovery did was ensure years of a
proactive approach to my health, ensure that my sisters monitor their own breast
health, and (hopefully) mean that my daughters will watch and keep the BC at bay
as well.
A year ago, a spot found when undergoing tests prior to surgery the year earlier
had changed enough to prompt (another) biopsy. Far from making me hysterical
with concern, worried beyond belief and all those things that these new
recommendations are trying to resolve (give me a break!), it made me even more
resolute in my determination to take charge of me. Not cancerous, in this case
definitely pre-cancerous, but it, and other things found are considered
non-obligate pre-cursors to cancer. My risk of BC will never drop.
What is needed is better screening (mammograms are notoriously ineffective for
v. young women) and more knowledge of what causes BC to grow, change, advance.
Whereas not that many years ago, many, many women with early stage BC received
chemo, new testing can help determine risk/benefit of chemo, and keep women who
clearly won't benefit from receiving it. Until the tests and screens are better,
I'll never consider waiting til 50 for an initial mammo to be a viable
recommendation.
I certainly don't want to be that 1 in 1900, nor do I want it to be my daughter,
my sister, my friend. Give me a false positive any day.
--
Pam K
saying eff off to cancer since 2007
my2...@yahoo.com
Thelma
: I certainly don't want to be that 1 in 1900, nor do I want it to be
: my daughter,
: my sister, my friend. Give me a false positive any day.
How about that woman given a false positive who dies of her
unnecessary treatment? That is not a zero-probability outcome,
and I think that it's becoming more of a possibility with the
rise in infections contracted during hospitalization.
--thelma
[don't ask, don't tell on this one]
Janet
> Janet wrote:
>
>> I read something in The New Yorker seseveral years ago that said that
>> "treatability" of breast cancer is really dependent on the
>> agressiveness (ie, growth rate) of the tumor. Period.
>
> Really? The stage at which you diagnose it doesn't matter? That
> seems counterintuitive.
Well, that's what I recall it saying. I recall the angry letter to the
editor from a woman whose recently-diagnosed daughter was in a state of
despair as a result of reading it.
To put it another way, the author, who was probably Groopman or Gowande,
might have been saying that there are tumors that cannot be "successfully"
treated no matter when they are detected because they are so aggressive that
by the time they are detectable by any means they are out of control. On the
other hand, there are tumors with a slower growth rate that ARE treatable
because they CAN be detected at a stage where they can be successfully
removed before metastasizing. The latter are the tumors that would respond
well to comparatively early detection and treatment.
The doctors I heard discussing this on NPR the other day were saying that
most women who self-detect find their tumors in the course of normal
activities such as bathing, rather than during formal self-exams after
having been taught such a technique. (On the other hand, I would venture to
guess that a lot of women do a kind of informal self-exam in the shower
quite frequently.)
Pam K
Very often, that so-called unnecessary treatment is something like surgery. 19
years ago, when my mom was dx with invasive BC, the idea of lumpectomy over
mastectomy was beginning. My mom opted for mastectomy. She also had chemo. Since
then, the Van Nuys prognosticator and Oncotype DX testing have come out. VN
talks recurrence. Oncotype talks benefits of chemo. Many, many women who would
have had chemo 20 years ago (not my mom, unfortunately) would not today because
of these tests and risk models.
Back then, the talk was empowerment and lumpectomy was seen as the way for women
to retain their breast (and sense of self, sexuality, a whole host of things).
Today, many women see mastectomy in the same way, funnily enough.
The odds of being overtreated with chemo are incredibly low these days. The odds
of being overtreated with surgery are too high, IMHO. I know of a number of
women who opted (forced) their surgeon to perform a mastectomy for single-focus,
tiny, low grade DCIS (stage 0, non-invasive). Can you say overkill? But it gave
them peace of mind.
Because of new digital mammograms, many more woment are dx with early stage,
including stage 0, BC. Because they DON'T KNOW and have NO way of knowing which
of these will advance to metastatic BC, they treat. It is up to the woman and
her doctor to decide. Very often it is just surgery/lumpectomy. Sometimes rads
are added, with invasive, maybe chemo too if the tests bear out.
The odds of being treated for a non-existent cancer are so low they're close to
zero. Anyone who is is likely in the hands of an incompetent doctor.
The best way to ensure that you aren't over or undertreated is to have your
mammogram performed at a breast center. The reading should be done by a
radiologist who reads 100's and 100's of them every month. The more they read,
the better they are. The expertise of the radiologist is key.
No one ever forces you to have a mammogram. Likewise, no one will force you into
treatment you don't want. Understand your risks and act accordingly.
Janet
I agree with both of you: emotional distress caused by a false positive
isn't even worth considering, but serious physical harm is.
On the other hand, there is a middle ground. Some women have completely
benign masses removed out of fear. The downside is that the resultant scar
tissue actually makes mammograms far more difficult to read for the rest of
their lives, and may obscure an actual cancer.
I have a mass that was first detected in high school. A decade later, my
then-ob/gyn (who had recently had breast cancer herself) sent me to a
breast specialist who tried to aspirate it, to no effect, then recommended
its removal. I was all set to have this done, when I got a phone call from
the hospital demanding $3K up front because they were certain that my health
insurance would refuse to pay on the grounds that it was a pre-existing
condition. (This was 30 years ago. Now they would probably demand $30K. <G>)
I didn't have that kind of money, so I called the doctor, who seemed
unconcerned about the idea of waiting 6 months or whatever until I would
qualify for coverage. This did not increase my confidence in his
recommendation for immediate removal. I asked about having a mammogram
instead--he never suggested it--on which it didn't show up at all. (And the
surgeon, an expensive Upper-East Side fellow in Manhattan, never bothered to
inform me of the result. I just assumed that since he didn't bother to call,
it wasn't a problem. Ha.)
Ten years later I described this episode to another breast specialist to
whom I had been sent as a result of a questionable spot on a mammogram. He
said that it was in his opinion wrong to remove such things, because of the
scar tissue/detection reason I cite above. So that is indeed a potential
actual harm from a false positive, especially when compounded by a greedy
surgeon.
The fix for it is for doctors to stand firm in refusing to remove benign
masses...but then they have to worry about being sued if the now-benign mass
turns cancerous, or even if a completely separate cancer turns up, so they
practice defensive medicine...and we all know where that leads.
Annie C
"Pam K" <my2...@noyahoospam.com> wrote in message
news:hec29...@drn.newsguy.com...
Can't thank you enough for posting. So refreshing to read an informed
opinion.
Where you choose to go for diagnosis and treatment can make such a
difference. Absolutely agree about the importance of the radiologist. So
important to work with the best one possible.
Have throw in too that most every woman I know who has survived BC,
intiially found the lump herself. (I realize this is anecdotal, but it's
also true.) That's the worst thing, imo, about the new findings by this task
force. What could possibly be the harm having something suspicious checked
out? Geez.
Annie
Janet
> In article <ZcidnbkICebpHpTW...@speakeasy.net>, Thelma
> says...
>>
>> Pam K <my2...@noyahoospam.com> wrote:
>>> I certainly don't want to be that 1 in 1900, nor do I want it to be
>>> my daughter,
>>> my sister, my friend. Give me a false positive any day.
>>
>> How about that woman given a false positive who dies of her
>> unnecessary treatment? That is not a zero-probability outcome,
>> and I think that it's becoming more of a possibility with the
>> rise in infections contracted during hospitalization.
>>
>> --thelma
>> [don't ask, don't tell on this one]
>>
>
> Very often, that so-called unnecessary treatment is something like
> surgery.
Thanks for the info, Pam. Obviously things have advanced far since my last
mammogram, 10 or so years ago!
Lynn Allen
> The odds of being treated for a non-existent cancer are so low they're close to
> zero. Anyone who is is likely in the hands of an incompetent doctor.
>
> The best way to ensure that you aren't over or undertreated is to have your
> mammogram performed at a breast center. The reading should be done by a
> radiologist who reads 100's and 100's of them every month. The more they read,
> the better they are. The expertise of the radiologist is key.
>
> No one ever forces you to have a mammogram. Likewise, no one will force
> you into
> treatment you don't want. Understand your risks and act accordingly.
Oddly, I didn't see anyone suggesting that the proper response to a
positive mammogram was....a second test to see if the first was a false
positive. Before undertaking treatment. I can't imagine why anyone
would leap into treatment before confirmation.
Treatment can always wait 1 day for redoing the test.
--
--
Lymaree
Francis A. Miniter
Well said. That also makes me wonder, since the task force
did a study of studies, how far did they go back? If they
went back too far, they wouldl have been using obsolete
techniques with bad outcomes to predict the outcomes of
modern techniques. As you said, this is an area where
medicine has been far from static.
ggg
The first three words: WE THE PEOPLE. We are tired of the Medical
Profession, the Pharmaceuticals, the Insurance Companies, and he
people afraid of us, charging us whatever they please, then crying
"Socialism, Communism, Liberalism," when their greedy hands are
threatened with a chop or two. Also that other document that begins
"When in the course of human events..." (Our system allows us a replay
of our original revolution each Election Day when we go to the polls
and try to change what's been bothering us.) and ends with"...our
lives and sacred honor." How many of you out there have read the
Declaration of Independence and would have the fortitude to sign it?
And remember, you're not looking down the barrel of British cannon!
Barry