Are mammograms effective?

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Kay Dickersin
Tuesday, October 12, 2010; 12:00 PM

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opinion not fact: music to my ears.

Kay Dickersin: mammograms are usually aimed at.

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Increase in young women with breast cancer: In recent years, I have known (or known of) as many young women with a breast cancer diagnosis (20s and 30s) as post-50 women. Is a dramatic increase in breast cancer diagnoses among younger women documented? And if so, what reasons for it are proposed?

Kay Dickersin: Mammography is probably part of the reason for an increase. Many cancers that otherwise would not have been found have been diagnosed. The problem with that is that many of those cancers would never have caused problems, so we are treating them unnecessarily. Unfortunately, we can't tell ahead of time which cancers will develop into invasive disease and which ones will just stay in the background. For this reason, many people are concerned that we are "overdiagnosing" and treatming breast cancer with mammograms.

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Are mammograms effective?: Veneta's personal thoughts on mammograms and oncology would be equally applicable to almost any area of medicine. That is, there is rarely ever a guarantee in medicine that a diagnostic or therapeutic tool will cure you and will do so indefinitely. As a couple examples, should we all stop getting annual physicals and stop filling our prescriptions because there is no guarantee our life will be saved by these interventions?

Kay Dickersin: Interesting issue and you are right, one can apply the issues of screening mammograms to other screening tests. That is what the US Preventive Services Task Force is concerned about -- where is there evidence for the tasks done in the typical physical and in screening tests.

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DCIS - genuine threat?: I have read many articles and studies that indicate that DCIS is often much like prostate cancer - it does not really pose a threat to most who are diagnosed with it. According to research, only 20% of DCIS goes on to be a life-threatening health risk, yet, most women undergo invasive treatments that may not be necessary. Some opt to watch-and-wait, as do many men with prostate cancer. There are reseachers attempting to find a marker for the actual threat posed by DCIS - any progress there?

Kay Dickersin: We can't tell yet who will progress from DCIS and who will not, but this is an area where a lot of work is being done.

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Validity of a study involving mostly white women: The primary study questioning the efficacy of mammograms was done in Scandanavia and thus it involved an ethnically similar group of white women. I'm sure that black women and Jewish women were not well represented, if at all, in this study. Yet we know that these two groups of women, of whom there are many in the USA, are at a higher risk of breast cancer than other women. Black women, in particular, get breast cancer earlier, and in more aggressive forms, than white women. I think it's completely irresponsible to rely on that study to discourage women from getting annual mammograms, or to buttress insurance companies' arguments against paying for mammograms, because, let's face facts, that's where this "debate" is going.

Kay Dickersin: with your doctor and come to a decision based on your risk factors. If you are in a higher risk group then this is something that would be taken into considerationin your personal decision.

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Prevention: The questions raised about the true efficacy of mammograms in preventing breast cancer deaths are overdue - many of us have learned to question the established "wisdom" of the medical industry (with industry being the key word). Some are now advocating that the billions invested in screening be turned to prevention. Many studies show that both diet and exercise likely play a role in the development of these cancers. Should a significant portion of the money now spent on technology instead be spent on programs on educating women about what they can do to reduce the odds of getting cancer?

Kay Dickersin: problem for researchers to "crack." More research dollars going to high quality studies will be essential to get us to our goal of eradicating this disease as soon as possible.

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Primary Research?: I appreciate the author for telling her story. I personally haven't made up my mind as to what I will do re: mammograms. I would like to see the primary data myself, so I can analyze it and determine what I think the best course of action for me is. Can you point me towards any specific studies on the efficacy of mammography? Or towards journals that are likely to contain these studies? I (and probably many others who want to see the information and draw our own conclusions) would be most appreciative. Thanks.

Kay Dickersin: evidence in one place, so you can see everything that is known about the effectiveness of an intervention at once.

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Breast Cancer Screening: What is your opinion on the current USPSTF recommendations on breast cancer screening? Do you think societies like the American College of Obstetrics and Gynecology or Radiological Societies are incorrect for advocating different standards? Lastly, what do you think the new Swedish study will say about how valuable routine screening is?

Kay Dickersin: is not dominating the recommendations.The Swedish study used methods that are non standard. Their results have been questioned by others in the field.

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USPSTF: You mentioned that USPSTF develops recommendations on the effectiveness of all screening tests, which is true, but USPSTF does not have equal criteria for all of their recommendations. In the mammography recommendations, USPSTF made the value judgement to subjectively weigh the estimated cost of stress of mammograms against the benefit of lives saved. USPSTF does not use presumed stress as a factor in their recommendations for all other screening tests. Any thoughts on the role of nonscientific, immeasurable values, like stress, in the supposedly unbiased "evidence-based" recommendations of the USPSTF?

Kay Dickersin:

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Mammogram use in Europe: What are the mammogram recommendations in most European countries? Do they start at the same time as the current US recommendations? What about frequency? What is the incidence of breast cancers found there vs. here?

Kay Dickersin: ages 50-69, where women are screened every two years.

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Policy issue: While I agree with the author about the limited value of mammograms, I think mammograms should be available to those who want them. Unfortunately articles such as this might influence insurance companies not to cover the procedure, and if so it will be out of reach to those who want them.Whether or not to get screened with a mammogram is a decision best made by the woman and her doctor, but without insurance coverage that decision is taken out of her hands.

Kay Dickersin: Have you seen evidence of this or is it just a fear? There are federal and state laws now that mandate insurance coverage for mammograms.

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Mammograms: You stated that "we can't tell ahead of time which cancers will develop into invasive disease and which ones will just stay in the background." Isn't that a compelling argument for early diagnosis and treatment?

Kay Dickersin:

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Misdiagnosis: Unfortunately, most women are not scientists and therefore cannot evaluate the research findings by themselves. They rely on medical doctors who read summaries of the research, which is not good either. Two things are needed to combat overdiagnosis: we need strong advocates for womens' health, and penalties for misdiagnosis.

Kay Dickersin: groups to help them get evidence-based info outr to their constiuencies. Oct 17 is a conference for consumer health groups on just this sort of thing.

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baseline testing: Now in my mid-30s, my doctor wants me to get a baseline mammogram. Is this standard practice? I'm in the average risk category. Thanks.

Kay Dickersin: no

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Sweden: Can you elaborate on why you reject the Swedish study (which is supported by all pertinent medical associations), and not the USPSTF's recommendations (which are rejected by all pertinent medical associations)? The Swedish study was the largest, longest, and most comprehensive mammography review ever, whereas the USPSTF based its recommendations on wildly varying computer models, rejecting out of hand all live clinical trials data (including the Swedish study).

Kay Dickersin: that the Swedish study has broad based support.

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Bias: Are you aware of evidence of reporting bias in this case? Yes - see the academic work of the lead AHRQ staff person before she became a federal employee.

Kay Dickersin:

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A more balanced set of recommendations: I think that you should also encourage women to read the positions and studies by organizations that do NOT advocate reducing mammogram screening, such as the American Cancer Society and Susan G. Komen. You're only citing to organizations that agree with your own position, and that's not fair.

Kay Dickersin: factor in our decisions, but it means it is where we start.

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Mandated coverage of mammograms: You said: "There are federal and state laws now that mandate insurance coverage for mammograms."Yes, that's true, but laws aren't written in stone, and studies that support no or fewer mammograms can lead to changes in mandated coverage. I'm still not convinced that reducing government costs for mammograms isn't prompting these studies.

Kay Dickersin: you don't have any reason to worry right now.


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