Tuesday, November 17, 2009

Guidelines for Mammograms Changed



For years women have been advised to have an annual mammogram starting at age 40. The advice and insurance coverage for mammograms has been so effective that nearly 2/3 of women over age 40 had mammograms. Scratch that advice. The new guidelines, published in the Annals of Internal Medicine will spark a wave of controversy. Women are now advised NOT to have screening mammograms until age 50 and then to space them every other year. The United States Preventive Services Task Force, an independent panel of experts, says the new guidelines were based on new data and analysis and were aimed at reducing the harm of overscreening.

Why the switch? The report says the risk/benefit of mammogram just doesn't pan out for women age 40-49. The task force said that once cancer death is prevented for every 1,904 women who are screened for 10 years in the 40-49 age range. As a woman ages, her risk of cancer increases so one death is prevented for every 377 women screened at age 60-69.

Mammograms often detect abnormalities that are not serious. These false positives cause women to undergo more testing and biopsies that can cause harm. The Task Force recommends the way to get the most benefit and the least harm is to start screening at age 50 and have approximately 10 mammograms in a lifetime.

The new advice will undoubtedly change the insurance and Medicare coverage for mammograms. Already the group that "grades" health plans on quality, the NCQA, is changing the measure for mammograms to women over age 50, every two years.

We can expect an outcry from women who had an early mammogram and it "saved my life". People will say it is part of "Obamacare" and meant to save billions of dollars ( BTW, it will save $billions) but they would be wrong as the USPSTF is probably the most impartial scientific group around.

The new guidelines do not apply to women with genetic markers or family history of early breast cancer. Let the debates begin.

23 comments:

Moremony services said...

Yes, I agree. Even though it might have been out of sincere intention, I was pursued-almost to the point of harrassment-concerning having the mammogram. Something just didn’t ‘feel right’ so the harder the medical people pushed me, the more I ‘dug my heels in’ (so to speak) and resisted. My ‘choice’ was not met with any respect, either. Instead, a kind of ‘fear tactic’ was used. It was SUCH a horrible experience, that I never went back. NOW, 3 years later, I see this reported on ?ABC News and here. Yes, certain people at high risk should be checked regularly and a person should always follow their ‘gut instincts’ concerning their health because NO ONE can do that better.

Attorney

Moremony

Michael Kirsch, M.D. said...

The USPSTF is a conservative an impartial organization. Although they have evolved their position on mammagraphy, their track record for objectivity is strong. We should realize that the medical benefits of mammography are much more modest than most women (and men) believe. In many instances, despite regular mammography, the sneaky disease gets through. www.MDWhistleblower.blogspot.com

CountryMidwife said...

I have long been concerned that we're over-radiating women with all these mammos. Though I do take issue with them questioning self-breast exam. What do you think on this one doc?

Now if only half of the other USPSTF recommendations would be even noticed, maybe we could actually save some $$$$.

CountryMidwife said...

And, for the lay people: you know all those stories you've heard like "oh, dear, it's breast cancer, how awful" and then "Praise God it's disappeared overnight!" --- that is exactly what this new recommendation is working to prevent. Because it never was breast cancer in the first place.

M.scott said...

After reviewing the credentials of the USPSTF members and noting that most are faculty members at large, prestigious universities, many in positions of leadership and influence, I have certain questions regarding the "strong track record for objectivity" that was sited by Dr. Kirsch. It is a known tactic of pharmaceutical companies to fund universities so as to influence their thought leaders into promoting certain therapies. Why shouldn't this same practice be carried out by insurance companies toward the end of reducing their bottom-line costs?

I am not accusing the members of the USPSTF of being in the pocket of big insurance, but when such a radical change in long-accepted health policy comes out-one that directly benefits insurers- then the cynical side of me has to wonder what else may be going on to motivate this policy change.

KM said...

I wonder why out of these 16 experts none of them are oncologists?

ERP said...

This will save Jillions of dollars....

Toni Brayer MD said...

CountryMidwife and others: I saw a patient today who said she would have every screening test available, even if there was a 1/million chance of it finding disease because it is that important to her to live a long, healthy life. She wants colonoscopy every 3 years and is not deterred by "guidelines".

Talking about populations means very little to people who are worried about one person..themselves. Doctors are reluctant to deny tests (even with low probability of benefit)because one mistake can lead to a huge lawsuit.

M.scott: While you are correct that Pharma has had cozy relationships with academia, I do believe the members of USPSTF are as impartial as we are likely to find. I've not heard of any academic doctors being influenced by Insurance Companies. The fact that guidelines change is indicative of the changing nature of Science.

I am anxious to hear what the Radiologic Societies have to say. Their revenue will take a big hit.

tracy said...

i just don't "get" people who want to live "forever"....

Knitted in the Womb said...

These guidelines are EXACTLY what I had already decided about 2-3 years ago that I would follow for myself. I'm 37, and have breastfed 5 children for a combined total of nearly 8 years. I don't smoke, don't have a family history of breast cancer. So I saw no reason--based on looking at the research--to start screenings prior to age 50, and then I plan to do them every other year or so--depending of course on previous findings and any "gut instinct."

I have a sister-in-law who says that a mammogram saved her life. I can't argue with her as she isn't going to budge her position...though I secretly have to wonder if the mammogram caused her a LOT of stress, and perhaps picked up a cancer that would have resolved itself...or worse...did her annual mammograms CAUSE the cancer?

Michael Kirsch, M.D. said...

I agree with Toni that USPSTF is highly regarded in the medical community for its thoughtful and conservative approach. I know of no more reliable organization. To KM, with all respect to my oncology colleagues, I haven't found this specialty to be quite as objective. Many tend to try to treat and cure devastating diseases, even when the medical evidence for these treatments is slim. In addition, their treatments are often extremely expensive and quite toxic to the patients. Of course, their intentions are good, but sometimes I wonder about the judgment. With regard to Toni's comment, " I saw a patient today who said she would have every screening test available, even if there was a 1/million chance of it finding disease because it is that important to her to live a long, healthy life. She wants colonoscopy every 3 years and is not deterred by "guidelines"; I am okay with this, but don't think it would be fair for her insurance company - or the rest of us - to pay for medical care that a patient demands that is entirely unsupported by medical evidence and standard practice. www.MDWhistleblower.blogspot.com

Toni Brayer MD said...

MichaelKirsh,MD: Agree, well said.

Toni Brayer MD said...

Knitted in the Womb: Yes, as you know, one of the theories of why the incidence of breast cancer is increasing is because we are picking up DCIS, which may have an entirely different natural course. Many women are undergoing mammograms and ultrasounds every 6 months for a lifetime because of the "risk". The anxiety it causes is profound.

Today's NYT says many doctors and patients are ignoring the new guidelines. I suspected this is a debate that will not be easily resolved but at least the subject is being discussed openly. We need to keep an open mind and not get hung up with a fixed ideology.

Anonymous said...

I would guess surgeons are more prom to suggesting yearly mammograms starting at 40 and going foreword with out skipping a year in the 50's-60's.

tracy said...

Maybe some people just like getting any and all medical tests they can...it's sad they "over-worry" soooo much about every aspect of their health...unless there's a specfic reasonn to worry. Did someone already mention Muncheausens? And yes, i am a nut, but i don't deal with it but going "nuts" with the medical tests.

KM said...

What the American College of Radiology is saying.

http://www.acr.org/HomePageCategories/News/ACRNewsCenter/UPSTFDetails.aspx

The American Cancer is similar in what they are saying.
I do know of two friends with normal mammograms. with lumps found in exams with doctors that tested positive for cancer in biopsy . Neither had a family history of breast cancer.

It is confusing.

M.scott said...

These tests are not the cause of anxiety in patients. Anxiety about our health is born out of the mountains of health care information (often conflicting and confusing) that we are buried in on a continuous basis. It is extremely difficult for an average non-medically trained consumer to make any type of sound judgment regarding his or her health care choices on their own, so we turn to the "experts", our personal physician, or, barring that, physicians who speak on behalf of respected health care organizations...but even then the opinions often vary and conflict with one another.

I don't think that it is fair to blame patients who prefer to be more diligent in their own health care choices. This diligence is a natural reaction to being confronted with more information than can be processed.

Sometimes I wonder if we have all just become far too smart and informed for our own good. Perhaps, as some of you seem to be implying, a certain degree of ignorance really is bliss.

Michael Kirsch, M.D. said...

Of course, it is confusing for ordinary folks to sort out conflicting medical information. This is why it is so critical why patients need more information, not ignorance. You need to advocate for yourself. Be skeptical and ask questions. Whenever possible, an individual who cannot effectively serve as his own advocate, should have someone with him to provide this necessary protective function. We manage to buy cars and appliances, despite being deluged with conflicting quality and price information. While the stakes in medicine are higher, the process is similar. www.MDWhistleblower.blogspot.com

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