Lessons from the mammography wars

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This is a thoughtful “sounding board” piece in the New England Journal of Medicine this week.

http://healthpolicyandreform.nejm.org/?p=12525

It is so important to keep this discussion alive. The miscommunication that took place last November of what the US Preventive Services Task Force tried to convey, and the complicity of some news organizations in adding to that confusion, provide lessons from which we simply must learn to do better.

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Gregory D. Pawelski

September 9, 2010 at 9:26 am

Good tracking Gary. Thanks!

Jeff Kreisberg

September 9, 2010 at 10:23 am

Also, the lack of courage displayed by Secretary Sebilius.

James Allison MD

September 9, 2010 at 3:48 pm

I totally agree that this was a very thoughtful and important piece which is as pertinent to prostate cancer screening and colorectal cancer screening guidelines as it is to guidelines for breast cancer screening.
I wonder if you would like to comment on Dr. Oz’s colonoscopy. Here is what I thought about it and the attendant publicity on ABC, Fox,Oprah et al.
Dr. Oz’s sharing of his “near cancer death” experience with the American public once again shows the media’s complicity in hyping the significance of small adenomatous polyps and will undoubtedly send thousands (those who have insurance) to get their normal colonoscopies (83-85% of colonoscopies in average risk patients are completely normal) for fear of dying from colon cancer. Why are the other evidence based effective screening tests for colon cancer not mentioned and what is the truth about the real risk to patients from colon polyps? Dr. David Morowitz Clinical Professor of Medicine at Georgetown University said in a 2006 issue of Gastroenterology & Endoscopy News that “The exaggerated hypothesis that every polyp regardless of how benign appearing, must be treated as a cancer waiting to happen demonstrates reasoning as flawed as managing every pigmented skin nevus as though it were a melanoma.”
For anyone willing to listen with an open mind here are the facts:
1. Most polyps, even the “advanced” ones, do not directly lead to death from colon cancer
2. Advanced neoplasia may be considered a convenient proxy for colorectal cancer but its use as an outcome measure may be misleading in screening studies because the natural history of this lesion is unknown
3. The prevalence of high grade dysplasia in subjects found with small adenomas was only 1% in a large U.S. colonoscopy study
4. Longitudinal studies assessing follow-up of unresected small colorectal adenomas harboring high grade dysplasia is lacking. We have no idea how many will progress to fatal cancer or over what period of time
5. The term “advanced adenoma” is misleading because the natural history of this lesion is unknown
6. The definition of an advanced neoplasm as used in the gastroenterology literature is very different from that found in a standard pathology textbook
7. Most advanced neoplasms are polyps and only a small percentage of them present a risk of progression from benign to malignant status
8. At present, our ability to identify those that will is limited and based on phenotype (what it looks like under the microscope)
Adenomas as they are portrayed by the U.S. media and some specialty societies could qualify as good examples of “overdiagnosis”. Hopefully, new biological tests (stool or serum markers) will be developed that are superior indicators of risk than polyp phenotype. Until we have such tools we must be mindful of our budget deficits and limited medical resources. We (including the media) must educate the public and legislators that the real risk of any polyp progressing to fatal cancer is small. Education will give patients the proper perspective about the real importance of finding or missing a polyp at screening and may both decrease fear and curb the enthusiasm for population screening with expensive and possibly harmful tests

Lisa Adams

September 9, 2010 at 6:39 pm

Having had a double mastectomy for stage 2 breast cancer 3 years ago I have thoughts about the mammogram guidelines. But I would like to take my space here to instead commend Dr. Allison for his insight and analysis of Dr. Oz’s dramatic and over-hyped colonoscopy experience.
I am surprised that, as a surgeon, Dr. Oz would indulge in this emotional response rather than a more analytical, calculated one. Over-reacting, portraying a finding as “more than it is,” only serves to frighten viewers, not educate them.
Dr. Oz could have used it as a teaching tool to show that “despite how scary it seems, this finding is not something to freak out about”… which unfortunately is exactly what he did– in public. He had an opportunity and an obligation to show how such situations can be handled with dignity, intellect, and reason, something I have tried to do in my own life.
I wasn’t a fan of his before, I am most certainly not now. He displayed with this instance that he has become more media-oriented and less scientific… and that is a dangerous thing.

c3

September 9, 2010 at 11:51 pm

I have had many discussions with my wife, other doctors and others regarding this. Two key aspects of this situation just seem unacceptable to folks:
1) that a cancer could go away without any treatment
2) That an accepted screen in one population would not “work” in another. And I should add that “too many false positives” by and large doesn’t resonate with folks as “not working”
We have oversold cancer as THE disease and there’s no going back.
(I’m mean doing that would be giving up right? And I don’t give up; I’m a fighter.)

Medical Contrarian

September 12, 2010 at 7:11 pm

This is where the world of science intersects with the world of politics. Science turns on data. Politics turns on emotion. The trajectory of current events takes us to a world where resources will be allocated more and more through political decision making. The fate of the Preventative Task force recommendations is a harbinger of the fate of politically unpopular but data driven decisions in health care.
See “Politics and bending the health care cost curve” at http://georgiacontrarian.blogspot.com/