Nuanced balance is not easily communicated on latest mammography study

A Systematic Assessment of Benefits and Risks to Guide Breast Cancer Screening Decisions” was published in the Journal of the American Medical Association this week. It reached a conclusion that you might think few could disagree with – although on this topic one should never underestimate the potential for disagreement.  The authors wrote:

“Mammography screening appears to be associated with reduced breast cancer mortality, but for some patients, the harms may outweigh the benefits. Until better screening methods are available, improved understanding of these harms, enhanced strategies to identify the highest-risk patients, and tools to help patients and clinicians incorporate these in their decisions should be research priorities.”

In an accompanying editorial, Drs. Joann Elmore and Barnett Kramer write that the “nuanced balance is not easily communicated.”  Indeed, they point out how federal government coverage policy may oversimplify the issue:

“With the goal of improving access to preventive services and medical screening, the Affordable Care Act (ACA) offers free screening mammography to women. However, women often pay for the consequences of screening, even if the screening examination is free. Women bear not only financial charges but also important human costs. Screening mammography can trigger recalls for more testing, biopsies, mastectomies, radiation, systemic therapy, days off work, and debt related to health care costs. These byproducts of screening can lead to adverse financial consequences and personal harm. ...Balanced messaging is essential to help each woman make her own individual decision regarding her participation in screening mammography. “

“Nuanced balance is not easily communicated.”  Certainly not in news headlines.

The Washington Post published a headline: “Despite strong benefits, mammograms may have greater harms than previously realized, study says.”  The story goes on to refer to “substantial” benefits. No reference to “strong” or “substantial” benefits appears anywhere in the JAMA article in question.  The story goes on to quote one of the authors of the study, saying:

“The data that we have are not perfect, and they are mixed. But they do strongly suggest that ­although mammography does have benefits, it does also have a lot of harms, and those harms are not insubstantial.”

” It is “profoundly disappointing that mammography doesn’t quite live up to its promise…it does not show as strong a benefit as is often suggested in the media.”

Strong and substantial versus profoundly disappointing and not as strong as suggested in the media – in the same story!  No, nuanced balance is not easily communicated.

A Hawaii TV station’s story boldly stated, “Mammogram benefits outweigh risks, new study says.” Which study was that?  No, nuanced balance is not easily communicated.

Meantime, as just one little glimpse of how special interests are in a battle for the hearts and minds of American women – and for the hearts and minds of journalists – on the mammography issue, The Society of Breast Imaging – the people who have a vested interest in mammography – paid to have an exhibit at the Association of Health Care Journalists conference in Denver last week.  The Association states that it “seeks to minimize the possibility and appearance of inappropriate influence from outside parties,” but that “a very limited number of organizations in this category (not-for-profit associations or societies that represent those who sell health care services or who lobby legislators on health care issues) will be allowed to exhibit at the annual conference.”  Below is a photo of Dr. Daniel Kopans making a point to a journalist who walked by the exhibit.

In response to the new study,  The Society of Breast Imaging issued a news release, “JAMA Article Breast Cancer Screening Recommendations Potentially Deadly for Many Women.” But the JAMA article was a review of the evidence, and didn’t make any direct recommendations about screening.  Rather, it focused on individualizing decisions based on patients’ risk profiles and preferences, and on an improved understanding of potential harms.

No, nuanced balance is not easily communicated.

In a past statement of “facts about mammography screening” on the Society of Breast Imaging website, Dr. Kopans gave advice to women over 40:

“Obviously, it is your decision, but I recommend that you have a mammogram every year as long as you are in good health and would have treatment if a cancer is found.”

That is a recommendation. Nuanced balance?  You be the judge.


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