They do not question their logic. That is, they don’t consider whether the outcome would have been any different without early detection or extensive treatment. And if the many healthy years do not materialize, it is seldom remarked on. The sad truth is that, despite excruciatingly slow advances in treatment, there is still no way of knowing with certainty whether the surgery, chemo, or radiation “got it all.”
These days, on the rare occasions when someone really wants to know why I don’t get mammograms, I’m glad to be able to share the information from a useful little pamphlet published online in eleven languages in 2008 by that remote-sounding Nordic Cochrane Centre. It’s located, as it happens, in Denmark:
“If 2,000 women are screened regularly for ten years, one will benefit from the screening, as she will avoid dying from breast cancer. At the same time, ten healthy women will…become cancer patients and will be treated unnecessarily. These women will have either a part of their breast or the whole breast removed, and they will often receive radiotherapy, and sometimes chemotherapy. Furthermore, about 200 healthy women will experience a false alarm. The psychological strain until one knows whether or not it was cancer, and even afterward, can be severe.”
Another important fact from my friends at the Nordic Cochrane Centre: It has not been shown that women who undergo regular screening live longer than those who don’t. This information is available elsewhere in different forms, but I like the clarity and concision of the Nordic Cochrane Centre pamphlet—as well as its list of solid scientific references.
Although I’m fully persuaded, I’m not naïve. I know it will take more than this information for many of my friends to shift their thinking. The “routine” mammogram has become part of the cycle of their year. They get prodding and support from their family, social networks, and doctors who must adhere to community standards of practice. Doctors and other providers, meanwhile, have to reckon with the knowledge that preventive health screening statistics might be collected from patients’ charts by review boards, insurers, or plaintiffs’ attorneys.
Discord In The Ranks
The Washington Post headline late in 2009, “Fierce Debate Raging over New Cancer Test Guidelines,” came as no surprise to me. The US Preventive Services Task Force had recommended that women age fifty or younger, as well as those over seventy-five, talk to their doctor about how often they should be screened, rather than automatically opting for an annual mammogram. What’s more, the task force recommended a screening mammogram every two years for women ages 50–74. The task force is an independent panel of private-sector experts in prevention and primary care; it is currently composed of ten physicians, one nurse, and a Ph.D. in health management and policy. The members had relied on the available evidence, statistical models, and their own professional judgment to reach their conclusions. (If you want to find out more about the basis on which the task force made its recommendation, read “Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement” in the November 17, 2009, issue of the Annals of Internal Medicine.) After the recommendations were released and a heated debate began, the disappointing news that government officials were quick to backpedal from the task force’s recommendations didn’t surprise me, either.
What? No more yearly mammograms? No routine screening for most women below fifty? The media were quick to highlight the discord among medical professionals who responded publicly to the recommendations.
Some activists suggested that the recommendations were a political move aimed at cutting costs, and that the government and private insurers would soon limit the number of mammograms they would pay for. Those breast cancer awareness advocates who believe that catching cancer early is a matter of life and death cried foul.