Great read David, thanks for covering this.

There’s a lot of concern (my wife included) among some women regarding the radiation ingested during mammograms.

With much personal testimony broadcast or published that the radiation alone is of itself the cause for some breast cancer manifestation.

I saw comments on the recent guidelines posts from some who posit there’s NO DATA that supports having mammograms increases cancer survival.

I wouldn’t know about that, but I can’t BELIEVE that early detection thru mammograms is outweighed by exposure to x-rays . . . . now, the age to START mammagrams, and the frequency of same is an open topic.

Women must educate themselves, not blindly follow their primary care doc’s or health plan’s dictates, but decide for themselves when and how often.

MORE education should be the issue, not the usage of mammograms. And self examination and awareness SHOULD be part of the dialogue . . . if a mass is detected, it should be looked into. Anything to empower women to have and make choices, and help them to protect themselves, should be on the table.

These new guidelines from a NON governmental source worry me, and I question the source funding for it all.

Again, thanks for your coverage of the issue(s).

Your News Desk is incredible in it’s breadth, and it’s depth.

Don’t know how you do it all . . . but thanks!

Considering the role of the HHS Secretary in setting which procedures will be covered under the minimum benefits package, and possibly what will be exempt from cost sharing, it’s notable that she is distancing herself so swiftly from the recommendations.

That’s because she knows it’s garbage. Not to diminish the big HOORAY from me.

Unfortunately the private insurance companies have already said they use the recommendations of this committee in determining coverage.

A very thoughtful review of this controversy:

http://www.sciencebasedmedicine.org/?p=1926

(Not me, BTW)

I don’t see how anyone can argue that the USPSTF recs won’t be used by private insurance in denying coverage for mammograms. Their guidelines are considered “the gold standard” by some of the biggest insurance companies in the nation. It’s fine to say, “well, the task force is just recommending that women have a conversation about risk with their doctors and decide on an individual basis if they want to have a routine screening or not,” if you are living in a country with national health coverage. But if you’re living in a country where private plans base their coverage on guidelines from the USPSTF, the question needs to be asked and answered: “What if a woman decides she wants routine screening? Is she going to have to fight for coverage, or is she going to have to shell out a few hundred bucks?” The answer most likely is going to be “yes,” if not this year then soon. And that means a number of women will forgo it.

That’s just the way it is. X = X. I’m not arguing against the research or science, although even the task force apparently graded their evidence a “C.” I’m just saying this is how it works with private insurance.

I could not agree more that each woman must educate herself as throughly as possible and must participate as fully as possible in determining her needs and treatment plans.

But that does not relieve the medical care institutions from the responsibility to do good science and to be crisp in their recommendations. No single woman can know all that is necessary nor do her own science. I am saying this to myself and my fellow physicians..

USPSTF trashed their credibility by changing a particularly sensitive set of recommendations without laying out their case in a thoughtful and considered way. I think anyone who has dealt with a number of physicians will recognize this form of tin-eared dimwittery.

So mammograms for those under 50 are going to be treated like abortions – legal but not covered by medical insurance?

Sheesh.

As I understand it (IANAD), the other risk from mammograms is a false positive, i.e., detecting something that turns out not to be a cancer, which therefore entails medical procedures which prove to be unnecessary, not to mention the emotional rollercoaster of the false diagnosis.

Yes. And one thing the discussions on this haven’t covered (largely through teh fault of the task force) is that the US treats a lot of DCIS that, in Europe, would not be treated. It’s why our cancer “survival” rates are higher. But the thing is, much of this DCIS will never become cancer. So you’re exposing people to chemo and/or radiation for “treatment” when they don’t have “cancer.”

We’re treating more DCIS because you find it via mammo and we do routine mammos more.

False positives are a natural function of a screening device. However, as I have pointed out before, it is the false negatives that kill you.

That, and treatment that itself can kill you.

My heart’s going to give out at least 10 years early bc of my treatment. Now I clearly needed. But imagine if I didn’t.

Great pic of Sibelius and this populist move on mammography seems just right too! Very good.

I think a bigger reason is that 49 states already mandate mammography coverage under the old guidelines for patients over 40. It would take a lot of politicking in the states to take that away. It’s certainly possible, but it would be anything but immediate.

Yes, good call.

But, would a woman prefer a false diagnosis, or skip the treatment and risk that there WAS something she didn’t know about?

Just curious what women think . . . my wife is against the radiation aspects, vehemently. She’s had mammograms in past, but won’t now unless self exam causes her concern. Or a doc check up detects reason to proceed further.

It’s her choice, and I honor it with few questions other than, ‘are you sure’?

From my perspective, the decision to have or not have a mammogram—like other healthcare decisions—should be between a woman and her doctor. Personally, I have chosen to forego regular mammograms for a number of reasons, not the least of which is an absence of family history predictive of breast cancer.

Merrill Goozner (at Gooznews.com) has questioned the cost-effectiveness of yearly screening. Speaking at a conference, he came up with back-of-the-envelope estimates that it costs approximately $3.8 million to save one life based on annual screening. Now if the one life being saved is your own . . . or your mother’s or daughter’s or best friend’s . . . $3.8 million may not seem like too big a price tag. But remember, it is being paid for primarily with other people’s money (the insurance pool, with ever-increasing premiums). If one wants to think logically about the cost of a life, ponder this. Do we insure each of our military personnel for $3.8 million so that in the event they die on the battlefield, their family will be adequately compensated for the loss of life? If a military life is not worth that cost (to the taxpayer) then how can we say that a life saved from cancer is worth that amount. [If you read Goozner’s follow-up post, the cost is actually much greater than $3.8 million per life saved . . . it is more on the order of $20 million.]

Again, it is my opinion that rationing—at least to the extent that those not at high risk space their screening at wider intervals—indeed seems a sensible approach. For those women who cannot live in peace without an annual mammogram . . . go for it. For many, though, the annual mammogram screening is merely a rote exercise in compliance, being good little foot soldiers, fattening the wallets of healthcare providers unnecessarily.

I agree it wouldn’t be immediate. But current coverage was mandated under old guidelines, as you say. Now we have new guidelines. So there is good reason to anticipate changes in mandated coverage.

Again, I can’t speak much to the evidence for the new guidelines. I’m just saying that, in a private health care “marketplace” like ours, I worry that one more segment of women will forego mammograms that they otherwise might need because of cost. Not right now, but in a few years down the road.

I understand that there is also a risk of false positives, and that some women undergo unnecessary biopsies and treatment for microcalcifications that probably wouldn’t shorten their lives. I think we all can agree that discussions about individual risk with your doctor are a key ingredient here. Still, all the discussion I’ve heard about this centers heavily on “you and your doctor decide what is best for you,” with little followup about coverage if “you and your doctor decide” it is best to get regular mammograms before age 50 but your insurance says “talk to the USPSTF guidelines, sucka.” And there is no reason to think that won’t happen.

Listen folks.

There is WAY too much very expensive and totally unnecessary testing going on in USA medicine. There are REASONS why medicine takes roughly double the share of GDP than any other nation on earth and unnecessary testing is a candidate for reason #1. When 98% of MRIs reveal nothing it is obvious they are being overused, for example.

And even beyond the rip-off, unnecessary medicine is actually dangerous. Mammograms introduce radiation, are very uncomfortable, and take place in the filthiest places on planet earth (I say this a former surgical orderly who lived with an accomplished woman who headed up the surgical infection control committee for a MAJOR hospital–she would NOT visit a hospital as a patient unless she was convinced she was at death’s door.)

If we are going to have medicine that covers everyone, we simply MUST cut down on the criminal levels of waste in the system. Yet every time someone even suggests that some expensive procedure MIGHT be being misused or overused, or simply wasting people’s time, the PR folks will roll out the six exceptions that “prove” some colossal rip-off actually works.

I think instead we should make these clowns PROVE that what they are doing is effective medicine. And since we are getting third-world outcomes for Mercedes prices, we should be VERY skeptical. And in my book, routine mammography for 40 year olds is a prime candidate for skepticism.

YES!

Thank you for this.

I wish you well on your decision. I am certain you would never impose your judgement on other womrm

Please document the 3.8 million figure.

Even if it is valid. Just how much do you think we spend on balloon boys and wealthy adventurers such as Fosse or stupid college students climbing Mt. Hood? And then there are the wars.

I won’t even pretend to document a 3.8 million figure. Mostly, it is irrelevant. What IS relevant is that we have a medical-industrial complex we simply cannot afford that leaves out 50 million people. And if you actually believe there isn’t massive waste and rip-offs in our current system, I would encourage you to go work in a hospital for a while. And then ask yourself, how can we spend double what they do in say, Finland, and get the ridiculously bad outcomes we do if there isn’t waste and fraud in the system?

BTW DCIS stands for Ductal Carcinoma in situ. So it is cancer. However as the name implies it is not metastatic or locally invasive.

In respect I think we are straying into striving to manipulate the insurance companies. What we need are consistent criteria for reimbursement as one would have with single payer. And that should provide adequate leeway for individualized decision making and study of such things as best management for carcinoma in situ. As things are now, both private and Medicare/Medicaid limit the options by limiting coverage. That is not to say there should be no limitations….. Ah……There’s the rub. But we certainly would have more reason and influence by the consumer with a Medicare for all type plan.

BTW DCIS stands for Ductal Carcinoma in situ. So it is cancer. However as the name implies it is not metastatic or locally invasive.

That would be at the time of diagnosis.

I certainly would not impose my decision on others. And quite frankly, I DO believe that insurance should pay for the screening. I just think there are a lot of women who do “the right thing, the expected thing” laid down by the medical “industry” that asserts responsibility equates with annual breast mammograms. As I said: I do not have a family history . . . and thuse choose NOT to have annual mammograms. I’ve saved my insurer thousands of dollars; have not further subjected myself to “false positives” with follow-up invasion (been there, done that). On the other hand, my daughter is adopted and I do NOT have a family history for her to base her decisions on. As a young mother, I hope she regularly performs self exams, and periodically avails herself of mammography.

I’m just tired of providers using scare mongering to herd us–sheeplike–into compliant behavior that, for many of us, provides nothing but a money stream for the providers and further strains insurers–at least to the point that they can inflate premiums for everyone.

Yes, there is way too much expensive testing. But even the (relative) inexpensive testing inflates healthcare costs. Here’s an example. My hubby is a T1 diabetic. Whenever he goes to the doctor, they ALWAYS perform a bG reading. Even though this provides only a snapshot of his blood glucose at a moment in time . . . and even though he may have performed a self-test only minutes before entering the doctor’s office, his insurance company is billed $10-$12 test for this non-useful test. Consider how many diabetics have their bG taken EVERY DAY (on top of their own consumption of bG strips) and it is easy to see why testing costs continue to rise . . . with no substantive benefit to the patient–only to the healthcare provider and the manufacturer of the testing equipment!

I apologize for being a git, but aren’t we for “science based medicine” and isn’t this “science based medicine?”

Don’t we want efficacy studies published?
Don’t we want to modify doctor/patient behavior to utilize the more effective, more efficient treatments?
Isn’t our only hope to bending the cost curve based on science based medicine and using it to eliminate the deadwood of treatment?

So then, shouldn’t we be upset with Sebelius and her obvious sop to misguided ill-informed feminist political pressures that insist this is misogyny and not science based medicine?

(There is some obvious trolling here. I myself want effectiveness studies published, but I do think there is a lot to be said for allowing the doctor and patient to set the treatment, even when that ignores the effectiveness studies.)

Yes, there is too much “inexpensive” testing too. Although, in my opinion, charging $12 for something as simple as bG test is a damn rip-off too.

Of course, charging $12 for a bG test, $25 for an aspirin in a hospital, and $40,000 for a pacemaker that is less sophisticated electronically than a $200 iPod and pretty soon you’re taking about real money.

What IS relevant is that we have a medical-industrial complex we simply cannot afford that leaves out 50 million people. And if you actually believe there isn’t massive waste and rip-offs in our current system, I would encourage you to go work in a hospital for a while. And then ask yourself, how can we spend double what they do in say, Finland, and get the ridiculously bad outcomes we do if there isn’t waste and fraud in the system?

I agree with everything you say. As it is my profession it breaks my heart. I know it does not have to be this way. That said I am impressed with the dedication that most bedside caretakers serve under deteriorating condition’s and am grateful for them. It is the power of the interaction between the suffering and the healer that keeps it going and always will modify much of the evil inherent in profiting from the helpless.

My dream would be a radical paradigm shift from the failed free market driven by competition to a caring community. I did put up a diary with some of my ideas but it has since scrolled off.

Yes indeed–the caregivers are beyond saints. Nurses are hideously overworked, etc.

When my mother was dying in a nursing home, I was astonished at the quality of care she got from aides making less than $9 an hour. Of course there are caring people in the medical world. It is a damn shame they are being eclipsed by the crooks and rip-off artists.

Yes, I did not mean to imply that it would stay that way. It is in fact the best situation for effective treatment.