Saving Stress And Saving Money (At The Cost Of A Few Lives)

With friends like this...

New guidelines issued by a Federal task force urge women to hold off on routine mammogram screenings until they are 50.

The WaPo recognizes that in the current debate over health care reform this news will spark discussion about saving  lives versus saving money.  Here is their third paragraph:

Coming amid a highly charged national debate over health-care reform and simmering suspicions about the possibility of rationing medical services, the recommendations immediately became enveloped in controversy.

The NY Times is much more trusting of the government and the scientific community.  They acknowledge the possibility of "controversy" in their fifth paragraph, but make no mention of the link to current politics:

Its new guidelines, which are different from those of some professional and advocacy organizations, are published online in The Annals of Internal Medicine They are likely to touch off yet another round of controversy over the benefits of screening for breast cancer.

Hmm - I guess there is controversy over whether Vitamin C reduces colds, too.  It is only in their final three paragraphs that the Times gets to the obvious:

Researchers worry the new report will be interpreted as a political effort by the Obama administration to save money on health care costs.

Of course, Dr. Berry noted, if the new guidelines are followed, billions of dollars will be saved.

“But the money was buying something of net negative value,” he said. “This decision is a no-brainer. The economy benefits, but women are the major beneficiaries.”

There is nothing to worry about and anyway, our watchdog media would bark if there was.  Wouldn't they?

FWIW:  Per the WaPo, the models indicate that moving the age for standard screening back to 50 does increase deaths, albeit slightly (my emphasis):

In addition, the task force commissioned an unusual study funded by the National Cancer Institute that involved six independent teams of researchers conducting separate mathematical modeling studies of the risks and benefits of 20 screening strategies.

While annual mammography for all women beginning at age 40 reduced the death rate from breast cancer by at least 15 percent, the modeling studies indicated that the added benefit of starting before age 50 was modest, the researchers concluded.

For every 1,000 women screened beginning at age 40, the modeling suggested that just about 0.7 deaths from breast cancer would be prevented, while about 470 additional women would receive a false-positive result and about 33 more would undergo unnecessary biopsies.

"What isn't in the model but is an issue is how many extra imaging tests are done to follow up on things that turn out to be falsely positive and the harm of the anxiety that goes along with that," Petitti said. "Then there's the whole other line of problems that come into play, which is where there are some breast cancers detected that grow very slowly and would never have killed you."

One also wonders about women in "at-risk" groups who misinterpret these new guidelines and skip early testing.

PUZZLING: I also wonder about this - for every 1,000 women tested in their 40's there willl be 470 false positives?  Is that per year, or 470 false positives over the decade of a woman's 40's.  Put another way, in a group of 1,000 women tested ten times each (ages 40-49), are we being told that 470 false positives will come back from 10,000 tests?  Is that 470 different women, or do the same women consistently return false positives, which I assume is less stressful after a while?

Comments

[Keep abreast of the panels' work.]

The false positive rate is so high because of the tremendous damage of a missed diagnosis. Easy solution, don't do the imaging. Oops, diagnoses are missed.
=====================================

[Janet for choice]

MY BODY, MY CHOICE!!

If I'm younger than 50 and want a mammogram then it is my choice...just like if I want to kill my baby. - and the government better pay for it.

[BumperStickerist]

"Then there's the whole other line of problems that come into play, which is where there are some breast cancers detected that grow very slowly and would never have killed you."

Call me male, but that's one odd definition of a "problem"

.

Back in the day, Reagan had polyps removed from his intestine. The polyps were benign. The comedy was, too. I recall one protestor's sign in particular:

If it's benign, neglect it.

.

closing thought - I wonder what Katie Couric's response to this will be - she had a colonoscopy on televison which created the "Couric Effect" and is a proponent of early, non-cost/benefit analyzed screening. Maybe she can square Obamacare's circle.

[daddy]

Well not to worry TM,

If we continue on this world apology tour of continuing weakness and dithering, and quietly sitting by while Afghanistan collapses and Iran continues to build nukes, one of these days every female in New York City is going to get as much personal radiation as she could possibly want, even without mammograms, and all provided free from some foreign source.

[Janet]

It shows how the government run health care will cut costs. "Experts" will periodically issue new findings..."Hold off on that Mammogram", "Prenatal care Overrated", "Broken Bones, No Problem: How I Learned To Live With My Arm Askew", " Jaundiced and Lovin It".

[Janet]

Leftists don't think things through as to the consequences of their actions. On our neighborhood listserve a neighbor writes that they have given up their car to be green. They now realize that they need their car to DO certain things...like get their recycling items to the city collection point. So they need rides! Good Lord! I'm tempted to type in the suggestion...buy a car.

[Hby]

My wife was diagnosed with Stage 2 breast cancer approximately 1 year ago (at age 44). She was not considered to be in a high risk group. The tumor was relatively small (<2cm) but it did spread to a few lymph nodes. We do not know if it metastasized to other areas (e.g. bone, brain, liver, lung). Full body scans are not routinely done for metastasis unless there are symptoms. Part of the reason is that once the cancer metastasizes there is really no chance of "cure". The breast tumor could not be felt on physical exam (even after the docs knew the exact location). So if my wife waited until 50 for the first screening, she would either be, worst case, dead or best case, Stage 4, with no chance for cure.

The survival rate for breast cancer has gone up over the last several decades. Sure some of it has been due to a better understanding of the biological makeup of the cancers plus a few key drug discoveries (e.g. Tamoxifen/AI's, Herceptin), but a large part of the increased survivability is due to detecting the cancer much earlier though improved screening before it has a chance to spread to lymph nodes or other areas.

Someone can refuse to be screened before 50, but no one should be denied annual mammograms.

I guess the death panels and gearing up in anticipation of passage of the Obamacare.

[cathyf]

Here's another turd in the cost-cutting punch bowl: these recommendations are done based upon studies of US populations, and so they are skewed towards the demographic makeup of the US. Whatever the "correct" age is, it's for white women -- black and hispanic women should start mammograms 5 years earlier, and asian women 5 years later.

Try putting THAT little piece of racial bias in a government regulation.

[MarkJ]

"But the money was buying something of net negative value,” he said. “This decision is a no-brainer. The economy benefits, but women are the major beneficiaries.”"

The biggest "no-brainer" we're dealing with today is currently parked behind a desk at 1600 Pennsylvania Avenue (when he's not off idiotically bowing to foreign emperors).

[Hby]

By the way, regarding this new government recommendation on mammograms, here a just a quick quotes pulled from a popular breast cancer forum site (LUN):

"...this just makes me so angry I am spitting nails!!!"

"...this just pisses me off beyond words. i was diagnosed this year at the age of 43."

"a pre-curser to government controlled healthcare."

"I just got interviewed by abc news about this. I should be Good Morning America in the morning. I don't think I came across as angry as I feel about this."

"This is outrageous! I was 42 when I was diagnosed, with no family history, and have known many women under the age of 50 and even 40 who have lost the battle. They are turning over in their graves as I type this message. This reeks of health care rationing . Unbelievable. Too pissed to say anything else right now."

"It's rationing, government controlled health care. They don't want to spend the money on us!"

"government recommendations......and we want the government to control the entire health system..."

"I am ticked off beyond belief at the sheer stupidity of this. I am at a loss for words. I am sad. I have tears in my eyes thinking about how many of us were diagnosed before the age of 50."

Just a sample from one of many threads.

[MikeS]

So, the new plan is to "entitle" millions more people to health-care and then to deny that they need it?

[narciso]

No, there's so such thing as 'death panels' it doesn't appear in the bill, WTH is wrong with these people

[J]

My impression of what dems do to women is not good. First telling them to go out and have indiscriminate sex...because men do and we are equal to men....then telling them to have abortions with NONE of the safeguards and warnings given in other surgeries....and now, of all times, telling them to cut back on mammograms....yeah, the dems have done a great job ON women.

[Bob K]

Statistician William Briggs has a decision calculator that can handle mammography and also prostrate. He also has some real-world data from 2002 that he uses in his example. A sample of 1000 mammograms age 40-60 show true positives 7, false positives 70, true negatives 922, false negatives 1.
http://wmbriggs.com/blog/?p=1229

[Janet]

Yes MikeS...that looks like the plan.
Perhaps we need to go back to school and get degrees in expertology so we can have a say in what medical treatments are needed. Or is that degree already in existence...called Journalism?

[bad]

Y'all are looking at this all wrong. With more women dying from breast cancer there will be less need for end of life death panels, and the dead women's share of Medicare and Social Security can be used for someone else. Plus, when thy're dead they won't be driving cars which is going to improve the environment.

"Be compassionate!! Skip your mammogram!!"

"WTH, blow off your colonoscopy, too"

[Ranger]

So, the new plan is to "entitle" millions more people to health-care and then to deny that they need it?

Posted by: MikeS | November 17, 2009 at 08:33 AM

Yes, exactly. The gliteratti and the credentialed moron classes think they will still be able to buy healthcare on the private market if they need it. So, why waste all this money on the common rif-raf. Their plan is to convince the rif-raf that everyone will have the same "health care experience" regardless of wealth, then sneak out the back and buy private health care out of their own pocket.

[clarice]

These facts have long been known and the issue long debated. In the end it comes down to whther you are in the .7% or know someone who is .
If you have the fast growing type, annual mammograms are not terribly likely to do much for your outlook unless they are timed in a way that's fortuitous; if you have the slow growing kind you might die decades later without ever even knowing you had it.
There was a great articles years ago by a pohysician in the Atlantic which explained this far better than I can (I think his name was Rappaport). In any event no matter what the hype is, true breast cancer death rates have not changed much for ages.

[clarice]

P.S. Regqrdless of my post, if this kills Obamacare which is truly horrendus, great!

[Jane]

Supposedly FWDAJ is supposed to be live streamed at the LUN. I'm not confident, but if you tune in, let me know.

[bad]

I thought Ibowma was all about preventative medicine.

Just another big fat lie.... sigh, my illusions continue to be shattered....sob, sob

[Rick Ballard]

Bob K,

Thank you for the link to Brigg's question. Briggs provides a rational answer regarding the value of testing. Somehow I doubt that will be greeted warmingly.

[clarice]

From the Plotkin article (which I think still is the best on the subject):
"If, as I suspect, a woman's fate is set very early in the development of a tumor, it seems implausible that advances in detection will have an impact on the disease. One can always hope that science will develop a wonder drug that eradicates tumors completely, even when they can't be seen or felt. But for the present I think we should focus research on improving our ability to distinguish between women with breast cancer who can benefit from aggressive treatment and the larger number who will gain little from it no matter what we do.

The ultimate hope is preventing this awful disease, perhaps by modifying the contemporary hormonal environment that seems to promote it. Researchers at the University of Southern California have been examining ways to lower young women's exposure to reproductive hormones. Another approach is to use an anti-estrogen drug like tamoxifen preventively in postmenopausal women whose histories of breast problems indicate that they are at high risk of developing cancer; I am involved in a study that is examining this kind of treatment. The risks in changing the hormonal balance of millions of women are considerable, however, and it seems likely that any new preventive for breast cancer will have its own side effects.

Advances in this area will surely be slow, but they may be the only realistic hope for eventually lowering the death rate from breast cancer. Meanwhile, we should carefully consider whether we are misleading some women with messages of unwarranted hope at the same time that we are needlessly terrifying and hurting other women by diagnosing and treating a condition that will never pose a threat to their lives. "

[Rick Ballard]

Bob K,

Thank you for the link to Brigg's Decision Calculator. It's well worth a read by anyone remotely interested in the answer to TM's "Put another way, in a group of 1,000 women tested ten times each (ages 40-49), are we being told that 470 false positives will come back from 10,000 tests?" question. Briggs provides a rational answer regarding the value of testing. Somehow I doubt that will be greeted warmingly.

Apologies for botching the HTML - I still blame TyphusPad.

[Appalled]

You know -- a lot of angst and government micromanaging could simply be avoided with limiting the big nasty national healtcare to high deductible health plans. If people pay for their own preventive healthcare, they can choose what they are screened for.

[clarice]

Bingo, appalled..and we could have a nationwide poll of people with pre-existing conditions which, if needed, the govt couls subsidize (we do anyway in effect by demanding hospitals turn no one away ).

OT: Obama has now officially lost the war on Fox..As it lost the war on Honduras and the was over Palestine.

A brilliant, perfect record.

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[jimmyk]

Someone can refuse to be screened before 50, but no one should be denied annual mammograms.

This exemplifies the key problem with nationalizing health care. What does that mean, "No one should be denied annual mammograms"? At taxpayers' expense? Private insurers should be forced to cover them?

Women should certainly have the option of paying for a mammogram out-of-pocket. They should even have the option of a "gold-plated" insurance policy that covers them. But if the evidence is that they are not cost-effective, and private insurere won't cover them annually, that's their business.

The real problem arises when we've nationalized insurance and eliminated individual choice. Then every decision becomes collective, which I guess is Obama's big dream for the entire economy.

[Bob K]

Rick Ballard,
,
I found his analysis persuasive. I've been enjoying his postings for a couple years now. I see he has a new post up on his main page today about the current mammography tiff. http://wmbriggs.com/blog/

One of his hats hangs at a NY hospital where he is a research scientist.

[Old Lurker]

Bingo, jimmyk

[anduril]

God, some of you people sound, like, really stressed! And, clarice, what's with these super long posts you've been doing--you know I never read past the fifth line.

To help ya'll lighten up, here's a little news item on the humorous side: Obama's Home Teleprompter Malfunctions. The best part doesn't actually come until right at the end.

[anduril]

When you come off that humor high, here's an item to bring you crashing back to earth:

China questions costs of U.S. healthcare reform

Guess what? It turns out the Chinese are kind of curious about how President Barack Obama’s healthcare reform plans would impact America’s huge fiscal deficit. Government officials are using his Asian trip as an opportunity to ask the White House questions. Detailed questions.

Boilerplate assurances that America won’t default on its debt or inflate the shortfall away are apparently not cutting it. Nor should they, when one owns nearly $2 trillion in assets denominated in the currency of a country about to double its national debt over the next decade.

Nothing happening in Washington today should give Beijing any comfort or confidence about what may happen tomorrow. Healthcare reform was originally promoted as a way to “bend the curve” on escalating entitlement costs, the major part of which is financing Medicare and Medicaid. That is looking more and more like an overpromised deliverable.

[DebinNC]

" Jaundiced and Lovin It"

lol, Janet

[clarice]

China seems to be teaching Obama a thing or two--It also killed the Copenhagen assault on capitalism and is reining in the big spender from Kendonesia--If he doesn't listen, I expect they'll find a way to illegally funnel money to his opponents--that just under ther eporting limit and jiggered online contribution site Obama used should pave the way if the SCOTUS doesn't kill CFR dead with a stake this term.

[anduril]

Ah! I'd forgotten about the Campaign Finance case.

[Ignatz]

One thing that I don't see mentioned is the potential harm caused by repeated mammograms. There have been conflicting studies on just how great the risk of repeated mammography xray exposure is or if there is any at all. Almost surely there is some added risk for the 90% of women who will never develop breast cancer otherwise. If there is some added risk seems to me it ought to definitively confirmed and fed into the risk/benefit calculations.

What is little known is that there is a specific MRI procedure just for breast cancer and that it is far more sensitive than a standard mammogram and does not expose the woman to xrays. Kind of expensive though so, it's usually reserved for those already diagnosed.

Hope your wife is OK Hby. I'm interested that they don't routinely do full body scans in your area unless there are symptoms. Asymptomatic PET scans here in CA are routinely done after surgery precisely because they want to know if it has spread and symptoms are only a matter of time.
Just to give you some encouragement, my wife was diagnosed Stage 4 four years ago and is presently, by the grace of God, going strong with her tumor marker in the normal range.

[MikeS]

Too bad there is not a way to make the medical devices that do the mammograms and the devices that do the lab tests on biopsied samples cheaper and more accessible. Include the devices that do MRIs and CT scans, along with all the other devices that are now used and even more devices that are as yet undeveloped in that sentiment.

Oh wait! What if we raised taxes on medical devices? Now wouldn't that be a brilliant idea?

[Ranger]

Hot Air catches an interesting point about all of this after taking a look at the people who is on the US Preventive Services Task Force:

http://hotair.com/archives/2009/11/17/feds-to-women-in-their-40s-skip-the-mammogram/>What do they have in common? There isn’t a single oncologist among them, at least not by the USPSTF published roster.

Capt. Ed also points out:

Just six months ago, the U.S Preventive Services Task Force, which works within the Department of Health and Human Services as a “best practice” panel on prevention, sounded a warning signal over a slight decline in annual mammograms among women in their 40s. In fact, they warned women of this age bracket that they could be risking their lives if they didn’t get the annual preventive exam...

[fredm]

For those who do not think catching breast cancer a year or two earlier makes a difference, the stats say otherwise. There is a site called "cancermath" (LUN) where you can input various variables on your specific cancer (e.g. tumor size, # positive nodes, hormone receptor status, grade, histological type, etc) and it will output mortality risk (annual out to 15 years). The data is based on 10's of thousands of breast cancer patients (same data as "adjuvant" - another software used by oncologists).

For example if you enter data say for a 45 year old with 2cm tumor, 2 positive nodes, etc, the 15 year mortality is 23%. So if you wait 1 year or 2 assume tumor grows to 2.5cm (not unreasonable) and 1 more node to 3 total, the 15 year mortality goes up to 30%. This assumes age and other factors are held constant between both cases. The mortality is based on no treatment (if you assume treatment, the mortality drops dramatically, but the proportional difference between the 2 scenarios is the same).

It's a interesting reference site (LUN).

Side note:

"Impact of Mammography and Adjuvant Therapy on the Decline in U.S. Breast Cancer Mortality: 1975–2000.

After remaining relatively constant for many years, breast cancer mortality in the United States decreased by a dramatic 24% from 1989 to 2000.

All models agree on three points:

1. Both screening and treatment reduced breast cancer mortality,
2. The observed reduction in the overall population could not be attributed to either one acting alone, and
3. Each contributed about equally to this decline."

http://cisnet.cancer.gov/breast/landmark.html

[clarice]

fredm, again I recommend the Atlantic article I cited upthread.

The difference is in the rate of growth of the cancer..and mamograms have a tiny role in the imrpoved cancer outcome.
ranger, Dr Plotkin is an oncologist --what we need is scientists/statisticians, not folks looking to get more funding to show us what's going on.

David Plotkin, M.D. ("Good News and Bad News About Breast Cancer" ), is the director of the Memorial Cancer Research Foundation of Southern California.

[Ranger]

Clarice,

Plotkin may be an oncologist, but he's not part of the US Preventive Services Task Force.

The issue here is that these same people have made a 180 degree turn in their view of the subject in 6 months. At the beginning of the year, this same Task Force was warning about the dire consequences of a 1% drop off in preventive mammograms.

Clearly this is a question that has significant advocates on both sides, so why the turn on a dime by the US Preventive Services Task Force?

[Charlie (Colorado)]

Ignatz, it's not straightforward that the extra exposure of mammograms would actually increase risk. The data for that is right down at the limits of statistical detectability, and there's also data that says low level radiation exposure reduces general cancer death rates. (The magic word there is "radiation hormesis" — okay, two words — and may explain why we have a very low cancer rate up here in the Rockies but have about three times the background count you flatlanders have.)

[TheRadicalModerate]

Seems like the problem here is that nobody's willing to assert that decisions made by public health institutions to improve public health are sometimes different from decisions made by individuals to improve their private health. There is clearly a role for a public health organization to do analysis and make decisions that a saving of xx more lives for yy more dollars isn't worth it. If there weren't, then all public health organizations would need infinite budgets. TM, the emphasis you added in the quote talked about saving an additional 0.7 lives per 1000 by screening after 40 instead of 50. But somewhere, there will be another statistic that says that you can save, say, an additional 0.1 lives per thousand by screening after 30 instead of 40. You have to draw the line somewhere.

However, the decision that a woman makes on whether to start annual mammography at 40 vs. 50 doesn't have to factor into any particular public health recommendation--as long as she's willing to pay for it. If she's not willing to pay for it, then somebody else is going to make the decision. I'd prefer that it's an insurance company rather than the government, since they're actually willing to reflect the consequences of their decision in the premium price, but it's still somebody else.

Of course, if you force people to pay for the screening, chances are that a lot more women will die of breast cancer. If they were largely paying for their own treatment, that might be fiscally viable. But, since it's almost certain that the treatment will use dollars from some kind of risk pool (insurance premiums or tax revenue, take your pick), you have to apply some kind of statistical metric and make a recommendation on what kinds of tests are effective.

Ultimately, the only way out of this trap is to have a highly informed populace that's capable of making mostly rational decisions about their own care. The dems' policies all assume that this is impossible. Personally, I'd rather be treated like a grownup and live with the consequences of my own grownup decisions.

[clarice]

Why the turn seems obvious --Pardon my cyncicism but it's all down to who pays for this and whose ox is fattened. The big Cancer charities have made a lot of money offering an expensive and ineffective nostrum and touting inadequate studies to show it works more effectively than it does.

Until we have faster, easier tests to determine what kind of breast cancer you have (fast or slow) the effectiveness of all this expenditure and anxiety producing stuff is limited.
(Later--I have a damned dental implant procedure UGH)

[Ignatz]

--..and mamograms have a tiny role in the imrpoved cancer outcome..--

I'm sure Dr Plotkin is a sharp guy but the decrease in breast cancer morbidity is almost solely due to earlier detection of breast cancer via more widespread mammography. The sad fact is the actual treatments for breast cancer have not changed much in 40 years. Arimidex and Herceptin and a few other drugs have lenghtened disease progression times but have not significantly reduced overall mortality.
Mammograms, while blunt instruments which produce many false negatives and positives, do catch cancers in situ which could never possibly be felt by self exam and which have yet to reach the lymph nodes. When those are treated by lumpectomy and whatever follow up treatment is necessary, whether they are fast or slow growing, the cure rate is vastly increased.
0.7 deaths per thousand prevented seems like a small number and probably is, in the vast scheme of things.
But in the small scheme of things of individual lives, being one of that 0.7 cohort is a mighty big and important thing, especially if you're forty something and have kids to raise and most of your life before you.

[Ignatz]

--Ignatz, it's not straightforward that the extra exposure of mammograms would actually increase risk.--

That's why I said there are conflicting studies and the risk, if any, needs to be quantified. I did probably overstate it by asserting that "almost surely" there is added risk to those women who would not have developed breast cancer otherwise.

--and may explain why we have a very low cancer rate up here in the Rockies but have about three times the background count you flatlanders have--

Well I live in the Sierra Nevada whose highest peak, last time I checked anyway, is higher than the highest peak in the Colorado Rockies.;)

[MayBee]

decisions made by public health institutions to improve public health are sometimes different from decisions made by individuals to improve their private health. There is clearly a role for a public health organization to do analysis and make decisions that a saving of xx more lives for yy more dollars isn't worth it. If there weren't, then all public health organizations would need infinite budgets.

That's exactly it.

[bad]

I suspect my friend, who died of breast cancer shortly after her 30th birthday, would have been in favor of mammogram screening starting at age 25.

I know her husband and children are.

[clarice]

I agree with MayBee--we cannot confuse statistical information from personal health decisions.

[Jim Ryan]

...you flatlanders...

Wha? Who said that? Couldn't tell which direction it was coming from.

[Onc 1]

Yes, I know when I need top notch cancer research, I turn to the world renowned medical journal, The Atlantic. I've seen it on the coffee table at the doctor's office next to People & Readers Digest, however, little did I realize that the Doctor was using it to further her medical knowledge.

Mammograms, especially the newer digital mammograms, have greatly improve early detection of breast cancer. The earlier breast cancer is diagnosed the better chances of eliminating it before it has the opportunity to metastasize.

When someone admits that their knowledge of cancer is limited to an article in the Atlantic and refers to cancer as two types: "fast" and "slow", you know you have a nominee on your hands for Obama's Breast Cancer Czar.

To the "clarice" lady: don't quit your day job.

[Onc 1]

If "clarice" is referring to the Dr. Plotkin Atlantic article I found, it is from 1996, 13 years ago. That is before the development of digital mammography which is better at detecting cancer and before the approval of key drug discoveries for early stage cancers including Herceptin (for HER2+ cancer...or "fast" as clarice calls it) and Aromatase Inhibitors (for hormone receptor + women, more effective and additive to prior Tamoxifen therapy).

Oh, and more info on a "Dr." David Plotkin (same name & an oncologist & both from the one man Medical Research Foundation in So Cal):

"Oncologist Faces Ethics Questions Over Release of Files
By SHERYL STOLBERG, TIMES MEDICAL WRITER|May 03, 1994

A Westside oncologist, already under scrutiny from the National Cancer Institute for discrepancies in data he submitted to a major national breast cancer study, is now the target of criticism for an alleged breach of medical ethics--releasing confidential patient files to a Chicago newspaper reporter.

A top NCI official said Monday that Dr. David Plotkin released the records without the permission of his patients. The agency has notified the federal Office for Protection From Research Risks--which monitors scientific research and has disciplinary powers--and an internal review board at Brotman Medical Center in Culver City, where Plotkin practices.

{snip}

They have also spurred audits of participating institutions in New York and Louisiana, as well as the Memorial Cancer Research Foundation of Southern California, a one-doctor center run by Plotkin.

The NCI has found no evidence that Plotkin committed fraud, although it has found deficiencies in his files, including one case in which a woman who died after open-heart surgery was reported as being alive."

http://74.125.95.132/search?q=cache:uA0eIKHk3d0J:articles.latimes.com/1994-05-03/local/me-53180_1_breast-cancer-research+David+Plotkin+oncologist&cd=14&hl=en&ct=clnk&gl=us

[clarice]

The article was written as I noted by a well-recognized oncologist. Perhaps you ought to read it before flaming.It is written from the same sort of statistical analysis viewpoint as the article which inspired this thread so it is relevant and adds to it. It is NOT written as a guide to personal behavior, and as MayBee notes that's another kettle of fish altogether.

There are fast growing and slow growing breast cancers. The much hyped improvement in breast cancer outcomes, as Dr Plotkin notes, is not the result so much of early detection which catches many many cases of the slow growing stuff and not so much of the fast growing stuff in time to make a difference.

The article it seems to me us useful not as a guide to the perplexed consumer but as a pointer toward research areas which might actually make a difference. If you have to expend millions of dollars on tests which statistically make no difference in outcome but in fact may lead to unnecssary anxiety and needless surgeries and treatments with their own costs and dangers when you could put that money into developing a means to test which kind of breast cancer is which, something that really could make an outcome difference the decision might be an easier one to make.

[Rick Ballard]

"Mammograms, especially the newer digital mammograms, have greatly improve early detection of breast cancer. The earlier breast cancer is diagnosed the better chances of eliminating it before it has the opportunity to metastasize."

Therefore, girls should have their breasts irradiated as soon as they appear and further irradiated at 12 month intervals for the rest of their lives regardless of the level of incidence or cost.

Makes sense to me. No nasty math or statistics involved either - that's a real plus.

[clarice]

Yes, let's ignore the statistics and the downsides of the procedure and put on pink ribbons and race around and buy overpriced junk at Department stores which promise to give a few shekels back to the cancer outfits so that they can keep promoting annual irradiation--Never mind there are mose fruitful areas of research from which this siphons money .

It's all about feeling good and math is so hard.

[MayBee]

If anybody can look at the reaction to this study and at the reaction of the abortion funding debate and think a public option in health care is NOT going to be a huge clusterfork, they are crazy.

[hit and run]

Abortions? Mammograms? Pheh,Jane has podiatry coverage AND I DON'T!!!!

[clarice]

Crystals and shamans.

[clarice]

BTW onc 1, I just noticed your effort to slur the Dr whose views you disagree with--a standard practice these days. What I don't understand is how you found the complaint but not that he was completely exonerated:
"COMPLETION OF INVESTIGATION

NIH GUIDE, Volume 24, Number 25, July 14, 1995

P.T. 34

Keywords:

Ethics/Values in Science & Technol

Grants Administration/Policy+

Department of Health and Human Services

Notice is hereby given that the Office of Research Integrity (ORI)

has completed an investigation and DOES NOT find scientific

misconduct in the following case:

David Plotkin, M.D., Memorial Cancer Research Foundation of Southern

California: The Division of Research Investigations (DRI), Office of

Research Integrity (ORI), investigated allegations that clinical

trial data forms submitted from the Memorial Cancer Research

Foundation of Southern California (MCRF), Los Angeles, California,

contained falsified and fabricated information. The data forms were

submitted to the Statistical Office of the National Surgical Adjuvant

Breast and Bowel Project (NSABP) located at the University of

Pittsburgh. The NSABP project at MCRF received funding from the

National Cancer Institute (NCI), with Dr. David Plotkin as Principal

Investigator.

In mid April 1994, the Chicago Tribune obtained a copy of an April

1990 NSABP Audit Report that indicated there was a ~serious problem .

. . with respect to the accuracy of the data reported to the NSABP~

from the MCRF. A Chicago Tribune reporter reviewed records on some

subjects entered on NSABP trials at MCRF and found apparent

discrepancies between reported data and medical records. Much of the

questioned data was related to the B-06 clinical trial which compared

lumpectomy (with or without radiation therapy) to total mastectomy

for the treatment of breast cancer.

ORI reviewed records and data on 59 patients reported to NSABP

between 1973 and 1994 and did not find falsification, fabrication, or

deliberate misrepresentation on the part of Dr. Plotkin or his staff.

ORI found that many of the discrepancies originally identified by the

NSABP and the Chicago Tribune were the result of a review of

incomplete records, honest error on the part of one or more of the

participating parties, or differences in interpretations or judgments

of the facts."

http://grants.nih.gov/grants/guide/notice-files/not95-177.html

[daddy]

Well obviously Clarice he's either in the Administration or a member of the MSM. Where else can one find such ignorance?

[clarice]

Who knows--but I doubt it's the administration...more likely someone somehow connected to the people who promote annual mammograms for whatever reason --maybe radiologists.
It's like the inverted food chart backed to the hilt by the grain industry that added ten lbs to a lot of Americans' hips and attacked viciously any who promoted a high protein diet, which better more recent studies confirm is better for a great many people.
Everything it seems is political these days.

[Flodigarry]

Looking at the 180 the government has done on mammogram screenings, I have to wonder, would they also like to reevaluate the extensive and expensive safety guidelines they impose on automakers?

Well hell, perhaps their findings on tobacco were all wrong as well! Smoke more - the government needs the tax monies!

Given their track record to date, no proclamations the government has to proffer with regard to health care has anything to recommend them, nor will they as long as Congress has that obamanation of a "health care" bill in play.

[bgates]

Onc 1, that was a lot of typing to get a few dozen people to dislike you intensely. Clarice is known and respected here. You? Now, you're known.

[cathyf]

The most important factor in lowering breast cancer deaths over the last decade was the discovery that HRT increases breast cancer and getting menopausal women to stop taking it.

[Harry P]

"Therefore, girls should have their breasts irradiated as soon as they appear and further irradiated at 12 month intervals for the rest of their lives regardless of the level of incidence or cost."

That's quite a clueless stretch. But if a girl found a lump and it was diagnosed as breast cancer why not treat it? Due to density of breast tissue for younger women (i.e. <40), mammograms are not an effective screening tool. Plus no one said screen everyone for a 1 in a 100,000,000 chance.

"It's all about feeling good and math is so hard."

Yes, because figuring out there are two types of breast cancer "fast and slow" requires some heavy duty thinking. You neglected to explain the 25% reduction in mortality rates over the last 20 years. Let me guess, a third type of cancer...super duper slow?

"or deliberate misrepresentation"

Deliberate or not, the end result is the same...bogus conclusions.

Listen, if you don't want to get annual mammograms after 40, then don't. No one is forcing anyone. But don't quote 15 year old articles and claim you know it all.

It is curious on why some people are in such denial. Is it a personal thing? Trying to convince themselves that timing didn't matter?

Just to piss you off, I am going to get two mammograms a year...and I'm a guy! The logic used in these postings make me think maybe liberals have some valid points.

[Ignatz]

To beat a dead horse, it is just not clear how valuable mammograms are but it is clear they do have value. There are several conflicting studies and issues, but there is little doubt they save some lives and often young and vital ones, so the argument that they should simply be stopped prior to the age of fifty because the number of lives saved isn't demonstrably huge is uncomfortably close to the rationing and death panel proposals so many here deride. There is some point at which cost overides benefit but I'm not sure that has been demonstrated here.
Cathyf is correct that the incidence of breast cancer in the population should show a decline with the reduction of HRT. However that is not the same as the survival rate previously discussed, which is how long and how many survive who actually do contract the disease. That, despite Dr. Plotkin's opinion, is generally held by most researchers to be primarily the result of catching the marginally larger number of early cases which are overwhelmingly curable. As I said before Tamoxifen and the other mainstays of chemo are largely the same drugs as have been used for forty or more years. Newer drugs like Taxol, Herceptin and Arimidex have helped in certain limited cases but their effect on overall survival rates has been very slight.
It is interesting to note that even a fast growing tumor, such as the one my wife had, still, in the estimation of her surgeon and oncologist, took about eight years to grow from a few cells to its 3-4 cm size at surgery. Obviously, had a mammogram (which my wife unfortunately did not get) caught it when it was stil in situ or prior to its escape to her lymph nodes it would have been far more curable.

[clarice]

Again--the discussion is not whether any given individual should have mammograms but the effectiveness and costs (financial and personal) to having every woman have them every year. I think one reason this issue has struck a nerve is that it is obvious that this is precisely what you will get with Obamacare. Cost/effectiveness ratios to keep the costs contained or no such analysies in which case we can turn over the entire GDP to medical care.

Not only are radiologists fighting this switch in recommendations--one first made in 1997--but so are those people in states where, relying on earlier contrary recommendatins, health insurers MUST cover annual mammograms.

As to the downplaying of the non-financial costs of annual mammograms, I am one of those people who for almost forty years has suffered with painful surgical scars from the excision of perfectly benign tumors picked up on early mamogram screening after I detected them in a routine self-examination.

cathy's right too when she says:"The most important factor in lowering breast cancer deaths over the last decade was the discovery that HRT increases breast cancer and getting menopausal women to stop taking it."

[Rick Ballard]

Ignatz,

Who argued that they should be stopped? The issue is a change in recommendation wrt utility. The 40-49 age group contains roughly 20 million women. The cost of mammograms for the total group is roughly $2.56 billion. Epidemiological studies indicate that 160,000 cases of breast cancer would be revealed by the mammograms. Is a policy recommendation with a cost of $16,000 per discovered incidence an effective public health measure? It seems a tad high to me. Alternatively, I have absolutley no problem with any individual spending $128 per year to eliminate the 8 in 1,000 probability that they have a potentially life threatening disease. I might counsel them that there is a very limited probability for them doing so for more than 90 years or so...

[clarice]

BTW re HRT the prevailing recommendation when I began taking it (and I quit on my own after a couple of years despite the recommendation) was that it provided protection against heart attacks. My doctor encouraged me to take it on that very basis.

Guess what, it doesn't.

For most women the downside is probably greater than any upside.

[Ignatz]

--Is a policy recommendation with a cost of $16,000 per discovered incidence an effective public health measure? It seems a tad high to me.--

Rick,
I'm not sure that's a complete analysis. Any breast cancer that is there will be discovered eventually, mammogram or not and will almost always then be treated.
It's entirely possible that enough early detections by mammograms might in the long run save money due to the savings of lumpectomy vs mastectomy and the need for much less therapy for non metastisized cancer.
Virtually every single woman who ever has breast cancer is going to receive treatment and the more advanced the cancer the more it will cost. My wife's treatments are easily in the $400,000 range. Had it been caught via mammogram in situ as her mother's was just a couple of years later the total cost of treatment would have been less than $100,000 as her mother didn't even need chemo because it was caught prior to lymphatic involvement.
I know biopsies are no fun and can leave scarring and discomfort, and if it proves unnecessary it's even more traumatic. But an unnecesary biopsy on a false positive seems, from my perspective, preferable to a mastectomy that could have been avoided with an early mammogram and and a minor lumpectomy which is often not much more than a biopsy.

[Rick Ballard]

Ignatz,

It wasn't meant as any sort of analysis. The problem that I have is that actual incidence is rarely mentioned wrt health issues and when it is it is rarely used in a manner which is useful for evaluating actual probability of occurrence. The recommendation (per the NHS) in the UK is every three years for women over fifty. How should the difference between the two recommendations be reconciled? Would a fair comparison be based upon days of life lost? What if the average days of life lost turns out to be 3? Is the expenditure of $1,280 (10 years of mammograms) worth 3 extra days?

I understand the lower cost of treatment argument but unless it is quantified for the population in question and expressed in terms of days (or months or years) of life extended then I question the utility. I don't deny it, I just question it - I'm one of those who smile when I see "lives saved". I keep waiting for a live TV interview of someone born before 1880.