We're Probably Screening for Breast Cancer Too Much: Healthcare Triage News
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- Опубліковано 23 кві 2015
- HCT Mugs and Posters! dft.ba/-HCTMerch
How often should you get a mammogram? After writing for years about how research shows we may be too aggressive in screening for breast cancer, it's only fair that I acknowledge the newer - and more conservative - recommendations from the USPSTF. This it Healthcare Triage News:
For those of you who want to read more, go here: theincidentaleconomist.com/wor...
John Green -- Executive Producer
Stan Muller -- Director, Producer
Aaron Carroll -- Writer
Mark Olsen -- Graphics
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Excellent video!! I was just reading an article about how doctors have a hard time following evidence-based care guidelines for multiple reasons. Very interesting. A lot of people in healthcare want to cover their butt, which usually includes ordering tests that might not be indicated. As a nurse I completely understand the want to cover all bases in order to keep patients healthy and safe, it's sometimes very difficult when evidence comes out that completely changes practice guidelines. We become so used to doing things a certain way and change is difficult.
Ashley LeClaire I think he did another video on exactly what you're talking about...how difficult it is to get medical professionals to change their ways, even when presented with strong evidence. It feels strange to me how that's a thing.
Thanks Aaron! I swear these videos save lives.
I hate to provide one of those not data (singular antidote), but at 47 my wife had her first mammogram and was sent to have a mastectomy within two months. Years later she has a lumpectomy on the other side. She was the first to have breast cancer in her family. Her mother had breast cancer after her.
My issue with the "recommendations" is that women who have no family history can still get breast cancer at ridiculously young ages and doctors will look for everything except breast cancer as a cause of their symptoms. At my 10 year class reunion one of the sweetest people I've ever met couldn't attend because she was in chemo and radiation therapy. She hounded doctors for months and months before she finally convinced someone to screen her for breast cancer. She was 27 at the time and stage 4 before anyone gave her any sort of attention. She had recently had a child and was told she was blowing her symptoms out of proportion and that it was probably postpartum depression manifesting its self physically... We know our bodies and we know when something is wrong. More doctors need to take their patients seriously and stop clinging to the recommendations so dramatically. I know that her case is rare and I don't think that everyone needs to be screened really young. What I want is for doctors to just listen more to the patients when they feel something is wrong. Because no one listened, she endured chemo, radiation, a double mastectomy and a full hysterectomy and her children came close to losing their mother.
Charlotte Burnside Well they don't listen becuase obviously the patient gets it wrong in most cases which then relates back to why we don't do breast scans for everyone - the risk is not worth the harm.
It sucks when the patient does know what they're on about but in that instance that should be fairly obvious the the doctor.
Charlotte Burnside in their defense, it only makes sense to look for the most likely causes of symptoms. rather then to jump to extremes, and I know a lot of people that don't know their body as well as they think they do (but I admit, that is anecdotal)
but I agree, if a person is concerned that they may have cancer and are showing symptoms, it may be best to screen them for it.
I get kinda brushing off a patient if they tend to be a hypochondriac, but when you have a generally healthy person suddenly just this side of death you ought to take them seriously.
Charlotte Burnside what makes the screening process also more difficult, is that woman's breast tissue undergoes a change around age 30. It turns from firm tissue to softer tissue - so the mammogram is useless.
An alternative is ultrasound, but its not sensitive enough at all... The potential cancer needs to be several times bigger...
Woman who breastfeed, or recently have had a child have the very same issue with their tissue as women under 30: the breast tissue is too dense for screening.
That said... im guessing any normal doctor would do a breast exam, and feel if there were any lumps... unfortunately, when you breast feed, that becomes a good bit harder to feel irregularities... And lumps may be other benign things such as cysts (which are often responsible for false positive mammograms)
So its not rlly that her case is rare - while at 27 it is - its that she had other things going on that make it a difficult case to justify those tests.
My point being that there is a limit to the tests and, as sorry as i feel for her, its likely that her own body was part of the difficulty...
Charlotte Burnside Thats not rlly how it works though...
Medical history may help if its relevant. Someone who had a brain injury in the past, may be troubled by that injury this time. But it doesnt matter if there is no history - medical history is just another puzzle piece to put together a diagnosis.
The recommendations are based on a lot of things. They check for those things that are most common first; which may differ per age (or situation such as breast feeding). They also try less invasive methods before the invasive ones - an x-ray image may reveil plenty of information, so you have to be cut open. Finally, waiting time and costs are considered as well - the total makes for a fairly effective system.
However it all needs to be justified. If you come in with a painful toe, im not allowed to make a head scan... Every exam or test needs an indication - it needs a collection of symptomes to justify the tests. This means you cannot just test for everything - and the doctor doesnt have the power to test patients on whatever he likes.
Let me tell you a story about a patient who came in with the following issue: She was around 50, had trouble holding in food and pain on the upper stomach. It fit what would be a classic case of gallstones causing trouble - resulting in the pain and the digestive issues. Her condition and symptomes were plenty to order a ultrasound - and ill spare you the details, but she was send in for surgery to have the gallbladder removed with all the stones.
The surgeon however, refused to operate, and required additional tests first. You may be furious about it, as was the patient - however it makes complete sense from the surgeons perspective. First of, gallstones dont always cause issues. Some people have them and never have issues, others have them for years before developing symptomes. The sugeon wanted to have the stomach checked, because if that was the underlying cause of the problem, treatment was taking pills - and not surgery...
The stomach checked out fine and the gallbladder was surgically removed.
But imagine the fcked up situation where you wake up from surgery, still have the same symptomes - now have recovery as well, and all risks involved - and it turns out it was your stomach, and here are some pills for that...
Diagnostics just isnt that easy and straightforward...
That means, unfortunately, your friend was right to push forward to get that diagnosed - and as i mentioned she had other factors against her in the process - but its a result of making an efficient system for all patients.
I hope this puts things in a bit of perspective.
This is shocking news! Thanks for sharing, Dr. Aaron.
could you do a HCT about cellphone radiation, and wifi and all that stuff? i've tried looking through some articles, but none of it seems very conclusive! thank you and keep up the good work!
I missed this when it first aired, and when I read the title I didn't hurry to watch it because I thought there would be nothing new I would learn from it. I already knew that the harms potentially outweighed the benefits when it came to yearly screenings, especially under 50.
BUT THEN... at 1:02 ( ua-cam.com/video/D1mObgVdgdU/v-deo.htmlm2s ) he said: "But about 20% of women who are diagnosed with and treated for breast cancer are getting therapy for something that otherwise never would have caused a health problem"
WHOA. I had NO IDEA. I need to know more about THAT. Wow.
This video would fit in brilliantly with the kind of work done by Ben Goldacre in the UK. I hope you guys get an opportunity to team up.
The problem with offering voluntary screenings to women 40+ is that a large number will opt in due to outcome bias.
Can you please do one on cervical cancer screening? New guidelines also highlight the burden of over screening.
Can you discuss (live or otherwise) any research on the benefits or otherwise of the supplement 5-HTP (from Griffonia) and claims as a natural anti-depressant and weight loss treatment?
It's hard for me to agree with this, even if the only evidence I have to support my position of frequent breast cancer is personal. My family has no history of ANY cancer, yet my 49 year old mother has undergone yearly mammograms for at least the last decade. In late December of 2016, her mammogram results were abnormal so I took her to a biopsy last week. Today, we found out that she has breast cancer in spite of a complete lack of risk factors (other than use of hormonal birth control, which I've heard can contribute). I am hopeful, although terrified of losing my mom, for the sheer reason that we have caught this cancer very early. I dunno. I'm not a doctor but if that one fewer death is my mom, then I think it's worth it.
I saw some people in the comments saying that mammograms should be used, because they are the only way to screen for breast cancer. However, that's not true. There is a newer way, and one which does not use radiation and is not painful, it used infrared temperature readings. I don't remember what it's called, but my mother had it done several times until we ran out of money (not covered by insurance at that time, maybe now?) and I believe it was supposed to be more accurate.
Could you do a video discussing prenatal sensation, specifically fetal pain.
I am 30 and I have a family history of breast cancer. Could you direct me toward some research on how often and early women at a higher risk should be screened? I am pretty comfortable just talking to my doctor about it but my mom (who had it twice) is always very worried that I am not being screened yet so it would be nice to give her something to read.
Also, your liknk to the article to "read more" doesn't work. FYI
Gemma Ohlemacher screeningforbreastcancer.org/frequently-asked-questions#e2
Gemma Ohlemacher You should probably check if your mom had a breast cancer associated with the BRCA1/2 gene mutations, cause that changes things quite significantly.
Gemma Ohlemacher talk to a genetic counselor!
Gemma Ohlemacher I recently wrote a 20 page essay on this topic. I did all the math and breast cancer history in a family is a risk but it is very low. At age 30 taking a mammography, even with family history, would probably be useless and stressful for nothing because the risk of having breast cancer at 30 is too low for the mammogram to give you trustworthy results. However, if you are concerned speak with a physician to determine if you have any other risk factors. :)
Thanks all. Like I said I really trust my doctor, I was just hoping to give my mom something to read to ease her mind.
Is this guy related to vlogbrothers/crashcourse
Personally, I'm paranoid about breast cancer because of a friend who had it under the age of 30. As a woman with a large chest, I often experience pain and numbness in my breast tissue, and while I'm sure that its normal I can't help but feel paranoid. Perhaps if internet symptom searches didn't point immediately to the worst diagnosis possible I would feel less like I need to go in for an unneeded mamogram. Maybe a video about normal pain vs. abnormal pain in certain areas of the body would be beneficial to many with internet-born hypochondria?
XxBaconPandaxX Ugh, and the worst part for large-breasted younger women is that mammography isn't very useful. I keep waiting for the tech outlined in www.ted.com/talks/deborah_rhodes?language=en that TED talk to come to the market. I have other syndromes that result in me basically always having the classic symptoms of cancer, so if I ever _did_ develop cancer I'm afraid it wouldn't be detected in time. Every stupid pang in one of my breasts makes me have a momentary struggle with reason over panic, trying to figure out what's reasonable, what's unknown and what's likely. It's awful, especially when it seems like the older I get, the more instances of random, weird pain I have. And every dang time, I wonder, "Is this normal?" So, uh, what you said. Oi oi oi.
I feel that if there is family history of breast cancer then one should be tested every year; if not every two years is acceptable. Excessive testing can result in false positives changing ones life completely. However one should always perform monthly breast exams at home.
Aaron, why in your video on antibiotic resistance, you never mentioned that most antibiotics are used on livestock and not people?
… cause he's talking about people, not livestock?
Yet it's a bigger contributor to antibiotic resistance. It would be like trying to mitigate carbon emissions without discussing coal fire power plants.
Diana Peña Can you cite a study? Not saying it's false, but without proper research it can't make it into HT
This article goes deeper than I want to type.
www.medicalnewstoday.com/articles/291295.php
Diana Peña Seems to be very speculative. It is convincing but again: Without actual research it won't make it into HT
I'm 51 & give myself regular checks. There is no history At All for breast cancer in either side of my family. I'd rather put off Xray exposure for as long as possible. what's the longest reasonable amount of time to wait?
I've never had a mammogram, but that's probably because I'm a 13 year old male but I don't know
Gracious Carrot your mom will probably have to take them when your 20 or so (and every year from then on). it's just an X-Ray of the breasts to look for cancer. it's a pretty uncomfortable procedure, (they pretty much put your breast in a vice, sometimes even leading to bruising) so I'm sure quite a few women will be glad if it they don't have to do it as often.
it's not necessary for you to know at your age, but down the road it'll be useful information to have (plus, I believe everyone should know as much as they can :p)
Lol I know what it is I was just saying I haven't had one
what about the harm of the screening itself. Mammography exposes the woman to ionizing radiation so the screening itself may increase the rate of breast cancer!
Same shit happens with prostate cancer.
Maybe with other types too.
Is it true that men can get breast cancer?
aaa303 Yes
Is it too uncommon to warrant screenings for men? Why is there never any mention of it?
I know it is much less common than for women, though that is the extent of my knowledge
Interesting that Dr. Carrol in two places in the above video advocated that under certain circumstances we allow individuals to make their own decisions about health care. Doesn't he realize the danger in that? It means the seeds of liberty are always present in society. No. We should never allow people to think they ever have a choice. The cost of the enforcement arm of the health care system would grow out of hand if self-interest isn't stamped out.
Walter Clark ...dafuq...
DanThePropMan I'm suspecting sarcasm here. Poe strikes again.
If screening to breast cancer gets more thant 5% error it should be reconsidered as a medical tool. It means it's only significant at a level of 12% error chance, or 88% level chance. That a REALLY high Type I error chances. This screening is pontentially useless!
without acknowledging Type II error, the false negatives, that with this error rate should be even higher and are not accounted too.
MrUtak according to the information that I have, the sensitivity of mammogram screening is 80%, and the specificity is 90.4%, which is pretty good, but not nearly as good as something like the AIDS tests.
(in case you're unfamiliar with the medical terminology, that means a 20% false negatives rate, and a 9.6% false positives rate)
assuming these numbers are correct, it's not useless: a positive result does mean a only small chance of cancer (7.8%), but a negative result means a 99.78% chance of no cancer, which seems pretty worthwhile.
the other issue is that there's no other screening at present. whereas with AIDS testing, there are several types of tests, and they can be used to confirm each other, there's just nothing else available with breast cancer screening, now.
*edit:*
it looks like my numbers are a bit different from his; mine may be out of date. he said 121 false positives / thousand screens, and I only have 95. I don't know what sensitivity his numbers are based on, so I can't recalculate. it's also possible that his prevalence numbers are different: I have 1% prevalence (which I think was in the same age 40-49 range).
Hm, than maybe my assumptions were wrong. I was just questioning his numbers, they sounded odd, but maybe I have no idea of what I'm talking about. thanks for the answer!
MrUtak dunno, man, it sounds like you know more about stats than me. I've just been looking into this specific issue.
I'm a little frustrated that the numbers I have apparently aren't the most current, but I shouldn't be surprised.
one of the calculations I ran was _if_ there was another type of screening (which apparently there isn't), with the same accuracy rates as mammograms, what would be the confirmatory power of the second test: it came out to a little over 60% chance of cancer after two positives. up from a posterior probability of 7.8%, that's quite a big jump, but it's still terrifyingly low.
the other worrying thing is that (according to some research that I've read _about,_ but not read) a laaaaaaaarge majority of doctors *replace* the 1% prior probability (aka _prevalence,_ in this case) with the 80% sensitivity when a patient gets a positive mammogram, instead of adjusting it based on the positive result. that's _got_ to affect outcomes for patients.
ThoperSought What I was also thinking is what ways do doctors already use (or should use) to alleviate this 20% error (summing false positive and negative). Physical touch and inspection chirurgy should also decrease that error. Still, those different methods should be accounted in the result (it's not like the screening is just an X-ray). Anyway, I think this kind of statistics is never well done, and the numbers flagged a possible error.
The advertiser for this video deals in viaticals. Wow.
This video is...troubling. You speak of "one more death" or "ten more deaths" as if the women who would die are an abstract, a number on paper, and not actual human beings.
I'm reminded of the old saying "'Tis better that ten guilty men go free than one innocent person be punished." It's better to do ten "unnecessary" mammograms to save that one life than to let that woman die because it's cheaper not to do mammograms.
stormbob No it is not. Because that kills more people...
You idealists are fucking dire. You are the ones who kill more people.
This is the purpose of healthcare economics. To save lives. To maximise the wellbeing of everyone in the country via healthcare.
stormbob unfortunately the world doesn't work like that, with the population in the billions, you can't set guidelines for each specific individual, you have to try and find a balance between the benefits of people surviving, and the harms of misdiagnosis (and the risks that come with it) to try and achieve the best overall survival/quality of life rate.
stormbob Doing a mammograms diverts money from everything doctors could spend it on; dementia care, screening for conditions in fetuses, vaccines...etc. Normally, this is justifiable, but there must be limits.
The money government and society can spend on healthcare will never be infinite. The aim of the game is to save as many people as possible with the money you have. Which means that ineffective and costly screening should not be carried out, even if some people could potentially be saved.
stormbob
0:43 "... the *_harms_* of yearly screening might outweigh the benefits."
1:02 "But, about 20% of women who are diagnosed with and treated for breast cancer are getting treatment for something that otherwise would *never* have caused a health problem... And the treatment for breast cancer is *_not_*_ benign."_
1:33 "... but they had a significant increase in *_harms."_*
1:50 "There are *_no_* randomized controlled trials that show a benefit in [the 75+ age group], at all. The *_harms_* are still there, though."
so, your quote should be adapted to say, "'tis better that 121 new women out of every thousand undergo unnecessary, dangerous treatment every year, risking death-including an elevated risk of suicide-having their lives turned upside down and creating gut wrenching worry for them and everyone in their families than that one woman die because her cancer was caught too late."