Mammography is Unjustified--A Letter Few Newspapers Will Print

The following is an editorial I sent to over a dozen major US newspapers and so far I know of only one to print it (the Honolulu Advertiser).  You may want to submit this letter to your newspaper.  At the end of this article you will find the links to the original papers cited so you can read and come to your own conclusions.

Mammography is Unjustified
The Cochrane review¹ on screening mammography and an accompanying editorial²  published in the October 20, 2001 issue of the Lancet have created an emotionally charged stir in the medical business and many responses to try to control the damage. (See “Playing with Women’s Lives” by Spyros Andreopoulos in the Wednesday 12/19/01 San Francisco Chronicle and “Changing Medical Advice” in Wednesday 12/26/01 San Francisco Chronicle).

A systematic review of the randomized trials of mammography by the highly respected Nordic Cochrane Center came to the conclusion “that there is no reliable evidence that screening for breast cancer reduces mortality,” and  “that screening leads to more aggressive treatment.”  Many other highly respected researchers have come to similar conclusions.  In 1995 Dr. Charles Wright, Clinical Professor, Department of Health Care and Epidemiology at the University of British Columbia, reported in the Lancet³ his conclusions after reviewing the data: “Since the benefit achieved is marginal, the harm caused is substantial, and the costs incurred are enormous, we suggest that public funding for breast cancer screening in any age group is not justifiable.”

Prior to this, writing in a 1989 edition of the British Medical Journal, M. Maureen Roberts,⁴ clinical director of the Edinburgh Breast Cancer Screening Project since 1979, stated that, "We can no longer ignore the possibility that screening may not reduce the mortality in women of any age, however disappointing this may be ... I believe that a rethink is required before the programme goes any further.  I feel sad to be writing this; sad because naturally after so many years I am sorry that breast cancer screening may not be beneficial, I am also sad to seem to be critical of the many dear and valued colleagues I've worked with over the years, particularly those who have made such a magnificent contribution to the care and welfare of women with breast cancer.  But they will recognize that I am telling the truth."  Ms. Roberts' article was published posthumously after her death from breast cancer.

The reason mammography fails is because it is a crude technique that most often finds the cancer in the breast only after it has been growing there for 8 to 12 years.  By this time, if it is truly cancer, it has spread to other parts of the body, beyond the reach of surgery and/or radiation.  Unfortunately, our methods of dealing with disease that has spread – chemotherapy and hormone therapy – are of limited benefit.

Beyond the billions of health care dollars fruitlessly spent, what are the real harms to a woman from mammography?  Fear and anxiety surrounding this test take a toll on her daily life. Once an abnormality is found on a mammogram she will likely have surgery.  In eight out of ten cases the lump is not cancer – so surgery was unnecessary.  If she is diagnosed with cancer her whole world changes: she can no longer get life or health insurance, a career may no longer be available, and now everyone worries about “the breast cancer victim.”  Furthermore, if the tests and treatments really do add little to a woman’s chance of surviving, then think of all the unnecessary costs, pain, and suffering caused by surgery, radiation, and chemotherapy -- and all the disappointment that follows false hope.

The burden of proof lies with those who recommend tests and treatments.  If you believe that the Cochrane review, Charles Wright, Maureen Roberts and many other respected researchers are correct in their position that “screening for breast cancer with mammography is unjustified,” then it is way past the time when we should have brought this universal medical practice in line with the scientific evidence.  Unfortunately, I believe politics, pride, fear of medical malpractice suits and billions of lost dollars will allow this behemoth to continue to trample over the health and welfare of women.  Finally, for my colleagues I paraphrase Maureen Roberts,  “But you will recognize that I am telling the truth.”

John McDougall, MD
Author of the McDougall Program for Women

drmcdougall@drmcdougall.com

707-576-1654
PO Box 14039
Santa Rosa, CA 95402

References to the above:
1.  Olsen O, Gotzsche P. Cochrane review on screening for breast cancer with mammography.  Lancet 358:1340-2, 2001.

2.  Horton R. Screening mammography -- an overview revisited.  Lancet 358:1284-85, 2001.

3.  Wright C.  Screening mammography and public health policy:  the need for perspective. Lancet 346:29, 1995.

4.  Roberts M.  Breast screening: time for a rethink?  BMJ 299:1153, 1989.

[End here when sending to your newspaper]

The Cochrane report has sent shock waves through the nation, especially for women and the medical business. And the pillars supporting mammography (and of all early detection screening programs) are starting to crumble.  Most recently an independent panel of medical experts which writes information for the National Cancer Institute has concluded that there is insufficient evidence to show that mammography prevents death from breast cancer.⁵ Unfortunately, the media are not playing fair.  A recent study on “Newspaper reporting of screening mammography,” in the Annals of Internal Medicine found that newspapers over-represent support by 2 to 1 for screening mammography at the highly controversial ages of 40 to 49 years.⁶  Maybe you can counteract some of this biased reporting, by getting your local paper to print my letter.  I encourage you to read the Cochrane report from the Lancet, the accompanying editorial, the news from the medical experts and the responses to these articles (see below for all the links).

Those of you interested in the subject will find a thorough discussion of mammography in the book The McDougall Program for Women. You will also learn why you should put your efforts into a healthful diet and lifestyle in order to prevent breast cancer.

5. Charatan F. News--US panel finds insufficient evidence to support mammography. BMJ;324:255. 2002.

6.  Wells J.  Newspaper reporting of screening mammography.  Ann Intern Med 135:1029-37, 2001.

Links to above:
The Report: http://thelancet.com/journal/vol358/iss9290/full/llan.358.9290.original_research.18001.1

Medical Expert Panel for the National Cancer Institute:
http://bmj.com/cgi/content/full/324/7332/255

The Editorial: http://thelancet.com/journal/vol358/iss9290/full/llan.358.9290.editorial_and_review.18003.1

Electronic Letters:
http://bmj.com/cgi/eletters/323/7319/956

“Playing with Women’s Lives” by Spyros Andreopoulos in the Wednesday 12/19/01 San Francisco Chronicle
http://www.sfgate.com/cgi-bin/article.cgi?file=/chronicle/archive/2001/12/19/ED147120.DTL

“Changing medical advice” in Wednesday 12/26/01 San Francisco Chronicle
http://www.sfgate.com/cgi-bin/article.cgi?file=/chronicle/archive/2001/12/26/ED144228.DTL.

August 11, 2009

How to Rein in Medical Costs, RIGHT NOW

By GEORGE LUNDBERG

http://www.lundberginstitute.org/

I believe that there are still many ethical and professional American physicians and many intelligent American patients who are capable of, in an alliance of patients and physicians, doing "the right things". Their combined clout is being underestimated in the current healthcare reform debate.

Efforts to control American medical costs date from at least 1932. With few exceptions, they have failed. Health care reform, 2009 politics-style, is again in trouble over cost control. It would be such a shame if we once again fail to cover the uninsured because of hang-ups over costs.

Physician decisions drive the majority of expenditures in the US health care system. American health care costs will never be controlled until most physicians are no longer paid fees for specific services. The lure of economic incentives to provide unnecessary or unproven care, or even that known to be ineffective, drives many physicians to make the lucrative choice. Hospitals and especially academic medical centers are also motivated to profit from many expensive procedures. Alternative payment forms used in integrated multispecialty delivery systems such as those at Geisinger, Mayo, and Kaiser Permanente are far more efficient and effective.

Fee-for-service incentives are a key reason why at least 30% of the $2.5 trillion expended annually for American health care is unnecessary. Eliminating that waste could save $750 billion annually with no harm to patient outcomes.

Currently several House and Senate bills include various proposals to lower costs. But they are tepid at best, in danger of being bought out by special interests at worst.

So, what can we in the USA do RIGHT NOW to begin to cut health care costs?

An alliance of informed patients and physicians can widely apply recently learned comparative effectiveness science to big ticket items, saving vast sums while improving quality of care.

1.     Intensive medical therapy should be substituted for coronary artery bypass grafting (currently around 500,000 procedures annually) for many patients with established coronary artery disease, saving many billions of dollars annually.

2.      The same for invasive angioplasty and stenting (currently around 1,000,000 procedures per year) saving tens of billions of dollars annually.

3.     Most non-indicated PSA screening for prostate cancer should be stopped. Radical surgery as the usual treatment for most prostate cancers should cease since it causes more harm than good. Billions saved here.

4.     Screening mammography in women under 50 who have no clinical indication should be stopped and for those over 50 sharply curtailed, since it now seems to lead to at least as much harm as good. More billions saved.

5.     CAT scans and MRIs are impressive art forms and can be useful clinically. However, their use is unnecessary much of the time to guide correct therapeutic decisions. Such expensive diagnostic tests should not be paid for on a case by case basis but grouped along with other diagnostic tests, by some capitated or packaged method that is use-neutral. More billions saved.

6.     We must stop paying huge sums to clinical oncologists and their institutions for administering chemotherapeutic false hope, along with real suffering from adverse effects, to patients with widespread metastatic cancer. More billions saved.

7.     Death, which comes to us all, should be as dignified and free from pain and suffering as possible. We should stop paying physicians and institutions to prolong dying with false hope, bravado, and intensive therapy which only adds to their profit margin. Such behavior is almost unthinkable and yet is commonplace. More billions saved.

Why might many physicians, their patients and their institutions suddenly now change these established behaviors? Patriotism, recognition of new science, stewardship, and the economic survival of the America we love. No legislation is necessary to effect these huge savings. Physicians, patients, and their institutions need only take a good hard look in the mirror and then follow the medical science that most benefits patients and the public health at lowest cost. Academic medical centers should take the lead, rather than continuing to teach new doctors to "take the money and run".

Physicians can re-affirm their professionalism and patients their rights, with sound ethical behavior without undue concern for meeting revenue needs. The interests of the patients and the public must again supersede the self interest of the learned professional.

George D. Lundberg MD, is former Editor in Chief of Medscape, eMedicine, and the Journal of the American Medical Association. He's now President and Chair of the Board of The Lundberg Institute

August 11, 2009 | Permalink