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So it is that month again. The pink one. Fuck pink. But lets talk awareness.
There's a subject I've wanted to post about but held off until I felt I understood the controversy enough to say anything. Mammograms. Specifically the practice of routine screening mammograms, and please note I am not talking about diagnostic or high-risk screening, and neither are the controversial recommendations or studies. Routine screening, the once a year boob squish.
Thing is, there shouldn't be a controversy at all. The science is about as clear as science gets on these things. Routine screening mammograms in women under 50 do not save lives. They just don't. What they do is increase the incidence of unnecessary invasive (and sometimes disfiguring) procedures for no real benefit.
What's hard about this is that it feels like they should. It seems logical, so the debate surrounding it has taken on that on the face of it logic and run with it, claiming the new recommendations that screenings do not begin until 50 are anti-woman when it is the exact opposite.
So I kind of want to pick apart that logic that isn't. It all rests on the 'common sense' assumption that the earlier you find a tumor, the better the outcome. That isn't always true. I wish it was, but it's not. That's just not how cancer works. A tumor that presents as teeny tiny can kill you within a year and a whopper the size of a tennis ball might never rear it's ugly head again after removal. The key of early detection is figuring out which tumors will respond in such a way that earlier treatment is more effective than later.
Breast tumors that are undetectable except by mammography (not talking about palpable lumps you or your doctor find) in women under 50 don't fit that category. If they are going to respond to treatment, they will when you find it in the shower and just aren't likely to have spread before then. If they are not going to respond to treatment, they were gonna kill you anyway regardless of when you find it. Sucks doesn't it? But it's true.
Jane and Jill have identical malignant breast tumors that become detectable by mammography at age 42. Jane has yearly mammograms and hers is treated initially at 42, she goes on to die of the disease at 55. Jill discovers a lump in the shower at 45, she goes on to die of the disease at...age 55. Or alternately, both Jane and Jill go on to never have a recurrence at all. That's how the stats shake out except on a larger scale. Jane has gained nothing by her earlier treatment except a few more years of being aware of it. Nothing at all, not even extra time on the back end.
You can feel free to punch something now and scream about it not being fair. Because it's not. Cancer doesn't play fair. It's kind of a bitch that way.
Now here's the flip side. False positives are actually pretty common with mammograms. 80 percent of all biopsies done as the result of a suspicious mammogram are negative, and the suspicious whatever will resolve/disappear on it's own within a year. And then there's the weirdness that is some malignant tumors will actually spontaneously regress or resolve as well, though there's no way of a doctor being able to tell which ones will do that once they are aware of it.
So what does that mean? It means women, lots and lots of women undergoing expensive and painful/invasive testing for NOTHING. Think about the cost, both financial and emotional in a world of limited resources. Just think about it. For what? For a false sense of security? So the Janes of the world can live with full knowledge of the ticking time bomb in their body for an extra four years but not actually live any longer? Really? Isn't the first rule of medicine 'do no harm'? I'd call terrifying the shit out of large groups of women and subjecting them to surgical procedures they don't need for no long term benefit harm by any definition.
It's just...this reminds me, though with far less devastating consequences, of the 'controversy' surrounding the surgical treatment of breast cancer once upon a time ago. 'Logic' dictated for a long time that the more aggressive the surgery, the less likely there was to be a recurrence. And it made sense on the face of it. The more tissue you take, the less there is for the cancer to set up shop in again. Radical mastectomies that removed the entire chest wall (often a rib or two for good measure) and all levels of axillary and clavicle lymph nodes were the order of the day. It was worth the trade off for devastating physical disability and disfigurement if you could keep the cancer from coming back. Only...you couldn't, not like that. The less nuclear modified radical mastectomy or lumpectomy depending on the tumor had the same results. It took years before people, both patients and surgeons, would accept that and for the practice to die out, regardless of all evidence. Lets not do that again, okay?
And just to reiterate, neither I nor the recommendations are talking about diagnostic mammograms for already discovered lumps, or high risk screening. Nor do they refer to regular screening mammograms for women over the age of 50 where early detection is of benefit.
So, that's what I have to say about that.
There's a subject I've wanted to post about but held off until I felt I understood the controversy enough to say anything. Mammograms. Specifically the practice of routine screening mammograms, and please note I am not talking about diagnostic or high-risk screening, and neither are the controversial recommendations or studies. Routine screening, the once a year boob squish.
Thing is, there shouldn't be a controversy at all. The science is about as clear as science gets on these things. Routine screening mammograms in women under 50 do not save lives. They just don't. What they do is increase the incidence of unnecessary invasive (and sometimes disfiguring) procedures for no real benefit.
What's hard about this is that it feels like they should. It seems logical, so the debate surrounding it has taken on that on the face of it logic and run with it, claiming the new recommendations that screenings do not begin until 50 are anti-woman when it is the exact opposite.
So I kind of want to pick apart that logic that isn't. It all rests on the 'common sense' assumption that the earlier you find a tumor, the better the outcome. That isn't always true. I wish it was, but it's not. That's just not how cancer works. A tumor that presents as teeny tiny can kill you within a year and a whopper the size of a tennis ball might never rear it's ugly head again after removal. The key of early detection is figuring out which tumors will respond in such a way that earlier treatment is more effective than later.
Breast tumors that are undetectable except by mammography (not talking about palpable lumps you or your doctor find) in women under 50 don't fit that category. If they are going to respond to treatment, they will when you find it in the shower and just aren't likely to have spread before then. If they are not going to respond to treatment, they were gonna kill you anyway regardless of when you find it. Sucks doesn't it? But it's true.
Jane and Jill have identical malignant breast tumors that become detectable by mammography at age 42. Jane has yearly mammograms and hers is treated initially at 42, she goes on to die of the disease at 55. Jill discovers a lump in the shower at 45, she goes on to die of the disease at...age 55. Or alternately, both Jane and Jill go on to never have a recurrence at all. That's how the stats shake out except on a larger scale. Jane has gained nothing by her earlier treatment except a few more years of being aware of it. Nothing at all, not even extra time on the back end.
You can feel free to punch something now and scream about it not being fair. Because it's not. Cancer doesn't play fair. It's kind of a bitch that way.
Now here's the flip side. False positives are actually pretty common with mammograms. 80 percent of all biopsies done as the result of a suspicious mammogram are negative, and the suspicious whatever will resolve/disappear on it's own within a year. And then there's the weirdness that is some malignant tumors will actually spontaneously regress or resolve as well, though there's no way of a doctor being able to tell which ones will do that once they are aware of it.
So what does that mean? It means women, lots and lots of women undergoing expensive and painful/invasive testing for NOTHING. Think about the cost, both financial and emotional in a world of limited resources. Just think about it. For what? For a false sense of security? So the Janes of the world can live with full knowledge of the ticking time bomb in their body for an extra four years but not actually live any longer? Really? Isn't the first rule of medicine 'do no harm'? I'd call terrifying the shit out of large groups of women and subjecting them to surgical procedures they don't need for no long term benefit harm by any definition.
It's just...this reminds me, though with far less devastating consequences, of the 'controversy' surrounding the surgical treatment of breast cancer once upon a time ago. 'Logic' dictated for a long time that the more aggressive the surgery, the less likely there was to be a recurrence. And it made sense on the face of it. The more tissue you take, the less there is for the cancer to set up shop in again. Radical mastectomies that removed the entire chest wall (often a rib or two for good measure) and all levels of axillary and clavicle lymph nodes were the order of the day. It was worth the trade off for devastating physical disability and disfigurement if you could keep the cancer from coming back. Only...you couldn't, not like that. The less nuclear modified radical mastectomy or lumpectomy depending on the tumor had the same results. It took years before people, both patients and surgeons, would accept that and for the practice to die out, regardless of all evidence. Lets not do that again, okay?
And just to reiterate, neither I nor the recommendations are talking about diagnostic mammograms for already discovered lumps, or high risk screening. Nor do they refer to regular screening mammograms for women over the age of 50 where early detection is of benefit.
So, that's what I have to say about that.
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Is it okay if I PM you with some questions?
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Always, dude...always. I'm home all day today.
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Thank you. I will definitely look into the book, and Orac's blog.
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Re: mammograms
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Re: mammograms
The former is easy to understand...the latter? Well, who in the hell wants to be told that there very well could be cancer growing in her breast but it's okay if it hangs around for a bit, so we won't look for it. Even if you intellectually understand the harm it would cause to other women, and that there is little benefit to you....I can't imagine very many people for whom the emotional reaction isn't GET IT OUT, GET IT OUT, FIND IT AND GET IT OUT and fuck all those women who had to have an unnecessary biopsy to get to you.
I don't actually know how you get past that reaction, though it is basically what the objections to the newer guidelines boil down too...so I hope there is a way.
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Re: mammograms