HELL HATH NO FURY LIKE 287 BREAST CANCER PATIENTS SCORNED

Unless any of my fellow primary care pathologists out there have been way off the grid for the past 72 hours, you have by now heard the news of the revised guidelines for screening of breast cancer published by the group of luminaries known as the US Preventative Services Task Force - and hopefully you are following in some capacity the resulting sound and fury, which in this case, is signifying something - something very, very big.

I will confess and apologize at the outset of this posting that my attempts to keep my emotions in check after reading the original paper and some of the press coverage of this medical travesty, have largely failed.  One of my zeniths of outrage was hit early this morning as I read this article in the Seattle Times.  I’ll give you a minute to compose yourself and to clean up the coffee that you just threw at your computer screen after you read it. 

Thank Hippocrates, there are cries of outrage from every stakeholder’s camp in this very public discussion.  And at last - the discussion is substantive, not the manufactured  “death panel” crap of this summer.  This is the real deal - Rationing (note the capital “R”).  A quick Googling of the news on this Wednesday afternoon shows that already those who are calling this what it is are labelled with the stigmatizing words “Conservative”, “Republican”, and “FOX News”.  Let me also state at this juncture that I am politically middle of the road, a registered Independent, and often mistake FOX News for The Comedy Channel.  And I too am willing to call this what it is  - Rationing!  And it is Rationing red in tooth and claw, because it is Rationing done based upon the wisdom of a “Task Force”.  And this task force, consisting predominately of physicians with expertise in public health and epidemiology did what they do best - they analyzed numbers.  They are the hammer, and the numbers are their nail.  And the wisdom that these oracles have extracted from the numbers is, in essence, this:

1904 women between the ages of 40-49 have to be screened by mammography to save the life of one woman.

1339 women between the ages of 50-59 have to be screened by mammography to save the life of one woman.

That difference of 565 women doesn’t justify the risk of screening.

And directly quoted from the study, the “harms” are:

“Screening detects not only cancer that could lead to a woman's death but also cancer that will not shorten a woman's life. Women cannot benefit from—but can be harmed by—the discovery and treatment of this second type of cancer, which includes both cancer that might some day become clinically apparent and cancer that never will. Detection of cancer that would never have become clinically apparent is called overdiagnosis, and it is usually followed by overtreatment. Because of a shortened life span among women 75 years or older, the probability of overdiagnosis and unnecessary earlier treatment increases dramatically after about age 70 or 75 years. Overdiagnosis and unnecessary earlier treatment are important potential harms from screening women in this age group.”

As I was driving into work today calming my emotional apoplexy, I had the bright idea to consult my own Task Force and crunch one very important number.  A quick call to Task Force Teresa, the ever-diligent keeper of the tumor registry at Harrison Medical Center  gave me that number - 287, which is exactly the number of patients at our hospital between the ages of 40-49, who have been diagnosed with breast cancer over the past 10 years.  And the vast majority of them were diagnosed as a result of screening mammogram.  Now I understand that the USPS Task Force leader Dr. Bruce Calonge is spending some time with the press  defending the wisdom of his committee's numbers.  As much as I want to keep the discussion rational, my overwhelming wish is that Dr. Calonge had to spend some one-on-one time with any those 287 women who have survived the ordeal - hold their hand, and explain the wisdom of his task forces numbers to them, and not to the press.  But that kind of messy work will be left up to us who take care of breast cancer patients every day.

Finally, among all the levels of medical folly that this represents - let us pathologists of every type and sub-specialty take note of the overt spit in our microscope-worn eyes message that is clearly conveyed by the statement above from the Task Force.  In those few lines they not only completely devalue the necessity of accurate histologic diagnosis in the management of breast diseases, but we are being made to be the central cause of all this harm with our “overdiagnosis” of “second types of cancer” before it becomes “clinically apparent” and leads to all of this horrific “overtreatment”.  I guess the role of accurate pathologist’s diagnoses in such landmark breast cancer prevention studies as NSABP P-1 is harmful overdiagnosis and overtreatment for this Task Force.  Now I know it takes a lot to get pathologists riled up about things.  As a rule, many in our specialty tend to display a high threshold of tacit acceptance.  But quite frankly, if this doesn’t piss every one of us off to the point of at least public rebuttal and hopefully action, then we really may be doomed as a medical species.  This statement by a committee of extremely influential policy-advising physicians, none of whom appear to be board-certified pathologists, have just published a statement that shows a fundamental lack of understanding of the characteristics of all screening procedures and of breast disease.  At least in this regard, one could easily presume that this study was done by the US Postal Service and not the US Preventative Service.  

And so the closing question for all of you to ponder is - what are we going to do about it, both individually and as a specialty?  Now is very good time to aggressively defend our honor.   And if we can’t be roused to that call, let us at least follow the prime medical directive and defend our patients.

P.S. I arrived home tonight to find my wife watching the French news coverage of this report on TV5 Monde.  A summary of her translation of the story:  American physicians have decided to stop overdiagnosing and overtreating breast cancer by ceasing mammogram screening before age 50. [Gallic jubilant tone] American medicine is now just like France and the rest of European countries.

oh happy day

Comments

[Chukwuma]

I must disagree. Are you really not concerned with overdiagnosis and overtreatment? Have you no sympathy with the justifiable fact that the rise in health care costs and current dilemma in health care are directly related to superfluous testing which *does not* improve health outcomes? Indeed, there is good data elsewhere that overtreatment and overdiagnosis decreases health quality. (See Magee Mahar for details).

Rhetorical question. Why not routine mammography for asymptomatic women at 30? Why not 20?

[Chukwuma]

Sorry, that's Maggie Mahar

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There are miravulous advances in breast cancer identification and treatment. It is now possible to disocver if a woman has the gene that would likely make her susceptible. Even today in DNA news there is an announcement of a new type of 3-D mamography that will give doctors a massive boost in their armory of tools for treatment.

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