Above, Aaron Carroll explains the difference between mortality (important) and survival (less so).
Cardiologist Lisa Rosenbaum writes about squaring the circle between evidence based medicine and what we fear in
“Misfearing” — Culture, Identity, and Our Perceptions of Health RisksIt's especially pertinent to the debate about mammograms. But read the part about tribalism and think: politics. Thanks to NEJM for freeing this from the paywall.
The ongoing controversy surrounding mammography screening highlights the clash of identity and data at the social level. In 2009, the U.S. Preventive Services Task Force recommended decreased frequency of mammography for most women younger than 50 years old, noting that the potential harms outweighed the benefits. Although the recommendations were based on an unbiased review of decades' worth of data, a public outcry ensued. The recommendations were criticized as an assault on women's health, and a 2009 USA Today poll found that 84% of women 35 to 49 years of age planned to ignore them.
So intense was the outrage over these evidence-based recommendations that a provision was added to the Affordable Care Act specifying that insurers were to base coverage decisions on the previous screening guidelines. Rather than acknowledge this blatant dismissal of new guidelines, many political leaders, physicians, and advocacy organizations argued that we simply didn't have enough data to justify the new recommendations. But data have shown for years that early mammography screening doesn't save lives, just as data show that preventing heart disease, through certain lifestyle modifications and appropriate use of medications, does. So why do we resist these data?
More on the same topic here from Christie Aschwanden:
What’s the number one killer of women? It’s a question that practitioners asked every new patient at a clinic where physician Lisa Rosenbaum once worked, and she hasn’t forgotten the answer given to her by one middle-aged woman with high blood pressure and elevated blood lipids. “I know the right answer is heart disease,” the patient told Rosenbaum, “But I’m still going to say ‘breast cancer.’”Best advice, btw, is still individualize your care and talk to your doc. But given the interface between facts, culture, cost control, vested interest and ACA, expect a lot more commentary.
Rosenbaum recounts this experience in a perspective published yesterday in the New England Journal of Medicine, which follows on the heels of a long-term study published online Tuesday in BMJ that found no benefit from screening mammography. The two papers make fine companions.
The Rosenbaum commentary explores a phenomenon that Cass Sunstein dubbed “misfearing” — our human nature to fear instinctively, rather than factually. Her patient’s first answer is correct — heart disease kills more women than all cancers combined, and yet breast cancer seems to invoke far more fear among most women. “What is it about being at risk for heart disease that is emotionally dissonant for women?,” Rosenbaum asks. “Might we view heart disease as the consequence of having done something bad, whereas to get breast cancer is to have something bad happen to you?”
More politics and policy below the fold.
I HAVE never had a mammogram. I’m almost 50 — nearly a decade into the age when the screening is recommended by the American Cancer Society. I’m college educated, adequately insured. And I am the bane of my health care providers. Once, my midwife went so far as to request that I never speak of my decision in any space where other patients might hear.This anecdote is included, not because it's wrong or right, but to reinforce the need for individualized care based on history, family history and a discussion with your doctor.
This week, I was vindicated. On Tuesday, a Canadian study, one of the largest ever done on mammograms, was published in the British Medical Journal. The study found that mammograms did not reduce breast cancer deaths in women around my age compared to physical exams, and that one in five women screened was overdiagnosed, possibly leading to unnecessary surgery or radiation.
It seems astonishing, but it reinforced what smaller studies had told me, as someone with no family history of breast cancer: that getting a mammogram was unlikely to affect my chances of dying from the disease. What it would do is increase the probability of my mistakenly becoming a breast-cancer patient.
Last week, the British Medical Journal released a blockbuster long-term study of nearly 90,000 Canadian women. It concluded that yearly mammography screenings for women 40 to 59 do not reduce breast cancer deaths, though they make a diagnosis of breast cancer more likely. That is, the study found that regular mammography leads to more cancers detected but does not lead to fewer women dying of breast cancer.We knew when this study came out, there'd be some discussion.
"We found absolutely no benefit in terms of reduction of deaths from the use of mammography," said study leader Dr. Anthony Miller, an epidemiologist at the University of Toronto's Dalla Lana School of Public Health.
A BMJ editorial bluntly concluded: "Too much mammography."
It won't shock you to know that many people vehemently disagree. The American College of Radiology and Society of Breast Imaging called the BMJ study "an incredibly misleading analysis" based on a "deeply flawed and widely discredited " previous study. Critics said the Canadian study used outdated equipment and faulty methods that erroneously made mammograms look ineffective.
It's awfully difficult for the public to try to referee this continuing medical debate. What we know: Breast cancer is a fearsome disease. Studies have shown that mammography saves lives. But it also can lead to overdiagnosis, prompting women to undergo unnecessary and potentially harmful treatments. Some tumors are so aggressive that early detection still doesn't save lives. Some cancers progress so slowly that they would never kill.
And remember: The Canadian researchers aren't the first to raise red flags about widespread mammography screenings.
In other news:
At least every week now, there is a new story supporting the narrative of an inevitable 2016 Hillary Clinton presidential bid. Indeed, the conventional wisdom is that it is an absolute certainty that she will run. If anyone is currently saying, flat out, that Hillary isn't running, I haven't come across them. Is the inevitability of her run really as certain as the conventional wisdom suggests, and further, is it unfolding in an optimal manner for the potential candidate?Eugene Robinson:
In all likelihood, Clinton will not make a final, "go-or-no-go" decision until early next year, after the dust has settled from the midterm election. Generally speaking, few presidential contenders make their final decisions before the preceding midterm, and, with the notable exception of Texas Gov. Rick Perry in 2011, most have been laying the groundwork for a long time for a potential run. Most have already been attending countless state and county Jefferson-Jackson (for Democrats) or Lincoln (for Republicans) dinners, meet and greets, and other events to prepare for the potential campaign and the ensuring shakedown (if they do, in fact, decide to run).
Wednesday’s status report on the health-insurance reforms was by far the best news for Democrats and the Obama administration since the program’s incompetent launch. January was the first month when new enrollments surpassed expectations, as the balky HealthCare.gov Web site began functioning more or less as intended.NY Times:
Cumulatively, 3.3 million people had chosen insurance plans through the state and federal exchanges by the end of January. That is fewer than the administration had originally hoped but well above the predictions of critics who believed — or hoped — that the program would never succeed. The Congressional Budget Office projects that 6 million people will have chosen plans through Obamacare when the initial enrollment period ends March 31, down from a pre-launch estimate of 7 million. Not bad at all.
A sweeping decision on Thursday night struck down Virginia’s ban on same-sex marriage and continued a remarkable winning streak for gay rights advocates, putting new pressure on the Supreme Court to decide the momentous question it ducked last summer: whether there is a constitutional right to same-sex marriage.