Skip to main content

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 Risks

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?

It'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.

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.’”

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?”

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.

More politics and policy below the fold.

Marie Myung-Ok Lee:

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 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.

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.

Chicago Tribune:

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 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.

We knew when this study came out, there'd be some discussion.

In other news:

Charlie Cook:

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?

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).

Eugene Robinson:
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.

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.

NY Times:
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.
EMAIL TO A FRIEND X
Your Email has been sent.
You must add at least one tag to this diary before publishing it.

Add keywords that describe this diary. Separate multiple keywords with commas.
Tagging tips - Search For Tags - Browse For Tags

?

More Tagging tips:

A tag is a way to search for this diary. If someone is searching for "Barack Obama," is this a diary they'd be trying to find?

Use a person's full name, without any title. Senator Obama may become President Obama, and Michelle Obama might run for office.

If your diary covers an election or elected official, use election tags, which are generally the state abbreviation followed by the office. CA-01 is the first district House seat. CA-Sen covers both senate races. NY-GOV covers the New York governor's race.

Tags do not compound: that is, "education reform" is a completely different tag from "education". A tag like "reform" alone is probably not meaningful.

Consider if one or more of these tags fits your diary: Civil Rights, Community, Congress, Culture, Economy, Education, Elections, Energy, Environment, Health Care, International, Labor, Law, Media, Meta, National Security, Science, Transportation, or White House. If your diary is specific to a state, consider adding the state (California, Texas, etc). Keep in mind, though, that there are many wonderful and important diaries that don't fit in any of these tags. Don't worry if yours doesn't.

You can add a private note to this diary when hotlisting it:
Are you sure you want to remove this diary from your hotlist?
Are you sure you want to remove your recommendation? You can only recommend a diary once, so you will not be able to re-recommend it afterwards.
Rescue this diary, and add a note:
Are you sure you want to remove this diary from Rescue?
Choose where to republish this diary. The diary will be added to the queue for that group. Publish it from the queue to make it appear.

You must be a member of a group to use this feature.

Add a quick update to your diary without changing the diary itself:
Are you sure you want to remove this diary?
(The diary will be removed from the site and returned to your drafts for further editing.)
(The diary will be removed.)
Are you sure you want to save these changes to the published diary?

Comment Preferences

  •  I am bemused but not surprised by the (50+ / 0-)

    ChiTrib bit about how radiologists reacted. I

    t 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.
    if you do a 25 year study, the oldest parts of it will naturally have dated equipment,. But it's the real world.
    I leave you with one final thought. If you’re not going to be swayed at all by a randomized controlled trial of 90,000 women with 25 year follow up, excellent compliance, and damn good methods, it might be time to consider that there’s really no study at all that will make you change your mind.
    http://theincidentaleconomist.com/...

    It's not for everyone. But talk to your doc.

    "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

    by Greg Dworkin on Sat Feb 15, 2014 at 04:38:12 AM PST

    •  Sure, talk to your doctor (14+ / 0-)

      but remember he or she is just one person with an opinion, too. If what your doctor says doesn't make sense to you, if he or she simply repeats the mantra "mammograms save lives!" without considering the science, you may want to rethink your choice of doctors.

      My older sister fired her OB/GYN, the one she'd been seeing for 30 years, when he insisted that all women should go on hormone replacement "therapy" when they approach menopause. This was before the results of the nurse's study.

      •  an informed patient is a great patient (5+ / 0-)
        Recommended by:
        David54, jnhobbs, Oh Mary Oh, Sylv, elmo

        no question about that.

        "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

        by Greg Dworkin on Sat Feb 15, 2014 at 05:50:13 AM PST

        [ Parent ]

        •  I wish all doctors held this opinion (11+ / 0-)

          but that is not always the case.  My doctor was not very pleased when I declined to take a statin based on studies I had read indicating that statins do not increase life expectancy in women under 65 who have not had a heart attack.  After several discussions we agreed to disagree, and she no longer checks my cholesterol level.

          If the Republicans ever find out that Barack Obama favors respiration, we'll be a one-party system inside two minutes. - Alan Lewis

          by MadRuth on Sat Feb 15, 2014 at 06:06:38 AM PST

          [ Parent ]

          •  My mother had doctors who told her that (3+ / 0-)
            Recommended by:
            Laconic Lib, historys mysteries, elmo

            the drugs they prescribed "did not have side effects". I finally broke them of that when I got involved.

            You can't make this stuff up.

            by David54 on Sat Feb 15, 2014 at 06:34:24 AM PST

            [ Parent ]

            •  My mother fears her doctor (8+ / 0-)

              My mother takes statins, is 81 and has had painful side effects from every one but won't stop because her internist "gets mad at her"!  

              •  Don't even get me started on this! My grandpa (6+ / 0-)
                Recommended by:
                sillia, Sylv, Laconic Lib, Wee Mama, elmo, David54

                did whatever the doctors told him to do no matter how ridiculous! If they told him standing on his head would help him, he would do it! There is a huge compliance to medicine from this generation, with no questions asked. They look at doctors as gods and don't question them...ever. I don't know if it was because he had grown up during the first uses of immunizations and antibiotics which were seen as miracle drugs or what, but there is simply a stoic allegiance even if you explain that docs are 'practicing' medicine. Crazy.

                •  I have a friend in her 90's (4+ / 0-)
                  Recommended by:
                  Wee Mama, xenothaulus, antimony, David54

                  who won't tell her doctor about her symptoms. When I asked her why not, she said because it's his job to figure out if there's anything wrong with her. Using his professional expertise I suppose, along with scientific testing. But she feels that input from the patient is irrelevant. Arg!

                  She could save money and just go to a veterinarian...they're used to treating patients who don't articulate their problems!

                  Where in the Constitution does it say: "...on behalf of corporate interests" ???

                  by sillia on Sat Feb 15, 2014 at 08:32:15 AM PST

                  [ Parent ]

              •  Same here; it makes me so mad (5+ / 0-)

                My mom is also 81. A few years ago I got her to change her diet so she could get off Lipitor which was giving her leg pains. She succeeded, yay!

                Now she's slipped back into old eating habits and her doctor gives her blood pressure meds. Now she's complaining of memory problems, cognitive issues (a well-known side effect of hypertension drugs). I told her to ask the doctor about changing her blood pressure med or reducing the dose but she's AFRAID of the doctor and won't do it.

                It makes me so mad, I could scream. Really, I could SCREAM.

                Where in the Constitution does it say: "...on behalf of corporate interests" ???

                by sillia on Sat Feb 15, 2014 at 08:28:26 AM PST

                [ Parent ]

            •  Never believe anything about side-effects. (4+ / 0-)

              I have HIV and a number of other conditions that require medication. Years of experience have taught me that side-effects are very much an individual matter.

              HIV meds that supposedly don't cause lipoatrophy end up causing it. The ones that supposedly cause nausea and diarrhea don't. I'm on a drug now that isn't supposed to cause loss of appetite, but I've lost my appetite since I started it.

              The bottom line is that you can't predict what side-effects you'll have from a drug until you take it.  Always, always bear that in mind.

              "Ça c'est une chanson que j'aurais vraiment aimé ne pas avoir écrite." -- Barbara

              by FogCityJohn on Sat Feb 15, 2014 at 10:44:16 AM PST

              [ Parent ]

        •  Or an unnerving one (2+ / 0-)
          Recommended by:
          Sylv, elmo

          When we sent the neurologist a brand new study he hadn't seen yet he was a little taken aback.

          If you think you're too small to be effective, you've never been in the dark with a mosquito.

          by marykk on Sat Feb 15, 2014 at 07:46:27 AM PST

          [ Parent ]

      •  Women have been abused (7+ / 0-)

        By the health care and pharma industries for over a century. Glad we're finally starting to get evidence based care. I still can't believe how many docs are still pushing HRT on menopausal women.

        Moving away from the emphasis on mass screening mammography and "early" detection is finally allowing us to focus more on stopping bc metastasis and exploring real prevention.

        Its horrific to realize how many women have been inaccurately diagnosed with breast cancer and lost their breasts while undergoing chemo and/or radiation therapy.

        Money is property, not speech. Overturn Citizens United.

        by Betty Pinson on Sat Feb 15, 2014 at 05:55:35 AM PST

        [ Parent ]

        •  Chemo and radiation (5+ / 0-)

          that themselves have long term health implications. It's like that bitter old joke: the procedure was successful but the patient died.

        •  they're still doing most of the research on men (2+ / 0-)
          Recommended by:
          historys mysteries, elmo

          heart disease is the number one killer of women but the majority of the research is still being done on men, isn't it?

          Politics is like driving. To go backward put it in R. To go forward put it in D.
          DEMAND CREATES JOBS!!!
          Drop by The Grieving Room on Monday nights to talk about grief.

          by TrueBlueMajority on Sat Feb 15, 2014 at 08:34:01 AM PST

          [ Parent ]

        •  Ironic given cancer fears focus on breast (4+ / 0-)

          As a 71-year old survivor of 3 cancers (breast twice, kidney once, and skin cancer which I don't even count)  I can offer the following perspective.  I think women fear breat cancer because of fear of mastectomy, plus fear of pain.  I know my fear of dying of cancer is totally about pain and a long, drawn out death.  Heart attacks are so often quick.  That is a huge part of the fear of cancer.

          And for women especially breast cancer has a special fear because of mastectomy.  I had a lumpectomy in 1995.  I had already had a hysterectomy in 1992 because of huge fibroids.  I then had one cancerous kidney removed in early 2011 (related to a genetic issue).  Then on Labor Day I  found another lump in the same breast as before.  Lumpectomy was not an option.  The surgery itself was not bad--no overnight in the hospital, unlike the others.  The recovery was not too bad, a little harder than the kidney because of node removal.  But psychologically there is absolutely no comparison.  This really surprised me because of my age, the fact that I always had small breasts and, as my niece put it, I am not exactly a glam girl.  But I couldn't look in the mirror for at least a week and still start when I do.  It is just really, qualitatively different from the other surgeries.  And I think that has a whole lot to do with fear of breast cancer over heart attacks or strokes.  

          The irony of course is that despite what some people say, there is probably nothing or very little  a woman can do to reduce the chances of breast cancer, but heart attacks are related to diet and exercise, about which one could do something, although it is harder than many people suppose.

          Don't bet your future on 97% of climate scientists being wrong. Take action on climate now!

          by Mimikatz on Sat Feb 15, 2014 at 09:10:33 AM PST

          [ Parent ]

      •  The smallest dose for the shortest time (1+ / 0-)
        Recommended by:
        elmo

        is the current recommendation for hormone replacement therapy with the indication being hot flashes. It was the Womens Health Initiative Study that reversed the previous thinking about HRT. But it's important to remember the average age in that study was 63. The risks turn out to be pretty small for women around the menopause age of 50-51 but not zero. So it presents another case of needing to individualize to a patient's specific risks and severity of symptoms.

    •  Nail on head comment Greg! (2+ / 0-)
      Recommended by:
      marykk, Dragon5616

      Not all scientists are doctors, and not all doctors are scientists. The best doctors are great clinicians who also understand, and are up to date on, the relevant science.

      I'm from the Elizabeth Warren wing of the Democratic Party

      by voicemail on Sat Feb 15, 2014 at 06:18:01 AM PST

      [ Parent ]

      •  Yup! If my doctor doesn't know of a study I (0+ / 0-)

        think he should because it is in his specialty, I change doctors. What a doctor, especially an older one learned 20 years ago isn't even hardly relevant in some specialties, especially cancer. I also asked them how they stay up to date, what conferences they have been to recently, etc.

        •  Experience (0+ / 0-)

          Family doctors with lots of experience can be spectacular diagnosticians. Younger doctors often don't look up from their computers. I have numerous friends who know more than any doctor they have ever seen, so I consult them as well.  

          I'm from the Elizabeth Warren wing of the Democratic Party

          by voicemail on Sun Feb 16, 2014 at 06:40:26 PM PST

          [ Parent ]

    •  I'm generally somewhat skeptical of these studies (6+ / 0-)

      Long-term studies like the Canadian one indeed do not reflect the state of the art in breast cancer detection, so historical data can be misleading as well as being helpful.  The cardiac risk formula used in the new cholesterol guidelines is an example -- using decades-old data to predict current risks when the prevalence of heart disease is falling.

      I'm not so much skeptical of the studies, really, but of the broad and universal conclusions drawn from them by people telling medical professionals what we should be doing.  What these studies don't include is the n of 1.  Individual patient factors, such as the size and density of breast tissue that may make breast exams more or less sensitive and specific.  I've never seen large studies on the efficacy and variability of breast exams by clinicians, so using such robust statistical analysis to suggest changing current practice to a methodology not nearly so well studied as being adequate is questionable at best.

      Other factors, such as local and regional breast cancer incidence, racial and economic variables, and the like, are also not included in these one-size-fits-all recommendations.  "Evidence-based medicine" is only as good as the evidence we have, who paid for that evidence and what their agenda might be, the limitations of the analysis to which it is subjected, and the justifiability of the conclusions drawn.  The idea that evidence-based medicine is some sort of objective truth that we would all be stupid not to follow is going to look painfully naive in retrospect, I believe.  Like all studies, these meta-analyses provide very useful information.  But they do not necessarily provide the right answer in the exam room for an individual patient.  

      We have always been at war with al Qaeda.

      by Dallasdoc on Sat Feb 15, 2014 at 07:03:29 AM PST

      [ Parent ]

      •  as I have so stated (individualize!) (4+ / 0-)
        Recommended by:
        NotActingNaive, marykk, sillia, Sylv

        but it is an indictment of corporate Susan G Komen "one size fits all" approach. And it needs to be taken with U.S. Preventive Services Task Force in 2009 (Federal panel recommends reducing number of mammograms) and acknowledge that 1. no perfect studies 2. there is resistance to change in general and 3. there are vested interests that fight change for other than evidence based medicine reasons 4. despite that, legit concerns are legit discussion.

        In the end, data should drive the discussion.

        "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

        by Greg Dworkin on Sat Feb 15, 2014 at 07:39:53 AM PST

        [ Parent ]

      •  PS great subheading here (0+ / 0-)

        from Christie Aschwanden's blog:

        "Science says the first word on everything, and the last word on nothing" – Victor Hugo

        "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

        by Greg Dworkin on Sat Feb 15, 2014 at 07:41:31 AM PST

        [ Parent ]

        •  Greg: could you comment on this: (0+ / 0-)

          Introductory history:
          15 years ago, my wife was diagnosed with breast cancer.  She found the lesion herself, just incidentally.  It was quite large - 2.5 centimeters - but fortunately not metastatic.  She had been getting annual mammograms, the last one 5 months earlier.  On the last several studies, that area had been read as "benign calcifications".  She's fine after treatment.  But it was in the aftermath of that discovery that we learned that mammography is relatively ineffective for those with very dense breast tissue.  A female radiologist with a specialty in mammography explained to her that she really needed breast ultrasound for her ongoing surveillance.  
          Here's the part that I would be interested in your thoughts on: Male radiologists over the next several years were almost fanatically determined to prevent her from getting breast ultrasound.  Not just not talking about it or offering it, but actively determined to keep her from it.  That has subsided in the last few years, and a couple of years ago California actually passed a law requiring that women with dense breast tissue be informed of the ultrasound option.  But the resistance of the radiologists to its use was astonishingly vehement back then.  Any thoughts on why?

          "Wouldn't you rather vote for what you want and not get it than vote for what you don't want - and get it?" Eugene Debs. "Le courage, c'est de chercher la verité et de la dire" Jean Jaures

          by Chico David RN on Sat Feb 15, 2014 at 08:37:05 AM PST

          [ Parent ]

          •  not informed ones (2+ / 0-)
            Recommended by:
            EAColeInEmporia, Piren

            as a pediatrician I have no professional experience on those specifics, and unlike Bill Frist, that's enough to make me be quiet ;-P

            "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

            by Greg Dworkin on Sat Feb 15, 2014 at 09:18:21 AM PST

            [ Parent ]

            •  Appreciate the humility. (0+ / 0-)

              I didn't expect you to know the technical aspects, but thought you might have some insight into the vehemence of the opposition.  But I honor your unwillingness to go where you are not knowledgeable.

              "Wouldn't you rather vote for what you want and not get it than vote for what you don't want - and get it?" Eugene Debs. "Le courage, c'est de chercher la verité et de la dire" Jean Jaures

              by Chico David RN on Sat Feb 15, 2014 at 10:12:37 AM PST

              [ Parent ]

    •  This concept of overdiagnosis is tough. (0+ / 0-)

      They are saying that if a cancer is sitting there it may not be lethal. So then it would be better not to even know about it. The problem is all cancers start out small. Do you want to miss the chance of picking up a cancer early, if it's the lethal kind?

      As far as the decision to forego screening mammogram and just get an annual breast exam instead, women should consider if they have an elevated risk for breast cancer. Family history, early first period, late menopause, alcohol ingestion, first birth over age 29, previous biopsy, the measured choice of menopausal combined hormones, obesity and most especially breast density are risk factors that should make women think harder about it.  Apart from BRCA mutation and previous chest wall radiation, breast density is biggest single risk factor by far. California thinks every woman should know not just if her mammogram is negative, but whether her breasts are dense. Unfortunately dense breasts are harder to evaluate by mammogram. This study sounds like it was based on mass screening, and it would be interesting to know if it were stratified by risk whether it would yield the same result for those higher risk patients.

    •  Trained nurse examiners vs old equipment (1+ / 0-)
      Recommended by:
      Greg Dworkin

      If I had trained Canadian nurses in my clinic specializing in breast exams, and the alternative was 25yo mammography machines, sure, I'ld go with the nurses when recommending early detection strategies for breast cancer.  But I don't have either of those.  I have modern mammography equipment and grossly overworked nurses.

      A British officer at Waterloo remarked that longbows would have done better than the muskets they had at that battle.  But longbows require a lot of training to master and constant practice to keep up the mastery, while you could train recruits to use muskets in a few weeks.  Technology, especially when it's just introduced, is usually not as good as highly trained people, but it tends to be a lot more available.  And, unlike the standard of performance of highly trained people, which has usually already maxed out, technology can generally be much improved over the early models.

      The other part of the story here, the other reason this study showed no improvement in outcomes for the method that can find smaller masses, is that finding breast cancers smaller than can be felt by hand has not proven as useful as we thought it would before we started using MMG to try to find these smaller masses.  The initial hope was that cancers smaller than 2cm could be safely treated with lumpectomy alone, but we found that that strategy missed too many <2cms that had already spread locally, so now it's lumpectomy plus lymph node dissection (usually) plus chemo plus XRT plus tamoxifen (usually) for years.

      What we really need is some way to differentiate small breast cancers that aren't aggressive, from those that are.  Size itself is a pretty good differentiator, but not nearly good enough.  If we quit looking for the small ones early, we're not going to be able to take that next step.  The old solution, trained exam nurses, however wonderful it is at finding the bigger masses, won't meet that need to find the small ones early.

      The states must be abolished.

      by gtomkins on Sat Feb 15, 2014 at 02:13:17 PM PST

      [ Parent ]

      •  hmm... (0+ / 0-)

        Here's an idea for study critics: find studies that show mammography decreases mortality and post them. It's surprisingly hard to do.

        or as Jen Gunther put it:

        Here is a summary from the [Cochrane search] results section:

        “Eight eligible trials were identified. We excluded a trial because the randomisation had failed to produce comparable groups.The eligible trials included 600,000 women in the analyses in the age range 39 to 74 years. Three trials with adequate randomisation did not show a statistically significant reduction in breast cancer mortality at 13 years (relative risk (RR) 0.90, 95% confidence interval (CI) 0.79 to 1.02); four trials with suboptimal randomisation showed a significant reduction in breast cancer mortality with an RR of 0.75 (95% CI 0.67 to 0.83). The RR for all seven trials combined was 0.81 (95% CI 0.74 to 0.87). We found that breast cancer mortality was an unreliable outcome that was biased in favour of screening, mainly because of differential misclassification of cause of death. The trials with adequate randomisation did not find an effect of screening on total cancer mortality, including breast cancer, after 10 years (RR 1.02, 95% CI 0.95 to 1.10) or on all-cause mortality after 13 years (RR 0.99, 95% CI 0.95 to 1.03).”

        My conclusion? If the literature concerning digital mammography (the new, better mammography that wasn’t in the BMJ study) was so robust studies like the CNBSS would barely get the time of day in The Journal of Medical Obscurata. No one would care about a study on old equipment if studies on the newer equipment existed and truly showed a benefit.

        my bold.

        http://drjengunter.wordpress.com/...

        "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

        by Greg Dworkin on Sat Feb 15, 2014 at 03:07:12 PM PST

        [ Parent ]

        •  Two points (1+ / 0-)
          Recommended by:
          Oh Mary Oh

          I'm not sure what to make of the bolded excerpt.  It would be rare, even among underserved populations in the US, for breast cancer to not present clinically some time before it causes death.  You wouldn't think there would be much room for differential misclassification, at least not for primary cause of death, though the certifying physician might list a breast cancer known only through screening as a secondary or contributing cause.

          As to the conclusion, studies on the newer equipment, and the newer protocols for responding to a worrisome MMG that have arisen over the decades we've been doing this, would have to have lengthy follow-ups to find what we are looking for as the prospective benefit of adding MMG to regular exams by professionals.  

          The breast cancers that would make a difference in mortality earliest are those that present clinically, with incidentally found masses, or peau d'orange, or some such.  These are the typically >4cm masses, and the only thing that worked at all reliably for them was radical mastectomy.  You would expect to see differences very quickly in breast cancer mortality between women who presented clinically to medical attention with such large masses and had radical mastectomy available to them, and those who had no medical attention available prior to that of the coroner.

          The cancers that would be second in terms of affecting mortality quickly, would be those that can be found on screening manual breast exams, masses down to around 2cm.  Last of all, expected to affect mortality the furthest out into the future, are the <2cm lesions that you need MMG to find.

          The aim of early detection is to detect early.  It's not a refutation of the utility of finding breast cancer at 1cm that you can't show a difference in breast cancer mortality until many years down the road.

          Sure, that's a shifting target.  30 years ago, we believed that breast cancers were almost always fast growers, unlike, say, prostate cancers, which we already knew from autopsy studies were histologically present in much higher percentages of men our age than would ever develop clinical prostate cancer.  We thought that finding and treating breast cancer at 1cm would have a practically immediate effect on breast cancer mortality.  We were so worried by the potential of breast cancer to get more malignant quickly, and to have already spread to undetectable micro-metastases by the time the primary was found, that for years many thought that radical mastectomy was the only responsibly safe response to any breast cancer of any size.

          We know that's not true any more, but we know that because of having done MMG screening for decades.  When the Mayo Clinic launched its huge study of FOBT screening for CRC, it thought it was testing the utility of FOBT, followed by colonoscopy to f/u heme-positive results, to find early colon cancer.  That didn't pan out.  They found practically no colon cancer as the source of the tens of thousands of heme-positives they came up with.  But adenomatous polyps were systematically removed in all those tens of thousands who got f/u c-scopes that the numbers tell us were completely worthless at finding colon cancer.  The FOBT group had a significantly lower rate, decades later, of death from CRC, because those polyps turned out to be, as was suspected but not known before those tens of thousands of scopes, precursor lesions to CRC.

          The current rationale for MMG is similar to doing screening scopes to remove those pre-CRC lesions from the colon.  We have yet to prove the utility of that strategy, that it will make a difference if we nip all the <1cm breast cancer masses that we can find in the bud, but we certainly haven't proven its lack of utility.  We'll have to follow the application of the latest equipment to that strategy for decades before we can say that what seems to be a very reasonable strategy will not work.

          And even if that strategy is eventually proven to not be helpful, we still need to go forward in proving that proposition.  We abandoned screening CXRs of smokers for the early detection of lung cancer because we found tons of benign SPNs for every cancer, and most of the latter weren't treatable anyway by the time we found them.  But following that strategy to its end told us both that lung cancer is not a slow grower, and, perhaps more importantly, it told us that we did not have to do open lung biopsies for any but a small select group of incidentally found SPNs.  I tend to part ways with self-styled Evidence Based Medicine when its proponents tell us to stop gathering evidence.    

          Finally, even if we were to accept now that this study is to be treated as Gospel truth dictating what we do from today, and that we should therefore stop MMG+annual exam by breast nurses in favor of just annual exam by breast nurses, the fact remains that those are not the practical alternatives we have today.  Those would be MMG+nothing systematic in the way of manual exams, vs nothing systematic in the way of manual exams, all by itself -- just wait for breast cancer to present clinically.  I'm sticking with MMG for now.  Sure, maybe we should do something systematic about manual exams in this country, but it is not at all clear that MMG is not a cheaper way of getting the same benefit as good systematic manual exams (that was the point of the longbow vs musket analogy in my prior reply).

          The states must be abolished.

          by gtomkins on Sat Feb 15, 2014 at 11:26:23 PM PST

          [ Parent ]

          •  best suggestion is individualize care (1+ / 0-)
            Recommended by:
            Oh Mary Oh

            not stop doing them. And the over-diagnosis rate from colonoscopy isn't 22%.

            my favorite observation is in the first comment by Aaron Carroll, who did the video at top of post:

            I leave you with one final thought. If you’re not going to be swayed at all by a randomized controlled trial of 90,000 women with 25 year follow up, excellent compliance, and damn good methods, it might be time to consider that there’s really no study at all that will make you change your mind.

            "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

            by Greg Dworkin on Sun Feb 16, 2014 at 04:48:56 AM PST

            [ Parent ]

            •  "Individualize care" misses the point (0+ / 0-)

              You have to individualize care even if you are a raving lunatic, start-at-age-20, MMG hawk, because you have to get the patient to go have the MMG.  To do that you have to convince the individual sitting in your office that it's worth their time and the indignity and outright pain of having the thing done, much less the human cost attendant on a false positive.  To that end, it has never been my practice to oversell the utility of MMG, as that behavior, quite aside from being wrong, puts your long-term credibility with the patient at the mercy of new research findings, such as this study, whether rightly or wrongly understood by the patient.

              The real issue for our purposes is the treatment of the population, not the individual, because that's what dictates public policy, which is pretty much what dKos is about.  The statement you quote, if accepted by the folks who make public policy on its face, as a categorical denial of the utility of MMG (people who support its utility are sort of like Flat Earthers), would mean that my patients, none of whom can afford MMG on an out-of-pocket basis (I volunteer in a free clinic), will not be able to get their individual choice respected if they choose MMG.  Very few of even the women who can afford insurance will be able to get MMG if public policy shifts so that insurers will no longer have to cover it.

              To put it another way, if you think that the glib statement you quote is true, you don't actually believe in individualizing the decision to add MMG to breast cancer screening as a public policy.  You believe that it shouldn't be supported by public policy, and thereby, you effectively believe that it shouldn't be an option for all but the wealthy who can afford out-of-pocket MMG.  And you believe that in an environment in which the alternative screening in this study, annual manual exams by trained nurse specialists, is arguably more out of reach than MMG.

              The states must be abolished.

              by gtomkins on Sun Feb 16, 2014 at 09:27:52 AM PST

              [ Parent ]

              •  well (1+ / 0-)
                Recommended by:
                gtomkins

                it seems clear by the day that mammograms for everyone over 50 as per ACS is not going stand the test of time.

                That fact based on this new study and a lack of defensible data,  is disruptive and uncomfortable, but looks like a new reality. I think it's highly appropriate while things get sorted out for each woman to talk with her doc and decide what to do. I'd expect over the next year or so, that advice will change in the direction of "do less" with mammograms. But we'll see.

                In the meantime, the points I am making with the data, not with personal attacks and impugning of motive, is that there is little to recommend them (post if you have data to challenge that) and a lot to caution. But it depends on personal hx, family hx, and other factors.

                People aren't wrong to still do them but they are not wrong to question them.

                "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

                by Greg Dworkin on Sun Feb 16, 2014 at 10:11:03 AM PST

                [ Parent ]

                •  The limits of quantitative evidence (0+ / 0-)

                  No, I don't have any data on the effect that screening with today's imaging technology, and today's protocols for responding to positives, will have on breast cancer mortality 30 years down the road.  No one does.

                  What you have is data on what 25yo technology, and 25yo protocols, have played out in the past 25 yrs of following patients who had that screening strategy applied to them.  

                  Your data, however informative it may be on all sorts of questions about the natural hx of breast cancer, is next to worthless at answering the question you seem to think it answers pretty definitively, whether or not patients today should have MMG.

                  I don't need a study to tell me that 25yrs ago, we had a lot more false positives from MMG, and that our only response to a positive back then was the blunderbuss of excisional biopsy.  In some cases, the suspect lesion was located so deep in the breast, that the only way to find out whether it was cancer versus the fibroadenoma it was pre-test probability much more likely to be, was to do a total mastectomy.  I was very skeptical of MMG 25yrs ago.  The human costs of MMG false positives was much greater with that 25yo strategy.

                  I am even more impressed with the progress the imaging technology is making on sensitivity.  I had a patient a few months ago who had what proved on US-guided needle to be DCIS flagged by MMG.  Your study absolutely says nothing about the utility of MMG+nurse exam vs nurse exam alone in finding and treating DCIS, because 25yo imaging was not finding DCIS.  

                  It may prove that imaging will never be able to do a very complete job of finding breast cancer at a pre-invasive stage like DCIS.  Even if it is, it may well prove that some very high percentage of women, much higher than will ever develop clinical breast cancer in the absence of tx, will be found to have such precursor conditions, and that therefore finding DCIS will be of questionable utility, especially if we don't come up with a way to eradicate DCIS that isn't way less costly (human costs are what I'm worried about).  

                  One day we may look back and say that you were 100% right to predict the demise of imaging in breast cancer screening.  But today is not that day.  Today, we can't say that all of those steps in the last para will not turn out the other way, and that finding and eradicating DCIS will not prove as useful as finding and eradicating adenomatous polyps in the colon.  As I pointed out a few posts ago, CRC screening also shifted goals and rationales.  For all that, a screening strategy whose initial rationale was decisively discredited by the large and long-term studies that were possible only 30+ years into the mass application of FOBT testing, turned out proving the utility of c-scope as screening, rather than a f/u to heme-pos results on screening.  We would never have gotten that proof without starting down a path that proved wrong 30 years later.  We will never know the similar key facts about imaging in breast cancer screening unless we maintain clinical engagement with that imaging, and we won't, as a society, at the population health level, continue that engagement if your idea that this study settles the question takes hold.

                  No reasonable person would argue against basing medicine on evidence.  But the Evidence Based Medicine crowd tends to look only at quantitative evidence.  While the numbers need to be granted final say in deciding what we do and don't do, quantitative methods only become possible way, way downstream in the process of generating and validating medical knowledge.  A whole lot of observation and clinical thinking takes place in the frighteningly anecdatal mudpit of clinical experience before these questions become clean enough for a quantitative study.  At that point, the RTCs that comes at the end of the process are useful mainly in proving what we already know, because the right question to be asking quantitative methods to answer only becomes clear at the end of the process.  To me, we don't seem anywhere near the end of the process, the point where we know what question to ask a quantitative study.    

                  You present a very typical example of the inherent design flaw in the Evidence Based Medicine approach.  You have a nicely designed, rigidly quantitative answer to a question that is 25 years out of date.  You're right, if breast cancers were all fast growers, and the 1-2cm size range that was the difference between MMG and manual exam 25 yrs ago was a critical differentiator, we sure should have seen a difference in outcomes by now.  25 years ago, people advocating MMG would indeed have tended to state the maximalist idea of its potential utility.  Congratulations to your study on shooting down the maximalist pro-MMG position of 25 yrs ago!  But we already knew, pretty well, qualitatively, anecdatally, that that initial rationale for MMG screening had been refuted.  The clinical state of play has long since moved on, that hockey puck has been around the arena dozens of times since that study got started.

                  Let me propose three questions that matter now, and you tell me if your study, or results of other quantitative studies, answer them, and whether or not continuing imaging as at least a component of a screening strategy has no potential to help answer them.  Is it worthwhile to try to find breast cancer at a pre-invasive stage?  Do systematic manual exams alone do better than just letting breast cancer be discovered clinically, i.e., does any screening strategy add anything?  If screening does add something, is imaging alone as good as manual exams alone, in terms of outcomes and costs?  We already have the imaging strategy in place, and don't have systematic manual exams in place, so you have to figure in transition costs.  

                  The states must be abolished.

                  by gtomkins on Sun Feb 16, 2014 at 12:58:48 PM PST

                  [ Parent ]

                  •  from what we know now (subject to more data) (1+ / 0-)
                    Recommended by:
                    gtomkins

                    Is it worthwhile to try to find breast cancer at a pre-invasive stage?  not if it it doesn't decrease mortality. Too many pre-invasive cancers would not have harmed if let alone,. vs dangers of chemo and surgery that turn out to be unnecessary. The interesting this is that it is not an automatic yes and that these concerns are not new:

                    Conclusions The increase in incidence of breast cancer was closely related to the introduction of screening and little of this increase was compensated for by a drop in incidence of breast cancer in previously screened women. One in three breast cancers detected in a population offered organised screening is overdiagnosed.
                     See also
                    Approximately 50% of women screened annually for 10 years in the United States will experience a false-positive, of whom 7% to 17% will have biopsies. Additional testing is less likely when prior mammograms are available for comparison.
                    from the following link. Surprisingly high numbers both for false positive w/intervention and for overdiagnosis. link That link, btw, gives the current thinking on mammography (do it). I think that will change.  Note also it does not agree with the 40-50 age cohort (ie start at 50) as per  United States Preventive Services Task Force in 2009. We are already in controversial territory.

                    Do systematic manual exams alone do better than just letting breast cancer be discovered clinically, i.e., does any screening strategy add anything?

                    Clinical breast examination (CBE) has not been tested independently; it was used in conjunction with mammography in one Canadian trial, and was the comparator modality versus mammography in another trial. Thus, it is not possible to assess the efficacy of CBE as a screening modality when it is used alone versus usual care (no screening activity).
                    Great question, needs an answer.  

                    Same link:

                    Breast self-examination (BSE) has been compared to usual care (no screening activity) but has not been shown to reduce breast cancer mortality.
                    If screening does add something, is imaging alone as good as manual exams alone, in terms of outcomes and costs? We don't know what the answer is there, either.  Sucks that we don't. But to point out that we don't means being careful with what we advise and what we do.

                    "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

                    by Greg Dworkin on Sun Feb 16, 2014 at 02:16:38 PM PST

                    [ Parent ]

                    •  "not if it it doesn't decrease mortality" (0+ / 0-)

                      Well, the only way to find out if finding and treating at a pre-invasive stage would decrease breast cancer mortality, is to keep doing imaging, ever more sensitive imaging, of very large numbers of the general population at risk.  That's pretty much a description of what we're doing now.

                      Most of the natural history of breast cancer is hidden from us unless we use imaging.  This is in contrast to, say, skin cancer, for which the entire natural history, from pre-invasive lesions on, is open for view with the naked eye.  Melanoma is the most threatening of them because it doesn't spend a long time in a pre-invasive stage, or it has pre-invasive stages in very common benign lesions.  For skin cancers, because we have been able to follow the natural history all the way back to AKs and other pre-invasive lesions, we have been able to try eradicating them at that stage, and it has proven useful to do so.  We'll never be able to try treating breast cancer at a pre-invasive stage until and unless we can find it at that stage.

                      Now, assume that when and if we do get imaging sensitive enough to find breast cancer at a pre-invasive stage, it turns out that the most pessimistic assumption is true, and that there are way more such early lesions than will ever progress to a cancer that will do the patient any harm.  In that case, breast cancer will prove to be sort of like prostate cancer, in that most men my age are walking around with prostate cancers that 9/10s of us are going to die with, not of, so, no thank you, you're not going to be removing my prostate until and unless the cancers I'm carrying around do something to make us think that they need eradicating.

                      Even if that turns out to be the case, that breast cancer shares that characteristic with prostate cancer, the next step for both out of that dilemma is to find one or both of two things:
                          1) a treatment of the early lesions that is so low cost (human cost, as always) that you would apply it to all comers
                          2) a screening marker that will tell us which and exactly when an early, non-threatening lesion turns dangerous, so that those can be targeted for treatment.
                      My thought is that neither of those two things happen, we don't get resources directed at either of those two things, until and unless we are faced with the dilemma.  We're already there with prostate cancer, my idea is that we should get there as soon as possible for breast cancer.

                      One of the reasons that people jumped all over imaging for breast cancer screening 30-40 years ago was that, unlike prostate cancer, autopsy studies did not show very much occult cancer at all.  We didn't think, going into the enterprise, that we would find the dilemma that we knew we were going to face for prostate cancer screening.  We thought that we were going to be able to treat any stage of breast cancer we found and reduce mortality.  Your study, however much it doesn't speak to the question of whether we should still do imaging, has to be given great weight at tending to show that one or both of two possible interpretations of what it tells us is true:
                          1) manual exam and 25yo imaging were covering the same ground, the imaging wasn't finding extra or earlier lesions
                          2) the ground that both were covering wasn't important to breast cancer mortality
                      That latter possibility is similar to what we found, unexpectedly, for CRC screening.  Screening c-scopes don't find enough CRC of any sort, early or late, to make any difference in mortality.  It's harvesting the pre-cancers that does that job.  CRC simply doesn't spend enough time at a pre-clinical stage to make any screening, for CRC itself, worthwhile.

                      The states must be abolished.

                      by gtomkins on Mon Feb 17, 2014 at 08:06:54 AM PST

                      [ Parent ]

                    •  "Great question, needs an answer." (0+ / 0-)

                      I don't think anyone is going to do an RTC of screening (of any sort, manual plus imaging, or either alone) vs no screening, letting breast cancer just present clinically, because of ethical concerns.  I don't think we can say, anymore, in 2014, that usual care is no screening.  Does any authority recommend no screening?  I assume that the study we're talking about had to be of imaging+manual exam vs manual exam, because a no treatment arm would not be acceptable.

                      No screening may be very common care, or lack of care, in the US in 2014, but my understanding of "usual care" is what we're supposed to be doing for patients to whom we provide care.  It's perfectly acceptable to have millions of women not get any screening, if and only if that outcome is a result of the infallible wisdom of the marketplace that dictates that they not receive any care, but totally unacceptable to have the absence of screening be something done for research.  Is this a great country, or what?

                      We're stuck with screening of some sort.  The only question is what the modality/ies will be for that screening.  If you phrase the problem that way, it's hard for me to agree that it's obvious that imaging is on the way out as the modality, perhaps the only modality until and unless we get tumor markers.  Not only can current imagining pretty clearly find smaller/earlier lesions than manual exams, it may be cheaper and more available than manual exams, at least systematic manual exams by dedicated nurses.

                      The states must be abolished.

                      by gtomkins on Mon Feb 17, 2014 at 08:25:34 AM PST

                      [ Parent ]

                  •  interestingly orac comes to the same conclusions (1+ / 0-)
                    Recommended by:
                    gtomkins
                    The point, obviously, is to find the “sweet spot,” which maximizes the benefit of screening and minimizes the harms due to overdiagnosis and overtreatment. Based on current evidence, of which the CNBSS is just one more part, I’m more and more of the opinion that our mammography screening guidelines need to be tweaked and personalized because the current “one size fits all” regimen is probably too aggressive for most women at average risk for breast cancer. It’s an evolution in my thought that’s been going on for years. In any case, in any statement I’d put something in there about determining what the “sweet spot” is for mammography. It’s also reasonable, for now at least, to stick with existing guidelines, with perhaps more of a personalized approach to screening of women between ages 40 and 49. That’s what I intend to do until new evidence-based guidelines emerge. And emerge they will, likely within a year.
                    http://scienceblogs.com/...

                    "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

                    by Greg Dworkin on Mon Feb 17, 2014 at 05:22:58 AM PST

                    [ Parent ]

                    •  Nothing to disagree with in this quote... (1+ / 0-)
                      Recommended by:
                      Greg Dworkin

                      ...but, really, the whole point of listening to the evidence that research provides is precisely for situations in which one size does fit all.  No difference in breast cancer mortality would seem to apply to all your patients along the whole spectrum of risk levels, or it doesn't apply much to any of them.  It sounds like this study had a healthy enough n that they could have done subgroup analysis, and told us if their results did or did not hold across the entire spectrum of pre-test risk.

                      Put it another way.  I don't think that even the most pro-MMG screening people have ever treated it as a one-size-fits all recommendation (though I'm sure you've caught hell over your posting from people who speak a lot more intemperately and categorically on a blog than they speak with patients), something as solid as recommending that a patient with bacterial meningitis take abx.  That advice applies to all comers, in spades, and a refusal should provoke consideration of forcing the tx on a patient on the grounds that they have created a presumption of mental impairment by their refusal.  MMG is not at all like that, we've always sold it harder to people with scary fam hxs, or other risk factors, and don't go to Ethics Panels to force MMG on refuseniks.  Okay, if there are any providers out there like that, I'm sure you've gotten an earful from each and every one of them, and you deserve some sort of award for taking that abuse.  

                      The states must be abolished.

                      by gtomkins on Mon Feb 17, 2014 at 08:49:13 AM PST

                      [ Parent ]

                  •  here's what I think will help (0+ / 0-)
                    The research is well done and will influence a global conversation. Dr. Richard Wender, chief of cancer control for the American Cancer Society, said an expert panel will factor this research into new guidelines to be released within the year. Until then, current recommendations stand.
                    http://www.theatlantic.com/...

                    "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

                    by Greg Dworkin on Mon Feb 17, 2014 at 06:30:39 AM PST

                    [ Parent ]

      •  however (0+ / 0-)

        appreciate the time you took to read and comment. It's a very informed one.

        "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

        by Greg Dworkin on Sat Feb 15, 2014 at 03:08:48 PM PST

        [ Parent ]

  •  It is breathtaking how fast marriage (16+ / 0-)

    equality is advancing.  And the states it's happening in are unbelievable.  I hope the Virginia case is the lead case at the Supreme Court.  It would be a beautiful reminder of how bigots always eventually lose.  After reading the Lawrence case and the DOMA case, Kennedy will be the swing vote FOR equality.

    "Jesus died for somebody's sins but not mine." -- Patti Smith

    by followyourbliss on Sat Feb 15, 2014 at 04:47:42 AM PST

  •  ... (2+ / 0-)
    Recommended by:
    elmo, Betty Pinson
    Fascinating article on how we perceive risk. Why many women fear breast cancer the most. Via @DemFromCT: http://t.co/...
    @DrRichardBesser

    "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

    by Greg Dworkin on Sat Feb 15, 2014 at 04:50:21 AM PST

  •  Glad you included the Cook piece (1+ / 0-)
    Recommended by:
    skohayes

    as I have been wondering when Hillary might "announce".  It is good to know when presidential candidates tend to announce, historically.

    Loved the video as the "thumb cancer" example made his point clear on mortality rates vs survival rates, thanks for finding and embedding it.

    As we express our gratitude, we must never forget that the highest appreciation is not to utter words, but to live by them. John F. Kennedy

    by JaxDem on Sat Feb 15, 2014 at 04:52:42 AM PST

  •  Thanks for this excellent APR, Greg (18+ / 0-)

    It's striking that the patient knew the correct answer and yet insisted that breast cancer is the No. 1 killer of women. IMHO far too much attention is directed to a "cure" and far too little to prevention with regard to breast cancer.

    Preventing heart disease would be much easier, yet everything in our culture conspires against that. Long commutes, long work days spent sitting in front of a computer screen with no chance of exercise, evenings filled with chores to be ready for the next day--what chance do people have to be healthy? It's not as if most work environments offered gyms or aerobics classes during the day.

    I'd like to see a six-hour work day. Cut out the useless meetings and chatter and it could be done.

    "Religion is what keeps the poor from murdering the rich."--Napoleon

    by Diana in NoVa on Sat Feb 15, 2014 at 04:53:05 AM PST

  •  I thought (12+ / 0-)

    the number one killer/health risk to women was men. Maybe they mean other health risks...

    I'm going in a different direction here, but one thing that I always hated about the breast cancer walks, pink ribbons, etc., was the almost total lack of any discussion of prevention. Mammograms were always presented as the first and last word in prevention, but mammograms are about detection. The kinds of food we eat, the chemicals we willingly and unwillingly put in our bodies, stress, anxiety, an inhumane and degrading economy that reduces us to wage sl***s...These are the biggest causes of cancer (and most diseases, in fact) and yet no one on the business end of health care gives a shit about real prevention. When illness is profitable, the system will do its best to keep us ill.

    Forgive the tangent...  

    Never be deceived that the rich will permit you to vote away their wealth. - Lucy Parsons

    by cruz on Sat Feb 15, 2014 at 05:00:34 AM PST

    •  Short answer.... (3+ / 0-)
      Recommended by:
      tobendaro, mmacdDE, Laconic Lib

      People, including women want easy answers to difficult and scary questions. Mammography has a role but it's not a panacea. Obesity is a big risk factor for developing breast cancer along with all sorts of other maladies, but it's a helluva lot easier to go get a mammogram than it is to buckle down and lose weight and still feel like your doing something important for your health.

      Just another day in Oceania.

      by drshatterhand on Sat Feb 15, 2014 at 05:30:48 AM PST

      [ Parent ]

    •  We don't know much about prevention (7+ / 0-)

      I have had breast cancer twice. I did all the things everyone recommended for "prevention," all through the probably ten years my first one was developing and thereafter. I am not overweight, do not have diabetes, exercise regularly, avoid all the chemicals I can, nursed two babies for more than six months each, etc. etc. etc. etc. And I got the genetic testing and no, I don't have the BRCA genes.

      So I'm at my wits end to figure out what else I could have done then, what I could do now that would affect the chances of getting a 3rd round -- or what my daughter could do to prevent having this disease at all.

      I think that's one reason cancer is so scary. There doesn't seem to be anything that is within our control.

      My suspicion is that hormone-disrupter plastics and pharmaceuticals in the drinking water and air, plus possibly the above-ground atomic bomb tests, plus some sort of infectious agent (mono? some unidentified virus?), have a lot to do with causation. Those are not things an individual can avoid; it would take concerted societal decisions that frankly are not going to happen because of the power of the oil/chemical/nuclear industries.

      So please, stop blaming breast cancer patients for just "not losing that weight, and then you wouldn't have gotten it."

      •  Just breathing our air (3+ / 0-)
        Recommended by:
        NotActingNaive, SueDe, antimony

        is probably giving us many cancers. I live on Lake Erie and we have one of the highest rates of cancer in the US. The theory is all the pollution from the western end of the lakes comes our way and settles into everything.  Very high rates of thyroid disorders too.

        Everyone! Arms akimbo! 68351

        by tobendaro on Sat Feb 15, 2014 at 06:58:39 AM PST

        [ Parent ]

      •  You put your finger on it (4+ / 0-)
        Recommended by:
        mmacdDE, revsue, SueDe, ebohlman
        I think that's one reason cancer is so scary. There doesn't seem to be anything that is within our control.
        For most women I've known who've had breast cancer, it struck like a lightning bolt out of nowhere.

        The prevention mantra can backfire, both with heart disease and breast cancer, as well as other health issues with complex or unknown origins. It can make people feel guilty and responsible for something over which they have little control.  

      •  There are things we could do, but the FDA doesn't (3+ / 0-)
        Recommended by:
        Stude Dude, sillia, SueDe

        allow some of the things that are working in many other countries, especially Sweden. I know this is anecdotal, but my mother has a friend who has a brain tumor that grew so fast, the docs here have her six months. They couldn't operate, but did give her a cocktail that really took her quality of life away. It shrunk the tumor to a certain point, but not completely. And then it grew again, very aggressively. They have lots of money and hired a doc from Sweden. The doc made an individual cocktail for her that shrunk the tumor and now it's gone and hasn't returned. He said that he's hoping this treatment will be available in the U.S. soon, but it still hasn't and he isn't holding his breath. I know it sounds stupid, but sometimes I wonder if those silly ads that say there is a cure in some plant in Mexico are true and the Big Pharma just doesn't want us to know...but I can't just wrap my head around something so evil and sinister in our country like withholding something so life preserving.

      •  Thank you so much for sharing this. (0+ / 0-)

        I did not, in any way, intend for my comment to read as your last line suggested. If it does, that was carelessness on my part, and I'm sorry.

        Never be deceived that the rich will permit you to vote away their wealth. - Lucy Parsons

        by cruz on Sat Feb 15, 2014 at 06:13:31 PM PST

        [ Parent ]

  •  Why cancer is more feared (22+ / 0-)

    It frustrates me at times, all these academics turning themselves in circles over the "perplexing question" of why cancer is feared more than heart disease despite that the latter accounts for more deaths.  To the point that they go dragging in human beings' faulty risk analysis mechanisms and/or subtly implying that people overall are too stupid to understand numbers like they do.

    Cancer brings up images of months or years of chemotherapy induced illness and extended, wracking deaths full of pain.  Heart disease bring up images of everyone's old uncle who keeled over shoveling snow or died in his sleep.  Even though the picture of both diseases is incomplete, I know which of those stereotyped ways I would prefer to go.  I don't think it's any more complicated than that.

    •  excellent point (3+ / 0-)
      Recommended by:
      OHdog, skohayes, Heart of the Rockies

      though the  question asked of the patient was "What’s the number one killer of women? " and the answer was  “I know the right answer is heart disease,” the patient told Rosenbaum, “But I’m still going to say ‘breast cancer.’”

      Worthy of commentary.

      "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

      by Greg Dworkin on Sat Feb 15, 2014 at 05:11:33 AM PST

      [ Parent ]

    •  Not to mention "disfigurement" (8+ / 0-)

      I remember my mother (when I was in my early 20s, I'm now 56) saying she'd rather die than have a mastectomy, if she were diagnosed with breast cancer.   Of course that was before breast reconstruction would available for many patients.  Also, some women are so obsessed with their hair, the thought of losing it even temporarily is frightening.  Hard to believe some people would chose vanity over life.

      •  It's deeper than a matter of vanity (3+ / 0-)

        Loss of hair and breasts hits at self identity and very basic views of who you are.  Having a heart attack can also make people feel less capable and fearful of their own body, but it hardly advertises it to the world with major overt body changes.

        •  And as I mentioned upthread, breasts and hair too (2+ / 0-)
          Recommended by:
          Heart of the Rockies, benamery21

          have a label on them that say "this is what makes me feminine" and the though of taking that away is what makes some women say it is scarier. Our society focuses on breasts and hair so much that they ARE the identity to some people. It may seem sad, but it is what it is. Feminism has a long way to go it seems when people identify more with their breasts than their hearts as to who they are. It says a lot about us in our culture as women and the brainwashing by men that we 'are our boobs'.

      •  My mother avoided open heart surgery (1+ / 0-)
        Recommended by:
        benamery21

        because of the scar. Eventually the symptoms of congestive heart failure convinced her that it was surgery or death. She is now kind of proud of the scar and the ordeal she went through.

        Fire burn and cauldron bubble, bendy straws or my fee is double - via Twitter about half-term governor Sarah Palin

        by alrdouglas on Sat Feb 15, 2014 at 08:12:50 AM PST

        [ Parent ]

    •  This link leads (1+ / 0-)
      Recommended by:
      Forward is D not R

      to an incredible photo diary of a man whose wife is diagnosed with breast cancer, and her struggle with the disease.
      A Husband Took These Photos Of His Wife And Captured Love And Loss Beautifully

      Your beliefs don't make you a better person. Your behavior does.

      by skohayes on Sat Feb 15, 2014 at 05:30:12 AM PST

      [ Parent ]

    •  Why is that those images are brought up? (1+ / 0-)
      Recommended by:
      sweatyb

      Marketing. I don't think they make many TV movies about women who keel over from heart attacks. Yet they do make movie after movie about women who get breast cancer.

      •  for once I don't think marketing is the problem (1+ / 0-)
        Recommended by:
        revsue

        i blame marketing for almost all the ills of this world, but I do not think it is responsible here

        almost every woman actually knows a woman with breast cancer

        and saw first hand what that experience did to her friend/family member/coworker/neighbor.

        no TV movie required

        Politics is like driving. To go backward put it in R. To go forward put it in D.
        DEMAND CREATES JOBS!!!
        Drop by The Grieving Room on Monday nights to talk about grief.

        by TrueBlueMajority on Sat Feb 15, 2014 at 07:10:23 AM PST

        [ Parent ]

        •  It's true that breast cancer treatment (1+ / 0-)
          Recommended by:
          TrueBlueMajority

          has become far more common, but that's one of the problems this study is highlighting. Far more women are being treated for breast cancer than really need to be.

        •  However, just about every woman knows (0+ / 0-)

          or knew someone with heart disease as well.

          I suspect a big factor is the perception of control. As I mentioned in another comment, we greatly overestimate the extent to which we can control our risk of heart disease through lifestyle choices. That makes it seem less scary than something like breast cancer.

          It's similar to the way the average parent is far more concerned that her child will be kidnapped and murdered than that he/she will be killed in a car crash, even though the odds of the latter are 25 times higher (even to the point of driving their kids to places the kids could walk to; in terms of relative risks, this is as rational as taking up smoking to avoid gaining weight). The risk of car crashes feels controllable in a way that the risk of kidnapping doesn't and so gets emotionally discounted.

          Unfortunately when smart and educated people get crazy ideas they can come up with plausibly truthy arguments. -- Andrew F Cockburn

          by ebohlman on Sat Feb 15, 2014 at 06:26:11 PM PST

          [ Parent ]

          •  i do not know any women my age w/heart disease (0+ / 0-)

            but for the last 20 years there has always been at least one woman in my circle with breast cancer

            Politics is like driving. To go backward put it in R. To go forward put it in D.
            DEMAND CREATES JOBS!!!
            Drop by The Grieving Room on Monday nights to talk about grief.

            by TrueBlueMajority on Sat Feb 15, 2014 at 07:29:58 PM PST

            [ Parent ]

            •  I didn't qualify it by saying "their age" (1+ / 0-)
              Recommended by:
              Greg Dworkin

              I meant in terms of having people they've ever known (many of whom would have been older than them) die of or suffer from heart disease.

              Unfortunately when smart and educated people get crazy ideas they can come up with plausibly truthy arguments. -- Andrew F Cockburn

              by ebohlman on Sat Feb 15, 2014 at 09:00:12 PM PST

              [ Parent ]

              •  i know you didn't (1+ / 0-)
                Recommended by:
                Greg Dworkin

                but younger people don't think as much about diseases older people get until they reach that age themselves.

                whereas all throughout my 20s and 30s and 40s I knew women struggling with breast cancer, dealing with chemo and radiation, having mastectomies, and dying.

                that had a different impact on me than knowing my grandmother had heart disease, and i think that is an obvious psychological truth for all women

                Politics is like driving. To go backward put it in R. To go forward put it in D.
                DEMAND CREATES JOBS!!!
                Drop by The Grieving Room on Monday nights to talk about grief.

                by TrueBlueMajority on Sun Feb 16, 2014 at 06:13:53 AM PST

                [ Parent ]

  •  Milbank gets it right on Cruz and company (4+ / 0-)

    and I examine the Washington Post column in which he does so in this post to which I invite your attention

    "Teachers teach. Well-trained teachers teach better. Great teachers change lives." - David Greene, from "Doing the Right Thing: A Teacher Speaks"

    by teacherken on Sat Feb 15, 2014 at 05:08:01 AM PST

    •  Dan Milbank can be so squishy sometimes (5+ / 0-)
      But Cruz doesn’t care about all that. Leaving the chamber, he told reporters McConnell’s fate would be “ultimately a decision . . . for the voters in Kentucky.”

      His actions suggest Cruz has put himself before his party and even the nation’s solvency.

      Suggest?? He's directly responsible for the government shutdown and is now actively working against Republican leadership, and that only suggests to Milbank that he's putting himself before the party?

      Your beliefs don't make you a better person. Your behavior does.

      by skohayes on Sat Feb 15, 2014 at 05:36:00 AM PST

      [ Parent ]

  •  It's complicated (1+ / 0-)
    Recommended by:
    Heart of the Rockies

    The Diane Rehm Show on NPR did a terrific program on this. The remarks by Dr. Daniel Kopans of Harvard Medical School on the quality of the underlying Canadian study are of particular interest (about 20 minutes in). In a nutshell, he explains why he found the Canadian data of very poor quality.
    http://thedianerehmshow.org/...

    •  radiologists can be considered (5+ / 0-)

      a "vested interest."

      "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

      by Greg Dworkin on Sat Feb 15, 2014 at 05:14:01 AM PST

      [ Parent ]

      •  Good lord, yes (2+ / 0-)
        Recommended by:
        OleHippieChick, htowngenie

        This could impact their bottom line considerably. My PA pushes me about getting one every year, because of course, it's another service provided by this tiny hospital (and convenient for me, too), but I haven't had one in quite a few years.

        Your beliefs don't make you a better person. Your behavior does.

        by skohayes on Sat Feb 15, 2014 at 05:40:58 AM PST

        [ Parent ]

    •  counterpoint (4+ / 0-)
      Recommended by:
      skohayes, elmo, Betty Pinson, Laconic Lib

      http://theincidentaleconomist.com/...

      Bottom line: no study is perfect, and we should consider the limitations of all studies when interpreting their results. But if you do 25-year follow up, the technology at the start of the trial will always be older. People in studies never perfectly match what’s happening in the real world. And there’s always a measure of trust in science. You should consider the biases and conflicts of all involved, including the people attacking the study.

      "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

      by Greg Dworkin on Sat Feb 15, 2014 at 05:15:34 AM PST

      [ Parent ]

      •  Generic dismissal (0+ / 0-)

        Diarists who have expressed a point of view might also be considered "vested interests." May I suggest that the more intelligent course of action would be to first listen to what the man had to say. More specifically, the column you link a) does not address the some of specific concerns raised by Kopans and b) offers a rather weak, 'well all studies are flawed' sort of defense.

        •  not a generic dismissal at all (6+ / 0-)

          the guy you are citing is a radiologist. As for me, i have no vested interest other than supporting "evidence based medicine".  

          The radiologist cited poor quality equipment, the standard radiology critique. Again, the counterpoint i posted is exactly on point. the technology at the start of the trial will always be older.  A 25 year study will always have that problem, but also has the advantages of being 25 years.

          "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

          by Greg Dworkin on Sat Feb 15, 2014 at 05:59:03 AM PST

          [ Parent ]

          •  Thanks Greg (1+ / 0-)
            Recommended by:
            htowngenie

            Your analysis is accurate. The new results from the Canadian study build on evidence already out there about the problems with screening mammography and overdiagnosis.

            And U.S. studies can't offer much because we've never had universal health care, making it difficult to design and conduct good trials or retrospective analysis of mass screening programs.

            Money is property, not speech. Overturn Citizens United.

            by Betty Pinson on Sat Feb 15, 2014 at 06:25:42 AM PST

            [ Parent ]

          •  Kopans critique (1+ / 0-)
            Recommended by:
            Greg Dworkin

            I think it needs to be noted that Kopans' critique is, in part, that even given the equipment and standards at the time the study was done, it was poorly conducted and produced unreliable results. His involvement with the Canadian study goes back to at least 1990 and he published a a detailed critique at least as early as 1993.
            http://www.ncbi.nlm.nih.gov/...
            http://www.ncbi.nlm.nih.gov/...
            There is also this exchange from 1999: http://jnci.oxfordjournals.org/...

            That said, I am not a radiologist, or even a columnist. But it does seem to me that there is a very good likelihood that the current study rests on a weak foundation. In any case, I think it legitimate to advise that anyone interested in what could be an extremely important decision on health should take a careful look at the whole of the evidence, if at all possible.

            •  fair comment (0+ / 0-)

              hallmark of science is reproducibility, but this study is not in a vacuum. There appears to be a growing question of utility, and I'm certain this is not the last word.

              "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

              by Greg Dworkin on Sat Feb 15, 2014 at 07:46:56 AM PST

              [ Parent ]

            •  more on Kopans critique (1+ / 0-)
              Recommended by:
              hmi

              ACR is American College of Radiology

              http://drjengunter.wordpress.com/...

              The ACR claim rests on these 3 points:

              The mammography equipment is old/bad and this was confirmed by independent experts. The lead author, Anthony Miller has refuted this claim in interviews with several Canadian news outlets and an expert from Dartmouth (Dr. Gilbert Welch) calls this study the most meticulously conducted and reported randomized trial on screening mammography. The ACR cites a paper in a radiology journal from 1990 that they say evaluated the equipment and Dr. B. Kopans, a Professor of radiology from Harvard, says he personally reviewed the equipment and found it lacking. How do you deal with these kinds of claims? Maybe ask the radiologists who read the films? It is an important point.

              Only 32% of cancers were detected by mammography in the study. This is the most interesting from a scientific standpoint and not a “he said/she said” argument. I wanted to write more on this until I saw the last point made by the ACR…

              Where the ACR basically accuses the authors of misconduct. The ACR statement: ”To be valid, randomized, controlled trials (RCT) must employ a system to ensure that the assignment of women to the screening group or the unscreened control group is random. Nothing can/should be known about participants until they have been assigned to one of these groups. The CNBSS violated these fundamental rules. Every woman first had a clinical breast examination by a trained nurse so that they knew which women had breast lumps, many of which were cancers, and which women had large lymph nodes in their armpits many of which indicated advanced cancer. Before assigning the women to be in the group offered screening or the control women, investigators knew who had large incurable cancers. This was a major violation of RCT protocol. It most likely resulted in the statistically significant excess of women with advanced breast cancers assigned to the screening arm compared to those assigned to the control arm. This guaranteed more deaths among the screened women than the control women. The five year survival from breast cancer among women ages 40–49 in Canada in the 1980s was only 75 percent, yet the control women in the CNBSS, who were supposed to reflect the Canadian population at the time, had a greater than 90 percent five year survival. This indicates that cancers may have been shifted from the control arm to the screening arm. Coupling the fundamentally corrupted allocation process…   (the italics are mine).

              However, the exact wording from the BMJ article about the randomization is as follows:

              “The examiners had no role in the randomisation that followed; this was performed by the study coordinators in each centre. Randomisation was individual and stratified by centre and five year age group. Irrespective of the findings on physical examination, women aged 40-49 were independently and blindly assigned randomly to receive mammography or no mammography.”

              So the authors are saying their randomization was blinded and the ACR’s counter-claim is that is couldn’t have been. Both can’t be right. The ACR is either accusing the author of lying or saying he had rogue study nurses who didn’t follow protocol. The ACR does not provide any references to support this claim.

              Interesting perpective and criticism of the criticism. Read the whole thing.

              "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

              by Greg Dworkin on Sat Feb 15, 2014 at 09:58:41 AM PST

              [ Parent ]

        •  in any case (0+ / 0-)

          thank you for posting the link (and yes I listened).

          "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

          by Greg Dworkin on Sat Feb 15, 2014 at 06:11:19 AM PST

          [ Parent ]

    •  Ok, fine (3+ / 0-)
      Recommended by:
      skohayes, OleHippieChick, Laconic Lib

      Where's the scientific study that establishes that the benefits outweigh the risks of mammography?

      Medicine should be evidence based, after all. Recall how many woman took hormone replacement therapy for years and were told it was for their benefit when there was actually no science to support that claim. And, when the research was finally done, the science not only disproved the claim of benefit, but proved that hormone use was harmful for most women in the way it was being prescribed.

    •  orac has some interesting things to say about (0+ / 0-)

      Dr Kopans.

      Dr. Kopan’s first criticism was that the quality of the mammograms was below state of the art, even for the 1980s. Indeed, Dr. Kopans has made these arguments before for the last 24 years. However, as has been pointed out, the purpose of the CNBSS was to examine whether the addition of mammography added anything to breast cancer screening and resulted in decreased mortality from breast cancer using community-based settings, in other words, using mammography as it was practiced in the community. Moreover, as others have pointed out, the quality of mammography increased over time. In any case, this and many of the criticisms leveled by Dr. Kopans and others have been fairly convincingly refuted CNBSS investigator Cornelia J. Baines, the latter of whom published an article entitled Rational and Irrational Issues in Breast Cancer Screening and by an article in which Kopans himself was a coauthor, which showed that, although only 50% of mammograms had satisfactory image quality in 1980, by 1987 85% were judged to have satisfactory quality.
      Make no mistake, Dr. Kopans is accusing the investigators running the CNBSS of scientific fraud here. I’m surprised he’s so bold about it. You’d think he’d have strong evidence to back up this charge. You’d be wrong. If what Dr. Kopans said were true, then the Canadian government should be going after the investigators. The authors themselves are aware of this charge and even answered it in their article:
      We believe that the lack of an impact of mammography screening on mortality from breast cancer in this study cannot be explained by design issues, lack of statistical power, or poor quality mammography. It has been suggested that women with a positive physical examination before randomisation were preferentially assigned to the mammography arm.12 13 If this were so, the bias would only impact on the results from breast cancers diagnosed during the first round of screening (women retained their group assignment throughout the study). However, after excluding the prevalent breast cancers from the mortality analysis, the data do not support a benefit for mammography screening (hazard ratio 0.90, 95% confidence interval 0.69 to 1.16).
      And point of agreement that did not matter much:
      I actually agree with Dr. Kopans on this one point. Only women with no physical findings should have been randomized to screening mammography. That is perhaps the biggest flaw in the design of the CNBSS. However, excluding women diagnosed with a cancer on the first round of mammography, as the authors argue, and finding no difference in breast cancer mortality do rather argue that it probably didn’t make a difference. The author also points out that another criticism, apparently leveled by Siddhartha Mukherjee in The Emperor of All Maladies, that the women in the mammography group were somehow at a higher risk for cancer. The authors point out that breast cancer was diagnosed in 5.8% of women in the mammography arm and in 5.9% of women in the control arm (P=0.80), showing that the risk of breast cancer was the same in both groups.
      and
      And so the battle rages on, same as it ever was. What amuses me most about this is the seeming underlying assumption that the CNBSS investigators wanted to find no benefit due to screening mammography. My guess is that they were horribly disappointed at the results. No one does the enormous amount of work and spend the money to do a large multicenter trial involving tens of thousands of women because he wants to end up with a negative study, to the point that he would be willing to mess with the randomization to make it happen. The assumption underlying Dr. Kopans’ accusation is ludicrous.

      "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

      by Greg Dworkin on Mon Feb 17, 2014 at 05:20:55 AM PST

      [ Parent ]

  •  VW worker union vote makes me sad. Not so much (11+ / 0-)

    for what it means to this particular group of workers but because it reminds me of all the advances and benefits that have been lost over the past thirty or forty years. Pensions, job protection, health care, seniority rules, etc. These things were fought for from the coal mines in the late 1800's through the automobile strikes and teacher organizing of the 1900's and a thousand other struggles large and small carried out with bravery and fortitude by those who came before today's workers. Reagan gave a big boost to the forces of capitalism and ownership when he fired all air controllers and the other unions did not carry out a national strike in support of them but instead rolled over figuring their day would never come. But it did come and now people making minimum wage at a big box store can explain to you the evils of unionization as they go through donated bags of cans at the local food bank hoping to find one with some protein in it.

  •  Interesting stuff from Rosenbaum (5+ / 0-)

    Not sure how I feel about the breast cancer diagnosis situation other than cynical (and guilty because of that emotion) - I know so many survivors in my almost 50 age group that it's turned me into a skeptic. And the Koman fraud doesn't help. I can take my pick with family history of heart disease & breast cancer - I'll admit breast cancer strikes more fear.

  •  I had experience with the harm of mammograms (16+ / 0-)

    in my own family.

    First and foremost, I must give a nod to the evils of health insurance and their crazy pattern of referring everything out to a different doctor/group.

    Second, I must give a nod to the evils of surgeons (and presumably other physicians) who see patients as bags of water and bones from whom money can be made.

    Finally, I must give a nod to what I suspect is a highly profitable pattern of referrals aimed at maximizing the money extracted from those bags of water and bones.

    Our story is simple and straightforward:

    A little spot on a mammogram.

    Probably not cancer. Not in the area where cancer most often forms.  Just a little bitty shadow on the film.

    But -- patient is terrified because cancer is very scary. And that terror plays into a system designed to exploit it.

    OK. A biopsy follows -- a procedure for which it was all but impossible to get a price beforehand, btw -- one done with a needle, stereoscopic gizmos, and great care. Importantly: not performed by original radiology group and not performed by referred surgeon.

    As I'm not a doctor and because nobody ever got access to an actual cancer expert, I'm not sure the expensive, time-consuming, and painful biopsy was actually the right best step, but...remember the terror.

    And it finds -- nada. Nothing. Zip, zam, zowie, and swoosh. No cyst, no cancer, just perfectly healthy tissue.

    Surgeon's response?
    Must have missed it.  We need to open 'er up and take a chunk big enough to make sure we get it.

    When queried about such things as, "Gee -- are there less invasive ways, what are the odds, etc", the response is a dismissive "Well, if it were my wife..."

    Clever.  If you are completely healthy, it must mean that the biopsy missed (or that the "mass" has melted away on its own or that some malpractice or fraud has been committed along the way).  Heck -- even if it missed, it means that the mass was too small to get and had no cancer cells around it.  Hey -- might be worth another picture, don't you think?

    Patient went to the hospital (generating a significant hospital bill as happens, it seems, from walking in the door and breathing the air) for surgery. Got prepped and --- fortunately --- went down to radiology.  Good stroke of luck (or, perhaps, suspicion) here: The head of the group that performed the biopsy was present and ordered a particular picture.

    Seems the good doc inserted a tiny titanium clip in the breast to mark the spot where tissue was collected.  Take a second picture showing nothing evil around the clip, compare to the first picture and he got on the phone with the surgeon and called the whole thing off, except, of course, for the bills.

    Terror (stoked by the doctors in the process) led this woman to go along with a badly broken promise to the point that she almost went into surgery, under anesthesia, and had a part of her breast removed.

    Remembering that there is no such thing as routine surgery, especially when anesthesia is involved, that original mammogram could literally have killed her.

    At no point would anybody answer a simple question like:

    What is the risk of taking another picture vs invasive procedures?

    Personally, I suspect that the right procedure after that initial mammogram would have been a follow-up picture by a different radiologist, but I don't know that to be true.

    Fact-based medicine is a good thing.  It would be even better if doctors practiced it.

    LG: You know what? You got spunk. MR: Well, Yes... LG: I hate spunk!

    by dinotrac on Sat Feb 15, 2014 at 05:22:15 AM PST

    •  hey where do you stand with ACA these days (2+ / 0-)
      Recommended by:
      dinotrac, Betty Pinson

      and thanks for the comment(s) over the last few days.

      "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

      by Greg Dworkin on Sat Feb 15, 2014 at 05:25:12 AM PST

      [ Parent ]

    •  Your suspicion is correct. (1+ / 0-)
      Recommended by:
      dinotrac

      The usual follow-up to an abnormal finding is a repeat mammogram. At the clinic I use, they go ahead and reserve a time slot in ultrasound so you can do that immediately if the second mammogram also shows an abnormality.

      Not sure if a needle biopsy can be done on the spot. Fortunately, I've never needed one/had one recommended.

      Just because you're not a drummer doesn't mean that you don't have to keep time. -- T. Monk

      by susanala on Sat Feb 15, 2014 at 06:34:36 AM PST

      [ Parent ]

    •  that sounds awful! (1+ / 0-)
      Recommended by:
      dinotrac
      Personally, I suspect that the right procedure after that initial mammogram would have been a follow-up picture by a different radiologist, but I don't know that to be true.
      That's exactly what my doc did!  A spot one month, a couple months later there was no spot.

      “It is the job of the artist to think outside the boundaries of permissible thought and dare say things that no one else will say."—Howard Zinn

      by musiclady on Sat Feb 15, 2014 at 08:43:10 AM PST

      [ Parent ]

    •  It's utterly absurd (2+ / 0-)
      Recommended by:
      Wee Mama, dinotrac

      This Xray technology is really a very poor way to diagnose bc. It is my firm conviction that they don't really know what they are doing or what they are looking at. It seems to be a clumsy tool.

      I had "something strange" on a mammogram many years ago, was called back for a gazillion more pics. Was told it was nothing, just an artifact on the first exposures. Well, I felt very jerked around and abused by all that. How much radiation did I absorb from a gazillion more Xrays than I should have had? Doesn't it matter that this procedure is excrutiatingly painful for me? Not to mention the psychological effects of worrying you might have cancer.

      Never again. I do not participate in this particular ritual any more. It shocks my doctors profoundly that I am skeptical and won't do any more mammograms. But I am convinced based on other studies even before this current one that it's a useless, possibly harmful procedure for me.

      Where in the Constitution does it say: "...on behalf of corporate interests" ???

      by sillia on Sat Feb 15, 2014 at 08:56:29 AM PST

      [ Parent ]

      •  Once upon a time I would have thought you foolish (1+ / 0-)
        Recommended by:
        sillia

        but those days are long gone.

        I can't remember his name, but there is (was?) a Harvard professor who refuses to have his cholesterol measured.  He bases his refusal on some serious statistical analyses on reams of data that told him you are more likely to die early if you get it tested than if you don't, though I think there were some qualifiers regarding family history, etc.

        Just like the survival rate vs mortality rate thing, people tend to look at all this stuff the wrong way.

        LG: You know what? You got spunk. MR: Well, Yes... LG: I hate spunk!

        by dinotrac on Sat Feb 15, 2014 at 10:58:44 AM PST

        [ Parent ]

        •  You can tell if you're at risk for a heart attack (1+ / 0-)
          Recommended by:
          dinotrac

          By what you are eating. It's pretty simple. I always direct people to the film "Forks Over Knives" available on Netflix, or the China Study book, or any of the doctors teaching this cure (Dr. John McDougall, Dr. Caldwell Esselstyn, Dr. Neal Barnard, Dr. Joel Fuhrman, Dr. Dean Ornish, etc,  etc, etc.) If you are following those basic guidelines for healthy eating then you will never have to worry about cholesterol or blood pressure again. Because your levels will stay down in the "heart attack proof" zone.

          If you're eating a typical American diet you are definitely at risk for heart issues. However getting the cholesterol tested in that case just means they'll put you on statins which could have side effects and unknown long-term health consequences. There is no evidence, though, that statins are helpful for patients except for those who have already had a heart attack! In other words, zillions of people (including my parents) are taking meds to bring down their cholesterol numbers but which are possibly giving them NO BENEFIT.

          So I can see why that Harvard prof would want to avoid playing that game. On the other hand, a bad cholesterol result might scare a person into a healthier lifestyle--that is what happened to my husband. He wanted to avoid the meds at all costs and did it the natural way. It does work!

          //useless rant mode OFF

          Where in the Constitution does it say: "...on behalf of corporate interests" ???

          by sillia on Sat Feb 15, 2014 at 12:50:28 PM PST

          [ Parent ]

          •  And that's not even getting into the possibility (1+ / 0-)
            Recommended by:
            sillia

            of being pushed into unneeded open heart surgery.  Bypass surgery is a profit center in many hospitals, whether or not the patients need the operation, are afflicted with  "metal head" or die on the operating table.

            LG: You know what? You got spunk. MR: Well, Yes... LG: I hate spunk!

            by dinotrac on Sat Feb 15, 2014 at 01:12:21 PM PST

            [ Parent ]

          •  Veganism doesn't eliminate heart disease n/t (0+ / 0-)

            Unfortunately when smart and educated people get crazy ideas they can come up with plausibly truthy arguments. -- Andrew F Cockburn

            by ebohlman on Sat Feb 15, 2014 at 06:35:22 PM PST

            [ Parent ]

            •  this approach is not called 'vegan' (0+ / 0-)

              a vegan diet might be very unhealthy. Lots of vegans eat junk food, high fat, processed foods, etc.

              However a whole-foods, plant-based diet, centered on healthy starches with the addition of vegetables and fruit, with no added fats or processed food--that is heart-healthy. You can not only prevent, but even reverse heart disease by following this regimen.

              Read Dr. Caldwell Esselstyn's book, Prevent and Reverse Heart Disease: The Revolutionary, Scientifically Proven, Nutrition-Based Cure

              He took a group of patients who were supposed to die from their heart disease and has kept them healthy for over twenty years now. And proved with before and after angiograms that the disease can be reversed with diet. It's a very eye-opening study! Many people might be dismayed at giving up meat and dairy, however if it means life vs death, (or health vs sickness) why not?

              Where in the Constitution does it say: "...on behalf of corporate interests" ???

              by sillia on Sat Feb 15, 2014 at 07:00:51 PM PST

              [ Parent ]

              •  Peer-reviewed literature would be more (0+ / 0-)

                helpful than popular books by diet gurus (who all say pretty much the same things about the supposed benefits of wildly different dietary regimes).

                Unfortunately when smart and educated people get crazy ideas they can come up with plausibly truthy arguments. -- Andrew F Cockburn

                by ebohlman on Sat Feb 15, 2014 at 08:57:56 PM PST

                [ Parent ]

                •  the scientific literature on this (0+ / 0-)

                  is very good. The doctors I listed have published books with extensive references to the peer-reviewed literature. Pick any of them--McDougall, the Esselstyn book--libraries will have these. And Prof. Colin Campbell (the China Study) is one of the premier experts in the country on nutrition (Cornell U. prof emeritus). Only a true science geek can appreciate his work, lol. These folks are not gurus. None of them started out wanting to follow this diet but got there because that's what the science says.

                  I do get what you're saying--there's a lot of junk out there. How does the reader know what's true and what isn't? Especially if it seems to go against common practice? Well, you need a pretty good BS detector, along with an open mind, and you need to look at the evidence pretty carefully.

                  My husband is a scientist (academic/research) and I am also very science oriented. We changed to this diet after very careful consideration of the studies, data and clinical experience of several of these medical doctors. When you delve into the China Study, for example, the evidence is quite convincing. Another good resource was Dr. McDougall's website, where he has all of his past newsletters archived and available for free--every article in there contains references to scientific research and you can follow through on this all you want. I did a huge amount of reading on this.

                  We've followed Dr. McDougall's plan (which is the same scientifically based strategy as the other people I mentioned) for eleven years now. My husband got his cholesterol down by 100 points--without meds--into the safety zone and lost 25 pounds. He is 58 years old and currently takes no meds. There is heart disease in his family and all of his relatives, even the younger ones, are on big doses of statins and hypertension drugs. Me, I was already slim but lost a few pounds, too. My cholesterol has been 126 since the first year we started this; previously it was 176.

                  Doctors may tell you 176 total cholesterol is good, but I know two people who had their heart attacks with numbers like that, so it's not true. The true heart-attack free zone seems to be 150 or lower, according to the famous 40-year Framingham Heart Study. See Dr. William P. Castelli (the original leader of this massive study)--who by the way doesn't advocate meat & dairy free diet, mainly because he doesn't think people will follow it. So his books say to reduce those foods. See, he's working with the same data as the other people but giving somewhat different advice. We tried this for a couple of years, actually but my husband's cholesterol continued to climb and we needed something more drastic.

                  We are very happy eating this way. It took some adjustment to learn some new recipes, but there is plenty of help out there, free on the net or books you can buy. Most of my recipes I just got from fellow McDougallers on their forum. It gets very easy with some practice.

                  There,  I've no doubt bored you into a coma...LOL. Have a nice day!

                  Where in the Constitution does it say: "...on behalf of corporate interests" ???

                  by sillia on Sun Feb 16, 2014 at 09:47:46 AM PST

                  [ Parent ]

                  •  Don't forget Dr Dean Ornish... (1+ / 0-)
                    Recommended by:
                    sillia

                    He showed that you could actually reverse some heart disease with a combination of diet, exercise, and stress reduction.

                    LG: You know what? You got spunk. MR: Well, Yes... LG: I hate spunk!

                    by dinotrac on Sun Feb 16, 2014 at 01:42:13 PM PST

                    [ Parent ]

                    •  Absolutely! (1+ / 0-)
                      Recommended by:
                      dinotrac

                      He was on my list, way upstream in this thread, lol. I still think that Dr. Esselstyn's study is so powerful--not only reversing heart disease but maintaining the improvement for 20+ years in the same patients!!!  There isn't any good reason for someone to die of heart disease, it can be prevented. That is the bottom line--but to modern Americans this seems so incredible as to be unbelievable. But it's a fact.

                      Where in the Constitution does it say: "...on behalf of corporate interests" ???

                      by sillia on Sun Feb 16, 2014 at 03:59:16 PM PST

                      [ Parent ]

                      •  That's probably an overstatement of a general (1+ / 0-)
                        Recommended by:
                        sillia

                        truth, but I believe that most heart disease is both preventable and reversible without cutting veins out of the leg and sewing them onto the heart.

                        LG: You know what? You got spunk. MR: Well, Yes... LG: I hate spunk!

                        by dinotrac on Sun Feb 16, 2014 at 07:44:27 PM PST

                        [ Parent ]

                        •  We've lost touch (1+ / 0-)
                          Recommended by:
                          dinotrac

                          with the extent to which heart disease is a lifestyle disease. Because if you look around, everybody seems to get heart problems eventually, unless cancer gets them first. It seems normal. It has BECOME normal, but it's not an essential condition for humans.

                          Where in the Constitution does it say: "...on behalf of corporate interests" ???

                          by sillia on Mon Feb 17, 2014 at 07:23:26 AM PST

                          [ Parent ]

  •  My ACA experience (9+ / 0-)

    so far been a learning one.
    First off I'm an unusual candidate.
    I have never borrowed money from a financial institution.
    So mid Dec when I first tried to apply I couldn't be verified.
    I had to mail a photo copy of my drivers license to a place in Kentucky. so it was like Jan 8th before I called back to find out what was going on.
    I looked at my options & decided to wait till I had more time to understand the plans, My job was in the way.

    Well Jan 24th I had appendicitis !

    so Feb 6th I decided to call healthcare.gov & decide what to do. I decided on a Blue Value Bronze 5000 plan. I was told I would be contacted in the next 10 days by BCBS to finish the application. That didn't happen. So when I call Monday to find out what happened it will be another month before I get covered.

    I will get this completed. But I really don't give two shits about it. I refuse to believe I should live in fear of medical bills. I don't own very much, a 96 Dakota, a trailer, tools & clothes is IT ! I don't even own a bed! LOL I do own 3 radios though LOL

    so far the bills sent to me on the appendix removal total $22,327.87. I could still get a bill from the Anesthesiologist. The hospital is sending me an application to fill out to see if I qualify for a reduced bill.

    I haven't woke up thinking about medical bills, That's how I plan my day, I work on what I wake up thinking about. February 6th I woke up & had healthcare.gov on my mind, by the end of the day I solved my end.

    weird eh?

    :=)

    •  amazing story (6+ / 0-)

      you don't know how much you need it until you need it.

      "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!" — Upton Sinclair

      by Greg Dworkin on Sat Feb 15, 2014 at 05:26:51 AM PST

      [ Parent ]

    •  That's how so many families lost their homes. (4+ / 0-)
      Recommended by:
      skohayes, eeff, OleHippieChick, revsue

      Over 60% of foreclosures came about because of medical problems that snowballled nto massive medical bills, loss of job due to medical problems, and therefore loss of any insurance they may have had etc. until there is not enough money to pay for new medical costs and food and shelter. Most of those 60% had medical insurance when their nightmare started (though much of it may have been the junk insurance that people complained about losing when ACA started).

      Life is just a bowl of Cherries, that stain your hands and clothes and have pits that break your teeth.

      by OHdog on Sat Feb 15, 2014 at 05:33:49 AM PST

      [ Parent ]

  •  Misfearing... (12+ / 0-)

    Since I am a forester who does a lot of field work, people often ask:

    Aren't you afraid of snakes?
    Aren't you afraid of bears?
    Aren't you afraid of armed marijuana farmers?
    Aren't you afraid of getting lost?
    Being injured or killed in that manner is possible, but the probabilities are extremely small. Here are the things that concern me the most. Their importance varies depending on location and terrain:
    The chance of being in a wreck on the way to and from the woods.
    Tripping/falling hazards, especially in steep terrain.
    Falling trees and limbs on windy days.
    Stinging insects.
    Heat stroke or hypothermia.
    And, no, Bigfoot didn't make either list. I know some people with outdoor jobs who have irrational fears of spiders or snakes, but they are in a distinct minority. Most of us are fully aware of the biggest risks, and we strive to minimize them.
    •  Misfearing: Terrorism vs. Climate Change (nt) (10+ / 0-)

      Hard to have a government when one-third of your representatives are insane and the other two-thirds have been sold to the highest bidder.

      by Rikon Snow on Sat Feb 15, 2014 at 05:45:11 AM PST

      [ Parent ]

      •  NYT op ed--real & perceived risks (3+ / 0-)
        Recommended by:
        revsue, foresterbob, the autonomist

        A number of years ago the NYT had an op ed about real and perceived risks.  It included a graph. There was an inverse relationship between what people feared most and the likelihood it would kill them.  White sharks, bees and snakes were some of the most feared while car accidents, skin cancer and strokes were the least feared.

    •  Lyme disease (1+ / 0-)
      Recommended by:
      foresterbob

      ...and other tick-borne diseases. It is not likely to kill you (though people do die from it). But it can make you sick enough that you'll wish you were dead. Don't ask me how I know...

      There are steps you can take to minimize the risk of tick bites--proper clothing, treated with permethrin insecticide which they find unappetizing, careful inspection when coming back indoors to remove any hitchhikers.

      Where in the Constitution does it say: "...on behalf of corporate interests" ???

      by sillia on Sat Feb 15, 2014 at 09:02:22 AM PST

      [ Parent ]

      •  I knew I was forgetting something. (1+ / 0-)
        Recommended by:
        sillia

        Tick-borne diseases belong on the feared list. They are common enough that I personally know people who have suffered from them. And yes, those folks tell me that it's something you don't want to endure.

        •  Take precautions. (1+ / 0-)
          Recommended by:
          foresterbob

          Probably not everybody falls ill with this infection--some people have it but no symptoms. But they don't know what the factors could possibly be that make one vulnerable.

          Really, do the prevention things. I have wasted 10 years of what was otherwise a wonderful life, and still not well, though slowly making improvements. I wouldn't wish this on any other human being.

          Where in the Constitution does it say: "...on behalf of corporate interests" ???

          by sillia on Sat Feb 15, 2014 at 09:35:08 AM PST

          [ Parent ]

  •  The browning of California.....There Will Be (1+ / 0-)
    Recommended by:
    Heart of the Rockies
  •  Just an idle thought . . . (3+ / 0-)
    Recommended by:
    skillet, foresterbob, PugetSound
    ... 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).
    Wonder how long it will be before they become Lincoln-Reagan dinners?

    Hard to have a government when one-third of your representatives are insane and the other two-thirds have been sold to the highest bidder.

    by Rikon Snow on Sat Feb 15, 2014 at 05:44:14 AM PST

  •  F Zakaria is better late than never: now...blame (4+ / 0-)
    Watching the machinations in Washington over the past two weeks, it is now impossible to talk about how both political parties are to blame for the country’s gridlock.
    In WaPo at: http://www.washingtonpost.com/...

    Zakaria also reports Theda Skocpol's findings from hundreds of interviews that

    "...Crackdowns on immigrants, fierce opposition to Democrats, and cuts in spending for the young were the overriding priorities we heard from volunteer Tea Partiers, who are often, themselves, collecting costly Social Security, Medicare, and veterans benefits to which they feel fully entitled as Americans who have ‘paid their dues’ in lifetimes of hard work.”
    Quoted from: http://www.democracyjournal.org/...
  •  ALL women will get breast cancer (3+ / 0-)
    Recommended by:
    htowngenie, revsue, antimony

    Unless of course they die of something else first. That isn't to say that all women will get early breast cancer and some may not get it at 120 years old, (if they live that long), but the fact is that if a woman doesn't die from heart disease, diabetes, other cancers, cardio-pulmonary diseases, old age, injury or etc., she will eventually get breast cancer. The same thing can be said about prostate cancer in men. The question of screening should be based on factors like risk, family history, etc. but it shouldn't be based on what a profit motivated insurance company wants you to do because they will always be interested in their own self interests and never in yours. Make an informed choice, not a reflexive one. This rule is applicable across all lines. Any time one makes an important decision, it should be based on knowledge, rather than someone else' bottom line.

    "Given the choice between a Republican and someone who acts like a Republican, people will vote for a real Republican every time." Harry Truman

    by MargaretPOA on Sat Feb 15, 2014 at 05:53:15 AM PST

  •  House Armed Services Committee (7+ / 0-)

    report on BENGHAAAAzzzI is out:

    In a new report released on Tuesday, the House Armed Services Committee concludes that there was no way for the U.S. military to have responded in time to the 2012 terrorist attack in Benghazi, Libya to save the four Americans killed that night. In doing so, the report debunks entirely a right-wing myth that says the White House ordered the military not to intervene.
    For months after the attack that resulted in the death of U.S. Ambassador to Libya J. Christopher Stevens, conservative media was awash in reports that on the night of the assault the Obama administration at some point ordered the military not to take action that would have saved lives. This supposed “stand down order” led to a bevy of right-wing conspiracies about why the President and his administration had let the Americans die.
    “Who told the SEALs to stand down?” Rep. Steve King asked in Nov. 2012, in just one of many interviews with Republicans referring to the response to Benghazi as “worse than Watergate.”
    http://thinkprogress.org/...

    From the report itself:

    There was no “stand down” order issued to U.S. military personnel in Tripoli who
    sought to join the fight in Benghazi.
    However, because official reviews after the attack
    were not sufficiently comprehensive, there was confusion about the roles and
    responsibilities of these individuals

    Your beliefs don't make you a better person. Your behavior does.

    by skohayes on Sat Feb 15, 2014 at 06:13:28 AM PST

  •  Is Donald Trump becoming a caricature (3+ / 0-)

    of himself?

    The notion that he is simply too big — too presidential — for a measly job in the Albany Statehouse has temporarily quelled his insecurity. But after this morning, Trump can no longer escape the fact that his political “career” — a long con that the blustery billionaire has perpetrated on the country for 25 years by repeatedly pretending to consider various runs for office, only to bail out after generating hundreds of headlines — finally appears to be on the brink of collapse.

    The reason: Nobody seems to believe him anymore.
    36 Hours On The Fake Campaign Trail with Donald Trump

    Your beliefs don't make you a better person. Your behavior does.

    by skohayes on Sat Feb 15, 2014 at 06:16:05 AM PST

  •  MEN invented and perfected the tit mashers (6+ / 0-)

    used on WOMEN.

    "He went to Harvard, not Hogwarts." ~Wanda Sykes
    Teh Twitterz, I'z awn dem.
    Blessinz of teh Ceiling Cat be apwn yu, srsly.

    by OleHippieChick on Sat Feb 15, 2014 at 06:17:54 AM PST

    •  Thank you! nt (1+ / 0-)
      Recommended by:
      OleHippieChick
    •  if there were a device to detect testicular cancer (2+ / 0-)
      Recommended by:
      tb mare, OleHippieChick

      you can bet it would be very very gentle

      not mashing sensitive body parts flat between a plastic shield and a metal plate!!!

      Politics is like driving. To go backward put it in R. To go forward put it in D.
      DEMAND CREATES JOBS!!!
      Drop by The Grieving Room on Monday nights to talk about grief.

      by TrueBlueMajority on Sat Feb 15, 2014 at 06:55:11 AM PST

      [ Parent ]

    •  I'd rec this a million times if I could. (4+ / 0-)

      When I finally succumbed to all the pressure to get a mammogram at age 48 in 2006, it was excruciatingly painful.  With no family history of breast cancer, in fact, no family history of cancer of any kind, I demurred for another 5 years and gave in again on the recommendation of a new family doctor in 2011.

      The imaging center I was referred to was beautiful - leather couches, original artwork, fluffy robes and hot tea in the spa like locker room complete with tinkly music.  Problem was, I was the only customer, er, patient.  

      After giving me the all clear, the radiologist was aghast when I said I didn't want to schedule another one for 2012 right then and there.  I mentioned the CDC recommendations had been changed to every other year, but she pressured me like a used car salesman.  The year rolled around and I got a call and an email from the imaging center to schedule my annual appointment!  

      I'm a finance major, not a science person at all.  But I know when people are giving me a sales pitch.  Those idle mammogram machines were causing big headaches for some finance person up the chain.  

      We are all in this together.

      by htowngenie on Sat Feb 15, 2014 at 07:08:59 AM PST

      [ Parent ]

  •  When I think of "distressed babies," (0+ / 0-)

    I don't think of actual babies or any kind of ill health; I think of this guy.
    http://www.msnbc.com/...

    "Optimism is better than despair." --Jack Layton, the late Canadian MP, liberal, and Christian.

    by lungfish on Sat Feb 15, 2014 at 07:37:59 AM PST

  •  The Lisa Rosenbaum article may be (4+ / 0-)
    Recommended by:
    Livvy5, revsue, foresterbob, Greg Dworkin

    more relevant to dKos than merely enlightening smart people about "misfearing." I was struck by this paragraph (emphasis mine):

    If you survived middle school, you know how powerful the desire to belong to a group can be. But psychologists since Freud have emphasized that maintaining our group identities drives us unconsciously throughout life. The desire has particular implications for our health because it shapes the information we seek — and our willingness to accept it. Scholars such as Dan Kahan, who leads the Cultural Cognition Project at Yale, call our denial, in this context, “identity protective cognition.”4 Kahan's research emphasizes that we often don't judge empirical data on the basis of accuracy. Rather, we pick and choose evidence that reinforces our sense of who we are or our allegiances to our “tribes.”
    We keep insisting that "you're entitled to your own opinion, but not to your own facts." However, what is a "fact" to different people may depend on what evidence they can allow to filter in, while they keep out any that will damage their group identity - as, say, a fundamentalist Christian.
  •  Prostate cancer parallels are eerie! (2+ / 0-)
    Recommended by:
    sillia, Anna M

    What I took away from the reporting on the mammogram study was very similar to the studies on PSA blood test and prostate cancer.
    1. Both may detect cancer that may never kill the patient.
    2. The psychological pain of knowing that you are a "cancer victim" may be worse than the disease.
    3. The treatment often is worse than the disease.
    4. The Medical-Industrial Complex is in the breast and prostate cancer business and in the business of promoting their business.
    5. Both sexes are highly vulnerable as these two cancers are important markers of their identities as women and men.

    In fact, the mammogram controversy is worse because, unlike the PSA test, the radiation from the mammograms over multiple years causes some breast cancers!

    Women and men should learn about the conclusions from these types of studies and then challenge their health care provider to explain her/his professional analysis. Make them answer the hard questions; don't be afraid to put them on the spot. Make a decision on your timeline not the timeline demanded by the MIC - you're the one who has to live with your decision.

  •  The wife of a close friend of mine (0+ / 0-)

    told us that when she was 50, she decided "no more mammographies".  She had read that the medical community in Europe was starting to back off of them as a possible cause of cancer.  It made sense when she said that mammographies "squish and radiate" all the little blood vessels and lymph glands that work to remove toxins from the breast tissue.  Also, it was well documented and still is that mammographies do not change the overall death rates from breast cancer.  She decided to continue just doing regular self exams.  That was about 13 years ago and so far she is fine.

  •  Thank you for highlighting the b.c. study (1+ / 0-)
    Recommended by:
    Greg Dworkin

    I hope this study gets attention far and wide. For over a decade I have been convinced, for scientific reasons as well as personal bad experience, that mammography is more or less a boondoggle.

    There are other studies that precede this one, it's starting to look like fact. This paper from 2004 is interesting, and concludes that: "...all [mammogram] advocacy groups accepted financial support from industry, apparently without restrictions." So imo some of this "fear" is manufactured, due to propaganda. Money, money, money...and it's not just Komen.

    Presentation on websites of possible benefits and harms from screening for breast cancer: cross sectional study

    I have personally lost my fear of breast cancer after reading the China Study and understanding the nutritional factors that underlie most cancers. Following this way of eating along with moderate exercise, I am doing what is humanly possible for prevention. If I DO develop a cancer, then so be it, I'll deal with it then. But no more mammograms.

    Where in the Constitution does it say: "...on behalf of corporate interests" ???

    by sillia on Sat Feb 15, 2014 at 09:30:43 AM PST

  •  There is new tech coming (0+ / 0-)

    that would make mammograms unnecessary for screening purposes for the most part. Namely, a simple, quick and easy way to i.d. cancer cells from a blood sample. It works really well, can even sort out accurately what TYPE of cancer cell they are looking at. So as a patient you'd have a lot more information about what your options are, without invasive procedures.

    This article is the leading edge of this tech. Unfortunately it may be pretty opaque unless you're a biophysicist/biochemist; there isn't anything out there yet for the lay reader.

    (article on using ferroelectrics to i.d. cancer cells)
    from Biointerphases journal (Springer) Oct 2013; Open Access article.

    Where in the Constitution does it say: "...on behalf of corporate interests" ???

    by sillia on Sat Feb 15, 2014 at 12:27:43 PM PST

  •  I will never have another Mammogram. Yay! (0+ / 0-)

    I hate them and every year my young doctor says come on just one more.  Never, never never.  Thank you for the 90,000 women who didn't really need one.  and I
    am way over 55.
    The reason any woman stays on the  postmenopausal estrogen progesterone supplements is sex.  I got off the stuff after 21 years because the statistics on ovarian cancer scared me.  But I am healthily going into my mid seventies.  I miss the pills but what the hell.
    Love you guys.  You are all so serious.

    WE must hang together or we will all hang separately. B.Franklin

    by ruthhmiller on Sat Feb 15, 2014 at 02:19:01 PM PST

  •  Another case of evidence based medicine (0+ / 0-)

    being viscerally disregarded, from the National Blood Authority in Australia:

    And, antibiotic use for viruses, etc.

    Iron sharpens Iron. Normal is a dryer setting. STOP illegal immigration NOW! -- Make it LEGAL. If Corporations are People--Let's draft them.

    by benamery21 on Sat Feb 15, 2014 at 03:54:55 PM PST

Subscribe or Donate to support Daily Kos.

Click here for the mobile view of the site