Anti-ScienceScience

No, Ladies, the New Breast Cancer Guidelines Aren’t Patronizing

A US government task force recently came out with new guidelines for breast cancer screening, suggesting that women shouldn’t bother getting checked until the age of 50. The American Cancer Society currently recommends women start screening at 40.

Feministing reported this as “New patronizing guidelines for mammograms have been implemented by a government task force, recommending that women over 40 shouldn’t get routine mammograms because of certain risks like women’s “anxiety,”” which made me sigh sadly, because it is bullshit.

They link to Feminist Law Professors, who writes this about the subject:

A government task force claims that women don’t need to have routine screening for breast cancer until age 50. (See the AP story here.) But the American Cancer Society recommends routine mammograms for women 40 and over.

The government task force’s reasoning? Because the “anxieties” caused by mammography, false positives and biopsies do not decrease mortality.

If the federal government is so concerned about women’s anxieties, how about more jobs, affordable child care, lower tax rates, clean air to breathe, and an end to discrimination?

I can control my own anxiety about having my breast squished by a mammography machine, thank you.

The commenters at Feministing quickly jumped in to correct the original poster, but at FLP things only got sillier. Because these are usually good sources of intelligent information, I wanted to post this to reassure women who might be thinking along similar lines: these guidelines are not patronizing and they are based upon real data that suggest women will be better off this way. Here are a few points to bear in mind:

A government task force claims that women don’t need to have routine screening for breast cancer until age 50.
No. The task force recommends that most women don’t need it until the age of 50, but stipulates that “The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.” In other words, if you have risk factors, then your doctor may recommend you begin earlier.

But the American Cancer Society recommends routine mammograms for women 40 and over.
The ACS’s guidelines are twenty years old. The task force’s recommendation was just released, based on updated data and learning from the past 20 years. As a side note, the ACS does not recommend self-examination, and the World Health Organization recommends beginning screenings at age 50.

The government task force’s reasoning? Because the “anxieties” caused by mammography, false positives and biopsies do not decrease mortality.
Interesting that those are listed in the reverse order of their relative importance. The basic fact of the matter is that current evidence shows that we do not save more lives by screening all women before the age of 50. These screenings only contribute to more false positives, which in turn causes an incredible amount of anxiety. Have you ever been told you have cancer? Kind of upsetting, I’d imagine.

If the federal government is so concerned about women’s anxieties, how about more jobs, affordable child care, lower tax rates, clean air to breathe, and an end to discrimination?
Okay, sure. This panel of doctors will immediately stop trying to improve lives and safeguard women’s health and immediately get going on lowering your taxes. That’s a red herring, in which completely unrelated issues are introduced in order to distract from the issue at hand.

I can control my own anxiety about having my breast squished by a mammography machine, thank you.
It should be quite clear by now that the anxiety doesn’t come from the inconvenience and pain of the mammography machine, but in being told you have cancer when you do not.

The first commenter at FLP says:

Just who is this government task force? Probably a bunch of men… Why havent they given the people an updated stating that men should only be screened for testicular cancer when they turn 50?

CD Dorsey

Obviously, CD didn’t bother to actually read the linked article or do the slightest bit of research, which is exactly why I’m writing this post. So many people read something online and immediately believe whatever it is, not even pausing long enough to click a link. To those of you who are reading this right now, please do not believe me. Click the links. Thanks.

To answer CD, the vice chair of the task force is quoted in the AP article:

“The benefits are less and the harms are greater when screening starts in the 40s,” said Dr. Diana Petitti, vice chair of the panel.

I’m going to guess Diana is a woman. Of course you could always visit the web site of the US Preventative Services Task Force to see that at least 8 out of 16 members are women (I’m not including one “Sandy” who could be a man or a woman), but that took all of 30 seconds so I can see how one would shy from doing that.

So, kudos to the Feministing crowd for sticking up for evidence-based medicine in the comments section. Hopefully, that kind of rational thinking will influence future posts on women’s health.

Rebecca Watson

Rebecca leads a team of skeptical female activists at Skepchick.org. She travels around the world delivering entertaining talks on science, atheism, feminism, and skepticism. There is currently an asteroid orbiting the sun with her name on it. You can follow her every fascinating move on Twitter or on Google+.

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39 Comments

  1. I used to be an associate editor at Diagnostic Imaging and related publications. Among the radiological community, there was a constant back-and-forth on the matter of what age women should start mammography. This taught me to take any official word on the subject with a grain of salt, and make the decision with my doctor.

    Granted, I’m lucky to have a doctor I trust, who has been seeing me for 10 years and whose experience has served me very well, so I feel confident doing that. I’m sadly aware not all women are as fortunate as I am in that regard.

  2. Awesome post. I was curious about the real facts of this hot button issue but I haven’t had time to look for myself.

    I think people are really missing the point, that the choice to get regular screening is relative to your risk and you talk to your doctor because guidelines aren’t for you specifically. I doubt this change will affect me much since my mother had breast tumors (Luckily caught before becoming cancer) so I’ll probably need to be screened earlier than 50 anyway. *shrugs*

  3. The general public has a really strong tendency to believe that doing anything and everything to detect cancer earlier is a good thing. Even when the data say otherwise, it is a hard sell. False positives and their relative impact are key aspects of any diagnostic test but can be diificult concepts to grasp. Even for doctors and nurses.

    The idea that earlier screening doesn’t reduce mortality is just so unintuitive that you want to not believe it. Personally, that’s what I love about my job as a biostatistcian, sometimes the data tell you something unexpected and exciting!

  4. I was surprised when I saw the headline, too, but looking into it more makes it understandable. Why subject people to more tests and worries and false positives, if the benefit isn’t there, if lives aren’t being saved?
    My only worry is that insurance companies would take this as an excuse to refuse payment for mammograms before age 50, now, because ‘they guidelines say we can.’ But I’m also pretty confident that my family history and my doctor can beat up my insurance company.

  5. Good stuff.

    As to the anxiety you nailed it. I’m only in my mid-40’s and most people I know including me and my wife have heard one of several words meaning “cancer” from our doctors at least once. Usually it’s something fairly minor like a basal-cell carcinoma or a benign breast lump, but the intervals between “that might be cancer” and a test and the results of the test can feel like a lifetime. The experience not something to trivialize.

  6. While I don’t read this blog, and I’ve got a sample size of 2, both negative, so I can’t draw a really strong conclusion, from what you’ve shared, that I’ve seen, it almost feels like this blog is a women’s-equality denier. No matter what you show them to point out equal opportunity, they’ll just move the goalpost, or jump to another topic, like other deniers/conspiracy theorists.

    Please note, this is just an observation and not a conclusion. I don’t have enough information to make up my mind.

  7. @infinitemonkey: I read the blog fairly regularly. They tend to over-react over some of the stupidest shit. Some of it has a basis in reality; some of it doesn’t (like this). I mean, clearly feminism still has a place in society, but they do tend to focus mostly on the negative. They are fairly on-target with the LGBT stuff, though.

    And, at least they aren’t http://www.feministe.us/blog/, which is even worse — and which silences dissenters, even if the dissenter is reasonable (I seem to recall that some crazy woman silenced Rebecca by posting pictures of *pandas* in reply to Rebecca — it was ridiculous and childish).

  8. This seems to be a relatively recent trend in cancer-research, as I recall just recently some top medical officials saying that we’re over-screening, which may be just as dangerous.

    link

    I remember my knee-jerk reaction at the time, because cancer is a way-worse “c-word”, but it seems to be corroborated at multiple levels.

  9. This reminds me of a segment on a recent “This American Life” about healthcare and how doing anything and everything (more tests) is not always the best approach, but that, as mentioned above, it can seem counter-intuitive so many patients will demand them anyway.
    I think in that segment, there was also a story about a doctor who was following prostate screening guidelines and told a patient that the screening wasn’t worth the risk at his age. Then the guy got cancer and died and the family sued the doctor. Slippery, slippery slope.

  10. @Vengeful Harridan (Elexina):

    My only worry is that insurance companies would take this as an excuse to refuse payment for mammograms before age 50, now, because ‘they guidelines say we can.’ But I’m also pretty confident that my family history and my doctor can beat up my insurance company.

    That would seem unlikely to me, because this is only a recommendation against frequent, routine scanning every year or two until 50.

    But then again, this is insurance companies we’re talking about.

  11. From personal experience, I think this is a good recommendation. I had a baseline done at age 40 per the guidelines at that time. Everything was clear and there is no family history, so I’ve only had screenings at 45 and 50 after. Both of those were clear. I don’t plan on having another until I’m 55.

    I think a best guideline is family history and age of onset for perimenopause. Women whose family history includes breast or lymphatic cancer should consider starting screenings earlier. Perimenopause is happening to younger women, and the hormonal changes could trigger more than just hot flashes.

    The only cancer for which I screen regularly is colon cancer. All the male members of my father’s family has suffered and died from colon cancer. While none of the women have ever been affected, I’m taking no chances.

    ETA: On the matter of insurance coverage, every October (Breast Cancer Awareness Month) there are some hospitals and diagnostic clinics that will do screenings for free – no doctor’s prescription required.

  12. I read a scientific study about this subject a while ago. They were explaining that when you get tested too early, it is possible that they will detect something so tiny, that it might never developped as a cancer. Or, it might do but, in like 20-30 years from now. So, is it worth it to worry about it for all those years when we don’t even know if it will ever happen one day. So, I think it is a good recommendation, except for people with a history of problems in their family.

  13. I was thrilled to read this news yesterday. I’m clutching at any straw to put off the annual tit-squashing. I dutifully had my baseline mammogram [insert mandatory joke of sticking one’s breast in an envelope and mailing it] in my mid 30s. I’m scheduled to go under the squasher again in late December. *sigh* I do not like getting mammograms. Owie. I just might cancel this year’s Fun Event.

  14. I was a little surprised at the recommendation because it honestly doesn’t make much sense to me. No screening at all until 50 then every two years? Wouldn’t screening at 40, 45, then every 2 years after 50 make more sense? The logic behind no screening then frequent screening just seems odd. If someone could explain this to me, please do.

  15. @Noadi: It’s a question of statistics. The risks increase with age, so early on there are very few actual cases, and the rate of true positives to false positives will be horrible. You will be creating anxiety and unnecessary medical procedures for almost nothing. At some point (a value judgment) the rate of true/false improves sufficiently to recommend routine testing for everyone. Now testing often _will_ mean more false positives, but the rate of true/false will be the same and “improving” for each year, so it’s justified by a significant number of true positives.

  16. Rebecca, why can’t you just admit that Obama’s new and “improved” nazi government wants to kill off cougars for fear that one of them might be the next Sarah Palin? Obama hates strong white women.

  17. And all this time I thought the whole boob-squishies-start-at-40 thing was only for women who had breast cancer in their families.
    Until I lost both of mine to complications from plastic surgery (check out boobcast.wordpress.com to find out more) I had been getting yearlies since the age of 39.

    Now I have a whole new dilemma. Since the Twins are brand new, being only 7 months old, do I ever have to get a mammogram again? This is all tissue from my back so I would think that I wouldn’t have to worry about breast cancer.

    Dr. Elliott, my reconstruction surgeon said that yes, I should have one yearly but I have to wonder why. If anyone knows a logical reason I’d love to hear it.

  18. @sporefrog:

    That would seem unlikely to me, because this is only a recommendation against frequent, routine scanning every year or two until 50.

    But then again, this is insurance companies we’re talking about.

    Why would you want insurance to pay for a regular predictable expense? I understand this is how US health insurance “works”, but I still don’t understand it.

  19. @James K:
    Why would you want insurance to pay for a regular predictable expense?

    Because I assume that in your healthcare policy, the insurer says they’ll pay for all your medical expenses, and these are medical expenses. The fact you know in advance they’ll be coming is no excuse. It’s not technically a pre-existing condition either. And it’s not optional, like plastic surgery for example. So it’s probably covered.

    The tricky part then becomes the fact they’re no longer “recommended” until age 50, which insurers will no doubt jump at as an excuse to not pay for them until that age because it’s now a voluntary procedure (i.e. you’d probably need a doctor to prescribe them in order to get the insurance to pay for it).

  20. Sorry, but I just don’t have the same degree of trust of government task forces as you may enjoy. One of the considerations of this panel was => cost <= which puts a whole 'nother layer of cynicism into the equation, as far as I am concerned.

    Screening mammographies are not going to save lives, even in 40-49 year old women? Sorry – I don't think that is true. I think what might be closer to the mark is that the number of saved lives doesn't meet some undisclosed underwriter's threshold. In other words, it is too expensive to justify.

    Gobbleygook about the negatives of anxiety and false positives – please. They occur in all strata. They have increased as technology has become more sensitive. Nobody really believes that a spot on an initial mammogram “means you have cancer” anymore, and no physician would tell a patient that, either. You go back for a rescreen, you may go for a biopsy.

    Guess what – this is the price for early detection and it should NOT be used as a rationalization for increased cost ‘efficiencies’ for insurers. In my humble opinion.

    And in my opinion, increased cost ‘efficiencies’ is what this is all about. And we need a national conversation about whether the medical community itself is doing us any favors here, or if they are merely doing the insurance industry lobbying for them.

    We spend double what other nations do per capita. We have more than enough money being spent here to pay for screening mammograms for men as well as all women if we wanted to do such a thing. But health care professionals have swallowed the insurance company meme that there isn’t enough money to pay for healthcare, so that the only ‘moral’ thing to do is to restrict access, that is, ration and deny services. I say this is bullshit!

    Instead of denying care, we should be demanding that HMO execs can not take home billion dollar bonuses, or that insurance companies simply can not get away with devoting 36% of their income to infrastructures to deny benefits and physician payments.

    I blame the medical professional community most of all. They have watched the destruction of the US health system and have really done nothing courageous about it. The AMA (for one example) should have been lobbying about this, they should have been organizing strikes. Sadly, like every other player in this drama, they merely protected their own interests, instead of their sacred duty to protect the interests of their patients.

  21. @exarch:
    Yes, but why would you have a policy that pays for regular expenses? All the insurance company does is add the cost of those expenses to your premiums, plus a bit for their administrative overhead.

    I assume it has to do with the tax deductibility of health insurance in the US, but this is one of the core reasons your health system is so horribly broken. My insurance policy (which I pay for on top of the taxes that go to our lacklustre government system) costs me about USD 25 per month precisely because it only pays for hospital care. The little stuff I pay for myself.

  22. The other thing I’m noticing, now that we’re in to the second day of the shrill hysteria, is that a lot of people seem to be confusing the recommendations with the reporting that’s being done of them. Like for example, the whole “anxiety” issue really isn’t huge in the recommendations. I looked through them. They’re more concerned with the false positives, etc. The “anxiety” crap is getting way overemphasized in the media, and it’s those articles that are getting people up in arms about how “patronizing” this is.

    The real answer: It’s not the guidelines that are patronizing. It’s the reporting. Are we surprised?

  23. @KingMerv00:

    I applaud that initiative, and wish to hereby offer my application for the position of boob-inspector. (After all, if it’s to be performed several times a week, for every woman, there’s going to be some issues with understaffing).

  24. Offered in jest? The people opposed to the new guidelines keep saying their stance is about saving just one more life. Don’t they really mean it? Don’t they think women can handle it?

    Oh and I also suggest we start prostate exams in utero.

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