VR - ENOUGH ALREADY!!!!!

Beesie - thank you for explaining that QOL point which is very relevant and has broadened my view of the subject.  Earlier detection means more people avoiding harsher treatments.  I was focusing on the mortality issue.

 To me this is more than a statistical matter, it is an ethical issue.  Even the anti-screening proponents admit that early screening, BSE and CBE reduce mortality, just not enough to warrant the expenditure in their opinion.  So, if we know for a fact that lives will be lost with the new guidelines, is it not then unethical to implement them?  Goverments do other things based on ethics rather than cost.  For example, Canadians do not have capital punishment, although it is cheaper to kill criminals than to house them for many years.  But killing them is considered unethical - state sanctioned murder.  Is this not analagous?  We know these guidlines will result in deaths of individuals, although we can't see those individuals beforehand as we would with criminals to be executed.  To the anti-screeners, they are numbers, not individuals. 

 bluedahlia - stay away from propofal lol.  Isn't that what did in Michael Jackson? 

I like Propofal! LOL  It's the one reason why I looked forward to my colonoscopy! LOL

For Ontarians, you might be interested in completing the following survey... huge study...

https://ontariohealthstudy.ca/

Is ignorance bliss?



I am dump founded y they don't encourage cbe and bse!?! How would u know if u had the classic breast cancer symptom? A lump? Should women ignore their breasts and wait until the lump changes the appearance of their breast? Or until it's bleeding?!

I was refused a diagnostic mammo in Ontario even though I had a dr. order! I made a fuss but, they said I was too young for one.  5 months later I was diagnosed with a 8cm locally advanced tumour with lymph node and chest wall involvement.

I can't sue.  the "delay" isn't considered long enough.  The Canadian Physician's protetion laws are too strong and I won't win.

Great article

So, her SCREENING mammogram was normal?  And then several months later a DIAGNOSTIC mammogram confirmed an aggressive tumor.   She was low risk?   Hmmmm....Perhaps at the conference her doctor learned that after age 50 her patient's risk of breast cancer INCREASES....and that diagnostic mammograms are important for EVERY age group? 

Thanks very much to voraciousreader and cp418 for posting the links to studies and articles that we would otherwise not be aware of.

There is an article today by a professor from UBC that says a lot of what I am trying to say, but in a much better way. http://www.theglobeandmail.com/news/opinions/opinion/the-breast-screening-debates-about-values-and-resources/article2252546/?utm_medium=Feeds%3A%20RSS%2FAtom&utm_source=Home&utm_content=2252546

A couple of brief excerpts: "Last week, The Globe and Mail's public health reporter and columnist, André Picard, presented the new breast-cancer screening guidelines - guidelines that would reduce the number of screening mammograms done - as the unalloyed product of science. Citing women's health pioneer Susan Love, he argued that those who support earlier guidelines are caught up in "wishful thinking." ....This opposition of science and wishful thinking misrepresents the debate: All health policy guidelines express values, and the new guidelines, while they take into account considerable scientific evidence, also represent a shift in social and economic values.....It must be hard to be a women who has been diagnosed with and treated for breast cancer after a screening mammogram, not only to read that you were among the deluded wishful thinkers, but also to realize that if the new guidelines had been in place at the time, you wouldn't now be engaged in wishful or illusory thinking, because you'd be dead."

My feeling is - we know that this screening has saved the lives of women in that age group, so how can we now take those life-saving measures away from them.

Andre Picard had another aticle in today's Globe as well.

http://m.theglobeandmail.com/life/health/new-health/andre-picard/breast-cancer-reality-check-be-aware-not-frightened/article2252257/?service=mobile

He refers to the "angry doubters of the science" but never once indicates that it is just some of the science and that the science he is citing is in dispute in other studies.  Interestingly, the header over his column is "Money" - an error in placement?

OUCH:  also represent a shift in social and economic values

Breast Cancer Screening: Not ‘If', but ‘Which?'By Todd Neff |November 29, 2011

---

CHICAGO - Carol Lee, MD, a Memorial Sloan-Kettering Cancer Center radiologist, presented a balanced menu of evidence on breast-cancer screening at RSNA 2011 on Monday. She offered up a slew of studies that, collectively, have found mammography to cut breast cancer mortality around 25 percent. She highlighted other studies, one dating back to 1976, that questioned whether mammography made any difference at all for women.

Lee mentioned the screening recommendations of the American College of Obstetricians and Gynecologists, the National Comprehensive Cancer network, the American College of Radiology, and the American Cancer Society (all who suggest annual screening for women ages 40 and older) as well as those for the National Cancer Institute (biannually starting at age 40) and the U.S. Preventive Services Task Force, which recommends biannual screens starting at age 50.

Indeed, to capture her true thoughts on the issue, one had to wait for the Q&A.

"I wonder what the motivation of those who continually attack screening mammography is," she wondered aloud. "We have some pretty good science behind our position." She added that the Scandinavian studies (Kalager et all in the New England Journal of Medicine and Jorgensen et al in the British Medical Journal, both in 2010) that have questioned the value of screening mammography, are weaker than some of the studies supporting screening because they weren't randomized, prospective, controlled trials.

And so most the discussion during the panel "Screening for Breast Cancer: Where do we stand?" was not about whether to screen, but how to screen, with a focus on emerging alternatives to mainstay mammography. Lee briefly covered two of the latest options herself: positron emission mammography (PEM) and breast-specific gamma imaging (BSGI). Both, she said, have been shown to detect otherwise occult breast cancers - indeed, two studies presented Tuesday at RSNA 2011 found BGSI to have greater sensitivity and sensitivity - as well as effectiveness in diagnosis among women with dense-breasts -- than with mammography or ultrasound. But both BGSI and PEM expose patients to radiation doses far higher than the roughly 0.44 millisieverts of a digital mammogram - 6.2 mSv for BGSI and 9.3 mSv per PEM scan, she said.

Janice Sung, MD, also of Memorial Sloan-Kettering, picked up the thread for MRI screening. MRI shines with women with risk factors such as a personal history of cancer, a history of chest irradiation when young, and BRCA 1 or 2 mutations, Sung explained. Various studies have found MRI to help in detecting between 4 percent and 7 percent more cancers in high-risk women than would be the case with mammography, most of the tumors less than one centimeter in size.

Margarita Zuley, MD, the University of Pittsburgh's medical director for breast imaging, discussed research in tomosynthesis screening for breast cancer. The procedure, which creates a three-dimensional image of the breast using X-rays, won U.S. Food and Drug Administration approval in February. University of Pittsburgh researcher David Gur, ScD, and others have found it to be particularly good at highlighting small lesions and speculated masses. A current study by Gur and colleagues is yielding numbers similar to or better than a 2009 study showing a 30 percent reduction in recall rate with tomosynthesis-plus-mammography and a 10 percent reduction in recall rate with tomosynthesis alone, Zuley said.

Jean Weigert, MD, director of women's imaging at Mandell and Blau MDs, PC, and the Hospitals of Central Connecticut, picked up the thread with ultrasound. It's a good choice with dense breasts, where mammography is weak, she said. Data collected in the first year of a new study across six practices with 10 sites in Connecticut - covering 78,778 screening mammograms and 8,651 screening ultrasounds retrospectively - estimated that ultrasound screening caught an additional 3.2 cancers per 1,000 patients in the screening population, Weigert said.

Two of the main challenges for ultrasound breast cancer screening are the spottiness of insurance coverage for patients and lower insurance reimbursement rates for the procedure, Weigert said. But she added that several states, including New York, Texas and California, are making headway in requiring ultrasound as secondary screening.

When emotion prevails over cold, hard science in
public policy

JOHN ALLEMANG
Last updated Friday, Dec. 02, 2011 10:43PM
EST


An X-ray photograph of a mammography
screening. Mammography uses X-rays to detect any tumor or cyst in a breast.
(Sari Gustafsson/Lehtikuva OY)




A-
A+



Who is health care for?
The answer seems obvious: everyone. It's a certainty based on the powerful
utilitarian idea that public spending should provide the greatest good for the
greatest number of people.
So what's gone wrong with breast cancer treatment? According to the
guidelines issued last month by the Canadian Task Force on Preventive Health
Care, our extensive use of screening techniques provides only small benefits at
a great cost.





Demystifying breast
cancer screening
Is the decision to
recommend reduced breast screening ethical?
The breast screening
debate's about values and resources

The guidelines' authors argue that more women have been harmed than helped by
a public-health policy that has encouraged all women to see themselves as
potential victims, even though the high-risk group is substantially smaller in
number.
Critics dismiss the guidelines by pointing to the examples of women whose
lives have been saved by mass screening campaigns.
The heated debate around cancer treatment has provoked a larger question:
Should we be crafting policy and spending money on the basis of exceptionalism?
But how do we begin to answer that question when there's no public consensus on
the exact point where the general good is no longer served by the benefits to a
few?
"There's a perverse lack of calibration between science and policy," says
Ross Upshur, Canada Research Chair in Primary Care Research at the University of
Toronto. "And this rapidly turns into a classic conflict between the universal
and the particular, because there's always an exception to the rule, the patient
whose tumor was found through screening."
Exceptionalism is at the root of many public-policy issues where emotion,
self-interest and personal experience conflict with the more dispassionate,
evidence-based approach of science.
And with good reason: The individual story changes everything in how we
relate to a prickly policy issue, whether it's hunger in Africa made human
through a famine-ravaged baby on a TV fundraiser, or the survivors' testimony
that has been marshalled to criticize the task-force report.
"If you put a face on a death, the argument for the other side is lost," says
McGill epidemiologist Abby Lippman.
Compelling exceptions are hard to counteract, especially for political
leaders who can only look cruel by preferring abstract policy about death rates
over individuals who share stories of pain and survival.
Those warring values were put to the test last year with the widely
publicized campaign for funding of the controversial liberation therapy for
multiple sclerosis. "The scientific evidence has been very weak to date," says
Timothy Caulfield, Canada Research Chair in Health Law and Policy at the
University of Alberta. "If we made the science resource allocation the way we
usually do, we'd have basic research first, try to figure out a mode of action
and slowly move it into the clinical stage. But it's the people with the disease
who are driving the issue. And when the demand is so huge, there's an impetus to
take action."
Last week, federal Health Minister Leona Aglukkaq announced plans for
clinical trials of the treatment, reversing the government's previous policy.
"The science is very thin," says University of Manitoba bioethicist Arthur
Schafer, looking for a way to explain this change of heart. "But the drug
therapies we have are very oppressive, and you're dealing with people who are
desperate. So in the end, why not try it?"
When used as a policy tool, exceptionalism is understandable and even
defensible. Israel trades 1,027 Palestinian prisoners for a single soldier held
hostage by Hamas. The critics of that asymmetric deal take a position that is
proudly detached: It's wrong because it rewards hostage-takers, at the likely
cost of future retaliations toward Israel.Continue Reading

But the payoff from the return of that single Israeli soldier goes well
beyond the individual - other Israelis see themselves reflected in him and his
suffering, and take collective pride in the protective patriotism that sees his
life as so valuable. That compassionate sense of unity can be leveraged by
politicians who recognize the overriding power of emotion, even when it seems
irrational and potentially dangerous.
Likewise in Canada, a government that talks tough on criminals when crime
rates are falling prefers the anecdotal concerns of its supporters to the
collective power of statistics. Decision-makers who won't let gay men make blood
donations know the risk of spreading HIV is infinitesimal, but balance their bad
science against the possibility of undermining public faith in the blood supply.
Researchers tell governments that in-car headsets can be just as dangerously
distracting as cellphones. Yet only the phones are banned, because the argument
against a hand-held device is easier for the public to accept - public policy,
much more than science, has to pass the popularity test.
The tensions in the breast cancer issue are even more divisive, for the
paradoxical reason that the advocates for intensive mass monitoring of the
population don't accept that they represent an exceptional position. The
treatment of breast cancer, like prostate cancer, like colorectal cancer, has
been framed in general and universal human terms: If everyone should be tested
at some point, even the non-symptomatic, isn't that what preventive public
health is all about?
The scientists on the task force challenge this belief simply by pointing to
their seemingly overwhelming statistics: Screening 2,100 women aged 40 to 49
every two or three years for 11 years saves only one life. On balance, says the
task force, that's too much exceptionalism.
Of course in the real world, we don't know whose life that is - it might be
yours. And while science fixates on the mythical average woman, doctors see much
more room for variation from the mean - especially in breast cancer, where
family histories and genetic mutations can indicate a strong susceptibility to
the disease.
"The tension in medical practice comes from figuring out how to translate
guidelines," says Neel Shah, who runs an NGO called Costs of Care. "The very
best doctors look at patients and try to figure out how they could be different
from the average. Guidelines aren't gospel, they're just a starting
point."


Published on Friday, Dec. 02, 2011 10:40PM
EST

Thanks voracious, what a tempest in a teapot over these new guidelines.

Quote from the Margaret Summerville article above: "The very best doctors look at patients and try to figure out how they could be different from the average. Guidelines aren't gospel, they're just a starting point."

Quote from the Canadian Task Force on Preventive Health Care FAQ for patients:

The chance of getting breast cancer is lower and the chance of having a false positive mammogram s higher in the 40-49 age group, which can lead to further investigation, including other unnecessary procedures such as breast removal. We recommend not screening in women aged 40-49, however women in this age group who are interested in screening and less concerned about its undesirable consequences should discuss their options with a physician.

http://www.canadiantaskforce.ca/docs/FAQ_Patients_ENG.pdf

Kathy

Thanks voraciousreader.  I think this is a worthwhile debate. The article by Dr. Yaffe (link in Margaret somerville's article) is an interesting counterpoint to the Task Force. http://m.theglobeandmail.com/life/health/new-health/conditions/cancer/breast-cancer/why-i-reject-most-of-the-new-breast-cancer-screening-recommendations/article2252072/?service=mobile

Quote: "One sixth of breast cancer deaths and 40 per cent of years of life lost come from cancer that arises from women in their 40s. All the fuss that's been in the news is not because earlier detection of breast cancer with screening doesn't save lives. It does. Even the Task Force, despite not recommending screening for women in their 40s, agrees it reduces deaths by 15 per cent. And that's with antiquated 1980s mammography; with modern technology it's more like 24 per cent." 

I am in the over 50 age group.  Waiting 3 years for a mammogram (also suggested) would have been a problem for me.  My tumour found in the mammogram after  2 years was .3 mm from my chest wall.   I'm sure it would have been in my chest wall by 3 years.

Annual Mammography is Essential for Women in their 40's --- an article posted on Medscape.com in Ob/Gyn & Women's Health section. I'm posting the article in its entirety because the link was hard to post.

November 30, 2011 (Chicago, Illinois) - Women in their 40s with no family history of breast cancer are just as likely to develop invasive breast cancer as women with a family history, according to research presented here at the Radiological Society of North America 97th Scientific Assembly and Annual Meeting.

The finding offers conclusive evidence that women 40 to 49 years of age should be screened yearly with mammography, Stamatia V. Destounis, MD, from Elizabeth Wende Breast Care, Rochester, New York, told reporters at a press briefing.

This flies in the face of the 2009 recommendation by the US Preventive Services Task Force that came out against screening for women in their 40s.

In fact, just last week, a Canadian task force issued new guidelines recommending against screening women in this age group, and extending the interval between mammography screening in women 50 to 74 years to as much as 3 years.

"All these task forces are coming out saying don't screen, don't do breast self-exam, don't do clinical breast exam. It's just ridiculous," Dr. Destounis told Medscape Medical News.

She and her team performed a retrospective review of all patients who underwent screening mammography at their center from 2000 to 2010. During that period, 6154 cancers were found in 5813 women.

Of these cancers, 1116 (18.1%) were found in women 40 to 49 years of age, and 373 were diagnosed as a result of mammography screening. The remainder were diagnosed because the women presented with symptoms such as pain, a lump, nipple discharge, and skin changes.

When the researchers focused on the women who had their cancers detected on screening mammography, they found that 144 (39%) had a family history of breast cancer and 228 (61%) did not; in the case of 1 woman, family history was unknown.

All but 1 of the patients went on to have surgery. In the women with no family history, the percentage of invasive breast cancer was 64%; in the women with a family history, the percentage was 63.2%.

The researchers also found that 31% of the women with a family history and 29% without a family history had positive lymph nodes.

"Our conclusion is that family history really doesn't seem to impact the rate of invasive disease or metastatic rate in this patient cohort," Dr. Destounis noted.

"Obviously, we know that the risk of getting breast cancer increases per decade. We get that. But 40- to 49-year-old women get breast cancer, too. They get diagnosed with screening mammography, and a considerable number of these are invasive cancers. The groups against screening say we do not have to screen them, but we do have to screen them. These women have a considerable percentage of cancers that are invasive and a considerable number of lymph nodes that are positive," she said.

Breast Cancer Risk in Younger Women Higher Than Previously Thought

Nina A. Mayr, MD, a radiation oncologist from Ohio State University, Columbus, told Medscape Medical News that the study confirms what many people have suspected.

"Many of us believe that the breast cancer risk of younger women in their 40s is much higher than we probably thought, and the recurrence rate is also higher," she said.

"I see these young women. They didn't have a mammogram and then they come in with a cancer that is very large. Many of these women still have children at home, so the socioeconomic cost of breast cancer is very high,...much higher than for in a woman in her 70s. I think these aspects are very important and they tend to be overlooked," Dr. Mayr said.

Critics who oppose screening mammography say that those who are in favor of it have a vested interest in doing mammograms, but Dr. Mayr denied that this is the case.

"If we were talking about a very expensive nuclear medicine test or an expensive surgical procedure that makes a lot of money, they might have a point. But mammograms do not make much money," she said.

In fact, academic centers and private practices find it extremely difficult to find people who want to do mammography, she noted.

"The cost of a mammogram is about $75. It is a procedure that incurs a lot of liability, so the financial yield is low and the liability is high.... If you want to derive a lot of financial benefit, you do not want to do mammography."

Dr. Destounis reports financial relationships with Siemens, Fujifilm Holdings Corporation, Hologic, Koning Corporation, Koninklijke Philips Electronics NV, and Matakina International Limited. Dr. Mayr has disclosed no relevant financial relationships.

Radiological Society of North America (RSNA) 97th Scientific Assembly and Annual Meeting: Abstract SST01-01. Presented November 29, 2011.