Thursday, 9 July 2009

No squeeze, please

Women are constantly urged to have mammo-grams in order to spot cancer early and be more likely to survive. Seldom do they hear from doctors who think mammo-grams actually do more harm than good.

Many women who find the procedure horribly painful and unpleasant endure it only for the supposed health benefits. But Dr Iona Heath, a London GP, refuses to have a mammogram herself.

She maintains that often the only result is "overdiagnosis" and unnecessary treatment, increased anxiety for the patient and their family, and in some cases treatment for a cancer that would have resolved itself of its own accord.

Yet health authorities continue to promote mammograms and lead women to fear that if they don't have them they are tempting fate, being irresponsible and possibly heading for a premature death.

But according to one study*, the percentage of women surviving cancer for ten years is exactly the same whether or not they are screened. And screening can lead to unnecessary tumorectomies and mastectomies that cause serious psychological distress.

What really annoys Dr Heath is the lack of balanced information about the pros and cons of mammograms and the one-sided publicity that tries to hoodwink patients by suggesting they are 100% positive.

Well, good for her, cutting through the official consensus and pointing out that there's a different viewpoint that women are not being allowed to hear.

It's too often assumed that a certain medical procedure is the only correct one, when there are equally valid alternatives. When that procedure can lead to pain, distress and mutilation, it's particularly shocking that the alternatives are neither explained nor offered.

* Cochrane Review of Breast Cancer Screening

NB: This is based on an article by Dr Heath in the Independent on July 7, which is no longer publicly viewable. But there's more information here (thanks, Dave) and here.
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Ethnic organisations in Belfast have had letters from Combat 18, a fascist group, demanding they leave Northern Ireland by July 12 or have their buildings blown up. The Belfast Islamic Centre, the Polish Association and the Indian Community Centre have been told "non-whites" are not welcome in Northern Ireland. The police have pledged to increase security around their premises.

28 comments:

Jenny Muir said...

I am delighted to have an excuse not to go. If men had to go through a procedure that involved having their balls squeezed tightly into a vice, huge amounts of money would be spent finding an alternative.

Nick said...

Jenny - Well said! I don't think testiculograms will be coming in any time soon....

Baino said...

Hmm haven't had one for ages and they're free here to women over 50 but frankly . .I'd rather not no so until they have MRI for boobs, I'll take my chances. Don't worry Jen, they get theirs when the Prostate indicators start warning them! At least we're used to being prodded in unusual places from being teenagers. Comes as a bit of a shock to the fellas!

meno said...

Jenny, those are called man-o-grams.

Leah said...

I'm glad you posted this, actually. Although I am a nervous nellie and have had a yearly mammo since I turned 35, I am always game for another side of the official take on things. Especially salient is the point about scare tactics--we have become so self-blaming and scared that if we don't do everything just as "they" tell us we will die or, lol, worse!

Dave Hampton said...

Hi, Nick, 'great thoughts as always.

The performace of any detector is a tradeoff between sensitivity and specificity: detecting the condition when it's present and stayng silent when it's not. It sounds to me like the test is too biased towards sensitivity, trying not to miss any cases where cancer is present. The threshold criteria can be relaxed, giving a better cost/benefit balance, until a test with greater overall accuracy can be developed (we've done this with other monitoring tests in recent years).

The worst thing would be for people to miss the condition until it is too late (although I'm very sympathetic to the difficulty of ths test in partcular).

With the artcle gone, a related article just publshed in the BMJ: a popular link is through http://www.msnbc.msn.com/id/31831875/ns/health-cancer/

Brighid said...

Hooray for your post. I finally went in for a complete physical & mammy mashing this year. It had been well over fifteen years. Everything is fine, refused the bum scoping. Very thankful that I'm healthy (knock on wood) at 62. Will be another fifteen before they get a hold of me again.LOL

Nick said...

Baino - I'll get mine? Prostate indicators? Help! I'm not visiting my doctor ever again....

Meno - Manograms? Aren't they the ones you get on the Isle of Man?

Leah - I guess the scare tactics are quite effective, especially for mothers who don't want their kids to lose a parent.

Dave - Thanks for the professional input. I didn't think of things like over-sensitivity and threshold criteria. But would that make much difference if survival rates are the same for screened/ unscreened anyway? Thanks for the link. That's even scarier - one in three patients may be overtreated.

Brighid - Not too bad if you're only subjected to it every 15 years. But still the question, is it beneficial or not?

Dave Hampton said...

Hi, Nick,

'exactly correct: contemporary wisdom is that you have to balance the impact of a false negative (e.g.: cancer moving from treatable to untreatable) vs. the cost and risks of ruling out a false positive (e.g.: the cost and morbidity of a biopsy).

To your second point, survival stats alone are tricky things. A recent study showed no impact of having an implanted defibrillator on overall mortality, not because the defibrillator is ineffective, but because these are end-stage patients who then die from something else. This means that you have to look at other factors, quality of life, overall cost, etc. in picking the right treatment option.

In the end, I always come down to "What would I tell my grandmother to do?".

Overall, it's good that physicians, payers, and patients are taking an appropriately wider, and evidence-driven, view, rather than just eyeing the legal risk of a missed tumor, which drove preventative medical procedures in years past. And there are better tests with potentially higher overall accuracy in the pipeline, which would solve the whole problem.

Grannymar said...

I too have mixed feelings about all these tests, but for a very different reason.

Nowadays with modern medicine we are given the hope of removal of all pain and disease. We are inclined to forget that we must all die at some stage. The very thought of me going on for over 40 more years actually fills me with dread.

I don't wish to drag things out or be a burden to anyone, so a quick trip outside the igloo, will be in order thank you!

Suburbia said...

I had no idea. Thanks for that Nick. Why is the article no longer publicly viewable?

Nick said...

Dave - Thanks for that. I take your point that survival stats are tricky, as your example shows. The grandma question sounds a good rule of thumb! And it's good to know better tests are on the way.

Grannymar - I agree with you. The prospect of another 40 years, with more and more physical failings, is a terrifying one!

Suburbia - It comes from a journal which only allows its articles to be read on subscription. But see the other links I have added.

rummuser said...

Grannymar said what I wished to say and far more eloquently at that. All the problems of older people, that we have now, geriatrics, alzheimers,arthritis etc are all due to treating the symptoms to the point that at least I believe that we are doing things against what nature intended for us. We are getting caught in a vicious circle as it were.

I am not qualified in any way to comment about the mammogram, but your footnote on Combat 18 is a reminder of the times that we now live in. We have lunatics here doing similar things and it does not seem to stop at all.

Nick said...

Ramana - Indeed, the medics may be able to keep us all alive for another decade, but with what quality of life? Is it worth it?

This racist thuggery seems to be increasing, and the authorities are doing precious little to stop it.

Wisewebwoman said...

I know two many people of my age 60+ who are strung together with 60-70 pills a day, For everything, I only ever had one mammogram, when I was 50. I am appalled and have written about the Cancer Charity Corporatocracy who are obsessed with 'cures' and never talk about the underlying problems of our lifestyles and frankenfoods and plastics and pesticides, etc.
Like all posting here, I don't want to live, like one friend of mine today, missing a couple of limbs and being addled from all the drugs to 'cure' me. No thank you.
XO
WWW

Nick said...

www - I also know a few people who take an incredible cocktail of drugs every day and I wonder what is the point apart from stretching their life by a few years.

Good point about the lifestyle factors that cause cancers in the first place, many of which like the plastics and pesticides it's hard to avoid.

Brighid said...

It's quality of life for me. Lost a young (50's) Brother-in-law to cancer last year. There was no cure known, yet he suffered greatly with all the tests, treatments, drugs, surgeries. It made his last year miserable. No thanks, I don't ever want to put my family thru that.
I question that the drug companies, and treatment centers truly want cures. What happens to all that revenue they generate from the sick?

Nick said...

Brighid - Good question about the drug companies. I'm sure they're very keen to keep people alive and swallowing a mass of pills every day. And I agree about prolonged cancer treatment. After my father had had lung cancer for six months and was given a catheter, he decided enough was enough and simply let himself die.

Dave Hampton said...

I'll take the dissenting position, respectfully.

First, I know the pain of losing someone slowly and painfully due to cancer, and I understand the concern about prolonging life vs. relieving suffering. A historical philosophy of prolonging life by any means available, never giving up hope, pushes everyone into the difficult corners discussed here.
Now, families, physicians, and patients must manage treatment options together, more informed and effectively, balancing risks and benefits, deciding what course to follow in ther circumstances, and deciding when to say 'enough'. The law needs to protect patients from abuse without preventing them making decisions about their care (I have a Living Will, for example, which I insist that my caregivers and family respect).

Second, (and admitting to bias since I work in the medical device industry) I know that R&D people are passionate about helping patients.
Bringing treatments to market takes years of lab research, clinical trials, and regulatory review: over 95% of all development efforts never result in product. The commercial research system, both in motivation and process, genuinely does its best to market good product and to respond quickly when problems arise in practice.

Third, there is no question that the marketing and pricing of drug and device therapies is terrible and needs to be reformed.
Direct to Consumer ads are misleading, drug pricing in the US is out of control, patents are being used to create artificial barriers to competition, and clinical guidelines are being manipulated to increase drug sales. Systemic reform to prevent these practices is needed. I think that these abuses, more than product ineffectiveness, drives concerns like those expressed here, and real legislative reform is needed.

Finally, there is still a competitive market for drugs and devices thata drives nnovation in the industry.
It's not just between large companies, but among the thousands of small companies and universities developing new ideas. Even if a manufacturer has no incentive to improve their own product, there are many others looking for ways to take away their share. Year by year, we see the mix of products in any disease segment change, and no incumbent can maintain a market dominance for long.

Nick said...

Dave - Please feel free to dissent! Of course I'm not saying all drugs are useless and unnecessary. Many people's lives are radically improved or even saved with the appropriate drugs. At the same time, the profit motive must lead to a lot of superfluous or unhelpful drugs being taken. And if drugs are keeping someone alive but with a poor quality of life, the benefit is rather questionable.

Dave Hampton said...

'no dsagreement wth the qualty of life argument: the law has to give physicians and familes more flexibilty to tailor care appropriately. At the moment, there s pressure towards standardized best practices that may not fit everyone.

I agree, as well, that drug companies have every motve to push their product, and their marketng and manipulatng can be appalling. But it's also indirect: patients cannot directly purchase the product. A doctor must perscribe; an insurer must pay. Those are the gatekeepers who are supposed to ensure approprate use, and they've been showing more spine to tell patients 'no' when a drug is inapproprate in recent years.

Nick said...

Dave - Unfortunately I don't see much evidence that doctors in the UK are trying to withold inappropriate drugs. As I recollect, surveys repeatedly say that GPs are over-prescribing, and often giving patients prescriptions just because it's the easiest response.

Brighid said...

With my primary care doctor(linked to a large teaching university) many miles away, I asked to have the mamos & bone density done in my local area. In the process I learned that one hospital would do them for $125/no ins. or $775/ins. They would not let me pay the $125 cash, they said it couldn't be done as I had ins. After shopping around I did end up getting it done somewhat cheaper, but still. No wonder we are in such a medical/insurance mess.
As for prescriptions, & cures. It's not happening. Himself has been an insulin dependent diabetic for 54 years! We are constantly told that a Cure is just around the corner. It's a very long and costly curve. Having contributed to various research projects, to find them spending more on promoting themselves & their wine & dines. I am disheartened.

Nick said...

Brighid - I didn't realise fees got so jacked up if you have insurance. What a mess indeed. True, a cure for diabetes is always "on the way", but in reality nothing much has changed except easier insulin injections and new drugs.

Liz said...

A friend of mine was diagnosed with breast cancer and was sent for a mammogram (don't know why? stable and horse?). It came back as clear!

Having said that, as breast cancer is such a killer of women (and men), I shall continue to put up with the pain!

Nick said...

Liz - So which was right, the original diagnosis or the mammogram? As for enduring the pain, I can only reiterate what the critics say in my post!

Shantybang said...

Hi Nick,

Firstly, thanks for your comment on my blog (re: goals and swimming).

Secondly, I am the person who used to have a blog last year called originally "Goodbye to All Fat" (and then later on it became "Sharon's Lighter Life").

I went through a difficult time at the end of 2008 and ended up deleting my blog due to much emotional trauma at the time.

Have come back to blogging to refocus my efforts.

Anyway ....


Fourthly -- I had to have a mammogram this year (I am 41) as I had actually found a lump. It was very uncomfortable, but the end result of several hours being prodded and scanned (mammogram and ultrasound) was that my lump was benign.

I don't know what the alternative is .....? How else could they have made the diagnosis ....?

Regards,
Sharon

Nick said...

Hi Sharon/Shantybang! There seem to be several alternatives to mammograms, though whether they're available in the UK I don't know - how about the Anti-malignant Antibody Serum (AMAS) Test, thermography, an MRI scan or a tissue sample?