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The Canadian National Breast Screening Study ignites a new round in the mammography wars

The last couple of weeks, I’ve made allusions to the “Bat Signal” (or, as I called it, the “Cancer Signal,” although that’s a horrible name and I need to think of a better one). Basically, when the Bat Cancer Signal goes up (hey, I like that one better, but do bats get cancer?), it means that a study or story has hit the press that demands my attention. It happened again just last week, when stories started hitting the press hot and heavy about a new study of mammography, stories with titles like Vast Study Casts Doubts on Value of Mammograms and Do Mammograms Save Lives? ‘Hardly,’ a New Study Finds, but I had a dilemma. The reason is that the stories about this new study hit the press largely last Tuesday and Wednesday, the study having apparently been released “in the wild” Monday night. People were e-mailing me and Tweeting at me the study and asking if I was going to blog it. Even Harriet Hall wanted to know if I was going to cover it. (And you know we all have a damned hard time denying such a request when Harriet makes it.) Even worse, the PR person at my cancer center was sending out frantic e-mails to breast cancer clinicians because the press had been calling her and wanted expert comment. Yikes!

What to do? What to do? My turn to blog here wasn’t for five more days, and, although I have in the past occasionally jumped my turn and posted on a day not my own, I hate to draw attention from one of our other fine bloggers unless it’s something really critical. Yet, in the blogosphere, stories like this have a short half-life. I could have written something up and posted it on my not-so-secret other blog (NSSOB, for you newbies), but I like to save studies like this to appear either first here or, at worst, concurrently with a crosspost at my NSSOB. (Guess what’s happening today?) So that’s what I ended up doing, and in a way I’m glad I did. The reason is that it gave me time to cogitate and wait for reactions. True, it’s at the risk of the study fading from the public consciousness, as it had already begun to do by Friday, but such is life.

Mammograms don’t save lives, quoth the BMJ (and everyone covering the study)!

After my obligatory navel-gazing explanatory introduction that infuriates some and entertains others, let’s jump into the study itself. It was published in the BMJ and is, as the title tells us, the Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. Before we delve into the findings, I should take a moment to explain what the Canadian National Breast Screening Study (CNBSS) actually is. The first thing you need to know is that this study has been contentious since its very beginning. In particular, radiologists have been very critical of the study. One radiologist in particular, whom we’ve encountered before, pops up time and time again in articles critical of the CNBSS. This doesn’t mean that his criticisms of the study are invalid, but this particular radiologist sends up a red flag given his track record of some truly badly thought-out criticisms he’s leveled at other mammography studies, most notably about a year ago.

The CNBSS, conceived in the late 1970s and begun in 1980, was a randomized clinical trial that was designed to answer two questions, depending upon the age group: (1) to compare regular breast examination to breast examination plus screening mammography (age 50-59) and (2) compare screening mammography plus “usual care” (age 40-49). These were questions that had arisen from the only existing large study published at the time, the New York Health Insurance Plan (HIP) Study, which in 1963 had randomized (without informed consent) women between the ages of 40 and 64 such that around 30,000 received annual two-view mammography and clinical breast examination for three screens, with another 30,000 serving as controls who received “usual care” (i.e., clinical breast examination). The results, first published in 1977, indicated a statistically significant reduction in breast cancer mortality of 23%. However, no benefit was seen in the 40-49 year old age group. Also, over an eight-year period after diagnosis, breast cancer cases that were positive only on mammography when screened had a case fatality rate of 14%, compared to 32% for cases positive only in the clinical examination and 41% for cases positive on both modalities. The thought at the time was that the reason no difference was seen in younger women was because the incidence of breast cancer is so much lower in women aged 40-49 than it is in women aged 50-64. As I’ve discussed many times before, the less common a disease is in a population being screened, the more false positives there will be and the harder it will be to detect a decline in mortality from that disease due screening because the smaller (on an absolute basis) any observed decline will be. That’s almost certainly why the early mammography studies that led to the implementation of widespread mammographic screening programs for the most part were unable to demonstrate a benefit in terms of preventing death from breast cancer in women under 50.

In any case, the HIP Study had raised the question of what the incremental benefit of screening mammography was over “usual care,” which included, in most cases, regular visits to one’s primary care doctor and breast self-examination. This was described in the introduction to the study reported last week, thusly:

In 1980 a randomised controlled trial of screening mammography and physical examination of breasts in 89,835 women, aged 40 to 59, was initiated in Canada, the Canadian National Breast Screening Study.4 5 6 7 It was designed to tackle research questions that arose from a review of mammography screening in Canada8 and the report by the working group to review the US Breast Cancer Detection and Demonstration projects.9 At that time the only breast screening trial that had reported results was that conducted within the Health Insurance Plan of Greater New York.10 11 Benefit from combined mammography and breast physical examination screening was found in women aged 50-64, but not in women aged 40-49. Therefore the Canadian National Breast Screening Study was designed to evaluate the benefit of screening women aged 40-49 compared with usual care and the risk benefit of adding mammography to breast physical examination in women aged 50-59. It was not deemed ethical to include a no screening arm for women aged 50-59.

So basically, there were two parts to this study: Mammographic screening plus regular clinical breast examination versus usual care in women aged 40-49 and mammographic screening plus regular clinical breast examination plus regular clinical breast examination alone in women aged 50-59. Here’s the study schema:

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Women with any abnormal findings, be it on physical examination or mammography, were referred to a special review clinic directed by the surgeon affiliated with the study center, where, if indicated, diagnostic mammography was performed. (This study was carried out at 15 screening centres in six Canadian provinces, located in teaching hospitals or in cancer centers). I deem it important right here to emphasize yet again that all of these mammography studies were carried out in asymptomatic women (i.e., women who didn’t have any symptoms or lumps in their breasts). The reason I consider it important is that screening and diagnostic mammography are frequently confused in the minds of the lay public, and there is no controversy about what a woman who detects a lump in her breast or whose doctor detects one should do: Get it checked out with diagnostic mammography and (often) ultrasound, sometimes complemented with MRI. That’s the difference between diagnostic and screening mammography. Diagnostic mammography is done with the intention of working up an abnormality found on physical examination or screening mammography to determine if it needs to be biopsied. Pontification thus ended, I now point out that women who needed biopsies got them done by a surgeon to whom their primary care doctor referred them, and women who were thus diagnosed with cancer underwent treatment by surgeons and oncologists chosen by their primary care doctor.

Study subjects who enrolled had a physical examination (clinical breast exam) and were taught breast self-examination by trained nurses. Then they were randomized according to the schema above as described in the protocol:

Irrespective of the findings on physical examination, women aged 40-49 were independently and blindly assigned randomly to receive mammography or no mammography. Those allocated to mammography were offered another four rounds of annual mammography and physical examination, those allocated to no mammography were told to remain under the care of their family doctor, thus receiving usual care in the community, although they were asked to complete four annual follow-up questionnaires. Women aged 50-59 were randomised to receive mammography or no mammography, and subsequently to receive four rounds of annual mammography and physical examination or annual physical breast examinations without mammography at their screening centre.

In reporting the results, the investigators refer to the mammography plus breast physical examination arm in both age groups as the mammography arm, and the no mammography arms (usual care for women aged 40-49 and annual breast physical examinations for women aged 50-59) as the control arm. Also, the study is often referred to in two ways. The arm for women aged 40-49 is often referred to as CNBSS-1, and the arm for women aged 50-59 is often referred to as CNBSS-2. Just to make that clear.

So let’s get to the results. But before I do, let’s look at the last times the results were reported for this study, the 13 year follow-up in 2000 for CNBSS-2 and the 11-16 year follow-up in 2002 for CNBSS-1. The first report on CNBSS-2 showed no difference in breast cancer-specific mortality between the two groups in women aged 50-59; actually, the numbers showed slightly more deaths in the screening group, but that difference was nowhere near statistically significantly different. Although there was an unwritten assumption that there was likely to be a benefit to the addition of mammographic screening that just hadn’t shown up yet because the follow-up time was too short, the authors were forced to conclude that “our estimates of effect exclude a 30% reduction in breast cancer mortality from mammography screening” and that “chance is an unlikely explanation for our findings.” In the second study reporting the results for CNBSS-2, the investigators concluded:

After 11 to 16 years of follow-up, four or five annual screenings with mammography, breast physical examination, and breast self-examination had not reduced breast cancer mortality compared with usual community care after a single breast physical examination and instruction on breast self-examination. The study data show that true effects of 20% or greater are unlikely.

In other words, as of 2002, no benefit to adding mammography to routine care in women under 50 or to regular clinical breast examination in women 50-59 had yet been observed. The current study, unfortunately, completes the trend. Here’s the graph of all-cause mortality (all deaths of study participants):

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And here’s the graph for breast cancer-specific mortality (women who died of breast cancer)

F3.medium.gif

As you can see, the curves line up almost exactly. There is no statistically significant difference. There’s not even a whiff of a hint of a statistically significant difference.

Now that the data are more mature, the investigators could do what they couldn’t do before, namely to make an estimate of how much overdiagnosis was occurring in the study. (Overdiagnosis is the detection of disease that doesn’t need to be treated, disease that would never progress within the lifetime of the patient to endanger her life.) The authors noted that at the end of the screening period, there was an excess of 142 breast cancer cases in the mammography arm compared to the control arm (666 versus 524). By fifteen years after enrollment, the excess became constant at 106 cancers, which was 22% of all screen-detected breast cancers. Because the mortality rates were the same between the mammography versus control groups, these cancers represent overdiagnosis.

One notes that this number is remarkably similar to the estimates of overdiagnosis found in other clinical trials and epidemiological studies of mammography that I’ve discussed over the years. For example, way back in 2008, I discussed a study that suggested that 22% of breast cancers detected by screening mammography spontaneously regress.

Whoa. Maybe I shouldn’t have been so skeptical of that result when I wrote it up. And I’m not alone in noting how strikingly similar this number is to the rate of overdiagnosis in other studies. In an accompanying editorial, Kalager et al note the same thing, pointing out that “the amount of overdiagnosis observed in the previous randomised controlled trials is strikingly similar (22-24%).” Of course, there are others, many other studies, and in fact the 22% estimate is rather at the low end of some of the more recent studies. For example, the most recent “blockbuster” mammography study estimated the rate of overdiagnosis to be between 22% and 36%, depending upon the parameters used in the investigators’ model. One study that I discussed even suggested that one in three mammography-detected cancers were in fact overdiagnosed and overtreated, and I said:

Don’t get me wrong. There is no doubt that mammographic screening programs produce a rate of overdiagnosis. The question is: What is the rate? Unfortunately, the most accurate way to measure the true rate of overdiagnosis would be a prospective randomized trial, in which one group of women is screened and another is not, that follows both groups for many years, preferably their entire life. Such a study is highly unlikely ever to be done for obvious reasons, namely cost and the fact that there is sufficient evidence to show that mammographic screening reduces breast cancer-specific mortality for women between the ages of 50 and 70 at least, the latter of which would make such a study unethical. Consequently, we’re stuck with retrospective observational studies, such as the ones analyzed in this systematic review.

Well, the CNBSS is a randomized trial that follows women for their entire lives. Whatever its flaws (which will be discussed in the next section as I try to put it into context), it’s about as close to what I wanted four and a half years ago as we’re ever likely to get, which means that an overdiagnosis rate of somewhere around 20% or so is probably about as good an estimate of overdiagnosis of breast cancer by screening mammography as we’re ever likely to get. The problem, of course, boils down to two issues. First, we can’t tell which cancers diagnosed by screening mammography are overdiagnosed; i.e., which ones will never progress within the lifetimes of the women for whom they’re detected to endanger their lives. That leaves us a mandate to treat them all. Second, there is the question of whether this level of overdiagnosis is “worth it” for the level of benefit in reducing breast cancer mortality provided by screening mammography. The first problem, of course, can be solved by better predictive tests to separate the nasty players from the overdiagnosed players, but the second question is not so easy to answer.

Another important point is that this is the only large randomized study reported in the era of effective multimodality therapy with surgery, adjuvant chemotherapy regimens (chemotherapy administered after initial treatment to reduce the risk of recurrence), adjuvant Tamoxifen (Tamoxifen blocks the action of estrogen and can be used to decrease the risk of recurrence of tumors that respond to estrogen), and radiation therapy. This brings up the question of whether the reduction in mortality from breast cancer that we have observed since 1990—contrary to what you frequently hear, mortality from breast cancer is indeed falling and has been falling since around 1990—is primarily due to better treatment rather than earlier detection. There have been studies published over the last five years that suggest that this might be the case. But is it?

The knives come out, allowing me to (try to) put it all into context

Predictably, as always happens after a study like this, the knives came out, mostly wielded by radiologists. As is often commonly the case, the criticisms were a mixture of the reasonable, the ridiculous, and the obviously turf-protecting. What’s depressing about many of the criticisms of the study is that too many of the people making them seem unaware (or seem to deny) some very basic concepts about screening, namely overdiagnosis, overtreatment, lead time bias, and length bias. I’ve discussed them all before on multiple occasions, pointing out that the early detection of cancer does not always result in improved survival, and more sensitive tests can often lead to upstaging and more aggressive therapy without benefit. I’ve discussed overdiagnosis already. Lead time bias is a situation where early detection of the cancer doesn’t result in improved survival but only appears to do so because the disease is detected earlier and the patient lives longer with it. The best explanation of overdiagnosis (besides mine, of course) I’ve ever found can be read here. Length bias simply describes the tendency of screening to detect more slowly growing, indolent tumors. These problems have led to a major rethinking of prostate cancer screening and is beginning to do the same for breast cancer screening.

Indeed, the 15-25% reduction in breast cancer mortality cited by mammography proponents translates to an absolute risk picture in which averting one death from breast cancer with mammographic screening for women between the ages of 50-70 requires screening 838 women need to be screened over 6 years for a total of 5,866 screening visits, to detect 18 invasive cancers and 6 instances of ductal carcinoma in situ (DCIS). As reported in the New York Times treatment of this study, approximately 1 in 424 women in the CNBSS received unnecessary cancer treatment. In other words, mammographic screening is very labor- and resource-intensive, and a lot of women have to be screened to save one life. As I’ve also said many times in the past, whether this is “worth it” is more a value judgment than a scientific judgment, although that value judgment has to be informed by accurate science.

Of course, the CNBSS is not without shortcomings. Indeed, it’s been attacked nearly from its earliest reports, mostly by radiologists. Indeed, it’s instructive to peruse the criticisms posted after the article (one advantage of BMJ journal articles). They range from the reasonable to real howlers. An example of the latter comes, not surprisingly, from Daniel B. Kopans, a professor of radiology at the Harvard Medical School and someone who’s well known for attacking any study that questions mammography, particularly after the USPSTF guidelines were published in 2009, and who almost a year-and-a-half ago gave us this howler:

This is simply malicious nonsense,” said Dr. Daniel Kopans, a senior breast imager at Massachusetts General Hospital in Boston. “It is time to stop blaming mammography screening for over-diagnosis and over-treatment in an effort to deny women access to screening.”

He was referring to H. Gilbert Welch’s study published in late 2012 in the New England Journal of Medicine that found a high degree of overdiagnosis due to mammography. As I pointed out at the time, Dr. Kopans was completely wrong, and overdiagnosis is a pitfall of screening programs. He’s also known for saying things like this about the members of the USPSTF task force that published a set of recommendations in 2009:

I hate to say it, it’s an ego thing. These people are willing to let women die based on the fact that they don’t think there’s a benefit.

It’s therefore not surprising that after the BMJ article, Dr. Kopans makes the same sorts of statements, statements echoed in a statement on the American College of Radiology’s website and in an article entitled We do not want to go back to the Dark Ages of breast screening, by Dr. László Tabár and Tony Hsiu-Hsi Chen, DDS, PhD published on AuntieMinnie.com, described as providing “the first comprehensive community Internet site for radiologists and related professionals in the medical imaging industry”. Many of the criticisms are shared, although Dr. Tabár does appear to me a bit disingenuous when he says that “Canadian trials could not evaluate the independent impact of mammography because of the confounding effect of physical examination.” I suppose that’s why they compared physical examination to physical examination plus mammography in the 50-59 year old group.

Dr. Kopans’ 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, who 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.

Perhaps the most serious charge made by Dr. Kopans is that there was misallocation of nastier cancers to the control arm. In other words, he charges:

In order to be valid, randomized, controlled trials (RCT) require that assignment of the women to the screening group or the unscreened control group is totally random. A fundamental rule for an RCT is that nothing can be known about the participants until they have been randomly assigned so that there is no risk of compromising the random allocation. Furthermore, a system needs to be employed so that the assignment is truly random and cannot be compromised. The CNBSS violated these fundamental rules (6). Every woman first had a clinical breast examination by a trained nurse (or doctor) so that they knew the women who had breast lumps, many of which were cancers, and they knew the women who had large lymph nodes in their axillae indicating advanced cancer. Before assigning the women to be in the group offered screening or the control women they knew who had large incurable cancers. This was a major violation, but it went beyond that. Instead of a random system of assigning the women they used open lists. The study coordinators who were supposed to randomly assign the volunteers, probably with good, but misguided, intentions, could simply skip a line to be certain that the women with lumps and even advanced cancers got assigned to the screening arm to be sure they would get a mammogram. It is indisputable that this happened since there was a statistically significant excess of women with advanced breast cancers who were assigned to the screening arm compared to those assigned to the control arm (7). This guaranteed that there would be more early deaths among the screened women than the control women and this is what occurred in the NBSS. Shifting women from the control arm to the screening arm would increase the cancers in the screening arm and reduce the cancers in the control arm which would also account for what they claim is “overdiagnosis”.

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).

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 authors also address 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. Finally, there were reasons for why the allocation was done the way it was, and the explanation was not unreasonable:

Randomization was performed by the center coordinators after nurse examiners had clinically examined the participants. Center coordinators were blind to the results of the breast examination.

What in fact was the situation vis-a-vis randomization?

Most tellingly there was no incentive for screening personnel to subvert randomization. The CNBSS protocol required that anyone with an abnormal finding on [clinical breast examination] had to be referred to the study surgeon who would order a diagnostic mammogram when clinically indicated. Symptomatic women require diagnostic mammography, not screening mammography. It was not necessary to “place” as claimed [24] clinically positive participants in the mammography arm of the study in order for them to get a mammogram.

In the CNBSS there were more than 50 variables (demographic and risk factors) which were virtually identically distributed across control and study groups, clear evidence of successful randomization [25,26].

That certainly decreases—although it does not completely eliminate—my concern about the original design. There have also been other studies before that looked for evidence of subversion of randomization in the CNBSS and have failed to find evidence of nonrandom allocation of patients sufficient to affect the results of the trial. As was pointed out by a commenter after the BMJ article named Rolf Hefti, Dr. Kopans never mentions these studies that disagree with his conclusion, fails to note counterarguments that have been made to his accusations, and disingenuously complains about the low rate of detection by mammograms alone (32%), even though that number is consistent with rates reported in the 1990s, years after the screening period in the CBNSS ended.

And so the battle rages on, same as it ever was. What simultaneously amuses and depresses 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 probably horribly disappointed when they reported the first analysis and found no benefit to screening mammography and even more disappointed when the second analysis in the early 2000s found the same thing. No one does the enormous amount of work and spends 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.

The bottom line

I’m going to give you my bottom line, although it’s going to sound wishy-washy. Does the CNBSS “prove” that screening mammography is useless? Of course not, not any more than any single study ever could, given such a complex issue as screening for breast cancer. The CNBSS is a flawed study that could possibly be a false negative, such that any true benefit in terms of prevention of breast cancer mortality by mammography is buried in statistical noise. However, it is not nearly as flawed a study as its critics, such as Dr. Kopans and Dr. Tabár, would have you believe, nor is it a fraudulent study, as Dr. Kopans would apparently have you believe. It is the result of a group of investigators doing the best they could with the materials they had based on the knowledge they had in the late 1970s and must be weighed against all the other studies examining mammography finding benefit or no benefit. Moreover, it is not new information. It’s just a longer term follow-up of results first reported in the early 1990s and last reported more than ten years ago.

That being said, I still think it’s entirely appropriate for the study authors to conclude that “the data suggest that the value of mammography screening should be reassessed.” This isn’t a new conclusion either. It’s part of an evolution that’s been going on since before the USPSTF released its guidelines back in 2009. You’ll remember that back then I characterized those recommendations, which included not beginning routine mammographic screening until age 50, as “not the final word.” Clearly the CNBSS won’t be the last word, either, but it should be included as part of the evidence base for the reevaluation of mammography screening guidelines.

What doesn’t help is denial that overdiagnosis is a real phenomenon and rejection of the now-irrefutable contention that detecting a cancer earlier does not necessarily result in improved survival. There are some who are arguing that because patients with tumors detected by mammography-only in this study had better five year survivals than patients with tumors detected clinically, it means the mammography is worthwhile. That’s a horrible argument, because in reality the increased survival as observed in this study is, if anything, evidence in favor of overdiagnosis, an observation that was made, shockingly, in an article published in The Atlantic, given how much nonsense about medicine has been published in that magazine before. As I pointed out before, decreases in mortality, not necessarily improvements in survival, are the gold standard that shows a screening test (as opposed to a treatment) really does work.

Radiologists also argue that imaging technology is so much better today than it was in the 1980s. Even mammography itself is much better. This is undoubtedly true, but better, more sensitive imaging, while it could potentially make modern mammography screening programs more effective in preventing breast cancer, could also greatly exacerbate the problem of overdiagnosis. Overdiagnosis is real, and there are diminishing returns in the detection of cancer. If treatment of screen-detected cancers, adjusted for lead time bias, doesn’t clearly result in improved survival, then there’s a problem.

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.

ADDENDUM: Dr. Miller’s response to the criticisms leveled at the CNBSS have been published, and he very convincingly put Dr. Kopans and others in their place.

Posted in: Cancer, Clinical Trials, Diagnostic tests & procedures, Public Health

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234 thoughts on “The Canadian National Breast Screening Study ignites a new round in the mammography wars

  1. Sawyer says:

    I wonder how many medical professionals really understand the concept of lead time bias. My mother keeps complaining to me that both her doctor and nurses refuse to accept any evidence that mammogram frequency could be reduced. Granted she’s over 60, but she always makes sure to ask what the evidence shows for younger women. Like Dr. Kopans, I think her doctor even made some vague references to fraud by researchers, as if they’re all out to destroy screening tests. This only perpetuates the stereotypes that doctors are corrupt and pushing useless procedure on people to make money, giving more ammunition to the cranks.

    If prevention is the key to fighting cancer, maybe that prevention needs to include better statistics and methodology classes in college (or even high school).

    1. David Gorski says:

      I know. As I looked into this issue, the most ridiculous charge I found leveled against the CNBSS was that somehow the investigators allowed the misallocation of patients such that more patients with advanced cancer found their way into the group receiving mammography. If they did it unintentionally that would imply a degree of incompetence I find hard to fathom, but if, as Dr. Kopans seems to have been insinuating over the last 20 years, they did it intentionally, it’s a charge that’s mind-numbing in its nonsensical nature just based on human nature. Scientists and physicians don’t start up huge clinical trials like the CNBSS in order to find a negative result. Such trials are an enormous amount of work and cost large amounts of money, such that the danger investigators have to beware of when designing and executing such trials is the danger of subconsciously introducing a positive bias that will result in a false positive trial. Seriously. If they were going to do something to “rig” the trial, they would almost certainly have done something to produce exactly the opposite misallocation that the trial is criticized for. They would have ended up with a schema that put women with cancer or more likelihood of cancer into the control groups in order to make mammography look better, not to put such women in the mammography groups in order to make mammography look worse.

      I’m guessing that the CNBSS investigators were probably very disappointed that their study ended up being a negative study. Certainly 12 years ago, they seemed to be fishing for ways to salvage a positive result by implying that longer followup might reveal a benefit and putting upper limits on that putative benefit of 20% to 30% based on their results published in the early 2000s.

      1. goodnightirene says:

        One of the highest “recommended” comments to the NYTimes reporting of this study was the accusation of “all these studies are done in countries with single payer health care and they just want to save money even if women die”.

        The conspiracy mentality seems widespread indeed.

        1. Sawyer says:

          This is one of those topics that not only invites conspiracy theories, but mutually exclusive conspiracy theories. Somehow all those evil pharma companies and government scientists constantly pushing useless chemotherapy on patients have to do a 180 and cut back on screening tests that would ultimately net them more money.

        2. Probably written by radiologists-in-drag! (Ooops, now I’m a conspiracy theorist!)

    2. My wife is a primary care physician. Her comment is salient. She describes a “magical thinking” (in which she, herself participates). “mammogram OK – don’t worry for a year.” Changing that thinking to “I have to examine my breasts every month and worry about cancer at least once every month” is a titanic task for most women. We have ritualized reassurance by making one liner recommendations, “The ACR recommends women over 40 have a mammogram once a year.” The authority and simplicity of the statment assuages the patient with a false sense of hope. discussing risks and benefits of mammography with patients is a HUGE undertaking for a PCP. I have been doing this for 3 months and it is NOT going over well. but I will persevere!

  2. Ken Hamer says:

    Is it possible that Dr Kopans isn’t really as nasty/crazy as he seems, but rather is rationalizing away his guilt of contributing to the over-diagnosis?

    ‘Course my money is that he fears losing income, prestige, influence, etc if his imaging technology proves to be the double edged sword it looks like.

  3. Sawyer says:

    If anyone wants their blood pressure to shoot up I’d recommend reading the transcript from last week’s PBS Newshour on the topic:

    http://www.pbs.org/newshour/bb/debating-value-effectiveness-mammograms/

    Apparently CNBSS is “an outlier”. Yep. Thanks Sloan Kettering.

    1. David Gorski says:

      Well, in all fairness, it rather is an “outlier.” It’s just a real doozy of an outlier, big enough to pull the totality of evidence away from mammography somewhat, if you know what I mean. How much it does that is arguable, as is whether it’s enough to lead us to conclude that screening mammography doesn’t actually decrease breast cancer mortality, but it is enough to make me think that the benefits from screening mammography are not as great as I once accepted.

      To be honest, Dr. Lee got her clock cleaned by Dr. Welch, which is not surprising, as she was using the same old arguments used to attack those who question the utility of screening mammography, like this:

      Now, some people will argue that that is because of improvements in treatment. But we know, all of us who take care of women with breast cancer know that it is much more likely that treatment will be successful in achieving a cure when the cancers are caught early in their most treatable stage, than as opposed to when they are advanced and have spread, and mammography can achieve that.

      It never ceases to amaze me when prominent radiologists don’t seem to understand or acknowledge the concept of lead time bias and length bias.

      1. rork says:

        I think it’s possible to make a statement like that while simultaneously being aware of the biases. In a study that finds mortality differences, what other causes for that difference are there than earlier detection?
        I’m not saying Lee is actually aware (maybe that’s the real point), and agree that if you make statements like that, I’d want to know if you are aware of the biases, and if there was actually a mortality difference – otherwise mammography achieved nothing useful, for patient anyway, unless we use a false-peace of mind argument.

  4. windriven says:

    I would be interested to see a study of the differential value of mammography versus other screening, i.e. genetic screening for BRCA genes.

    In the industrial world mammography is akin to a quality sieve – a long discredited paradigm summed by the aphorism: you can’t inspect quality into a product. It is much more effective to understand the causes of failures and to address those causes directly rather than trying to find the resultant defects when they have already appeared in the product.

    We apparently do not completely understand all of the variables that predispose to breast cancer – but we do understand some. I wonder how good a job is done identifying those predispostive factors in the general population and in addressing them when found?

    1. goodnightirene says:

      My doctors (several over the years) have more than once considered my risk factors (very low) when making related health care decisions. For example, I am still using a very low dose estrogen patch for hot flashes ten years after hysterectomy, only because my risk factors are so low–and the hot flashes seemingly intractable in my case.

      In spite of very low risk, I am always informed that this does NOT mean that I will not get breast cancer. The bigger risk for me with estrogen use is stroke. It comes down to balance–and my telling the doc that I will get it “on the street” if he doesn’t let me have it.

      I think it was the process of trying every “alternative” I ever heard of for peri- and menopause that convinced me there was nothing to any of it. Sadly, a number of these “treatments” were recommended by a couple of (female) doctors.

    2. Sawyer says:

      I’m pretty sure BRCA positive women are supposed to be getting annual mammograms (if not semi-annually). I doubt there will be an RCT testing this though, since the relative risk is so high no BRCA positive women are going to want to join the control wing.

      1. Andrey Pavlov says:

        I believe windriven was asking about simply BRCA testing vs mammography with both as a screening test.

        I really don’t know but my gut is that BRCA as screening test would not be sensitive enough (though obviously specific) and the still relatively high cost of testing would render it significantly less useful than we’d otherwise hope.

        But I suppose in principle we could get enough GWAS data and specific SNPs and gene mutation data coupled with fast, cheap, and easy enough genetic testing to accurately risk stratify people. The problem is that you still need some sort of current exam to determine at that moment if there is cancer or not since all that genomic screen would do is assign a static risk category and thus never entirely supplant something like mammography.

        1. windriven says:

          “in principle we could get enough GWAS data and specific SNPs and gene mutation data coupled with fast, cheap, and easy enough genetic testing to accurately risk stratify people.”

          Yes, this is where I’m going. I understand that the technology really isn’t there on a cost-effective basis at the moment. But it seems that screening for predispositive factors as a ‘prefilter’ might make sense.

          1. Andrey Pavlov says:

            Indeed, and is an interesting point. I read Topol’s book The Creative Destruction of Medicine because it was recommended to me by a very smart neurointerventionalist I know. To me, the main point of the book was pretty “no duh” but apparently a lot of physicians don’t know much about things like SNPs and GWAS.

            One point I disagreed with Topo about is that this would be a completely new and revolutionary medicine. He draws a false comparison saying that current medicine is “population based” medicine and that SNPs and GWAS data will allow for “truly personalized” medicine which will be fundamentally different than the current paradigm of medical discovery and clinical trial we use now.

            I disagree. I see SNPs and GWAS as just refining our populations ever more finely to be able to better hedge our bets on risk stratification. It is exactly the same as doing screening mammograms on a 30 year old with every single one of her primary relatives having cancer vs not doing it on someone with no risk factors. We can just have different and much more accurate and objective metrics for assigning people into risk categories.

            1. rork says:

              Fully agree and a favorite point of mine. Some folks think there’s an invisible point where ever-more-highly-stratified magically becomes “truly personalized” (oh holy grail, I worship thee), or they forget where we already stratify. They’ve perhaps never written down a model in their entire lives, or considered how to estimate its parameters (or make expert system of some other kind), or validate it. That’s just more magic someone else does somehow that they don’t understand.

              1. Andrey Pavlov says:

                @rork:

                Indeed. What bothers me is that someone like Topol should know better. I personally found his book a very easy and very fast read. But I was really confused as to who he thought his audience would be. It is not technical enough to really interest someone like me. It is too technical in spots for the average non-medico. And he (very intentionally) uses terms like “priesthood” to refer to physicians and the delivery of medical care.

                He was basically making an argument for big data – which is all well and good – but I finished the book feeling underwhelmed and exasperated.

        2. MadisonMD says:

          GWAS has limitations for this problem:
          (1) Correlation does not mean causation.*
          (2) Many of the genetic contributions may be too small to identify.
          (3) It is difficult or impossible to identify complex genetic interactions**
          (4) Some assays may not actually identify the relevant polymorphisms (e.g. non-coding regions, or unknown SNPs in some cases).
          (5) In breast cancer, the estimate is that 30% are caused by inherited (germline) genetic factors. Other factors comprise to the remainder (estrogen/environment, stochastic). If accurate, it will be well nigh impossible to account for more than 30% by genetics.

          So while GWAS is a tool, and may contribute to risk stratification, we can expect it to push the needle from identifying a genetic reason for breast cancer from about ~10% of cases to at best 20%.

          ———————————
          *You might think identifying causative genetics doesn’t matter (if you can correlate a polymorphism with breast cancer risk, it should be good enough to use, right? Well the problem is that the results may lack external validity on other populations– e.g. using Iceland GWAS as reference to predict breast cancer risk in US)
          **A simple model of risk would require N parameters, one for each SNP. Considering all pairwise interactions would require N^2 parameters, thus requiring 4 times as many samples for a good model. For more complex (3, 4 SNP interactions), the number of samples required would increase exponentially.

          1. Andrey Pavlov says:

            Precisely. It is another tool to use, not a panacea that will tell us everything we ever needed to know.

            May be some day we will have complete enough knowledge and fast enough quantum computing to process insanely intricate models… but that won’t be anytime in my great-grandchildren’s lifetimes and it still won’t be a substitute for actually seeing someone.

          2. corky says:

            I completely agree with MadisonMD. GWAS studies do NOT identify causal variants, they identify variants that may be causal or may more likely be LINKED to causal variants. Also, we all carry variants that increase our risk or specific diseases and variants that decrease the same risk. Figuring out how all of these risks interact is way beyond our computational power, in part because the risk determined from a GWAS study is the risk on a background of varying risks thus for any one person, we don’t really know the risk. Note that even for women with a BRCA variant KNOWN to be associated with breast cancer, that risk is not absolute. Just one for instance, say there is a gene variant that increases the probability that a pre-neoplastic (benign) lesion will progress to cancer. If you never develop said lesion, that risk factor may not matter, but if we don’t know how it acts we can’t know that.
            I think that the real use of GWAS studies will be to help identify the genes involved in cancer development so that we can understand the biology of the disease better, which may help with treatments.

  5. R says:

    I have been following the discussions about screening and overdiagnosis with great interest the last few years (as a layperson). It seems that the most common consideration is the effect of screening on mortality rate. I’m wondering – even though early detection from screening probably does not improve mortality rate, could it possibly reduce the impacts of treatment, e.g., lumpectomy instead of mastectomy, radiation but no chemo versus radiation and chemo, etc.

    I’ve had lots of discussions with my mom since she was diagnosed with breast cancer (first identified by mammogram) about how most likely the mammogram did not save her life, but she always asks if treatment benefits of mammography should be part of the weighing of risks and pros and cons.

    1. MadisonMD says:

      could it possibly reduce the impacts of treatment, e.g., lumpectomy instead of mastectomy, radiation but no chemo versus radiation and chemo, etc.

      It could reduce the impacts of treatment by detecting earlier stage cancer. However, this is countered by the increased diagnosis of cancer that may not have required treatment at all (e.g. some DCIS). So is not obvious (to me) whether mammography would cause net increase or decrease treatment on a population.

  6. Harriet Hall says:

    I’m guessing the clinical breast exams in this study were meticulous ones. In actual practice in the community, I’m guessing there are a lot more cursory exams, especially since the clinician may think “she’s going to have a mammogram anyway, and that will pick up anything I might miss.”
    And what about the evidence that teaching patients to do self breast exams is not effective? Isn’t current advice to skip formal teaching and only tell patients to be aware of what their breasts are normally like and to report any change to their doctor? (That’s what I was telling patients back in the 80′s; I suppose I could have been sued for not following standard practice back then!)

    1. DJDenning says:

      I’m old enough to remember when monthly breast self-exams were heavily promoted as the best measure for making an earlier-stage diagnosis. (“Take your health into your hands…” etc.) When those studies came out (like that big Chinese study with thousands of factory workers) that found a lack of effectiveness for breast self-exams, the first reaction was from the advocacy community, saying that breast self-exams “empowered” women to “take charge” of their own health. I can recall getting into arguments at parties with people who took offense when I said, what’s so empowering about doing something that appears to be pretty much useless?

      And the flip side of this “empowerment” was the victim-blaming, when it was overtly implied that women who were diagnosed with later stage cancers were not diligent about doing their self exams.

      I’ve just turned fifty, so my mother is bugging me to get a mammogram. My mum was a participant in the CNBSS and is ardently pro-mammogram. I’m still making up my mind. Breast cancer is unheard of in my family, going back a hundred years or so. Thanks for your thorough update, Dr. Gorski!

      1. rork says:

        Hope this isn’t too persnickity, but it’s not self-exams that were found ineffective I believe, it was doc telling patients to do them that was ineffective as an intervention.
        I too wish it were simpler.

        1. Andrey Pavlov says:

          Indeed. (I seem to like that word).

          It wasn’t that breast exams are useless – it is that self administered breast exams by untrained non-professionals who have a significant vested interest in the outcome showed to produce too many false positives to be worthwhile.

          1. DJDenning says:

            I’m referring to the Shanghai study, where over a quarter million women were randomized to either a breast self-exam group, where they were instructed on how to do breast examinations, or a control group, and followed for 5 years. There were 135 breast cancer deaths in the BSE group and 131 in the “usual care” group. Furthermore, more benign breast lesions were identified in the BSE group. So yes; there was overdiagnosis and overtreatment in the BSE group.

            Back in the 80s, BSE was heavily promoted as life-saving. The “proper” way of doing it was lengthy and uncomfortable, and it was “useless” if you didn’t do it at the right time of the month. Women were made to feel guilty for not being diligent about it.

      2. mho says:

        I believe only about 10% of breast cancers are hereditary, so be wary of cultivating a false sense of security if you have no family history.

    2. I believe you have hit on a fundamental issue in breast cancer screening. the studies show that mammogram + bse was no better than bse + cbe. Getting women to actaully do it requires training, reminder systems, extra staff to do the exams (perhaps we should look at 3 to 4 times a year having a cbe – it would still be cheaper than a digital mammogram and much less expensive than the subsequent biopsies, ultrasounds and RT/chemo for patients with overdiagnosed lesions.

  7. Frederick says:

    Good read, Although as a Layman, i did not get all of it.
    I heard About that study, and others over the years, I was hoping you write a article on this as a oncologist/breast surgeon I was impatient to have you opinion on it.
    I any Case it was a good vulgarization of it Thank.

    I suppose that if the guidelines change, it will be to start mammogram screening at 50 years old.

  8. epmd says:

    Can someone explain how the Canadian Task Force on Preventive Health Care found a number-needed- to-screen (NNS) of about 720 for the age 50-69 year old group? How was this NNS determined, and why is it contradictory to the CNBSS? Thanks.

    1. epmd says:

      Anybody? I find it interesting how the 2011 canadian guideline states an NNS of ~720 to save 1 life from breast cancer death (age 50-59, screening mammogram q2-3 years x 11 years), while this new study found no benefit. Something doesn’t make sense here.

      Hopefully someone here has an explanation why.

      1. Sawyer says:

        That sounds like a difficult number-crunching challenge. In order for the two studies to agree, you’d have to show that the 1/720 figure is within the noise range of the newer CNBSS data. I don’t know if you can even do a direct comparison if the age groups differ or the treatment protocols changed over the course of the research (which is pretty much guaranteed with the length of the studies)

      2. MadisonMD says:

        I think the NNS 720 will likely incorporate data from other studies that did show a benefit of mammograms on mortality. One such study, HIP, was cited by Dr. Gorski in the post above.

  9. Sawyer says:

    How about “Pap Signal” instead of Bat Signal? Granted these stories are not about cervical cancers, but they are still screening tests.

    :)

  10. mousethatroared says:

    Ummm, sorry folks, but (to me) the obvious mammogram influenced reference to Bat Signal would be Boob Signal. And I can just see it shining up there in the sky.

    Secondly, I think I must have missed something in the article or it’s not covered. But why did they start recommending mammograms for women 40-50 in the first place?

    Apologies if I missed it, sometimes between ipad and scrolling, (and yes, I admit it, occasional skimming technical stuff that I think is over my head) I miss a line or paragraph.

    1. David Gorski says:

      I can’t use that one, for obvious reasons.

      1. mousethatroared says:

        Yup, as a medical doctor you are at a distinct disadvantage in regards to this joke.

  11. steney01 says:

    I disagree with using “overtreatment” as the justification for changing the screening guidelines. Overtreatment seems like another way of saying we just don’t have enough insight into the subclassification of a complex disease. As we’re learning more, we’re inevitably going to look back and realize, for example, that we shouldn’t have been performing a mastectomy for ductal carcinoma in situ. But that doesn’t mean we shouldn’t bother looking for the ductal carcinoma in situ in the first place. The problem is not that we looked, the problem is that we treated what we found in a way that we later learned was not appropriate. This overtreatment problem suggests that, as physicians and patients, we should be more comfortable with a wait and see approach when we don’t have enough information at hand. Unfortunately physicians and patients alike have all been hit over the head with how scary and deadly and horrible cancer is by the early detection people, so there’s little room for reasonable discourse. We need to re-evaluate what cancer is and is not and think a little more about how we should treat patients when we don’t know what we’re dealing with.
    We can’t just say that we overtreat what we find, so let’s look less often.

    1. David Gorski says:

      Overtreatment seems like another way of saying we just don’t have enough insight into the subclassification of a complex disease.

      Not exactly. Again, “overtreatment” is a description for treating something that doesn’t need treatment. Usually that something is found by a screening test carried out on asymptomatic patients and, absent the screening test, would never have become known in the patient’s lifetime because it would never have become symptomatic.

      And, actually, yes we can say that we overtreat overdiagnosed lesions, because we do. The trick is finding the “sweet spot,” where the harms from overdiagnosis the resulting overtreatment are minimized and the benefits of earlier detection maximized.

      1. steney01 says:

        “overtreatment is treating something that doesn’t need treatment.”

        Yes, but in this case either it wasn’t known at the time of diagnosis that this subtype of breast cancer did not need treatment, or the appropriate treatment protocol was known but the physician did something more aggressive than necessary. In either case, this isn’t a problem with the screening guidelines per se, it’s either a problem of information dissemination or the lack of research all together.

        1. David Gorski says:

          Overdiagnosis is absolutely a problem associated with screening. It is a problem that is inherent in the screening asymptomatic populations for subclinical disease, whatever that disease is. So, yes, overdiagnosis is a problem with the screening guidelines per se.

    2. rork says:

      Some overtreatment is expected. We accept that it happens to some extent, so long as on average people are helped. If they are not being helped much on average, we accept it less. If they aren’t being helped on average at all, it’s all bad.

      Where we are helping people on average, we still try to find subgroups who don’t benefit (or benefit less).

  12. Mary Russell says:

    One issue left unadressed by the study is the treatment related morbidity related to waiting until there’s a lump. Early diagnosis via mammography may not improve mortality, but what of the patient whose cancer is diagnosed early enough that her treatment consists just of a lumpectomy, rather than lumpectomy+radiation+ chemotherapy? Surely this is one advantage of early diagnosis.
    I am a family doctor out in the boonies, and am wondering how I’m going to translate this information into clinical practice. And I have yet to perfect a spiel about prostate cancer screening that is easy enough for someone with a 6th grade education to understand.

    1. David Gorski says:

      Right now, except sometimes when the patient is over 70 years old, radiation, at least, is always part of the standard of care for a lumpectomy. The local recurrence rate is too high without it.

    2. MadisonMD says:

      Countering your concern, Dr. Russell is that diagnosis of non-lethal cancer means more treatment. So yes, you might save chemotherapy in Ms. Smith by catching cancer at an earlier stage. But at the same time, you might end up treating Ms. Jones with surgery and radiation with no benefit to her.

  13. Steney01 says:

    You can screen without overtreating. Theoretically you could screen women at 15 years of age if you knew the appropriate treatment response for the subclinical disease you discovered. Screening for subclinical disease is a problem only when the treatment is inappropriate. To me the rush to aggressive treatment is the problem. Not the screening. Screen all you want just don’t overtreat once you do.

    1. Andrey Pavlov says:

      @steney01:

      There’s a Yiddish saying this reminds me of:

      And if your grandmother had balls she’d be your grandfather

      Yes, with perfect knowledge of all diseases and their states with perfect prognostication, you are correct. But that is arguably not actually possible though it may well be refined enough to the point where it is negligible. The crux, however, is that you are saying the problem is not with the screening it is with the rush to overly aggressively treat. Well, as Dr. Gorski – who is vastly more qualified than I to comment – has already stated, this is simply false.

      By definition a screening program must be done on asymptomatic individuals and must sacrifice specificity for sensitivity. Over here in the real world, nothing can ever be 100% sensitive and specific, so there is always some tradeoff to occur.

      Right now, with mammography screening that trade off is rather large because we have no means by which to prognosticate which findings will progress and which will regress. We could cut that edge finer – and we will – but that gap can never go away.

      Overtreatment also means unnecessary follow up diagnostic and confirmatory tests. So to take your example, how would we know which mammographic lesions will progress and which won’t? Be doing an FNA and performing cytological and genomic assays of it. Well, by definition, we must then identify at least some lesions that won’t progress and we can then just leave it at that. But those cases themselves needn’t necessarily have been further worked up! If we do screening starting at age 30 then a larger proportion of the lesions will be those we find need no further treatment. So what would be the rational course of action? Move the guidelines to capture fewer of those people who we know a priori will be more likely to be a false positive.

      So you see, it doesn’t matter whether we have the diagnostic tests you say we should (and I agree we should) but don’t have yet. It is an intrinsic feature of the very nature and meaning of screening tests to capture false positives and lead to unnecessary follow up and treatment. And yes, the appropriate thing to do is stop looking where we are just going to keep finding false positives!

      1. Sawyer says:

        And you haven’t even touched on the legal aspects of doing mammograms and then trying to reduce treatments.

        “Well Mrs. Johnson, you got a positive mammogram, but in order to keep the mortality stats looking good, we’ve randomly decided you should put all this out of your mind and pretend it came out negative until your next checkup. If your tumor metastasizes in the meantime it’s not our fault.”

      2. MadisonMD says:

        … and the cost. If you are not going to use the information you get from a a mammogram, then why do the test at all? And why should anyone pay for it?

  14. Edward C. Holmes says:

    Coursera’s Johns Hopkins University-presented free, on-line course “Design and Interpretation of Clinical Trials” begins today. Not too late to enroll. Runs through March 31.

    https://www.coursera.org/course/clintrials

    P.S. I have no relationship to the professors, the university, or to Coursera.

  15. MadisonMD says:

    Dr. Gorski, thank you for another careful, thoughtful, and balanced critique of a mammography paper. I just had a few thoughts I wanted to share:

    Are clinical breast exams good enough? The control arm in this study for age 50-59 included clinical breast exam. So the minimal effect of mammography on mortality here could be accounted for by a well done exam. (Harriet alluded to this above.) It could also explain why other mammography studies lacking a clinical breast exam control showed a benefit of mammogram. Would we be better off just doing very good annual clinical breast exams?

    The CNBSS included only 4 years of intervention. One thing that bothers me about this study is that subjects on both arms might have received regular mammogram screening 5 years after enrollment. If less frequent mammograms are adequate, this could have blunted the effect on mortality, when in fact occasional mammograms– say every 5 years– might actually provide sufficient mortality benefit.

    I was going to complain about conflating spontaneous regression for non-lethal cancers, but Dr. Gorski already covered this topic here.* Spontaneous regressions might occur, but probably not 22% of the time.

    *Currently, if you get diagnosed with cancer, walk out of the hospital and then get hit by a bus, some would count you as having had a ‘spontaneous regression,’ because the cancer wasn’t lethal.

    1. rork says:

      I’m doubtful about that last part. Death by bus would just be censored data in log-rank tests asking about cancer-caused mortality (Kaplan-Meier plots, or univariable Cox models). Although folks count and report cancer-caused deaths, because those are simple to understand, it is not a test of proportions that is ultimately used that I’ve ever seen – that’s way too oversimplified. There’s usually a multivariable Cox model that really delivers the good – even though you randomized, it can help to put some known influential variables in the model. You feel obliged to give results from univariable models just comparing the arms as well (and it corresponds to Kaplan-Meier plot, which many readers nearly understand – the Cox or other hazards models, not-so-much).

      And ofcourse for all-cause mortality it’s a death plain and simple (and perhaps more likely for those getting screened more often – extra trips and anxieties, extra procedures, extra surgeries and other treatments).

  16. PMoran says:

    I thought it was fairly well shown that breast examination alone has no benefit of breast cancer mortality. My recollection is that even with regular examination by doctors about fifty per cent of cancers were still discovered by the patient.

    It also seems counterintuitive that such an insensitive detection method would do so when a far more sensitive one has difficulty consistently demonstrating clear worth.

    With mortality rates from breast cancer dropping as much as they have it would be irresponsible to be drastically change current policies.

    1. MadisonMD says:

      Yes, Peter I agree that we should not drastically change guidelines. It may be appropriate to dial down the number of screening mammograms, but not eliminate altogether. Yet, it is hard to completely ignore these results.

      Regarding clinical breast exam (CBE), I don’t doubt what you say– but could you provide a citation*? Although less sensitive, exam might be more specific for finding high-risk cancers. For example DCIS is rarely palpable.

      *I wouldn’t regard it as evidence either way if the citation says that 50% of cancers were found by patients during a CBE-only screening program.

      1. PMoran says:

        IIRC, MadinsonMD, the study showing that particular weakness of CBE was referred to in an article on breast screening in Ca (Journal of the ACS) possibly thirty or forty years ago, and the fact has stuck in my mind. My recollection is that the CBE was being performed three monthly. I have had a quick look at Ca, but there is just too much material to try and sift through.

        My recollection is that even in those days there was little evidence for benefits from BSE and concern about the number of biopsies it engendered. The Cochrane collaboration has looked at two large studies and found no effect of BSE on breast cancer mortality.

  17. steney01 says:

    Thanks for taking the time to reply david, andrey and sawyer.

  18. Dorothy says:

    As someone diagnosed with FEA from a CNB, I have been navigating the waters of overtreatment. Thank you for this comprehensive essay. I have found some doctors – while still twitchy to operate or do something – nevertheless understand and accept my researched decision to watch and wait. Others have been absolutely opposed, but uniform in their arrogant attitudes and illogical arguments based on fear instead of facts.

    The latest radiologist made it clear that any so called overtreatment was the woman’s fault. If we agree to screening, in his mind, we should therefore agree to any followup that the medical folk want. The following dialog sums it up. “But you had atypia!” (And he reluctantly admitted the CNB site one year later was fine.) “Yes, an indolent, non-obligate pre–” “It’s only indolent if it’s not cancer!!”

    I have a question for Dr Gorski. You mentioned a reservoir study with 39% cancer rate on autopsies, or something like that, in a previous blog post. I have not been able to find this study and would appreciate a citation. Thanks.

  19. Whew! What a lot of beating around the bush retoric! The numbers identified in early mamography screening in the 40-49 age group may be low numbers, BUT lives were likely saved OR the breastcancer likely was caught and treated earlier. I am a breast cancer survivor. My early stage cancer was detected by a mammogram. I was older, BUT I would hate to see young women barred or disuaded from proper screening.

    I realioze mammography is NOT perfect. I do hope screening tools will improve, but until then, I am all for mammography.

    1. Sawyer says:

      Janis, do you understand that as you shift lower in age groups, the number of false positives go up? At some point these false positives will statistically outweigh the benefits of early treatment. There’s just no getting around this until better detection techniques are developed. Now there may be a whole bunch of secondary benefits from yearly mammograms, but the primary benefit of reduced mortality just isn’t there. Women under 50 can still make a choice to get them but doctors need to make sure they know the risks.

      I do worry about the public trust aspect if recommendations are changed though. If treatments and screening improve too quickly, we’ll see constantly fluctuating advice.

  20. Self Skeptic says:

    I’m late here, but I see the topic is still alive.
    The 2012 book Mammography Screening: Truth, Lies and Controversy by Peter Gotzsche (of the Cochrane Collaboration) is helpful in getting a detailed sense of how hard-won this public acknowledgment of overscreening and overdiagnosis has been. There has been a bitter struggle for more than a decade, to bring to light the evidence that mammography doesn’t live up to its hype. The Cochrane Breast Cancer group (who, as specialists in the field, were strongly invested in defending the status-quo) even succeeded in delaying, and then censoring, Gotzsche et al.’s Cochrane Review. This began in 2001 and went on for years. Gotzsche et al. stubbornly published their dissenting viewpoint anyway, in the Lancet, and have stood up resolutely to public insults from various thought leaders within the specialty, up to the present.

    It’s hard to turn around something as big and pervasive as the commitment to mammography screening in the US and Europe, once the capital and social investment has been made. Needless to say, far from being a purely medical or scientific matter, policy about mammography screening is the basis for a mid-sized, profitable industry, and industries don’t just accept having their market reduced without a struggle. Especially when they’ve been proudly thinking of their product as saving lives, all this time.

    1. David Gorski says:

      Actually, I’m not a big fan of Gotzsche. His treatment of mammography reminds me too much of Tom Jefferson’s treatment of the flu vaccine in that Gotzsche clearly has a major ax to grind. Such people don’t belong as editors in Cochrane. I am a big fan of Paul Ioannidis and Gilbert Welch.

  21. Self Skeptic says:

    The ax-to-grind idiom doesn’t seem apt; there’s no evidence that Gotzsche had it in for the mammography promoters, prior to examining the relevant evidence. Having a strong opinion about something after exhaustively examining the evidence, isn’t the same as having an ax to grind. Dirty-laundry-in-public seems like a more fitting cliche. But that is the purpose of the Cochrane Collaboration: to try to isolate and publicize the actual evidence, without bending to accommodate the social distortions it has undergone, during policy-making.

    Even if you don’t admire the author, the book provides an extremely detailed example of how science’s “self-correction” occurs, in medicine. Challenging an entrenched medical policy using nothing but evidence, is a long, frustrating battle between very unequal forces. The status quo has far greater political power, whether it’s right or wrong. Aside from mammography currently being an $8 billion/year industry just in the US, much effort has been spent educating doctors and the public to be true believers in annual screening. This was supported by the entire medical establishment, and was assumed to be based on scientific fact. It’s amazing that criticism of it got any traction at all, no matter what the evidence indicated.

    I doubt if we would know anything about the problems with excessive mammography screening, if it weren’t for Gotzsche’s efforts. It seems a little cavalier to ignore his account of the strong political opposition he encountered, in an article about the mammography controversy, if one is truly interested in moving medicine toward being science-based, and away from being eminence-based.

    I’ve gotten the feeling that most people here at SBM must feel there’s a Truth Fairy who quietly and privately goes around fixing bad or outdated science in mainstream medicine. In that view, vocal dissenters like Gotzsche are just making people uncomfortable, questioning established medical dogma, for no good reason. If only…

    1. Sawyer says:

      I’ve gotten the feeling that most people here at SBM must feel there’s a Truth Fairy who quietly and privately goes around fixing bad or outdated science in mainstream medicine.

      No. None of us here believe that. Please stop assuming everyone here is an ignorant rube about how medical research works.

      I know very little about Gotzsche so I don’t want to be unfair to him, but I can explain why many of us find his style so unproductive. While there’s plenty of money and prestige to be made being a part of the mainstream medical “establishment”, there’s also a tremendous amount of recognition for being a brave “crusader”. The mythos that you’re the ONLY person fighting against big evil drug companies, or ivory tower academics, or corrupt regulatory agencies is extremely appealing, but it doesn’t necessarily result in the best science. Tom Jefferson is the prototypical example of this. There are probably hundreds of scientists that are curious about the true efficacy of flu vaccines, but Jefferson pretty much branded himself as the go-to person on the topic. By taking a very aggressive stance against flu vaccines and oseltamivir, he ends up just pissing off most of the people that are interested in the topic, both within the drug companies and within academia. Research that could be accomplished fairly quickly with a bit cooperation is stretched out over years, and no one benefits.

      Again, I know very little about Gotzsche, but I suspect he falls into the same camp. The fact that many of us here already understood the mammogram screening problems without ever reading his work might be a signal you’re overestimating the importance of his research.

      1. David Gorski says:

        Again, I know very little about Gotzsche, but I suspect he falls into the same camp. The fact that many of us here already understood the mammogram screening problems without ever reading his work might be a signal you’re overestimating the importance of his research.

        I haven’t read Gotzche’s book, but people who have tell me he has a rather obvious anti-big pharma, anti-business bias as well, which leads him to be distrustful and dismissive of a lot of research. I suppose I should read his book to see if that’s really true, but if I were to read a book on screening and other medical topics, I’d much rather read Gilbert Welch’s book Overdiagnosed.

        1. WilliamLawrenceUtridge says:

          Short and available at my local library. Requested!

    2. weing says:

      “….annual screening. This was supported by the entire medical establishment, and was assumed to be based on scientific fact. It’s amazing that criticism of it got any traction at all, no matter what the evidence indicated.”
      I don’t think it’s amazing at all. Anyone in the field for any length of time is aware of the problems with screening tests, lead time bias, etc. I recommend http://www.nejm.org/doi/full/10.1056/NEJM198001033020104 detailing a lot of the same issues and 4 years before Gotzsche finished medical school. To me, his agenda is to sell his books. The main problems here are a public looking for simplistic solutions for a complicated problem and a legal system that most physicians seek to avoid like the plague.

      1. David Gorski says:

        @weing: Published in 1980? You beat me. The NEJM article I cite all the time on lead time bias, length bias, and overdiagnosis was published over 20 years ago. :-)

        See:

        http://www.nejm.org/doi/full/10.1056/NEJM199304293281706

        http://www.sciencebasedmedicine.org/the-early-detection-of-cancer-and-improved-survival-more-complicated-than-most-people-think/

        But it’s true. These issues have been argued almost incessantly among surgeons, radiologists, and oncologists since at least the 1970s. It’s nothing new. Nor is the argument over mammography, where whether to screen, when to start screening, and how often to screen, along with the risks of overdiagnosis, have been argued for at least 30 years. The thing is, only now are we having long enough followup to see a lot of these phenomena.

  22. Self Skeptic says:

    Thanks to you all for responding. I do appreciate your letting me know your thoughts.

    I’m sure you all know that Gandhi quote:

    “First they ignore you, then they ridicule you, then they fight you, and then you win.”

    It kind of ruins the rhythm, but one more phrase needs to be added, “and then they say it was inevitable, and would have happened anyway.”

    I’m not here to vouch personally for Gotzsche; for all I know, he and I disagree about many things, and wouldn’t enjoy each other’s company. With regard to mammography, he’s just the one who kept shouting the loudest, “But the emperor has no clothes!” for the last 12 years or so, despite many vigorous and persistent attempts to shut him up, and the one who has written a book about the experience including details of the political fight. I will now read “Overdiagnosed” by Welch, Schwartz, and Woloshin, and see what they reveal about their experience of the “mammography wars,” as Dr. Gorsky refers to them in the title of his post.

    I’m here to point out that if you avoid reading detailed accounts of how medical policy errors and placeholder fictions get corrected, you’ll continue to have the fantasy that it happens automatically, in a timely manner. It doesn’t. There is often (usually?), a “war.”

    Annual mammography has functioned as a place-holder fiction. The problem with these fictions is that while they are extant, they are believed to be true, and people who dare to criticize them are often vilified by the orthodox believers as disruptive, or at the extreme, as anti-science. It’s very hard to dismantle a medical placeholder fiction that has accrued a big infrastructure (both mental/emotional and economic) to execute the policies based on it.

    If you think that a multi-billion dollar big industry, supported by many millions of true believers, and led by the dominant academics, simply bows its head and backs off politely as new data automatically “comes in”, or that it’s easy to get people to assimilate data that threatens medical dogma, you haven’t been paying attention.

    It seems that SBM is committed to keeping this naivete as part of its belief system. I can see the emotional appeal, for both doctors and patients, but it does make SBM look rather simple-minded. The way to stop looking like a rube is to get more sophisticated in your world view, not to get offended at the messengers from the city.

    I’m especially bemused by the association to Tom Jefferson. That has got to be the loosest association yet: Gotzsche > Cochrane > dissenter > Jefferson > flu vaccine > vaccine > anti-vaxxers > bring out the torches and pitchforks > stab Gotzsche, Jefferson, and any other dissenters who happen to be standing around.

    I suppose we really shouldn’t discuss “Overdiagnosed” by Welch, Schwartz, and Woloshin, until we’ve read the book. ;) But while we’re judging books by their covers, I do have some concern about this one: I’m already worried about its polemical title. I think “Misdiagnosed” would be more promising, because it seems to me that there is almost as much of a problem with under-diagnosis of conditions said to be rare (which results in either substitute-diagnosis and wrong treatment, or shrugging and sending the despairing patient to CAM as a last resort), as with over-diagnosis and -treatment of things like high cholesterol. I’m finding that it’s hard to overestimate the danger of unintended consequences, in medical trends of thought that catch on. A one-sided title like Overdiagnosis, runs the risk of encouraging medicine to swing from one oversimplified extreme (More is Better) to the other pole (Less is Better), when what is really needed is less reliance on sweeping generalizations, and more attention to detail. But that doesn’t mean it’s not worth reading; I’ll check it out.

    1. Sawyer says:

      “Gotzsche > Cochrane > dissenter > Jefferson > flu vaccine > vaccine > anti-vaxxers > bring out the torches and pitchforks > stab Gotzsche”

      NOPE. Not even close. Stop pretending you have psychic powers and can read people’s minds. The parallels Dr. Gorski and I were pointing out are much deeper than your simple little flow chart.

      This is the second time in this thread you’ve made a huge erroneous assumption about how other people think. No one is going to bother talking with you if you keep making this mistake.

    2. weing says:

      Very interesting. “Overdiagnosed” is polemical, “Misdiagnosed” is not. It really shows your lack of naivete. We really need your sophisticated analysis to lead us out of the darkness.

  23. Dave says:

    SS makes the point that a big industry has developed over mammography screening with a lot of publicity to push this as absolutely necessary on the public. This is true. Weing and Dr Gorski are also correct that the true benefits of this have been argued forever in the medical literature, at least as far back as I can remember. At one point there was such a flap that Congress, not noted for their acumen in anything, got involved (I believe in the 1990′s but my dates could be off) and stated women over 40 should get mammograms. I do know that my decision algorithm for 40+ year old women in the 80′s and 90′s was pretty simple – if I didn’t get a mammogram on a woman and she was diagnosed with breast cancer 2 years later I’d wind up in court and probably lose. In addition we have a lot more longterm data now. As far as the Canadian study, some of the responses to the article posted in the British Medical Journal are pretty interesting.

    1. Dave says:

      My memory was not correct. Congress got involved in 2009.

  24. Self Skeptic says:

    Before I read any responses to my last post, let me engage in some spontaneous Self-Skepticism that occurred to me a couple of hours after I posted last:
    I succumbed to intemperance a couple of times in my last comment. I shouldn’t have taken the bait, on the Gotzsche – Cochrane – Jefferson – vaccine association, even though it was offered twice. Nothing good can come from mentioning the V word here; best to ignore it.
    Also scratch this comment, regarding failing to diagnose conditions that are perceived to be rare: “…shrugging and sending the despairing patient to CAM as a last resort.” That’s excessively hard on physicians who legitimately can’t make a diagnosis that’s justified by current decision trees. It’s much better to admit you don’t know what’s causing the symptoms (as long as you do express sympathy, and don’t blame the patient, while doing so), than to give a substitute diagnosis with an air of authority. What the patient does after that, is his responsibility.

    Okay, now I’ll face the music, for having posted in haste, and repented at leisure. ;)

  25. Self Skeptic says:

    Here’s another book about mammography screening:
    The Big Squeeze, by Handel Reynolds, MD, 2012, Cornell Press.

    “Handel E. Reynolds, MD, FACR, is a breast radiologist at the Doris Shaheen Breast Health Center at Piedmont Hospital in Atlanta, Georgia. – See more at: http://handelreynoldsmd.com/handel_reynolds_radiologist_author_history_mammography.html#sthash.XVqpJbf2.dpuf

    Reviews, and link to author interview, here:
    http://themammogramdilemma.com/the_big_squeeze_history_mammography.html
    I ordered this book from my local library and will read it.
    Amazon readers give it mostly good reviews. It’s available on Kindle.

    I am almost done with Overdiagnosis by Welch et al, recommended (pre-reading) by Dr. Gorski. It’s written for the literate layman. It is pleasant to read, and makes some good points about the problems of excessive screening, of people with no symptoms. My previously noted concerns about the biased title, potentially reinforcing an excessively generalized, unbalanced viewpoint within the medical community, remain.
    For this reason, I continue to recommend Jerome Groopman’s How Doctors Think. This book is also pleasant to read, and written for the literate layman. People need to thoroughly absorb all those general considerations, and keep in mind the big picture of common cognitive methods and their associated errors in medicine, before digging more specifically into the mechanics of just one type of error, like that emphasized in Overdiagnosed.

    Here’s a good summary of the chronology of cancer screening recommendations. As Dave helpfully pointed out, above, these are not really optional recommendations; failure to follow them opens a practitioner to losing potential malpractice suits.
    http://www.cancer.org/healthy/findcancerearly/cancerscreeningguidelines/chronological-history-of-acs-recommendations

    I’m also following the mammography debate through the decades by searching PubMed. That’s a good way to get the tone of the various episodes in the controversy, and to sort out who the people are, who have pushed various viewpoints into mainstream medical consideration, and fought for them, by fair means or foul. For starters, it seems worthwhile to look at how various officials, like directors of the National Cancer Institute, have influenced perceptions about the science behind cancer screening, as I presume this has had some effect on how patient activism, charities like the American Cancer Society, and any congressional actions have been focused. So far, I’ve just looked at GWB’s appointee, Andrew von Eschenbach, who headed the NCI from 2002-2006, and then headed the FDA from late 2006-early 2009. But this post is long enough, for now.

  26. weing says:

    @SS,
    I’ve gleaned from your posts and recommendations that you are on the side of doing less, testing or treatment. Not that there is anything wrong with that. Have you considered reading books that recommend more testing or treatment just to get a balanced view. All the books you’ve recommended just seem to be confirming views you already hold.

  27. Self Skeptic says:

    Weing,

    This is long; I have not the extra time that would be required to make it short. ;)

    Here’s a direct quote, from my comment above:
    “I’m finding that it’s hard to overestimate the danger of unintended consequences, in medical trends of thought that catch on. A one-sided title like Overdiagnosis, runs the risk of encouraging medicine to swing from one oversimplified extreme (More is Better) to the other pole (Less is Better), when what is really needed is less reliance on sweeping generalizations, and more attention to detail.”

    I am on the side of doing Less when less is indicated, More when more is indicated, and leaving things as they are, when they are just about right. When there is a controversy about matters of fact, people should suspend judgment, until they’ve looked at the details of the data and of the politics involved. I think that, before, during, and after they look at the data and the politics, they should examine themselves honestly for ideological biases. Then they should bend over backwards, as Feynman said, to understand how they might be misled by their biases.

    Members of my family happen to have suffered from 2 sets of guidelines that I think encourage(d) systematic underdiagnosis and treatment; one of those guidelines has been corrected since then, and one is stuck in a holding pattern, because of the field’s internal politics, and is causing a public health crisis and controversy. (I don’t want to distract everyone’s attention by bringing up specific examples here, though you could have gleaned them from my past comments.) I’ve also commented on the statin debate, just because it hit the news stand while I was in the middle of a related debate here at SBM. And I briefly mentioned drugs for dementia, when I had to help make a decision for a relative. So that’s two cases where I think there is (or was) systematic underdiagnosis and undertreatment, perhaps because the guidelines panels were weighted with people who are trying to avoid overtreatment. And then two cases where they I think there may be systematic overtreatment, at least partly due to drug companies’ attempts to create blockbusters.

    The kinds of bias a guideline-writing panel has, differs for each one. Where evidence is equivocal, as much medical evidence seems to be, assessments of the weight of the evidence will reasonably vary. When consensus is forced, despite equivocal evidence, it will be somewhat political and arbitrary, and subject to criticism on that account. If the panel has a politically skillful, strongly opinionated leader, with little talent for real science, it can be a disaster.

    Have you read Groopman’s “How Doctors Think”, which I just recommended (again)? There’s no bias toward doing Less, or doing More. It’s about how doctors can better figure out what is the right thing to do, by not falling into common, predictable cognitive errors. I realize medicine can never be perfect; we can just constantly work to make it a little bit better.

    I don’t know what radiologist Reynolds’ “The Big Squeeze” will say about mammography; I’m just passing along the fact that it exists, and presumably will offer more details about how one doctor experienced in the field, thinks and feels about the issues. We can discuss it after we read it, if you like.

    I originally posted in this thread, because Dr. Gorski hadn’t mentioned Peter Gotzsche’s very relevant book on the topic. It so happens that Gotzsche says that the best data on mammography suggests that less would be better. And, he describes in great detail how a people with a commitment to continuing the current level of screening, tried to block the publication of his team’s findings, because they didn’t like the results.

    I am interested in that, because it is this kind of back-room adjusting of what gets published in science, to make it concur with already-existing policies, that keeps medicine from being science-based. Such tinkering disables the famous self-correction function in science, that is (naively) assumed to guarantee that medical guidelines are honest, current, and scientifically defensible. If an honest, skillful attempt at unprejudiced analysis, indicates that some medical standard of care isn’t working as advertised, that information must be welcomed into the academic and public debate. If not, then medicine’s hope to be science-based, is a sham. We’ll be left with Truth-Fairy science, instead of the real thing.

    Gotzsche and all the other people who agree with him that mammography has been oversold, could be wrong. The only way I, or any one of us, can find that out, is by digging further into the detailed history of both the scientific research, and the politics and biases that may have colored our perception of the science.

    Early detection of cancer, and x-rays’ ability to see below the surface, are intuitively appealing; a child could appreciate this. They offer a superficially plausible match of problem, and solution. But that doesn’t tell us anything about their actual harms and benefits, when applied in the way that current guidelines say to apply them. We have to be careful that mere plausibility doesn’t color our (or the ranking experts’) interpretation of data, once data is available.

  28. Paul Fisher says:

    As a radiologist who has specialized in Breast Imaging for almost 30 years, my point of view may be thought biased, which I can understand! However, there is very little “controversy” about the documented benefits of screening mammography, within either my own specialty, or among the many medical oncologists, breast surgical specialists, and radiation therapists I work with on a daily basis- especially those of us who remember the “good old days” BEFORE mammography. Back then, small, easily treated cancers were relatively uncommon, and the death rates proved it.
    I have a one hour lecture on this subject, which barely scratches the surface, on the data about the benefits of mammography. The highlight of the lecture is a summary of the SEVEN large scale randomized trials of screening mammography. SIX of them showed a LARGE benefit..with many thousands of lives saved. ONLY ONE showed no benefit, and that is the Canadian study refered to in this article. The newest article in the BMJ showed no benefit after 25 years… from the one, outlier study that showed no benefit over a shorter period of time ( and thus, was no surprise!) If you want a FAIR review of the data, look up the excellent research studies done in Sweden, including the Two County Trial, Malmo, Goteberg, etc. The long term data from those studies show a clear large reduction in breast cancer deaths, persisting over decades. ( Long-term effects of mammography screening: updated overview of the Swedish randomised trials.The Lancet, Volume 359, Issue 9310, 16 March 2002, Pages 909–919) I would suggest NOT to “cherry pick” the studies that give you the answer you expect or want; if you were to perform a meta-analysis of ALL the studies, mammography lowers the death rate of breast cancer by about 30%. That’s not enough, of course, but if we as a nation decide to perform an “experiment” and stop mammographic screening, I am moderately convinced, after skeptical reflection on ALL of the data, that many lives will be lost unnecessarily.

    BTW, us radiologists LOSE money with each mammogram we perform and read. I would make a lot more money if we shut down screening mammogram, so I find it insulting to read those who claim we are only greedily protecting our “Turf”. We radiologists read mammograms at a loss, and at a tremendous liability risk, as a community service, and as a way to familiarize patients with our other services (from which we make our net profits and salaries!)

    Paul Fisher, MD
    Associate Professor
    Radiology and Surgery
    SUNY/ Stony Brook University Medical Center

    1. David Gorski says:

      As a radiologist who has specialized in Breast Imaging for almost 30 years, my point of view may be thought biased, which I can understand! However, there is very little “controversy” about the documented benefits of screening mammography, within either my own specialty, or among the many medical oncologists, breast surgical specialists, and radiation therapists I work with on a daily basis- especially those of us who remember the “good old days” BEFORE mammography. Back then, small, easily treated cancers were relatively uncommon, and the death rates proved it.

      Thanks for your comments. However, I have to point out that this would be a “citation needed” kind of statement. The Bleyer/Welch NEJM study from 2012 pretty well demonstrated that the diagnosis of more advanced cancers hasn’t decreased by nearly as much as the diagnosis of small cancers has increased. In other words, screening mammography hasn’t shifted the diagnosis curve towards less advanced cancers very much, which is what one expects if earlier treatment always (or at least frequently) leads to a higher chance of curative treatment. There is also the issue of lead time bias, which you haven’t even mentioned. It’s a huge confounder that radiologists seem to think doesn’t exist. Finally, I recommend the review by Laura Esserman from 2009 cited in a link above about “rethinking” breast and prostate screening. When the numbers are described as absolute risks, you find that the benefit of mammography, although significant on a relative basis, are less impressive on an absolute basis per patient.

      In any case, I would recommend that you go back again and read my post, as you seem to think that I think mammography is useless. I don’t. I do, however, detest fallacious attacks on reasonable studies, and I’ve seen a lot of those about the Canadian National Breast Screening Study, largely driven by radiologists like Dr. Kopans. I’ve written about mammography on this blog many times, many of which posts are linked to in my post above. The issue is that I believe we are not in the “sweet spot” that minimizes overdiagnosis and maximizes benefit and therefore need to tweak the guidelines, perhaps starting at age 50 and screening less frequently.

      Finally, yes, I know that radiologists usually either just barely break even or even lose money on reading screening mammography. However, I also know that radiologists are usually paid pretty well for the stereotactic biopsies, ultrasound biopsies, and MRI-guided biopsies that result from abnormal mammograms.

      Finally,

  29. Self Skeptic says:

    Yes, if radiologists are losing money on screening mammography, they seem to be making up for it on other procedures:
    http://www.studentdoc.com/radiology-salary.html
    http://www.studentdoc.com/internal-medicine-salary.html
    http://www.studentdoc.com/general-surgery-salary.html

    Maybe screening mammography is a loss-leader? or a way of keeping the facility supplied with a steady income? Even if it were not profitable, the staff salaries,building rent and maintenance, etc. all get helped out by the extra business. BTW, I’m sure the radiologists aren’t cynically promoting it for the money, but are true believers. I’m just thinking about how the business model works.

    Here is a site, at which patients discuss how the difference between the screening and diagnostic designation, affects them:
    http://health.costhelper.com/mammogram.html
    So if a woman or her doctor finds a lump, or she gets called back because the screening mammogram looks suspicious, it’s diagnostic rather than screening, and that often affects the patient’s out of pocket cost, and the radiologist’s profit.

    Reynolds’ The Big Squeeze has arrived at my library, so I’ll read that next. He’s also a radiologist.

    1. weing says:

      @SS
      Something fishy about those salaries. How come my salary is lower than the lowest reported for internists?

      1. Self Skeptic says:

        Yes, It depends on how they sample, and how they report. I didn’t dig into that, since I was just looking for ballpark, relative figures. Thanks for noticing and reporting that something was fishy.

        I suppose there are trade-offs between salary, life style, practice style (assembly-line vs. personalized), population served, and other such issues. Supply and demand matter, I suppose, though health care is a very non-classic market.

        Here are some other salary sites:

        http://www.salarylist.com/jobs/Radiologist-Salary.htm
        http://www.glassdoor.com/Salaries/radiologist-salary-SRCH_KO0,11.htm

        Below is my favorite site; it took me a while to find it again. There’s a distribution graph with marked percentiles and a methodology description. But the searches are running kind of slow, this morning. Once you get one histogram up, it works better to change locations and specialties directly in the url, rather than using their search boxes.

        Internists in Hartford, CT:
        http://swz.salary.com/SalaryWizard/Internist-Salary-Details-Hartford-CT.aspx

        Comparing family practice and radiology in Chicago, IL:
        http://www1.salary.com/IL/Chicago/family-physician-Salary.html
        http://swz.salary.com/SalaryWizard/radiologist-Salary-Details-Chicago-IL.aspx?&fromevent=swz.jobdetails.freepop

        Comparing family practice between a blue-collarish city, an Ivy academic city, and a non-NYC commuting town, in Connecticut:
        http://swz.salary.com/SalaryWizard/family-physician-Salary-Details-New-London-CT.aspx
        http://swz.salary.com/SalaryWizard/family-physician-Salary-Details-New-Haven-CT.aspx
        http://swz.salary.com/SalaryWizard/family-physician-Salary-Details-Putnam-CT.aspx?&fromevent=swz.jobdetails.freepop

  30. Self Skeptic says:

    Dr. Gorsky,
    Why do you think that mammography guidelines are likely to be modified “within a year”? (See the last paragraph of the original post in this thread.) I’ve been looking at more details about the history and current politics of this issue, and I don’t see any sign of movement among the radiologists. Handel Reynolds’ short and readable 2013 book The BIg Squeeze was no exception; after a reasonable view of the history of the controversy, he said, in an apparent non-sequitur, Mammography saves lives, and gave a paragraph of support for the current guidelines. (He’s a signatory on the ACR’s current guidelines, which were updated in 2013, and as you know, still recommend annual screening mammography for all women of average risk over age 40.)

    I agree with you that the evidence doesn’t support this policy; it hasn’t, for a long time. The 1997 NIH panel of non-radiologists made that pretty clear, and as you pointed out, even before that it didn’t look very good, whenever evidence rather than wishful thinking was considered. I don’t see that anything is very different now, than it was back then.

    The American Cancer Society (powerful in communication) and National Cancer Institutes (powerful in medical academia) have always supported the radiologists, who are, after all, the ranking medical experts and authorities on mammography. So far, the ACR and the ACS have explicitly committed to discrediting the Canadian study, and also evoking the irrelevant, but dependably inflammatory, meme of rationing. I think the NCI hasn’t said anything, officially, yet; but I can’t quite see it suddenly reversing itself, even with someone like Harold Varmus at the helm, trying to keep it real.

    So the appearance of revised guidelines from the ACR, who are the ranking experts, seems unlikely to me. The current guidelines made in 2013 won’t “sunset” until 2018. I could be wrong, and politics is always unpredictable. Please let me know if I’m missing something here.

  31. Self Skeptic says:

    I mean, Dr. Gorski; not -sky. Sorry about that.

  32. Alice says:

    Medical research out of the US is about as reliable as statistics out of China. Unless US comment is internationally peer reviewed, it isn’t worth reading.

    1. WilliamLawrenceUtridge says:

      On what basis do you make this statement?

      You think that other countries are somehow inherently better? That conflicts of interest don’t exist outside of the US? What do you think of German literature on homeopathy?

    2. Dave says:

      This current study is from CANADA, not from the USA. Although they are on the same continent they are separate countries with different health care systems.

      1. Alice says:

        As an international guest looking for the Canadian study, I was attracted by the title of this site “Science Based Medicine”. I am disappointed to find it is an American site and I can’t find any of the contributors here who have been published recently by any credible, medical, internationally peer reviewed journals . Time is too short to bother with the corrupt American medical profession, Sorry. The Canadian studies are being discussed in The Lancet and that is good enough for me.

        As the last civilised country to introduce a universal health care system, which doesn’t go far enough imo, Americans are just too weird for me.

        1. Dave says:

          The Canadian study was also featured in the British medical journal, which also profiles many American studies. Good science is good science, regardless of the place of origin, and so is bad science. An example is a recent flap about a flawed European study of preoperative beta blockers, which caused the guidelines in Europe to use more extensive beta blockers perioperatively than we do in the US, and is felt to be responsible for a number of patient deaths. The BMJ website is free and worth perusing frequently. There are problems (and successes) everywhere.

        2. David Gorski says:

          As an international guest looking for the Canadian study, I was attracted by the title of this site “Science Based Medicine”. I am disappointed to find it is an American site

          And what the heck does this being an American site have to do with anything, much less whether the discussions are reasonable and based on scientific evidence?

          and I can’t find any of the contributors here who have been published recently by any credible, medical, internationally peer reviewed journals

          Then obviously you haven’t looked very hard:

          http://www.ncbi.nlm.nih.gov/pubmed/24633367
          http://www.ncbi.nlm.nih.gov/pubmed/24404125
          http://www.ncbi.nlm.nih.gov/pubmed/23477556
          http://www.ncbi.nlm.nih.gov/pubmed/21681448
          http://www.ncbi.nlm.nih.gov/pubmed/20516212
          http://www.ncbi.nlm.nih.gov/pubmed/20421348
          http://www.ncbi.nlm.nih.gov/pubmed/17957028

          That’s just in the last five or six years. Not an overwhelming publication record (it took about two or three years to get back up to speed after moving to my current job in 2008), but definitely solid.

          Sorry. The Canadian studies are being discussed in The Lancet and that is good enough for me.

          Here’s a challenge for you. Rather than whining about my nationality and the home country of this blog, how about describing a specific deficiency in my analysis of the CNBSS and using a science- and evidence-based argument (complete with clinical trials and studies) to demonstrate why it is a deficiency?

          1. Alice says:

            I came here to learn, I read the first couple of paragraphs and thought “what is this self indulgent babble”. Perhaps you could call the site Science Based Medicine written for Americans by Americans.

            I haven’t read your article. I just assume it is corrupt because it is American and your track record of assisting women is woeful. Despite the US having enormous wealth, you have a higher ratio of maternal deaths than at least 40 other countries. Why is the problem of violence against children so much more acute in the US than anywhere else in the industrialised world? Your infant mortality is disgraceful. Children get shot because you allow corrupt gun fanatics to have power. You have politicians who have weird ideas about womens bodies.
            https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html
            http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2409165/
            http://www.bbc.co.uk/news/magazine-15193530

            http://www.independent.co.uk/voices/comment/most-of-us-know-the-body-does-not-have-a-way-of-shutting-down-to-prevent-rape-but-we-have-to-change-the-thinking-of-those-who-dont-8422119.html

            I don’t know who you are David Gorski, as you can tell I’m not impressed with the American medical profession and I wouldn’t know if you got your papers out of a cereal packet, I’m nothing more than a layperson looking for easy to understand, trustworthy, science based information. Your flippant and self indulgent opening has reinforced every negative stereotype I have about Americans.

            Those links you supplied look American. Where is the international peer reviewed papers?

            Imagine if you found a website called “Financial Planning for Women” and discovered it was owned and run by Nigerian men.

            1. weing says:

              You say you came to learn, but you didn’t say what, and you didn’t read the article as you assumed that it is corrupt as it is coming out of America. I would say that your assumptions are an obstacle to your learning anything.
              We all know the sad state of the US education system. What you need to compare is the university system to other countries. That has been the gem that has kept the US at the vanguard of science and technology. I do fear that the US is starting to fall here also, but is still ahead of other countries. I don’t know for how long.
              As to corruption being less in other countries and having experienced secondary education in the US and abroad, that is a joke and betrays great naivete on your part.

            2. WilliamLawrenceUtridge says:

              Hi Alice,

              Yep, the US has a lot of problems. The existing “health insurance reform” won’t address most of them. The lack of a public health care option is terrible, and responsible for many of the terrible health outcomes found in the US when compared to other first-world countries. You’re not telling us anything we don’t already know. Are you just here to tell us how awful Americans are? May I ask what country you are from? I have a couple complicated problems and quasi-racist assumptions for pretty much any country you could name that I would like to sound-off about, blaming every single citizen of the nation in the process. For instance – THE HAN CHINESE TREAT TIBET HORRIBLY, YOU SHOULD ALL BE ASHAMED, or perhaps DID YOU KNOW THAT BLACK CITIZENS IN SOUTH AFRICA SUFFER WORSE HEALTH OUTCOMES THAN WHITE!?!?!?!

              I’m nothing more than a layperson looking for easy to understand, trustworthy, science based information.

              Oh, well then – may I suggest simply trusting your doctor? Science is inherently fraught, complicated, tentative and nuanced. It doesn’t do “easy”. Really, the best recommendations are quite basic – don’t smoke, eat your fruits and vegetables, exercise, get enough sleep, find some form of relaxation you enjoy, and if you have serious symptoms, consult your doctor.

              Your flippant and self indulgent opening has reinforced every negative stereotype I have about Americans.

              Well, if it makes you feel any better, your bitter, condescending and misplaced criticisms has made me categorize every person named Alice as an ignorant little bint who should have her keyboard taken away. Yay for stereotyping!

              Also, did you notice that Scott Gavura and Paul Ingraham are actually Canadian?

              Imagine if you found a website called “Financial Planning for Women” and discovered it was owned and run by Nigerian men.

              What if it gave excellent advice on financial planning for women?

              I’m trying to understand the rules here – only non-Americans can criticize Americans, and any American who exhibits any traits you don’t like are emblematic of an entire nation of 300 million people? Only men/women can give financial/medical/marriage/etc. advice to men/women? Please let me know, I will adjust my online gender, race, ethnicity, nationality, dietary preferences and religious beliefs so I am genetically, culturally or lifestyle-ly compatible with your beliefs about who can criticize what.

              Thanks,

              Hajji William/Willemina Lawrence/Laura Utridge/Chan/von Mujen

            3. David Gorski says:

              I haven’t read your article. I just assume it is corrupt because it is American and your track record of assisting women is woeful.

              Which has absolutely zero to do with whether or not my analysis was reasonable, science-based, and on target. Of course, you are free to choose to read (or to abstain from reading) anything you like for any reason you like, but, quite frankly, this was one dumb reason not to read a post about a mammography study.

              I don’t know who you are David Gorski, as you can tell I’m not impressed with the American medical profession and I wouldn’t know if you got your papers out of a cereal packet, I’m nothing more than a layperson looking for easy to understand, trustworthy, science based information. Your flippant and self indulgent opening has reinforced every negative stereotype I have about Americans.

              There are plenty of people around who like my self-deprecatingly snarky navel-gazing style in introductions. Different strokes for different folks. Again, none of this has anything do with whether or not my analysis was reasonable, science-based, and on target.

              Those links you supplied look American. Where is the international peer reviewed papers?

              Are you really serious? This is perhaps the most ridiculous comment I’ve heard for quite a long time. But, hey, I was published in Nature back in the late 1990s as a co-author, and that’s a UK journal.

              http://www.ncbi.nlm.nih.gov/pubmed/9685160

              I’ve also been published in Cardiovascular Research, which is the official journal of the European Society of Cardiology:

              http://cardiovascres.oxfordjournals.org/content/87/4/723.long

              Described thusly:

              Cardiovascular Research is the international basic science journal of the European Society of Cardiology. The Journal is concerned with both basic and translational research, across different disciplines and areas, enhancing insight in cardiovascular disease mechanisms and the perspective for innovation. The Journal welcomes submission of papers both at the molecular, subcellular, cellular, organ, and organism level, and of clinical proof-of-concept and translational studies.

              I’m sure it’s not enough to satisfy you, but that’s not my point right now. It’s more than enough to demonstrate that I’ve gotten papers published that were “internationally peer reviewed.”

              To be honest, I’m having an increasingly difficult time taking you seriously.

              1. Alice says:

                I swallowed my prejudices and read your article. I like it, it is informative and easy to read. It will enable me to ask my doctor sensible questions and help my decision making.

                If you are having a difficult time taking me seriously you need to spend more time with everyday people. Perhaps you need to spend more time listening to the concerns laypeople have about taking responsibility for their own health and making sensible decisions in PARTNERSHIP with their doctor.

              2. David Gorski says:

                I do spend time with everyday people. Everyday people with cancer. Everyday women asking about mammography. Everyday people asking about science. I meet them in my practice. I correspond with them (when I have time) if they e-mail me. I sometimes spar with them (or just answer questions from them) on this blog. You are the first person I’ve ever encountered who started out dismissing me mainly because I’m an American and she views American science as corrupt. I’m not joking. As for my conversational and sometimes rambling style, well, that’s just me. No one’s forcing you to read.

                Maybe it is you who should reexamine her biases. Believe it or not, this blog helps me do that for myself all the time.

              3. Chris says:

                “If you are having a difficult time taking me seriously you need to spend more time with everyday people.”

                It is not because you are “everyday people” but you are espousing xenophobic rhetoric, which many of us dislike. Especially those of us with relatives on both sides of the border.

              4. WilliamLawrenceUtridge says:

                If you are having a difficult time taking me seriously you need to spend more time with everyday people. Perhaps you need to spend more time listening to the concerns laypeople have about taking responsibility for their own health and making sensible decisions in PARTNERSHIP with their doctor.

                Three points:
                1) Medicine isn’t a partnership, patients exist in a situation of assymetric information. Your doctor knows way more than you, and even spending years studying a single issue is unlikely to give you the perspective needed to understand medical decision making, just like years of reading about auto repair wouldn’t give you the experience to rebuild an engine.

                2) You want some countries bad at research? Try China and Russia. They systematically only produce positive studies of acupuncture, despite all other countries producing mixed results.

                3) I find it hard to take your comments about how Dr. Gorski should behave seriously given how you entered the comments section.

              5. Dave says:

                People who disregard another’s ideas because of where they were born, where they live, what their gender is or what their skin color is are, I think, “wierd” and should not expect a lot of respect on this site.

              6. Chris says:

                Just to let you know I was born on one of the two American continents, and English was not my first language. Though, while I am facile at the accent, which has a distinct Carib flavor, my grammar is as good as any three year old. I spent a good third of my youth under age eighteen either on or a bridge away from the South American continent.

                Though my citizenship is one of three of the countries that comprise the northern American continent.

                Here is the last hint: I lived where my country rented property for most of the twentieth century, which ended in 1999.

                Now, Alice, show us how much smarter you are than all Americans and tell everyone where I was born, and even lived when I was in high school. Show us how well you know history, geography and geopolitics.

              7. Alice says:

                WilliamLawrenceUtridge,

                “1) Medicine isn’t a partnership, patients exist in a situation of assymetric information. Your doctor knows way more than you, and even spending years studying a single issue is unlikely to give you the perspective needed to understand medical decision making, just like years of reading about auto repair wouldn’t give you the experience to rebuild an engine.”

                Sounds a bit “1950′s” to me. Sounds a bit “holier than thou”. Sounds a bit “American arrogant”. Sounds a bit “trust me I’m a doctor”. Is that the way it is STILL done in America? Is that how you get to drug little children, the elderly, the vulnerable?

                In Kentucky, 19% of children have been diagnosed with ADHD.

                “American Psychiatric Association itself is seems set to exacerbate the problem. Its new diagnostic manual, published last year, eased the guidelines for identifying ADHD. It instructs psychiatrists to look out for children who, among other things, are reluctant to do homework, who lose school books and who are fidgety. ”

                http://www.economist.com/blogs/democracyinamerica/2014/03/medicating-america-s-children

                What say you, American Doctors? How DID you let this happen to your youngest most vulnerable people?

                Oh, look at the next story: Capital Punishment: Death for the Mentally Disabled.

                ” Initially flummoxed, Mr Winsor replied: “Florida has an interest in ensuring that the people who evade execution because of mental retardation are people who are, in fact, mentally retarded.” Raising the IQ cutoff to 75 to take account of the margin of error, he said, “would double the number of people who are eligible for the…exemption.” In other words, Florida wants to execute more people, and therefore uses the most rigid definition of retardation that it can get away with.

                How did you feel when the EU banned the supply of drugs to the US because you were using them to execute people?

                http://www.newstatesman.com/future-proof/2014/01/us-prisons-foiled-eu-boycott-are-turning-untested-drugs-executions

                Oh look, surprise, surprise, US doctors get paid to prescribe drugs – March 2014.

                http://www.justice.gov/opa/pr/2014/March/14-civ-251.html

                Pharmaceutical manufacturer Teva Pharmaceuticals USA Inc. and a subsidiary, IVAX LLC, have agreed to pay the government and the state of Illinois $27.6 million for allegedly violating the False Claims Act by making payments to induce prescriptions of an anti-psychotic drug for Medicare and Medicaid beneficiaries . Teva Pharmaceuticals USA is located in North Wales, Pa., and IVAX LLC is a Florida company.

                Don’t even try to come up with excuses WilliamLawrenceUtridge. Don’t even go there. Whilst US doctors might feel terribly smug about their position in their own little insular communities, the world is watching. I for one am not amused.

              8. Andrey Pavlov says:

                Alice, you weren’t maligned here because you are an “everyday” or “lay” person, but because you were startlingly and rudely xenophobic. A Nobel laureate could have come here and said the same things and (s)he would have gotten the same cold response. Ideas stand on merit around these parts, not the nation, color, or creed of the person saying them. WLU pointed out the two exceptions to that rule in China and Russia, but that is not from reflexive xenophobia but from years of well documented empirical evidence as to their research practices and outputs. And even then we still read articles, just with a finer toothed comb and a more critical eye because we recognize that while a priori much less likely good ideas still do come from everywhere.

                We do often talk about patient partnerships here. Go ahead and look up my comment history and see what I have to say on the topic. WLU is correct that it is an asymmetrical partnership, but I would argue that is the case for just about any professional interaction.

                But one way to ensure there can be no partnership is to saunter in and say “Everyone in this room is weird and moronic. I won’t even bother talking to you because you all must be stupid.” So please, don’t have the gall to walk in to our room, not read our thoughts, make such an incredibly rude and bigoted comment, and then say we need to learn more about how to engage in a partnership with our patients.

              9. WilliamLawrenceUtridge says:

                Sounds a bit “1950′s” to me. Sounds a bit “holier than thou”. Sounds a bit “American arrogant”. Sounds a bit “trust me I’m a doctor”. Is that the way it is STILL done in America? Is that how you get to drug little children, the elderly, the vulnerable?

                You know what’s arrogant? Assuming you know better than a doctor, who spends years learning how the body functions. It doesn’t matter what country you live in – any conventionally-trained physician will know an order of magnitude more than you.

                Also, I don’t “get to drug” anyone, I’m not a doctor. I just realize how ignorant any non-doctor is in comparison, because I’ve educated myself enough to realize how friggin’ complicated the body is. I’m not enough of an arrogant asshat to claim I will ever know as much as even a med student. I get my medical information from mainstream medical pages and follow my doctor’s instructions religiously because I don’t fucking know how my body works. And as I say this, keep in mind that I spent four years of undergraduate education learning anatomy, physiology and biology. And I still don’t fucking know how my body works.

                Also, I can only describe your posts as “racist”, given how you describe “all Americans”. America is pretty broad, they protest their own governments quite regularly. You know who is American? Noam Chomsky. So was Howard Zinn. The best people to criticize Americans aren’t armchair zealots from wherever you come from, They are Americans.

                How did you feel when the EU banned the supply of drugs to the US because you were using them to execute people?

                I’m not an American and I think capital punishment is stupid. As do more than a third of Americans.

                Whilst US doctors might feel terribly smug about their position in their own little insular communities, the world is watching. I for one am not amused.

                If I were to guess, I would guess that your primary emotion is “sanctimonious”.

                Do you realize how stupid it is to judge an entire nation? Saying “All Americans are drug-pushing executioners” is as stupid and thoughtless as saying all Arabs are terrorists, all Afghanis are ignorant misogynists and all British people are white, well-educated and have bad teeth. It makes about as much sense as me saying, as I did above, that anyone named Alice should be kept in a straightjacket to avoid systematically murdering Americans she might accidentally come in contact with. I mean, seriously – have you even met an American? They’re not “all nice people”, they’re simply people. Some are nice, some are nasty. Some are xenophobic, some are incredibly welcoming. There’s 300 million of them, how about you don’t pretend they’re all alike.

                The simple stories you tell yourself might be comforting, but that doesn’t make them true.

        3. WilliamLawrenceUtridge says:

          I’m not even sure what the criticism is. That the authors are Americans? So what, most of the science in the world is conducted and published by Americans, or those trained in American schools. America has a large population, the third-largest in the world after China and India, and more educated citizens with advanced degrees than both of these countries (probably in absolute numbers, definitely in relative), thus having a substantial presence in international research. Its population outnumbers the next four largest English-speaking countries combined. It’s even borderline racist; would you say only Jews can (or can’t) research and publish on Judaism?

          That America doesn’t have a federally-funded health care system? Most contributors and many commentors would probably agree that such a system would be a tremendous improvement. I doubt any would object. And how does the lack of such a health care system influence the quality of the original paper and the discussion thereof? I am sure many American citizens would also love such a system, even more so if they had ever experienced one.

          I mean really, are you looking for something to complain about?

          1. Alice says:

            So well educated that the US is below the OECD average in the latest PISA survey on state of global education.

            http://www.oecd.org/newsroom/Asian-countries-top-OECD-s-latest-PISA-survey-on-state-of-global-education.htm

            Are those advanced degrees worth the paper they are written on?

            1. Dave says:

              The journal Science had an article about this a few months ago. As with so much in the USA there is a great disparity in different regions. Students from some school districts perform extremely well in comparison to students from other countries, whereas students from some other areas fare poorly. The poorly faring areas pull down the average. We also have disparities in access to health care and levels of socioeconomic status that lower us on health scores. (Example, the last I heard there were no Indian reservations, which have a high poverty and unemployment rate and major problems with certain diseases such as diabetes, in Sweden)

              I can’t reference the exact issue in Science from where I am now but it shouldn’t be hard to locate.

              Good and bad science, smart people and not-so-smart people, and good and bad people are found everywhere. I also believe most scientists are not nationalistic. In the areas I am most interested in outside of medicine – animal behavior, physical anthropology and vertebrate paleontology – there seems to be a lot of communication internationally, with scientists from all over doing work in Africa and Asia. For an insight into some of this, John Gurke wrote a recent book called Shaping Humanity, where he describes his process of reproducing fossil hominids for National Geographic and the Smithsonian’s Hall of Humanity. To do this he went to Africa several times to examine fossils and received casts and CT reproductions of bones from all over the world. Lots of international cooperation went into his work. That’s how it should be.

              1. Alice says:

                Take a look at the list of countries scoring above the OECD average. Count the number with poor and disadvantaged indigenous communities.

                Estonia, Korea, Viet Nam, Poland, Canada, Liechtenstein, Germany, Chinese Taipei, the Netherlands, Ireland, Australia, Macao-China, New Zealand, Switzerland, Slovenia, the United Kingdom, the Czech Republic and Belgium score above the OECD average in science.

              2. Dave says:

                The point, Alice, which you apparently missed, was that some American students do really well and are really smart, but we have a number who don’t, partly because of disparities in the school systems and not because some substance unique to the soil of the USA makes us dumb. Other countries may have disadvantaged people as well but more standardized school systems. They also will have very smart kids and some who aren’t. I totally agree we need to beef up the school systems which do not perform well here. That doesn’t negate the fact that some kids here are very smart.

                Intelligence is not based on place of origin, skin color, or gender, or on the policies and politics of a particular government. Nazi Germany was terrible but had some pretty intelligent scientists. Most people recognize this fact. You apparently do not.

                It’s obvious you really hate Americans and paint all of them with the same brush, even though there’s a lot of diversity in the country (just look at the acerbity in Congress). The American ideal (not always achieved in reality, but an ideal) is that if you work hard, apply yourself and are smart enough you can succeed for yoursself and your children, regardless of your creed, place of origin, skin color, and whether or not your daddy was an earl or baron, etc. That ideal is why so many immigrants moved here, including my ancestors, and it actually worked for them. My grandfather’s parents died in a steerage compartment on the boat here, he was raised in an orphanage and had an eighth grade education, but worked very hard, was very successful as a baker, and has a grandson who’s a doctor. The flip side to that idea, held by a lot of Americans, is that if you don’t do those things you should be allowed to fail. “Individualism” vs a “nanny state”, so to speak.That dichotomy has created some social problems which have yet to be worked out, including the resistance to some of the socialistic policies other countries have adopted and which might improve the lot of people here if we did adopt them. Again, this has little to do with the intelligence of individual people.

                And for the record, I firmly believe we should have a government run universal health care system.

                Personally I would appreciate it if you would restrain your anti-American diatribes and stick to whether the ideas presented are good or not.

            2. mousethatroared says:

              Clearly you should go find the science based medicine blog written by volunteers from your country then. There is one, right? There must be, since your country is clearly superior in every way…

              Oh wait, maybe not.

              http://www.nature.com/nature/journal/v453/n7191/full/453028a.html

            3. WilliamLawrenceUtridge says:

              Yeah, the average US citizen might be below the OECD average. That’d doesn’t change the fact that some of the best universities and research institutions in the world are found in the US, and in pure gross numbers, the number of well-educated US citizens outstrips all other nations (bar, perhaps, China and India). In fact, the number of citizens with advanced degrees in the US alone is probably greater than that of some countries overall. You rather missed my point. In your apparent hatred of Americans, you are committing a rather classic fallacy – because some things about the country apparently piss you off irrationally, that means nothing about the country can be good. Really? Even Hitler painted roses. GODWIN FTW!!!

              So, are those advanced degrees worth the paper they are written on? Yes, very much so. While science is responsible for the high standard of living you currently enjoy, much of that science was conducted in the United States of America. That doesn’t make the whole country saintly, any more than the existence of some assholes or ignorant rednecks makes the whole country demonic.

              And hey, Fred Phelps died recently, so the world just became a better place by some small but significant amount. Here’s hoping for the entire ruling juanta of North Korea next!

              1. David Gorski says:

                Actually, the Nazis built the Autobahn, too, dedicating 130,000 workers to the project in 1936.

                And we all know how that turned out. :-)

              2. Andrey Pavlov says:

                I love driving on the autobahn. Every time I go back to Germany I rent a nice manual transmission BMW or Audi and let loose. My friend live a little outside of Munich so I fly into Stuttgart or Dusseldorf (since the tickets are always $200+ cheaper) and use the money I saved on the flight to splurge on a fancy high end BMW/Audi rental and then cruise through the autobahn and the countryside, taking a full day to get there. I usually just keep the car for a day, since my friend typically has an extra car to loan me, which further justifies the splurge.

                Driving at 255kph* is certainly an exhilarating experience!

                *The “big 3″ German automakers agreed to have a factory limited top speed of 255kph on all their cars so that they didn’t get into a runaway “top speed” arms race. You can remove the limitation with an easy after market mod, but rental cars come limited. That said, 255kph is still a tremendously fast speed. I have only ever once gone faster than that (on the ground) and that was in a friend’s very heavily modified Corvette on the road towards Las Vegas. He was driving, which was a good thing since it gave me plenty of chance to contemplate how quickly death would come. At nearly 310kph (192mph) things happen very quickly.

        4. Andrey Pavlov says:

          That’s a surprisingly… nationalistic comment. And you obviously didn’t look very hard. Because Dr. Gorski has an article published in PLoS One this month.

          1. WilliamLawrenceUtridge says:

            Mazel Tov to Dr. Gorski!

        5. windriven says:

          “Americans are just too weird for me.”

          Ta-ta then. And do please take your stenotic cultural prejudices with you back to the land of loonies. I won’t bore the readers here with an inventory of things and thoughts great and useful of American provenance that are enjoyed the world over – including by those who live in your great nation. Happily, most of our northern neighbors take a more nuanced view of us.

          So I’m wondering from whence your venomous screeds? It isn’t as if you were dragged kicking and screaming to this site. I don’t much care for self-satisfied, intellectually vacuous shrews, but I don’t seek them out. I wouldn’t have wasted the three minutes this response has cost me – you really aren’t worth the investment – had you not come and defecated on my porch. Do you think your comments here reflect favorably on you personally or on your Canadian identity? Do you think the average Belgian or Dane or Chinese or Swede would think so?

  33. Alice says:

    I came here and thought you were discrediting a good study. Not so. My mistake. I don’t understand American humour.

    Maybe you are good people here, I don’t know. I certainly don’t understand how good people, wealthy and privileged and a world Super Power have developed a society which allows the infant and mother mortality rates the US has. I don’t understand the child abuse levels or the failing education, the child and mother poverty, the capital punishment, the violence. I don’t understand how a supposedly civilised country can disregard the rights of women and children.

    It is reasonable for an outsider to question whether an American website discussing a womens health issue is trustworthy. The corruption within the US medical system is in the international news regularly, it doesn’t inspire confidence.

    1. windriven says:

      “It is reasonable for an outsider to question whether an American website discussing a womens health issue is trustworthy.”

      Actually, it isn’t reasonable, it is intellectually dishonest. America, like all countries, is a wild mixture of ethical and unethical, broad-minded and parochial, caring and cold. People with intellectual honesty and personal integrity meet new information with an open if critical mind.

    2. WilliamLawrenceUtridge says:

      I came here and thought you were discrediting a good study. Not so. My mistake. I don’t understand American humour.

      Yeah, there really haven’t been many jokes. And there’s not really an “American” sense of humor, it’s pretty much universal.

      Maybe you are good people here, I don’t know.

      You’re rather missing the point – an argument is sound, or it is not. It doesn’t matter if it is made by “good people”. That’s rather the point of science, and it’s why you’re getting a lot of vitriol here based on your “Americans can do no right” stance. It’s stupid, it’s nationalist, it’s antiscientific, it’s elitist, and it’s manifestly wrong. And if nothing else, in terms of gross amounts Americans are quite generous and even when you pare back per capita and per portion of income, they’re still not doing too badly. Willingness to help a stranger is nothing to sneeze at.

      I certainly don’t understand how good people, wealthy and privileged and a world Super Power have developed a society which allows the infant and mother mortality rates the US has. I don’t understand the child abuse levels or the failing education, the child and mother poverty, the capital punishment, the violence. I don’t understand how a supposedly civilised country can disregard the rights of women and children.

      You’re mixing the average citizen with the in many ways dysfunctional political process. Also, you might want to check your figures – the US does poorly on infant and maternal mortality rates in part because they track these statistics differently than most of the world. What the US considers “infant mortality” other countries consider “stillbirth”. One can’t naively think they are the same thing without checking the definitions.

      And I think most contributors here, be they authors or commentors, would agree that the US would be better off with a real health care system. I’m sure there is a very interesting and complicated story for why it hasn’t happened. At least in part I’m sure it is state’s rights, an issue I don’t even pretend to understand.

      It is reasonable for an outsider to question whether an American website discussing a womens health issue is trustworthy.

      You’re not really “questioning” though, you’re knee-jerk rejecting. Your thinking process seems to be “that can’t be right because it doesn’t portray Americans badly”. Allow me to point out, one of your premises is wrong, and therefore so is your conclusion.

      The corruption within the US medical system is in the international news regularly, it doesn’t inspire confidence.

      You think that corruption is isolated solely to the United States? That all other countries are somehow immune? Curious.

      1. mousethatroared says:

        And there’s not really an “American” sense of humor, it’s pretty much universal.

        Oh come on – We get to claim Stewart and Colbert, at least, don’t we?

        1. WilliamLawrenceUtridge says:

          Colbert and Stewart have hosted Egyptian and (I believe) Russian versions of themselves on more than one occassion :)

          1. mousethatroared says:

            Off topic – and I’m sure I’m being taking this too seriously. But, while I’m sure finding some things humorous is universal, what we consider funny, when we consider it appropriate to insert humor and what we consider it appropriate to joke about seems to be steeped in cultural context. In other words there are really big in jokes that nations share.

            I have only anecdotal evidence, but my time in China and Kazakhstan gave me the distinct impression that, even when talking to a fluent English speaker from the area, using pretty mainstream U.S. humor can sometimes come across as “weird” to others. But, it turns out the look someone gets on their face when they think you’re being weird is pretty universal ;). Of course – there are definitely universally funny things.

  34. mousethatroared says:

    The point of the blog is to promote science based medicine with the goal of improving health outcomes, that would include improving women’s health and lowering infant mortality rates. You seem to be suggesting that the fact that health outcomes need improvement discredits the blog. This is circular reasoning.

    What’s on your agenda today? Find a Haitian blog discussing the challenges of reforestation and post a screed stating that clearly no one should trust a Haitian’s view on the environment?

  35. Alice says:

    Why am I here? I happened upon your site whilst I was searching for the Canadian Mammogram study . I find a screed by a “self proclaimed cancer expert” discussing Bat Signals and questioning whether bats get cancer. I think it is supposed to be funny but I’m not sure, I need to find out what sort of website I’ve landed in before wasting any more time reading further. Oh, look, it is a site which looks at unscientific and pseudoscientific health care ideas. I think, what a darn cheek, that Canadian study is receiving international attention in credible medical journals. I must have dropped into a site run by some Amazon book seller, corrupt, money hungry American scammers.

    Stage 2. Hmm, the screed is OK, I like it. Where is the catch? Why are they discussing this study when the rest of the site is dedicated to chiropractic, acupuncture, homoeopathy, reiki etc.

    Maybe it is a site trying to claw back a market share of patients from the booming “alternative” health market. That is a bit sneaky, put a credible study into a site which attracts the cashed up but easily conned, wishful thinkers looking for hope and simple solutions. Sow the seeds of negativity into women (who make up a significant portion of the “alternative health” users) before they even consider consulting an “alternative health” practitioner.

    Times must be tough for the US medical profession. No more cash from the drug companies and it is getting harder to hide the over-prescribing of drugs to the children, elderly and disadvantaged.

    “Editorial staff and contributors at Science-Based Medicine are physicians and other professionals who are alarmed at the manner in which unscientific and pseudoscientific health care ideas have increasingly infiltrated academic medicine and medicine at large. Our goal is to examine these claims in the light of science and skepticism. We believe that the best medicine is based on scientific principles — considering plausibility, for instance, and not just evidence.”

    1. Chris says:

      “I find a screed by a “self proclaimed cancer expert” discussing Bat Signals and questioning whether bats get cancer.”

      Have you even bothered clicking on the drop down menu at the top of the page to learn about the contributors to this blog? So you actually think someone who is a “surgical oncologist with “MD, PhD, FACS” behind his name is only a self proclaimed cancer expert? To tell us what kind of expert you proclaim yourself to be.

      We know it is not reading comprehension because your first comment on this blog was “Medical research out of the US …”, even though the title of the article starts with “The Canadian…” That was adorable.

      “I think, what a darn cheek, that Canadian study is receiving international attention in credible medical journals.”

      Please give those citations.

      ” I must have dropped into a site run by some Amazon book seller, corrupt, money hungry American scammers.”

      So what is your opinion of the two Canadian contributors to this blog? How about someone who is a naturalized American citizen, like one of those who has responded to you and a spouse of another?

      “Times must be tough for the US medical profession. No more cash from the drug companies and it is getting harder to hide the over-prescribing of drugs to the children, elderly and disadvantaged.”

      You have obviously not read much of this blog. But here is one article that is appropriate for that baseless accusation: The Pharma Shill Gambit. Enjoy.

      By the way, you also said: “Maybe it is a site trying to claw back a market share of patients from the booming “alternative” health market.”

      Are you a Burzynski shill?

    2. Dave says:

      I’ve never seen any evidence that the editors of this site are pushing anything to make money. It is true that a lot of the posts are about CAM, but another interpretation of this is that the site is designed to help keep unsuspecting people from spending money uselessly on things that do not work. Among the other advice given on this site has been the following series of lists about what mainstream medical things to avoid:

      “The American Academy of Dermatology list includes:

      Don’t prescribe oral antifungal therapy for suspected nail fungus without confirmation of fungal infection
      Don’t perform sentinel lymph node biopsy or other diagnostic tests for the evaluation of early, thin melanoma because they do not improve survival
      Don’t treat uncomplicated, non-melanoma skin cancer less than one centimeter in size on the trunk and extremities with Mohs micrographic surgery
      Don’t use oral antibiotics for treatment of atopic dermatitis unless there is clinical evidence of infection
      Don’t routinely use topical antibiotics on a surgical wound
      The American College of Physicians list includes:

      Don’t do screening exercise EKG testing in patients who are asymptomatic and at low risk for coronary heart disease
      Don’t do imaging studies in patients with non-specific low back pain
      In the evaluation of simple syncope with a normal neurological examination, don’t do brain imaging (CT or MRI)
      In patients with low pre-test probability of venous thromboembolism, do a high-sensitive D-dimer test rather than imaging studies as the initial diagnostic test.
      Don’t do pre-op chest x-rays unless there are symptoms of heart or lung disease.
      There are 46 of these lists. Each can be easily accessed by clicking on a link. They all make for interesting reading; but if you don’t want to bother, these two examples give you a good idea of what they are like. They address things that some doctors are still doing in the face of clear evidence that they shouldn’t. It always takes time for research findings to be translated into changing practices in the typical doctor’s office, and this is an effort to speed up the process. The goal is to improve patient care, not to boost physician income; in fact, almost everything on the lists is actually at odds with the financial interests of physicians.

      The American Academy of Family Practice was not content to list only 5; they came up with this list of 15 items:

      Don’t do imaging for low back pain within the first six weeks, unless red flags are present
      Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement
      Don’t do DEXA screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors
      Don’t order annual EKGS or any other cardiac screening for low-risk patients without symptoms
      Don’t do Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease
      Don’t schedule elective inductions of labor or C-sections before 39 weeks gestation
      Avoid elective induction of labor between 39 and 41 weeks gestation unless the cervix is favorable
      Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients
      Don’t screen women older than 65 for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer
      Don’t screen women younger than 30 years of age for cervical cancer with HPV testing alone or in combination with cytology
      Don’t prescribe antibiotics for otitis media in children aged 2-12 years with non-severe symptoms where the observation option is reasonable
      Don’t do voiding cystourethrograms (VCUG) routinely for the first febrile urinary tract infection in children aged 2-24 months
      Don’t routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam
      Don’t screen adolescents for scoliosis
      Don’t require a pelvic exam or other physical exam to prescribe oral contraceptives

      Please note that for almost every item on these lists, compliance will reduce the use of drugs, screening tests, and procedures.”

      The above lists have been posted on this site. Not exactly the kind of advice you would see from money hungry scammers.

      FYI, Dr Hall has in the past posted some articles on gender related issues and many of the commentors are female. Dr Hall is a woman. I’ve never seen anyone other than you commenting that this site is anti-women (“Sow the seeds of negativity into women”). You remind me of a comment in a book I read a long time ago, called “Do Black Patent Leather Shoes Really Reflect Up”, about the experiences of a young man in a Catholic high school in Chicago. The nuns would advise the girls to never wear black patent leather shoes because the nuns thought boys stared at them to try to see up girls’ skirts, and the nuns advised girls never to let boys take them to restaurants with white tablecloths, because that would remind the boys of bedsheets. The comment was to the effect that the nuns had lot dirtier minds than any of the boys did.

      1. Chris says:

        I think we are dealing with one of these.

        1. windriven says:

          “I think we are dealing with one of these.”

          Perhaps. Or maybe one of these.

      2. Alice says:

        Thanks for compiling the American Academy of Dermatology list and Family Practice list. It has given me something to think about. Always lovely to find helpful souls who can maintain their cool, humble and polite manner despite an assault. Meanwhile I rather like the patent shoe story, it’s very cute.

        1. WilliamLawrenceUtridge says:

          I believe those lists come from the “choosing wisely” campaign, which this website has featured several times now.

          Alice, are you now prepared to acknowledge that both this website and the contributors are not evil demons bent on destroying your health and the health of patients everywhere?

          Are you prepared to admit that your labeling of “all Americans” as somehow evil baby-eating monsters was a bit of a gross over-reaction?

          Just wondering. Admitting you are wrong is very liberating, and we are all wrong, all the time.

          1. mouse says:

            My dad swore his was only wrong 99.9% of the time.

            1. mouse says:

              Damn, he swore his was RIGHT 99.9 percentage of the time. Since we rarely agreed, that would make ME wrong 99.9 percentage of the time. :)

          2. Alice says:

            Ha, I just found your post. (I’ve got a time zone issue to deal with).

            YES.

            I think the site is legit. Still not convinced that the mammogram study belongs here, but, oh well, what would I know. I haven’t landed in a BLOG before. I’m not even sure what a blog is.

            1. WilliamLawrenceUtridge says:

              Why don’t you think the mammograph study belongs here? Why does nationality determine who can criticize a study? What specific points do you object to that Dr. Gorski made, aside from “he’s American”? Which is neither a point, nor an objection.

              A blog is abbreviation of “web log”. It’s a webpage maintained for discussion and dissemination purposes by individuals. This is a group blog.

              So you admit that the blog is not written by evil demons from hell bent on drugging children? Excellent. Will you now admit that your judgement of all Americans is misplaced, short-sighted and simply wrong?

    3. Chris says:

      Also, you do understand that this is a blog and not a journal article?

      The authors strive to write to a general audience, using both humor and geniality to get across an idea. Then they let only mildly moderate the comments, which allows the free flow of information.

      Many of those who comment often have no medical training, but have their own reasons to read this blog. Some have a general interest in medicine, some are in the other related fields (like device manufacturing), and many of us have dealt often with family medical issues. Oh, and there are few other doctors and medical researchers.

      I first came across Dr. Novella when folks were trying to push the Doman-Delacato patterning method for my disabled kid over ten years ago. It is bunk (also noted by a now out of print book by Berneen Bratt, No Time for Jello</cite). Quackwatch and some of the saner denizens of UseNet newsgroups (kids.health, misc.health.alternative) were very helpful to me when I encountered abject insanity on a listserv for my son's disability (where someone tried to get me banned for reminding them that the MMR vaccine never contained thimerosal). Some of those UseNet folks now post here, including the author of the above article.

      That is why I am here. I am a parent of a kid with multiple medical issues. I used to be intelligent, but then I had kids (I was an engineer, now "just a mom"). This is a place of sanity, common sense, and science. All without judging a person because of their nationality (have you figured out where I was born?). You might try prying your closed mind open, and actually read the actual content.

      If you think this blog is "bad", I really hate to hear what you think of the three podcasts hosted by Vincent Racaniello, Ph.D., Higgins Professor of Microbiology & Immunology, Ph.D., Mt. Sinai School of Medicine of Columbia University. Those podcasts are "This Week in Virology", "This Week in Microbiology" and "This Week in Parasitism." Each podcast includes a local weather report and lots of puns. Even worse, Prof. Racaniello is from New Jersey.

      1. Chris says:

        Sorry for flubbing up the html. At least I did not italicize teh internets.

    4. MadisonMD says:

      I’m trying to figure out if Alice thinks Dr. Gorski is trying to over-sell mammography to earn more money. If so, she somehow missed how the article was strikingly critical of mainstream radiologists such as Dr. Kopans who is unduly criticizing the study. Somehow she missed that Dr. Gorski thinks that the study provides evidence that U.S. doctors are screening too often; that Dr. Gorski expects U.S. future mammographic screening guidelines will decrease the number of mammograms. If, for example, they are decreased to biennial, then the recommendations would actually match the U.K. NHS.

      So basically, the thrust of the article could be read as– yeah, maybe UK/NHS has it right and the US should fix their recommendations based on the new Canadian evidence.

      Why it is almost as if Alice has nothing to criticize except that this site is hosted in the U.S and that Dr. Gorski lives in Detroit instead of Windsor. Then she criticizes that this is all about making more money for doctors. How did she miss that the scientific article is thoroughly Canadian, and that Dr. Gorski takes issue with current US guidelines in favor of a more UK-esq approach, which would decrease payments to physicians?

      How very odd. Alice, you need to actually read the blog post.

    5. mousethatroared says:

      @Alice OMG – Do you realize how obvious it is that your prejudice against Americans is causing you to come up with increasingly convoluted rationals for why the blog MUST be evil in some way?

      Have you noticed that you are trashing American education while demonstrating low reading comprehension and a lack of critical thinking skills. You are making yourself look like a fool in front of the readers from all over the world.

      It’s really rather delicious…please, please keep doing it.

      1. Alice says:

        From a rodent that makes BOOB jokes around a mammography article?

        Don’t worry you aren’t the only one to poop in your own nest.

        Nothing like a bit of old fashioned in-your-face criticism to get the regulars to display their true colours. Enjoy.

        1. mousethatroared says:

          Oh sorry – did I offended your Victorian sensibilities? Shouldn’t you be watching Downtown Abbey, writing pamphlets instructing females on maintaining appropriately ladylike behaviors or something?

          I read the article because I have a family history of breast cancer and I wanted to know how about breast cancer screening, I make jokes, so what? Where’s the criticism?

        2. nancy brownlee says:

          “Nothing like a bit of old fashioned in-your-face criticism to get the regulars to display their true colours.”

          You like critical? Stick around. There are commenters here that will render you right down to a puddle of grease. What’s more, they’ll be intelligent, accurate, and knowledgeable, traits which you have shown no trace of. Not a whisper.

          1. WilliamLawrenceUtridge says:

            Sadly, we won’t. The necessary points have already been made, Alice doesn’t care. You can’t reason someone out of a position they haven’t reasoned themselves into, and rather obviously reasoning isn’t her strong suit.

            1. mousethatroared says:

              Yup! To summarize…

    6. WilliamLawrenceUtridge says:

      I find a screed by a “self proclaimed cancer expert” discussing Bat Signals and questioning whether bats get cancer. I think it is supposed to be funny but I’m not sure, I need to find out what sort of website I’ve landed in before wasting any more time reading further.

      Three points:
      1) You do realize that Dr. Gorski is a full-time clinician-scientist, don’t you? Specifically a researcher and surgeon in breast cancers. If not, consider yourself educated. That “self-proclaimed cancer expert” is genuinely an expert in cancer. Perhaps not mammography screening, but that doesn’t mean he is incapable of making cogent points.
      2) Have you tried judging the paper on its substantive points, rather than the jokes you don’t get?
      3) There is certainly a considerable amount of time being wasted here. For instant, you making claims about “all Americans”. A complete waste of time, since there is nothing you can about “all Americans” that is not axiomatic. So before you sound off about “wasting time”, reflect on the fact that your starting comment, and most since, have wasted time.

      Oh, look, it is a site which looks at unscientific and pseudoscientific health care ideas. I think, what a darn cheek, that Canadian study is receiving international attention in credible medical journals. I must have dropped into a site run by some Amazon book seller, corrupt, money hungry American scammers.

      So…only Canadians can comment on Canadian studies? That’s…stupid. Can you justify this stance through anything resembling a coherent, rational statement?

      As for the rest of your post, all you’ve succeeded in demonstrating is that you fail to appreciate the topics this blog addresses, and the approach it uses. It criticizes any pseudoscientific idea that suits the contributors’ fancy. Dr. Jones posts regularly on pediatrics, including considerable basic information about infant and child development. Drs. Novella and Crislip tend to have more abstract, almost philosophical posts, while also delving into their specialties (neurology and infectious disease). Dr. Gorski generally posts about cancer-specific topics, but also comments on a lot of CAM as well. Dr Hall does a lot of book reviews and addresses generally quackery-specific topics too. However, all have ventured considerable criticism of the corrupt industry you so decry. For instance, Dr. Novella has posted about the multi-billion dollar fine paid by GSK. Scott Gavura has posted a book review of Ben Goldacre’s Bad Pharma, and Goldacre is cited approvingly throughout the site. Dr. Gorski has discussed a study of how doctors are critical of journal article funding sources. It’s almost as if the medical system, and these bloggers, were critical of conflicts of interest and corruption within medicine.

      So it looks like your “corruption” accusations are either incorrect, or the bloggers here at least (as well as the multitude of highly critical scientific articles published by American journals and/or written by American authors) are part of a very, very shell game. One could even venture that the reason why you aware of the “corruption” you are so outraged over is a direct product of American doctors and researchers.

      Anything to say about that?

  36. Alice says:

    Try this -
    Google – Canadian Breast Screening Study
    Depending on your location, this site comes up about 5th and it appears like this -

    The Canadian National Breast Screening Study ignites a new round …
    http://www.sciencebasedmedicine.org/the-canadian-national-breast-screening-s…‎
    Feb 17, 2014 – In 1980 a randomised controlled trial of screening mammography and physical examination of breasts in 89,835 women, aged 40 to 59, was

    CLICK and you arrive RIGHT HERE.

    Start reading. Imagine you have no prior knowledge about this site. After first paragraph in, click top left “About SBM” and choose first option. Read intro only. Flick over references – see Acupuncture, Chiropractic etc.

    Get annoyed at self for wasting time. Annoyed at getting conned by what seems like some sort of scam site, pick up enough to work out it is probably American. Whiz off a note to warn others to check for fake American research and corrupt American commentary.

    Did I know this is a blog? I do now. Yes, I know the research is Canadian. Yes, I get really annoyed when I read the neverending media reports of US corruption. Yes, I get annoyed when Americans make excuses for the corruption. No, I’m not automatically impressed by titles. Do I belong here? No, my irreverence won’t be appreciated, I’ll want to whack people into place if they start “blowing their own trumpets” – cultural difference I’m afraid.

    The Lancet link
    http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)62600-1/fulltext

    I don’t know what a Burzynski shill is, so I don’t think I am one. I’m not an expert in anything. I don’t know if the site is anti-women, some of the posters are patronising. For those who have taken the time to kindly supply information, thank you.

    1. windriven says:

      “Get annoyed at self for wasting time. Annoyed at getting conned by what seems like some sort of scam site, pick up enough to work out it is probably American. Whiz off a note to warn others to check for fake American research and corrupt American commentary.”

      Enough with the rabid anti-American crap; science knows no nationality. You are a nasty, whiny, small-minded, parochial little sh!t with a bad attitude and a chip on your shoulder. Bugger off. You won’t be missed as you haven’t added anything substantive to this discussion.

    2. MadisonMD says:

      Nothing substantive indeed. And then she links to a Dan Kopans letter to the editor in 1997? How odd. Is it scarcely possible she read the post?

      Alice seems to have an axe to grind but is being rather subversive.

    3. weing says:

      You really can’t blame her. All she reads is neverending reports of US corruption, medical and otherwise. Whether this exposure to such reports is self-inflicted is not clear. I have found it to be a common technique of diverting attention from your own problems and corruption by pointing out the corruption in other groups. It does seem that a lot of things do annoy her. Still not clear why. Maybe she likes being annoyed?

    4. Dave says:

      The absolute worst piece of medical corruption and bad science which has probably ever occurred was not American. You can educate yourself about it by accessing the British Medical Journal’s website and looking to the right column of “most read articles”. There’s a link to an article on Andrew Wakefield’s shenanigans with the MMR vaccine, and from that you can access their previous investigative journalism describing in detail the whole sordid mess, if you really want the information. And the BMJ is not an American publication, so you might just condescend to trust the information.

      It would be a good idea in the future if you actually read a blog before commenting on it. “I haven’t read your article. I just assume it is corrupt because it is American and your track record of assisting women is woeful.” That is probably the most inane statement I’ve ever seen.

    5. brewandferment says:

      by your own admission, your initial impressions were formed by only cursory glances. “after first paragraph…read intro only…flick over references.”

      Perhaps if you were more diligent in weighing the available information about this site, you’d have been less quick to fire off such an irritable (and irritating) screed and you might have made a worthwhile contribution instead of looking like a flame warrior.

    6. Andrey Pavlov says:

      I’m not an expert in anything

      Well, at least one bit of truth escapes your fingertips.

    7. WilliamLawrenceUtridge says:

      We’re not patronizing because you are a woman, we are patronizing because you are ignorant. And as close to “racist” as you can get when discussing a nation that is astonishingly welcoming of any “race” who cares to contribute to the GDP.

      Also, I’m not American, does that mean I can criticize you? You never answered my questions above.

    8. Chris says:

      “I think, what a darn cheek, that Canadian study is receiving international attention in credible medical journals.”

      Please give those citations. And not with a fifteen year old letter to Lancet, nor by telling us to “Google it.” You made a claim, therefore you need to support that claim.

      Then calmly explain what factual errors Dr. Gorski made in this blog article. Stick to the subject and try to stay away from your opinions of his nationality, or avatar picture.

      By the way, my avatar is me in a hammock reading a book about the development and use of calculus. The flowers are from a five meter tall Cecile Brunner deck eating climbing rose. Try to spin that one as an excuse to not engage in civil discourse.

    9. WilliamLawrenceUtridge says:

      I’m still not sure at the source of your criticism. Are you mad at google because this is a highly ranked website according to their search algorithm? That suggest you be mad at google, not Dr. Gorski. Are you mad because an American researcher is criticizing a Canadian study? That suggest you are irrational, since good ideas know no national boundaries. Are you annoyed at yourself for reading the page? That’s not really anyone’s fault here who isn’t named “Alice”. Are you annoyed because you think this is a scam site? That’s again your fault for misunderstanding the site – it makes no money. Are there any advertisements on the site? None that I can see. You could donate to the site, but that’s not really a conflict of interest as far as I can tell. Are you annoyed at the fact that you were wrong about the site being “American”? Again, that’s your own error. Are you annoyed at American corruption? That’s not this site’s fault, and in fact this site is often critical of corruption in medicine (as are many American doctors and researchers).

      Burzynski is an asshole from Poland who sells desperate cancer patients high-dose chemotherapy as well as some unproven piss extracts as a highly profitable way of making money. Everyone here hates him. They hate even more the fact that he pushes his desperate patients to attack anyone who has the temerity to point out that he sells high-dose chemotherapy and unproven piss extracts to desperate patients. There’s a lot of posts about him on this blog, try the search box.

      You’re welcome.

  37. Alice says:

    The swearing, cursing, name-calling, pitchforth wielding crowd surges forth, wanting to “render me right down to a puddle of grease”. Flapping their advanced degrees, calling for my comment on David Gs article so they can show off their fine, educated and intelligent minds.

    At what point did you forget that Alice, self proclaimed layperson and expert at nothing who came to read the study, has already commented ” I like it, it is informative and easy to read. It will enable me to ask my doctor sensible questions and help my decision making”.

    You realise of course, that this is the internet. A place to be careful of opportunists and wolves in sheep’s clothing and snake oil salesmen. A good prod can usually bring forth the authenticity and culture of a website.

    Meanwhile, I’ve asked myself a new question and it is something I never thought I would question. Is it possible that there is such a place where it might be useful to -

    medicate even more than 19% of children for ADHD
    lower the IQ level to enable more executions
    encourage an armed citizenry
    maintain or increase the maternal and infant death rate
    pay doctors to medicate more Medicaid and Medicare patients

    1. windriven says:

      @Alice

      Thank you! You made me laugh out loud!

      “The swearing, cursing, name-calling, pitchforth wielding crowd surges forth, wanting to “render me right down to a puddle of grease”. ”

      You can sure dish it out but my oh my, you squeal like a piglet when you are the target. If you take the time to peruse these pages going back as far as you’d like, you will find the discourse largely polite and respectful EXCEPT when douchebags cop an attitude. Then it can get a little ugly.

      The people who run this site and write the weekly posts do it as a labor of love. They aren’t paid for their work. Donations go to paying for bandwidth*, site maintenance, and other necessities*. And if you don’t think it is work, try banging out 1000 well researched and supported words each week – or 2000 in Dr. Gorski’s case.

      “You realise of course, that this is the internet. A place to be careful of opportunists and wolves in sheep’s clothing and snake oil salesmen. A good prod can usually bring forth the authenticity and culture of a website.”

      A good prod? If I came to your website and suggested that it was sh!t because Canadians are all beer-besotted, crypto-socialists whose entire culture is derivative of their neighbor to the south, save hockey and the Americans had to show you how to make money with that – would you respond politely? Ah, I didn’t think so.

      So you whine about how unfairly you’ve been treated and then exit in another stream of anti-American invective.

      You are one class act, lady.

      1. Chris says:

        “If I came to your website and suggested that it was sh!t because Canadians are all beer-besotted, crypto-socialists whose entire culture is derivative of their neighbor to the south, save hockey and the Americans had to show you how to make money with that – would you respond politely?”

        I must protest this bit. You live just a few hundred miles south of British Columbia. Have you tried to buy beer there?

        Oddly enough the liquor laws in the province just north of our state make our old laws look liberal. Like we used to have state liquor stores (past tense for a reason), they have provincial liquor stores. If you complain about the taxes our state puts on wine, wait until you hear what they do in BC! Dear spouse’s cousins go to Costco to buy wine kits because the taxes on wine, even from their Okanagan region, are so high.

        Still, Super Natural British Columbia is worth a visit. Avoid Victoria where they still dump raw sewage into the sea. Just go up to areas around Pt. Alberni and around the Alberni Inlet and Barkley Sound. One of dear spouse’s cousin supplies the restaurants and hotels in that area with dairy and produce. Yeah, I’m a Central Vancouver Island Tourism Shill, though I receive no payment.

        By the way, in the capital of “Super Natural BC” still dumps raw sewage into the ocean. I vividly remember the wide eyed look from a mommy hipster after relaying this bit of information several years ago after she told me they were passing through our city on the way to move to Vancouver Island from California because it was so much more connected to nature. Yeah, right. She obviously had no clue about reality. And I did not even mention that many of dear spouse’s relatives there worked in the logging industry.

        Still waiting for Alice to supply me whit those citations.

        1. windriven says:

          Oh my, Chris. The sentiments I expressed were caricatures drawn from comments I’ve heard others make and are certainly not my own. My oldest daughter is married to a terrific Canadian and they live in Canada. My youngest daughter attends a Canadian university. And if I didn’t live in the US, Canada would be in my top 5 of alternatives. I was simply trying to get sweet Alice to view the situation from a different perspective.

          I love BC. My daughter and her husband own a beautiful weekend home in Pemberton and another daughter spent some time as a ski bum in Whistler.

          As to waiting for Alice to give you those citations, your time would be better spent waiting for Godot.

    2. Chris says:

      “I think, what a darn cheek, that Canadian study is receiving international attention in credible medical journals.”

      Please give those citations. And not with a fifteen year old letter to Lancet, nor by telling us to “Google it.” You made a claim, therefore you need to support that claim.

      Then calmly explain what factual errors Dr. Gorski made in this blog article. Stick to the subject and try to stay away from your opinions of his nationality, or avatar picture.

      “The swearing, cursing, name-calling, pitchforth wielding crowd surges forth..”

      Please post the link to any comment where I have used any sort of profanity. Then answer the question that I posted to you at least three times.

      1. Alice says:

        Dear Chris, you seem sweet and I’m sure you are terribly clever, I’m impressed that you read books on calculus. The subject at hand is discussed in The Lancet, a credible medical journal with a serious medical community. The study is vast, it has been discussed over the years via many letters from many people. You don’t need me to link the entire discussion. The Lancet is old, very old, not like this website. This website is new. It is good that you like this website and come here to discuss science with other clever people.

        I’m not going to guess where you were born or live, that doesn’t show how clever I am. I’m not clever, Davids article is a good article. David would know that I think his article is good, I said “I like it, it is informative and easy to read. It will enable me to ask my doctor sensible questions and help my decision making”. That means I don’t have anything bad to say about it. I’m not clever enough to know whether there are any factual errors in Davids article.

        Now, some things that I do know and can tell you about. I’m not Canadian. I’m very careful with the internet and I don’t think it is wise to put too much personal information about yourself on the internet. If you don’t have a drinking problem you might need some help with low self-esteem. There is no shame in that. You need to keep some personal information private, this type of information can be used against you by dishonourable people.
        ****
        Yakima was my legal residence through out my childhood. My father was born and grew up there, and his aunt’s address was our legal address while he was transferred all over the place. My family homesteaded there starting in the late 19th century. My great-grandfather grew peaches in Tieton.

        We also visited it often, and yes, the peaches were lovely. I watched salmon spawn in the Naches River near my mother’s cousin’s house on Highway 410. I remember shopping at the Bon Marche downtown, and my great-aunt’s house not far from there. She was the one that told me to save at Washington Mutual since it had been on the same corner for fifty years.

        We just visited a couple of months ago, and the downtown is just a shadow of its former self. Mostly empty buildings. All of my family has essentially left. Though one huge improvement is the area around the Yakima River is now a very nice park. I’m not an immigrant, I’m an emigrant.
        ***

        1. windriven says:

          ” I’m not an immigrant, I’m an emigrant.”

          My condolences to your adoptive countrymen.

          1. Alice says:

            My turn to laugh out loud.

            You had better start apologising to Chris. She told you her story last year and you appear to have forgotten already.

            1. Windriven says:

              What on earth do I have to apologize for?

              1. Chris says:

                I have no idea. I have been busy, so I have only glanced at “recent comments.” Has she apologized for her xenophobia? Or for going way off topic? Or is her point that mammography is not a good test of ADHD?

              2. Windriven says:

                @Chris

                “Or is her point that mammography is not a good test of ADHD?”

                I’m beginning to suspect that ADHD is grossly under treated in her adopted country ;-)

              3. Alice says:

                I take it that you wished to insult me by expressing condolences to my adoptive countrymen. It isn’t my story. It is an example of revealing too much personal information on the internet.

              4. Chris says:

                Your blatant xenophobia and rolling off topic was already too much information.

            2. mouse says:

              windriven “What on earth do I have to apologize for?”

              Chris “I have no idea. I have been busy, so I have only glanced at “recent comments.””

              The gig is up – Alice has discovered the U.S. conspiracy to round up all rose loving, avid reader, cooking enthusiast, engineer trained, native born Canadians. After some extremely careful googling using your screenname and other keywords, U.S. Marshals will stake out one of your favorite local eateries or pubs to collect you for internment. Possibly, they will arrive at your home if your cecile brunner can be seen on google earth.

              If windriven was your real friend, he would have warned you, last year, when you brought up loving roses, reading, cooking, engineering or being from Canada (?)…because all of us native born U.S. folks know about “the plan”. The Obama administration sent out an email. Of course MY email went directly into my junk folder, because Obama emails me all the time (asking for money, mostly). Story of my life.

              Hope your camp has wifi, Chris, because I enjoy your “TMI”.

        2. WilliamLawrenceUtridge says:

          The study is vast, it has been discussed over the years via many letters from many people. You don’t need me to link the entire discussion.

          From our perspective, we can’t tell the difference between this being an accurate reflection of your actual reading, or you reading a single letter to the editor and considering the issue settled because it agreed with your prejudices.

          This is one of the reasons why your posts are not taken seriously.

          1. Alice says:

            I’m sure will be horrified to know that I only linked one letter (which I didn’t read) because I was asked only to provide evidence that discussions on the Canadian study were being held in credible medical journals. When I have time I shall return, read the letter and expect to be mortified by it’s contents by the sounds of it.

            1. WilliamLawrenceUtridge says:

              A letter to the editor isn’t really a “discussion”. A letter to the editor from the 90s really isn’t adding anything to the debate on this page, which is discussing the state of the art 20 years later. And I’m still not sure what your point is – that the study was Canadian and only Canadians can comment? Could you clarify what point exactly you are trying to make?

    3. Sawyer says:

      “lower the IQ level to enable more executions”

      I should probably ignore these comments, but I can’t let this one slide by because I think I know where you got it from. And you’ve got the narrative completely backwards. There was a segment on NPR last week (Morning Edition? Diane Rehm?) about states that were using extremely rigid cutoffs for determining IQ in regards to death penalty sentences. Pretty scary, yes, and not something anyone in the US should be happy about. However, the story I heard also featured an interview with a mental health expert (an American FYI), explaining how this was a really terrible idea, and that courts needed to heed the advice of doctors and psychologists rather than politicians or lawyers. People in the US that work in mental health are absolutely not promoting the idea we should be executing more people with disabilities. They are for more people staying alive, and they are for science-based decisions, in medicine and in our legal system.

      Alice if you don’t like people here just read the articles and ignore the comments section for a while. Otherwise things tend to get ugly for everyone.

      1. Alice says:

        Sage advice. Thank you, I definitely won’t fit in and the crowd is a little too feisty for me.

        It was an article in The Economist btw.

      2. Alice says:

        Forgot to mention – I read various international newspapers to try and understand issues around the world. I’m not up with the jargon around here and don’t know NPR, I don’t have access to American or Canadian radio or tv either. I mostly use PressDisplay to access newspapers online.

        1. mouse says:

          As an aside – If you have internet access, then you can stream U.S. National Public Radio (NPR) or CBC or BBC or Al Jazeera broadcasts. Just search with google for the network. You can also downloard podcasts from these sources if you don’t have a reliable internet hook-up.

          This is unrelated to the discussion. I just love radio so much, I can’t imagine having to do without.

      3. Andrey Pavlov says:

        @Sawyer:

        If you are interested, the Supreme Court has a podcast in which they summarize and offer clips of cases. The March 8 podcast has the case in question you are referencing. It is about 18 minutes long.

        You might find the discussion of the science of IQ and standard errors of measure interesting.

        I don’t listen to legal podcasts of any kind, but a good friend of mine is a philosopher and almost done with law school so he sent it my way. I had trouble parsing it given the foreign nature of the jargon used and the editing and splicing for time, but it seemed to me that the court and the lawyer really didn’t understand what it all meant in context and how that should be taken as a metric in determining a legal outcome.

        It also doesn’t go far enough in that the logical ramifications of absolution from the death penalty (which I am solidly against, in all cases but that is a different conversation) are not discussed. If we can argue that a mentally retarded person is somehow absolved from his crimes at what point do we draw the line on what is considered exculpable mental pathology and what is not? The reality is that someone like Jeffrey Dahmer has a neurocytochemical aberrancy that leads to his mental state of sociopathy and ultimate outcomes. If you or I had the same aberrancy with the same environment I believe it would be impossible to argue that we would have acted differently. The only difference lays in our inability to quantify and obviously point to the aberrancy and the sociocultural acceptance of what is and is not exculpatory which is completely arbitrary (or at least not grounded in consistent rationality and empirical data).

    4. mouse says:

      Do you have a point that is even slightly relevant to this article or even this blog?

      I mean “Bleeeerghh! – The United States has flaws!” Kinda a truism, but not particularily relevant.

      Oh wait, here’s a tiny thing, 19% of U.S. children on ADHD medication…citation needed. My source says closer to 6%

      http://www.cdc.gov/ncbddd/adhd/medicated.html

      See – we already more than cut the number of children using ADHD medication in the U.S. in half. I’m sure you are delighted! Of course, a number in isolation, without consideration of the correct diagnoses of ADHD, the cost/risks/benefits of medication is pretty pointless. Maybe 6% is too low or high or about right. Maybe the wrong 6% are getting medication. We can’t really know without looking at the evidence and the science.

      That is the point of the blog. I think it is a worthwhile effort. That is why people from all over the world come here and are so adamant about the evidence and the science. If you are interested in such things I encourage you to stick around and do some reading. Even if you aren’t into the focus of the site, debunking false health care claims, you might find some stuff of interest.

      But if you aren’t interested in evidence and science – and your comments here indicate you aren’t, then I recommend you take your irrelevant complaints about the U.S. somewhere where they will be more relevant. Go find a Tea party blog, IMO you guys desire each other.

      1. mouse says:

        Should say – deserve each other – not desire each other. Oy my brain.

      2. Alice says:

        Oh wait, here’s a tiny thing, 19% of U.S. children on ADHD medication…citation needed. My source says closer to 6%

        Medicating America’s children
        Beautiful minds
        Mar 1st 2014,
        http://www.economist.com/blogs/democracyinamerica/2014/03/medicating-america-s-children

        In America the number of children diagnosed with ADHD increased by an average of 3% each year from 1997 to 2006, then about 5% each year from 2003 to 2011, according to the CDC. By 2011 more than one in ten children and more than one in eight boys had been diagnosed with ADHD. In Kentucky a staggering 19% of children have been diagnosed with the disorder.

        1. WilliamLawrenceUtridge says:

          So…despite not knowing what a blog is, you are willing to cite them?

          Also, that number, 19%, is for Kentucky. You state this, attributing it to Kentucky, in an earlier comment, then make a more blanket statement later on, and Mouse appears to have taken the number as being from the entire US from that comment.

          May I point out that if both your and Mouse’s comments are accurate (a reasonable assumption given both of you cite sources), that means that there are states with rates considerably lower than 19%? Isn’t that a good thing?

          Also, so what? Why is this relevant to breast mammography? Don’t you tihnk the fact that Dr. Gorski is arguing for less, and better use of mammography to reduce overdiagnosis and overtreatment is therefore a very good thing? In other words, Dr. Gorski, an American, is agreeing with you about the flaws in American medicine, and is advocating for a change. Further, he is writing a general-public level post about the topic, ensuring that more people will be aware of and understand the issues. So why aren’t you celebrating? Why aren’t you praising Dr. Gorski’s work rather than excoriating him for issues he has no control over, no involvement with (he isn’t a pediatrician and thus would be extremely unlikely to prescribe ADHD to children), and weren’t actually the topic of this post?

          It appears you were quite thoroughly wrong and off the mark on this issue. Are you willing to admit this fact?

          1. mouse says:

            WLU – Thanks for pointing out that Alice’s source was a blog. I had missed that and was pretty discourage with the Economist…which typically has better journalism (IMO). It’s a pain in the rear that many of the more credible news outlets are hosting these blog sections that sometimes have far less oversight.

        2. mouse says:

          @Alice – That says 19% of children in Kentucky are diagnosed with ADHD. That is not children in U.S. taking medication. If you click on the link that the article gives, which is the same link I supplied above. The percentage of kids in Kentucky receiving medication is just above 10%.

          Also note it appears that Kentucky statistics are used in this article because they are the highest in the nation. That is not the national average, Kentucky has the highest rate of medication in the nation as well.

          A quote from the CDC statistics which your article used.

          “The prevalence of children 4-17 years of age taking ADHD medication increased from 4.8% in 2007 to 6.1% in 2011″

          I think you made some understandable mistakes in your reading of the statistic in the article. They are very easy mistakes to make. The article could have been much more clear, but I think it was more focused on make a point than being completely clear and accurate.

          I highly recommend the book, Damn Lies and Statistics by Joel Best. It talks about interpreting the statistics used in the media, political campaigns, etc. Even as a person with very minimal science/math training, I found the book very informative and entertaining. I think most people would find it even more approachable.

          In conclusion I’d like to note that your article is based on U.S. Center for Disease Control statistics. They received funding from our democratically elected government to track how children were being diagnosed and treated for ADHD. Why do you think we (as Americans) are employing people to track the rate of ADHD diagnoses and medication and publishing it for the whole world to see? Maybe one reason could be so that we can see where ADHD is possibly being over and under diagnosed and make efforts to correct those situations?

    5. WilliamLawrenceUtridge says:

      medicate even more than 19% of children for ADHD

      Yep, over-medicating kids due to ADHD is a problem, and a source of considerable debate in the medical literature.

      lower the IQ level to enable more executions

      Why would this be a goal? Who is helped by more executions? The company that sells the lethal injection? The electricity grid? Surely even in a worst case scenario you could see how that would be a minimally profitable part of any business.

      encourage an armed citizenry

      How is this a medical problem? Seems like you should be posting somewhere discussing the NRA, the primary drivers of gun ownership laws.

      maintain or increase the maternal and infant death rate

      Again, who benefits? What is your reasoning? Why would anyone want to kill mothers and children?

      pay doctors to medicate more Medicaid and Medicare patients

      Again, who benefits? Both programs are paid out of taxes, this costs the government money. What, the hospitals? Do they benefit? But then they have to pay doctors more too. Doesn’t seem like a good investment.

      I’m just not sure what you’re so incensed about, and why you are so focused on a country you don’t apparently live in. Is your homeland some sort of utopia? Do they accept immigrants?

  38. Dave says:

    I agree with Alice that overmedication and polypharmacy is a problem here. However, the issue is not medicating people, it is inappropriately medicating people. I put lots of Medicare patients on pills. If they have congestive heart failure, I try to make sure they are appropriately medicated with an ACE inhibitor, a beta blocker, spironolactone, and oftentimes a diuretic, all of which have been proven in randomized trials to make people feel better, prevent hospitalizations, and prolong life. If they have atrial fib I prescribe rate-controlling meds and appropriate anticoagulants to prevent strokes. Science based medicine is important to weed out what meds are inappropriate and fortunately there are signs of some headway here with the Choose Wisely program. A recent example is the change in hypertension guidelines, which opt for less medication of elderly patients. These issues are very complicated. When presented with a problem there’s a tendency to want to fix it, whether it be a heart attack or depression and anxiety. As has been quoted earlier in this site, Americans do not have good cultural tools for accepting a bad situation. If you go to a surgeon with a problem he’ll think of a surgical solution, a medical doctor may try pills, an accupuncturist will try needles and a reiki therapist will try modulating energy fields. None of these approaches are necessarily evil, but they may be ineffective or inappropriate, or at worst cause more problems than they solve. How do we determine which without studies? I have to agree with Alice that I wish the site would spend more time on mainstream medical practices which might be ineffective but I don’t choose the topics.

    I don’t do pediatrics and so have limited experience in ADHD. However, I volunteered to belay a group of disadvantaged children at a local climbing wall once, and one of the boys clearly had ADHD. It basically took the attention of one adult to monitor him so that he didn’t scamper up the wall unroped or get into other trouble. Considering that we had 4 adults and about 20 kids, this was significant. It made me realize that some kids have a real problem and need help. Maybe meds help kids like him.

    Much of the rancor here is the xenophobic issue. I could be wrong, but my feeling is that most people in every culture try to do a good job and most people are motivated to some degree by altruism. There’s been a lot written on altruism even dissecting the evolutionary underpinnings of it. However, most people feel good when they do a good job and bad when they don’t. They feel good when they help someone else and bad when they don’t, it’s not too complicated. A bad system can beat down a worker to the point he just doesn’t care. A small percentage of the population are true sociopaths and have absolutely no empathy or concern for others, A small percentage are corrupt and do anything to advance their own wealth and power. A small percentage are driven by hate. This is in any culture and those people create major problems for the rest of us.

    Finally, and then I’ll shut up. I read an editorial in JAMA a few years back that made me examine how I judge other people. It was by a female physician in the US who was born and raised in the Middle East and was planning on going back there, and she was writing about the attitude of Middle Eastern men towards women. She stated that most men in the Middle East love their wives and daughters as much as any men anywhere, to the point of being overly protective towards them – not allowing a daughter to go out with an uncle or other man to accompany her, etc. What went through my mind when I read the article was an image of men in the middle east sitting around a table, reading the statistics of rape and sexual assault in the western world (which are frightening) and wondering how western men could have such disregard for their daughters and wives as to let them go out without protection. Note I am in no way defending the terrible oppression of women in the middle east. I am pointing out a cultural difference, and the article was written by a woman. You have to be very careful about judging others.

    Enough said. Sorry for being longwinded

    1. Dave says:

      Sorry, the above should read “not allowing them to go out WITHOUT an uncle”. I could use some proofreading and typing improvement.

    2. WilliamLawrenceUtridge says:

      Hi Dave,

      They do accept guest posts you know, any systematic analysis of the problems of polypharmacy and overdiagnosis would be an interesting read. Speaking of which, have you read Welch’s Overdiagnosed? I just finished it on Dr. Gorski’s recommendation, and it was excellent. A bit terrifying though.

      Regards xenophobia, the problems are ubiquitous to humanity, as you say they are absolutely not limited to the United States. The US might, or might not, have more of them – but it definitely has an active, uncensored press and a national support for vigorous dialogue. Not to mention high visibility throughout the world. Meanwhile other countries may protest that they lack the flaws of the US (much like Iraq completely lacks homosexuals, by government fiat), but that’s merely national denial.

      . Note I am in no way defending the terrible oppression of women in the middle east. I am pointing out a cultural difference, and the article was written by a woman. You have to be very careful about judging others.

      One must also wonder about the cultural pressures that prevent the reporting of rape, in particular incest, in said countries. I wonder if the act of only being constantly escorted by an uncle, brother or father decreases such incidents, or creates more opportunities for a culturally vulnerable segment of the population – both through proximity and through the pressure to remain silent in order to not disgrace the family. Not that by any means the US is immune to such problems, far from it. And that’s rather the point – we are all humans, and thus we are all vulnerable across all societies.

  39. Dave says:

    Alice, you might also want to look up “argumentum ad hominem”. This is a logical fallacy wherein an individual disagreeing with another person who has an opposing view attacks that other person rather than the person’s arguments. “You can’t be right because you’re from America and everyone knows all Americans are stupid and corrupt” would be an example of this. It’s used often (Cicero used it in a sly fashion) because it’s emotionally effective, but it’s also obvious and easy to call people out on.

    1. Alice says:

      Because it is emotionally effective and easy to call people out on, it can also be a useful tool to quickly assess the authenticity of a website, participants values, culture and degree of moderation used within the site.

      For over 6 years I have been a participant in 2 other American forums (travel and travel scams). 95% of the participants are American residents and the subject attracts participants from all over. I am very well aware that conversation around American education, corruption, statistic collection, health care, capital punishment and guns can bring forth a lot of emotional discussion.

      To be honest, I was convinced that this was a scam site and I didn’t intend to stick around. The xenophobic insults have cut hard and I do regret startling and offending the participants here with such a rude assault. I would much prefer to feel smug and self satisfied that I’ve saved someone from being scammed.

      To whoever put that item called a pingback No 42, it is very interesting.

      1. WilliamLawrenceUtridge says:

        So your way of “testing” a website is to show up, be an asshole, and rate the response?

        Sounds dickish, and kinda like you’re not worth talking to. Have you tried reading the articles and determining if the content makes the site worth reading?

        1. mouse says:

          I think that last comment from Alice was a sort of apology, WLU.

          She does say she regrets startling and offending with a rude assault.

          I’m sure many of us have put our foot in it when getting used to a new social venues. It’s often a learning experience.

          I know the first time I visited Orac’s site, it was a REAL learning experience for me. (grim laughter).

          1. WilliamLawrenceUtridge says:

            I hope she sees the chilly and critical response as an indication of the consequences of her strategy. I hope she sees the alienation, loss of credit, and unwillingness to grant her more than a modicum of respect as another.

            These are pretty natural consequences to showing up in a group of monkeys and calling all the monkeys involved “corrupt idiots”. I don’t really think she can reasonably expect that all hurt feelings and contempt to be resolve through a half apology.

            Plus, a stupid strategy should be called stupid.

            1. weing says:

              My feelings don’t get hurt by those types of accusations. I know better. It just shows the accusers lack of knowledge and crudeness.

            2. mouse says:

              Okay, yeah. I’ll agree with you there. I think some admission of a flawed approach is better than nothing. But my characterization of Alice’s insults as an unintentional mis-step due to lack of understanding of venue was unrealistically Polly Anna.

              I’m writing a lecture on my artwork and I am trying to pretend EVERYONE in the world is very generous, uncritical and friendly today, so I can actually finish the job without major anxiety at the thought of standing up in front of people and presenting. ;)

              Doh – to late. Make that more anxiety than necessary.

              1. mouse says:

                Opps, my above comment should have been addressed to WLU comment “I hope she sees the chilly and critical response as an indication of the consequences of her strategy. “

              2. Alice says:

                Dear little Mouse, I decided to make one last post because I saw the name Polly Anna and I thought I would tell you a funny story. My American forum friends sometimes call me PollyAnna (they think I’m terribly silly) and I confessed to them that I found some “American scammers” and thought I would teach them a lesson. They laughed when I told them I became PollyAnna (Alice?) the Flame Warrior and they came to take a look. Apparently, I’m a terrible Flame Warrior (you need to be computer literate for a start). Now I’m getting in trouble from not only my American friends but also my grandchildren. Apparently Flame Warriors don’t come back and tell people to be careful about of posting personal information on the internet -who knew? So little mouse, stand up, do that presentation and think of Alice who turns 78 years old in 2 days time and made a fool of herself to friends and family. Enjoy.

              3. mouse says:

                @Alice – LOL! The hazards of the internet! Thanks and best of luck with your online adventures…try to stay out of trouble. ;)

              4. Chris says:

                Some advice I read when we first came online with a phone modem and a Compuserve account on what to do before you make your first comment:

                1: Lurk a while. Read the articles and then the comments. Get a feel for a place by getting to know the folks who regularly comment.

                2: Read your comment to yourself before hitting “Submit.” Make sure it is grammatically correct and is in the “voice” you that actually represents you. Do not use “TXT” speech if that is not what it being used at that site.

              5. Windriven says:

                Alice said, “So little mouse, stand up, do that presentation and think of Alice who turns 78 years old in 2 days time and made a fool of herself to friends and family. ”

                I had imagined.Alice to be a nasty, self-absorbed, not-too-bright teenager. Perhaps I confused youthful arrogance with incipient dementia in which case I owe Alice an apology. I would proffer this apology but for the fear that she would confuse me with her cousin Mildred and misunderstand the apology as an invitation to enjoy a second piece of baklava.

            3. mouse says:

              WLU “These are pretty natural consequences to showing up in a group of monkeys and calling all the monkeys involved “corrupt idiots”.

              Well, technically the monkeys probably couldn’t care less if you called them corrupt idiots….unless they are monkeys especially trained to understand english and even then I’m not sure that monkeys have the language capability to get verbal insults.

              Ahhhh, procrastination.

          2. Windriven says:

            @WLU
            Well said.

            @mouse
            Piss-poor apology; too little, too late.

  40. Self Skeptic says:

    If we’re done with that, I think I’ll ask my question again, as it never got answered. (See comment #33.) BTW, I agree that the original post was both well-written, and well-considered. And I congratulate Dr. G on his latest paper. It looks good. I plan to read it in detail, when I have time to do the background reading, as it’s a little far from my area.

    Dr. Gorski,
    Why do you think that mammography guidelines are likely to be modified “within a year”? (See the last paragraph of the original post in this thread.) I’ve been looking at more details about the history and current politics of this issue, and I don’t see any sign of movement among the radiologists. Handel Reynolds’ short and readable 2013 book The BIg Squeeze was no exception; after a reasonable view of the history of the controversy, he just said, in an apparent non-sequitur, Mammography saves lives, and gave a paragraph of support for the current guidelines. (He’s a signatory on the ACR’s current guidelines, which were updated in 2013, and as you know, still recommend annual screening mammography for all women of average risk over age 40.)

    I agree with you that the evidence doesn’t support this policy; it hasn’t, for a long time. The 1997 NIH panel of non-radiologists made that pretty clear, and as you pointed out, even before that it didn’t look very good, whenever evidence rather than wishful thinking was considered. I don’t see that anything is very different now, than it was back then.

    The American Cancer Society (powerful in communication) and National Cancer Institutes (powerful in medical academia) have always supported the radiologists, who are, after all, the ranking medical experts and authorities on mammography. So far, the ACR and the ACS have explicitly committed to discrediting the Canadian study, and also evoking the irrelevant, but dependably inflammatory, meme of rationing. I think the NCI hasn’t said anything, officially, yet; but I can’t quite see it suddenly reversing itself, even with someone like Harold Varmus at the helm, trying to keep it real.

    So the appearance of revised guidelines from the ACR, who are the ranking experts, seems unlikely to me. The current guidelines made in 2013 won’t “sunset” until 2018. I could be wrong, and politics is always unpredictable. Please let me know if I’m missing something here.

    1. Windriven says:

      ” I don’t see any sign of movement among the radiologists.”

      Radiologists are not usually primary providers. That is to say that a radiologist isn’t usually involved until a PCP orders the test.

      And while radiologists are, as you say, are the ranking experts on mammography, their expertise is in performing the tests and interpreting the results. Epidemiologists, oncologists, public health specialists, and governmental and private sector third party payers all have dogs in the fight. Radiologists have their words, but they won’t be the last words.

      1. Self Skeptic says:

        Windriven,
        I think there are some things about how medicine is organized that you haven’t examined (yet). The role of specialist societies and their guidelines is very important, both in setting the standard of care we all get when we see our doctors, and in affecting malpractice legal defenses and prosecutions.

        It’s possible that other groups will put great pressure on the radiologists to change their guidelines; and maybe Dr. Gorski will know if that’s being done. It seems doubtful to me; I’m getting the impression that there’s usually a hands-off policy between specialties, and the turf is divided up, so that breast imaging falls squarely into the American College of Radiology’s (ACR) domain. The radiologists seem to be no slouches at political activity, and seem to know what they want on this issue: see this, for example:
        http://www.acr.org/Advocacy/eNews

        In the February 21, 2014 Issue

        ACR Amplifies Critiques of Flawed Mammo Study
        CMS Considers Episode-based Payment Models for Specialty Care
        Regulatory Affairs Update: PCORI Accepting Letters of Intent for Large Pragmatic Clinical Studies Initiative
        Radiology Represented at RUC Meeting
        ACR Leads the Effort on Lung Cancer Screening
        ICD-10 Debate Intensifies on Capitol Hill
        Contact Your Member of Congress Today!

        and this:
        http://www.acr.org/News-Publications/News/News-Articles/2014/ACR/BMJ-Article-on-Breast-Cancer-Screening-Effectiveness-Incredibly-Flawed-and-Misleading

        and this:
        http://www.acr.org/Advocacy/ACR-Video

        But I’m also sure that there are some messy borders and turf wars going on here and there; even the most rigidly organized system has some of those. Knowing what is typical, doesn’t mean that is what will happen in this particular case. Again, Dr. Gorski is most likely to know about those, of all the people here. I asked him specifically, because he said he thought there would be new guidelines “within a year,” and that until then, he will support the old guidelines, despite being convinced they need tweaking.

        I’m looking forward to his answer.

        1. Andrey Pavlov says:

          You know SS, the answer is plain as day if you just took a second to read it.

          I asked him specifically, because he said he thought there would be new guidelines “within a year,” and that until then, he will support the old guidelines, despite being convinced they need tweaking.

          The “within a year” comes from the linked article in the Atlantic where “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.”

          So the guidelines are expected within the year, as per the best source for whether that is the case or not. The new study is to be taken into account when making those guidelines. Dr. Gorski is reasonably convinced that the data from the study is large and compelling enough that thoughtful consideration – which is precisely what Wender has explicitly said will happen – would change guidelines.

          I mean really, it is that simple.

          As for the idea he “supports the old guidelines, despite the need for tweaking”…. yeah, that’s kind of an obvious way to handle it as a clinician. The guidelines he is referring to are the USPTF guidelines which recommend mammography at >50 years of age. And he will take a more “personalized” approach to those women between 40-49 years of age.

          What, exactly, is the problem with this particular tack? And do you seriously not comprehend from whence the “within a year” prognostication came from?

        2. Self Skeptic says:

          Andrey,
          It’s not clear to me, what to say to you. We’re coming from very different places. So I’ll just have to be straightforward, speaking from my own place, and you’ll hear whatever comes through the static, and probably get annoyed by it. So be it.

          I don’t think you’re equipped to understand my question, about why one would believe that the ACS guidelines would change, in response to the Canadian study. That’s nothing to be ashamed of; I can see it might be better if someone who has just graduated from medical school doesn’t know much about the politics of clinical guidelines. Idealism is appropriate, at your stage of education. Your job as an intern will be to apply current guidelines as best as you can to the patients you see. There’s not going to be time to think about how guidelines are made, or to dabble in medical politics, in any intelligent and well-informed way.

          I think the situation is different for Dr. Gorski. He is old enough to know better, and enthusiastic about exposing, and harshly judging, medical scams. That’s why I addressed my question to him. He is apparently not going to answer it. This suggests that he isn’t interested in discussing, in detail, how the medical establishment is really working, in regard to this subject. That’s useful to me; it shows me one of the points at which attempts to make mainstream medicine more science-based, break down. It’s unusual for an MD to go as far as this post does, in perusing the science, and I do appreciate Dr. Gorski’s sharing this with us.

          It also provides further confirmation that, even if an MD understands that the science doesn’t support current guidelines, he isn’t going to break rank with his colleagues, in his clinical behavior. A few MDs do; but it’s not safe, and leads to being shunned by peers, rather than respected. In general, it’s silly to expect any but a few, in any population, to be heroes. They are so rare there is no point in discussing them, or their fates, here.

          This is one of the watershed differences in ethical values, between science and medicine. In science, the prime professional duty is to the physical truth, insofar as it can be ascertained. We are expected to stand up for it, even if it inconveniences a large lucrative industry, or the head of our department. Successful scientists don’t continue designing experiments that depend on information they’ve found not to be true, even if their whole field still believes it is is true; that would be an exercise in futility. (Not everyone meets this ideal, of course; I’m sure plenty of mediocre scientists don’t trust their own judgment enough to diverge from popular opinion in their field, even when they could know better.) There’s no guarantee of success, in persuading people that a popular working hypothesis is wrong, and should be demoted. But, we all know that this is what a scientist should do, and the good ones do it.

          In medicine, the prime professional duty is loyalty to one’s peers, and one’s place in the hierarchy. There is an unexamined assumption running throughout mainstream medicine, that it is ethically wrong, to publicly flout a set of clinical guidelines made by a plausible group of experts. So no matter how obvious a case an individual doctor may make, that this “legitimate” guideline is wrong, he is still enjoined by his professional ethics to follow it, anyway. I’ve seen this reversal from presenting evidence that the guideline is wrong, to recommending people follow it anyway, many times now, in several different disease fields. Though it is jarring, even shocking, to a scientist, is accepted as business as usual, by the medical community. The duty of maintaining unanimity is greater than the duty to examine and follow the evidence. This slows down scientific progress in medicine to a crawl.

          As I’ve said before, I can see that there are practical reasons for this value in medicine, like avoiding malpractice liability, nipping cranks in the bud, or not shaking the public’s faith in medicine by disagreeing. But it’s not an attitude that is respectful of science; quite the contrary. It says that social and political considerations trump science, whenever they might possibly conflict.

          It seems important to me that someone point out this difference in scientific and medical values. Especially since it doesn’t seem to ring a bell, among the doctors here, that whenever this reversal happens, the chain of logic has just been broken, and science has been thrown out the window.

          1. Andrey Pavlov says:

            Sorry SS, but I think you are still off base.

            I don’t think you’re equipped to understand my question, about why one would believe that the ACS guidelines would change, in response to the Canadian study.

            I’m well equipped. But you are confabulating your questions. You asked, repeatedly, from whence Dr. Gorski could possibly extrapolate the time frame. You even put that in quotes, repeatedly. Now you are shifting the question to “do you think it is politically tenable” which is a different beast.

            But even then, I’d say your answer is still there. The USPTF guidelines changed despite the wailing and gnashing of teeth and cries that they were attempted to kill women to save money.

            And yes, I am equipped to understand it. I do not know, in great detail or through personal experience, what all the non-scientific reasons for holding up changes such as that are. But you think me much too naive. On the flipside, it is you that have shown you are not equipped to understand how medicine does not and cannot function precisely as a “pure” or “hard” science would. And that is where you keep bashing your head into a wall and making what we here, myself included, see as very amateur mistakes.

            This suggests that he isn’t interested in discussing, in detail, how the medical establishment is really working, in regard to this subject. That’s useful to me; it shows me one of the points at which attempts to make mainstream medicine more science-based, break down.

            You think too highly of yourself. It is much more likely that he is busy and doesn’t have the desire to continue wasting time addressing amateurish complaints and questions regarding medicine. No doubt you know your science, but you are dealing with medicine over here. Doctors in a hospital do not and cannot work like physicists at CERN.

            It also provides further confirmation that, even if an MD understands that the science doesn’t support current guidelines, he isn’t going to break rank with his colleagues, in his clinical behavior.

            No, it doesn’t. It shows that you don’t know what you are talking about. The data does support (much more closely at least) the newly revised USPTF guidelines, which is what Dr. Gorski follows (with necessary adjustments as needed). The ACS guidelines are NOT supported by the data but they are different to the USPTF guidelines.

            A few MDs do; but it’s not safe, and leads to being shunned by peers, rather than respected.

            LOL. And this is what I mean by amateur analysis. We don’t feel compelled to stick to guidelines so we can hang out with our colleagues in the break room. We do so first and foremost because we tend to believe them to be the likeliest to be of benefit to our patients. But secondarily we do so, sometimes when we disagree with them, because that is how the law is structured. Malpractice and negligence are defined as relative to the standards of our peers and our profession. And even if our profession is wrong based on the data, that is not a legal protection. So if harm comes to a patient and we were within standard of care/guidelines we have legal protection. If we were outside of them, we do not. Granted, I agree that has its distinct drawbacks and problems, but the point here is that you make very confident statements that are not based in reality.

            In medicine, the prime professional duty is loyalty to one’s peers, and one’s place in the hierarchy.

            Amateur hour part deux. No, SS. Our prime professional duty is loyalty to our patients. If you only saw how much arguing there is behind the scenes when trying to decide a course of action for our patient care. Sure, individual bias can and does creep in under the guise of patient advocacy. But the point is that we argue with that in mind (truthfully or not) not the acceptance of our colleagues. Yet again you make a statement about how the medical world works that is a swing and a miss.

            There is an unexamined assumption running throughout mainstream medicine, that it is ethically wrong, to publicly flout a set of clinical guidelines made by a plausible group of experts.

            Ridiculous. You need to stop sniffing whatever reagents you work with. Ever heard of the most popular and rich physician in the US? His name is Mehmet Oz. And he makes a living off of bucking clinical guidelines. So much so the FDA issued an official letter reprimanding him for being so irresponsible. And it pains me to wander around the halls of the hospital and hear so many nurses and doctors speak positively of him. I even had an argument with an ER attending many years back as he was trying to defend Oz as a great new thinker.

            But thank you for attempting to (thinly) veil your condescension. You’ll find I’ll pay you the greater kindness of not veiling mine and plainly pointing out that you haven’t the relevant tools or understanding to parse how medicine actually works and why it cannot be made to model after particle physics.

          2. weing says:

            “It also provides further confirmation that, even if an MD understands that the science doesn’t support current guidelines, he isn’t going to break rank with his colleagues, in his clinical behavior.”
            As determined by fountains of wisdom like you? Maybe you are missing something? You seem to be seeking absolute certainty when guidelines only point in a general direction.

  41. Instead of “Bat Cancer Signal”, how about “Cancer Batsignal”?

  42. PMoran says:

    SS: “It also provides further confirmation that, even if an MD understands that the science doesn’t support current guidelines, he isn’t going to break rank with his colleagues, in his clinical behaviour.”

    I am sympathetic to some aspects of what you say, but not that this is an example of tribal allegiance.

    The evidence is worrying but not conclusive. We have to take into account that mortality rates from breast cancer have fallen substantially in the last few decades, during which mammographic screening has been an major element in overall management.

    While we must suspect that most of that change is due to better adjuvant treatment, it would be irresponsible on the basis of the present evidence to go back to forms of surveillance (or no surveillance) which we know will have no benefit on breast cancer mortality and which will inevitably lead to us having to deal with more of the more advanced cancers, ones that often require more drastic surgery and other treatments. There remain considerable advantages other than survival to treating breast cancer early e.g. lower rates of treatment-induced lymphedema.

    Time to stop and think, perhaps, and to re-evaluate what we are doing, It would be quite wrong to abruptly change course.

    1. Windriven says:

      Peter.
      What is the current practice in Australia regarding mammography? If it is remarkably different from that in the US, any future divergence (or absence of any) in mortality might provide some hints as to the actual utility of screening mammography (though admittedly there are a flurry of possible confounders).

    2. Self Skeptic says:

      PMoran,

      Thanks for responding; you raise good issues.

      I can see that you have no reason to support a change in the guidelines, as, unlike Dr. Gorski, you don’t think they are challenged by current evidence. So the dilemma I’m analyzing, doesn’t exist for you. Nevertheless, I’m glad to look into what you’re saying.

      There is a significant difference between the dominant US mammography guidelines, which recommend annual mammograms after age 40, and Australian ones, which recommend screening every two years, between ages 50 and 75, though they provide free screening on request to women of other ages. (In the US, the less aggressive USPSTF guidelines that Andrey keeps mentioning were reached by a committee independent of the radiologists, and were rejected; the “annually after 40″ guidelines of the ACR (radiologists) are currently supported by the American Cancer Society, the National Cancer Institute, and the American College of Surgeons. The American Cancer Society guidelines are the ones to which Dr. Gorski refers in his last paragraph, and are the ones which I have been questioning.)

      Here in the US where Dr. Gorski and I live, the elimination of all screening mammography isn’t on the table. The current issue here, would be to eliminate some of the harms of overdiagnosis and unnecessary treatment, by not recommending the annual screening of a population that is especially prone to over-diagnosis: women between the age of 40 and 49.

      Which set of guidelines do you support?

      The SBM-relevant problem I’m pinpointing, is specific to the problem of what a physician should do once he or she realizes that the data indicates that a guideline is probably doing more harm than good. I don’t know how it is in Australia; but in the US, it creates a moral dilemma, because it isn’t professionally or legally safe, to not follow guidelines, even if there is good evidence against them.

      The easiest and most common approach, to decrease this cognitive dissonance, is to avoid acknowledging any evidence that the guidelines are wrong. Then one can follow the guidelines with a clear conscience, and be safe from legal or professional trouble. But, obviously, this is the opposite of science-based medicine, in its literal sense.

      Some of us, including Dr. G, are in the uncomfortable position of being educated enough in science, to recognize it, when the guidelines aren’t supported by the evidence. (I don’t think MD training alone, prepares people for that; though to be fair, I’m sure plenty of PhD’s are too dependent on authority to get it, either.) I appreciate this, and it’s unfortunate that I need to impose on his honesty, to point out the contradiction between what the Science-based Medicine blog claims to support, and what actual mainstream medical practice in the US demands, which is allegiance to guidelines, unfortunately written by specialty society representatives, rather than (relatively) unbiased scientific analysts.

      Regarding your assertion, that reducing screening
      “…will inevitably lead to us having to deal with more of the more advanced cancers, ones that often require more drastic surgery and other treatments…”

      There are two reasons this appealing idea is questionable, on closer examination. (#1) One is that unnecessary cancer treatment, because it is so drastic (and potentially carcinogenic) in itself, can’t reasonably be externalized from the discussion. (#2) The other is that there doesn’t actually seem to be any reduction in advanced cancers, due to screening.

      Looking at issue #1:
      An over-diagnosis and unnecessary treatment rate of even the lower estimate of 20%, is definitely not a negligible harm. Cancer treatment is, necessarily but unfortunately, toxic, carcinogenic, and mutilating, so the harms are not trivial. Your rate of overdiagnosis in Australia may be lower, and our rate in the US is probably higher, since we do more frequent screening, and include a younger population than any other country. But the point stands.

      See comment 6, and Madison MD’s reply to it:

      MadisonMD says:
      February 17, 2014 at 11:48 pm
      “could it possibly reduce the impacts of treatment, e.g., lumpectomy instead of mastectomy, radiation but no chemo versus radiation and chemo, etc.”

      It could reduce the impacts of treatment by detecting earlier stage cancer. However, this is countered by the increased diagnosis of cancer that may not have required treatment at all…
      snip

      Regarding point #2, that it’s not clear that mammography screening actually does reduce the incidence of more advanced cancers:
      See Dr. Gorski’s answer to comment #30, above:

      David Gorski says:
      March 5, 2014 at 4:24 pm
      snip
      The Bleyer/Welch NEJM study from 2012 pretty well demonstrated that the diagnosis of more advanced cancers hasn’t decreased by nearly as much as the diagnosis of small cancers has increased. In other words, screening mammography hasn’t shifted the diagnosis curve towards less advanced cancers very much, which is what one expects if earlier treatment always (or at least frequently) leads to a higher chance of curative treatment.
      snip

      Of course, I welcome any plausible data-based challenges to this, and I respect your need to follow your own judgment on these difficult issues, which are to some extent value-driven rather than scientific, as Dr. G rightly pointed out.

      This comment is getting quite long: I’ll save my response to your other points for later.

      1. MadisonMD says:

        @SS

        In the US, the less aggressive USPSTF guidelines that Andrey keeps mentioning were reached by a committee independent of the radiologists, and were rejected

        Not true. My university-based health system adopted the USPSTF guidelines. Yes, some of the radiologists disagreed based on poor arguments– Like Peter Fisher’s@30 above and like the Kopans letters, which Dr. Gorski handled adroitly.

        I think Peter Moran is also right on the money and of course his strongest argument is regard to mortality. Peter clearly understands the limitations to the mortality argument (other interventions confound the effect of mammography) and uses the non-mortality evidence (e.g. diagnosis at earlier stage) only as supporting evidence. SS, you accurately point out the flaws in the non-mortality supporting evidence.

        So I don’t really see any disagreement here.

        Keep in mind that the best evidence compiled and used for USPTF recommendations suggested that the mortality benefit of annual screening for average risk women age 40-49 was 1 in 1934 (if I remember correctly). So it is a bit of judgement call whether it is worth screening 2000 women to save one life (also consider that given the younger age, more years of life are saved than when you screen older women). USPTF, and my health system says no. ACS and ACR say yes. It’s not really a black/white issue and these estimates may change given new data.

        So it seems like you are getting a lot of agreement here, SS, except that it is not a clear-cut black/white issue, even with the new evidence.

        1. Self Skeptic says:

          Thanks, Madison.
          I was intrigued by your university’s using the USPSTF, as I hadn’t seen anyone using it. So I looked around.

          At first I assumed you were at U. of Wisconsin, in Madison (probably because some of my friends and colleagues studied there, so it’s at the top of my mind when I hear “Madison.”)

          But when I typed “u of wisconsin mammography guidelines” into Bing, and it gave me a list of links, they were all to the radiology department.
          Here are their guidelines:
          http://www.uwhealth.org/radiology/breast-imaging-guidelines/20654
          Note that it says:

          snip
          Routine, annual, asymptomatic, no new problems
          Annually after age 40 Average Risk
          Annually after age 30 for High Risk Surveillence. The new guideline is published in the latest issue of the ACS journal CA: A Cancer Journal for Clinicians.
          snip

          These are the ACR (radiologist’s) guidelines.

          Then I realized that you’re probably not at U. of Wisc. at Madison after all. So I typed “madison USPSTF mammography guidelines” into Bing, and got this:

          http://depts.washington.edu/madclin/providers/guidelines/breast.html

          Here, there is a much more informative description of the different guidelines and who supports them. So, my congrats to University of Washington, for taking a more educational approach to its patients. This is the first place I’ve found that seriously and explicitly discusses the USPSTF guidelines.

          I realize I don’t know where you are, Madison MD, and that’s fine; it doesn’t matter to the point under discussion.

          I looked around some more, to see what other major universities and research institutes recommend. There is a big group of them called the NCCN (National Comprehensive Cancer Network) which includes Hopkins, Yale, Harvard, Stanford, Mayo, and slew of other biggies:
          http://www.nccn.org/members/network.asp

          They all use the ACR/ACS guidelines:
          http://demystifyingmedicine.od.nih.gov/DM10/0413-BreastCancer/NCCN%20breast-screening.pdf

          Here is Dr. G’s institution’s recommendation sheet:
          http://www.karmanos.org/upload/docs/Patient%20and%20Visitors/Fact%20Sheets/womens%20screening%20doublemay2013.pdf

          It provides some wiggle room, by using ambiguous language. It says, “Karmanos continues to recommend women 40 and older receive mammograms every year, based on a discussion of the risks and benefits of mammograms with their health care professional.”
          That’s clever; it should both satisfy the radiologists, and leave room for dissenting individual doctors.

          The lawsuit problem Dave mentioned still stands; presumably a patient can say that the standard of care requires a doctor to recommend annual mammograms after age forty, and if he doesn’t, he’s liable. But, if the doctor’s home institution hasn’t specifically laid down guidelinesm and if it will stand by him, presumably he could fight, based on the USPSTF guidelines, and perhaps win?

          Granted, all medicine isn’t necessarily conducted with fear of lawsuits in mind. One of my family’s doctors could be sued for breaking guidelines, but his willingness to break guidelines is why we see him. He doesn’t take insurance, and that helps keep the threat down.

          Dave, the idea of being sued, or of dealing with lawyers for any reason, fills me with dread, so I’m not trivializing it. I regard a credible threat of litigation to be a serious form of coersion; no one is obligated to do anything, including break questionable medical guidelines, that opens them up to that, in my view.

          1. MadisonMD says:

            @SS

            It provides some wiggle room, by using ambiguous language. It says, “Karmanos continues to recommend women 40 and older receive mammograms every year, based on a discussion of the risks and benefits of mammograms with their health care professional.”
            That’s clever; it should both satisfy the radiologists, and leave room for dissenting individual doctors.

            Actually, it follows USPSTF fairly closely. Here’s what USPSTF says:

            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.
            Grade: C recommendation.

            Regarding UW Madison, the website does not appear entirely consistent between the radiology website (thanks for pointing out that they are recommending ACR guidelines–interesting actually, but not surprising) and the health-system decision on part of primary care which adopted USPSTF type shared-decision making. See here, here, and here.

            You do have a point here, SS. There is a lot of pushback by radiology as evidenced above. (Still it is not a completely black/white issue.) I would hope we could adopt an appropriate risk-adapted approach.

          2. weing says:

            “I regard a credible threat of litigation to be a serious form of coersion; no one is obligated to do anything, including break questionable medical guidelines, that opens them up to that, in my view.”

            Not sure what you mean by that. Guidelines are just guidelines, they are frequent broken too. You have to document a cogent reason for breaking them and document that the patient is party to the decision. So I really don’t see any coercion here. I do think our knowledge is incomplete. What you seem to be asking for is the equivalent of asking the physicist for the exact position and velocity of an electron.

            1. Self Skeptic says:

              Weing,
              It sounds as if this could work, for a doctor who doesn’t fear being sued by a patient, or questioned by peers/superiors for not following the “standard of care.” But maybe you’re talking about cases where the patient has specifically said they don’t want the standard of care. That’s different, than what we’re talking about here, where there is good evidence that the US guidelines that are widely followed, have been skewed in a non-scientific direction, by the specialty society assumed to have the best expert authority. (Presumably, they are true-believers in the grip of group-think, rather than conscious scammers; but we’ve already established that whether something is quackery doesn’t depend on the conscious motives of the promoter, so that’s irrelevant. )

              I would be interested in knowing how this plays out, in practice.

              Have you ever broken dominant guidelines (that is, failed to follow the “standard of care”) because you think they are wrong? If so, how often? I won’t ask which guidelines, because that might get you in trouble with your peers here, many of whom think that it is impossible to detect which guidelines are scientifically unjustified.

      2. PMoran says:

        SS, that’s a different matter.

        it is true that the US has always had more aggressive ,mammography guidelines than many other countries (at least England and Australia and parts of Europe ), but I assumed that could largely be explained by the fact that the guidelines in those countries formed the basis for self-standing, entirely taxpayer-funded, screening programs. They aimed at keeping cost-effectiveness (cost per life saved) very high.

        The US guidelines, I suspect, are more advisory? –i.e. what was thought reasonable for anyone to do if, say, if wanting to give themselves the near-best possible chance of avoiding death from breast cancer (obviously, on the data available at that time). Also who would be surprised at different standards for cost-effectiveness in any medical scenario in the US?

        With regard to your understanding that radiological screening is not reducing treatment morbidity as much as we hoped, that may also be true, while bearing in mind that mammography came in when there was already very high breast cancer awareness in the public and a strong medical push for earlier diagnosis.

        But mainly, reducing morbidity should be regarded as a work- in-progress. Nothing stands still in medicine. I am hopeful that the next major advance in breast cancer management will be the ability to select out those early cases that can be treated by tiny little excisions or ablations alone, or even by observation.

        This would reduce overall morbidity substantially as well as resolving some of the issues in relation to over-diagnosis i.e. non-dangerous cancers.

  43. Dave says:

    SS, you wax very long on what doctors think (actually on what you think they think, which is a very different matter), about their blindly following guidelines (though in this matter you have to choose which guideline to follow) etc. I have one question – what would you recommend to an average risk woman the age of 45 , another the age of 55, and another who has found that she has a mutation in a gene other than BCRCA 1 or two associated with breast cancer (there are dozens, and the degree of risk is not known for many of them). You’ve obviously studied this, in your mind obtaining more knowledge than physicians have. Assume also that you will be held responsible for the outcome of your advice and your patient will suffer the consequences. I’d like to see your response.

    For others, the current issue of the journal Science has a number of articles on breast cancer. One article on DCIS has a graph of the incidence of localized, regional and in situ breast cancer incidence in the US from 1975 to 2005. Since screening became widespread in 1980 the incidence of localized and in situ cancers has risen, since more are detected. That of regional cancer has been flat. If early detection worked as was expected back in 1985 the incidence of regional cancer should have fallen. I think most physicians are very aware that the outcome of this disease depends a lot on the biological behavior of the individual’s cancer more than when it is detected. Does it then follow that we should quit looking for early disease, especially in view of other studies showing better outcomes in women over fifty?

    The following is a quote from an attorney, Fran Visco, for the National Breast Cancer Coalition from the article on DCIS:
    “We keep running down these roads putting a lot of time and money behind things but…. we don’t have the basic information that we need.” Her advice to women with DCIS is to study the data and balance the risks and benefits for themselves, because “we don’t really know the answer”.

    In the face of not having enough basic information, a decision still needs to be made to do or not do screening. I think there’s some wisdom in P Moran’s statement:

    “The evidence is worrying but not conclusive. We have to take into account that mortality rates from breast cancer have fallen substantially in the last few decades, during which mammographic screening has been an major element in overall management.

    While we must suspect that most of that change is due to better adjuvant treatment, it would be irresponsible on the basis of the present evidence to go back to forms of surveillance (or no surveillance) which we know will have no benefit on breast cancer mortality and which will inevitably lead to us having to deal with more of the more advanced cancers, ones that often require more drastic surgery and other treatments. There remain considerable advantages other than survival to treating breast cancer early e.g. lower rates of treatment-induced lymphedema.

    Time to stop and think, perhaps, and to re-evaluate what we are doing, It would be quite wrong to abruptly change course.”

    One thing is for sure – in five years the recommendation will be different and we’ll still be having disagreements on how to handle this.

    1. Andrey Pavlov says:

      SS, you wax very long on what doctors think (actually on what you think they think, which is a very different matter), about their blindly following guidelines (though in this matter you have to choose which guideline to follow) etc. I have one question – what would you recommend to an average risk woman the age of 45 , another the age of 55, and another who has found that she has a mutation in a gene other than BCRCA 1 or two associated with breast cancer (there are dozens, and the degree of risk is not known for many of them). You’ve obviously studied this, in your mind obtaining more knowledge than physicians have. Assume also that you will be held responsible for the outcome of your advice and your patient will suffer the consequences. I’d like to see your response.

      Very well put.

  44. PMoran says:

    I have often wondered what effect the female menopause, or ovarian ablation during the latter years of reproductive life, would have upon any breast cancers evolving at the same time.

    These events would predictably slow down or stop the progression of hormone sensitive cancers, creating a cancer subgroup that would be picked up on screening mammography, but which would not declare itself clinically or contribute to breast cancer mortality until much later, if ever. Since both the rate of these events and ultimate mortality rates should still be the same in both populations, this could be one factor contributing to a constant 22% surplus of cancers being found in the screened group.

    Is this reasoning sound? If so, is there any data relevant to this?

    1. MadisonMD says:

      It is plausible that ovarian ablation could slow down breast cancer growth and indeed there is very good classic evidence supporting this. And when you look at mortality rates, there are slight inflections in the curves a few years after menopause, supporting your model. See here and here (Figure 1– notice inflection in incidence precedes inflection in mortality, consistent with P Moran hypothesis).
      Another piece of corroborating evidence is that other antihormonal approaches (tamoxifen and AIs) reduce the rate of cancer diagnoses.

      So, menopause could contribute to lead-time bias of screening by delaying eventual mortality. In this way, I think it could credibly contribute to the surplus by increasing the fraction of DCIS that never progresses. However, less likely with invasive since this is generally found to be not curable with hormonal therapy alone due to inevitable resistance.

      1. agitato says:

        MadisonMD:
        That 1896 Lancet article was very interesting. It ends with “to be concluded”. Did she ever get written about again by Dr. Beatson?

  45. PMoran says:

    Thanks MMD. However, I think the studies showing an excess of cancer in screened populations exclude non-invasive cancer (DCIS).

    It seems some invasive cancers don’t progress. I should have published one of my cases, a woman who was told by the radiologist something like “you are fine to go” after having a screening mammogram performed. She assumed that this meant the mammogram showed nothing, so she never returned to the referring doctor for the results as she was supposed to, and they were just filed away .

    She was referred to me over 4 years later, when a follow-up mammogram, showed an typical 1.5cm cancer, proven to be so on biopsy.

    It looked exactly the same on both mammograms.

    1. MadisonMD says:

      Hi Peter,
      That is a very interesting idea that some invasive cancers never progress. It even harkens back to the extreme view of the systemic (Fisher) hypothesis (opposite of the Halstead mode:
      Either cancer is systemic at diagnosis or will never spread systemically
      It is an interesting concept, but it there is sufficient evidence to reject it being true in all breast cancers.

      However, I would be cautious to assert that invasive cancer does not spread even with the case report you specify because:
      (a) Some invasive breast cancers take more than a decade to grow and disseminate. See here. I’ve seen this occasionally in clinical practice when a woman who had surgery 10, 20, or even 30 years later is found to have metastatic disease (typically bone only or bone+lymph node).
      (b) Occasionally DCIS is incorrectly diagnosed as invasive cancer.
      (c) I would want to know that competing causes of death are accounted for by censoring (i.e. if an screened woman with cancer dies of another cause within a few years of diagnosis, we cannot say that is a non-progressing cancer).

      However, I think the studies showing an excess of cancer in screened populations exclude non-invasive cancer

      Can you provide the citation? I’m happy to change my mind, but I find it hard to accept the assertion that 22% of invasive breast cancers would not progress. I would need to know that the issues above are accounted for.

      ——
      *Perhaps it is an academic point whether it would have spread in 40 years or not if death would have occurred prior to that for other reasons. But I’m not sure 5-10 years is enough to make this assertion.

  46. PMoran says:

    “Can you provide the citation? I’m happy to change my mind, but I find it hard to accept the assertion that 22% of invasive breast cancers would not progress.”

    Well, it’s by no means my idea, the data seems to be forcing this conclusion upon everyone. That at is why I am looking for reasons other than errors in pathological diagnosis or in causes of death, which seem unlikely to be enough to account for such an excess.

    There is, however, some parallel with prostate cancer, which many patients outlive, Breast cancer is also one of those rare cancers that is known to lie apparently dormant for decades and then flare up.

    You will find a citation supporting what I say about DCIS if you follow the links (in the above in the section where David refers to this matter.

    1. Self Skeptic says:

      PMoran,
      Would you mind reposting that citation? I’m having a hard time picking it out of the crowd.
      Thanks, and also for the interesting discussion.

    1. MadisonMD says:

      From your link to Dr. Gorski’s article:

      I suspect that most surgeons, medical oncologists, and radiation oncologists who actually specialize in breast cancer will be skeptical of the magnitude of the rate of spontaneous regression reported by Dr. Maehlen but unlikely to reject out of hand that such regression may occur more often than has been documented. The reasons for this skepticism are buried within the methodology of the study itself, particularly its underlying assumptions. To some extent, I fear that Dr. Maehlen is confusing overdiagnosis by mammography with spontaneous regression in that he seems to be assuming that all the “overdiagnosed” tumors must have spontaneously regressed, an assumption that is not tenable.

      I think I agree with Dr. Gorski. You were correct, Peter, that this one study is limited to over diagnosis of invasive disease. However, the 6-year followup is insufficient to distinguish slowly progressive disease from spontaneous regression. Slowly progressive disease is not really surprising. So I don’t think we can conclude that 22% spontaneously regress. But maybe somewhat fewer do. We would need data that distinguishes regression from non-progression.

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