Recently, I had the opportunity to sit on a jury involving a motor vehicle accident. The plaintiff’s lawyer, who I suppose could be called an “ambulance chasing lawyer” by some, wanted to know how jurors would react if experts physician witnesses from the two side reached opposite conclusions. Such disagreement among physicians is much more common in medicine than the layperson would realize, and one person on the jury said that if two doctors disagreed then they both must be wrong, or that the victim’s claims of injury are not real. Unsurprisingly, this juror didn’t make the final cut to be on the jury. While we may not all be called to serve on jury involving medical claims, millions of women each year must weight evidence of a controversial topic: mammography screening for breast cancer.
In fact, if the case for, or against, mammography screening were tried in a modern courtroom, each side could easily call dozens of expert medical witnesses to argue their side. Even more daunting, the very age at which women should begin mammography screening is controversial itself.
On the one hand you have the US Preventive Services Task Force, which is a government entity which only recommends treatments and preventive care which have proven to have a beneficial effect. The reason being that much of what is done in medicine is done only for historical reasons of because it “sounds right” and makes sense.
The goal of the US Preventive Task Force is to avoid “doing more harm than good” by supporting only the good medicine. The difficulty thing is that a lot of what doctors do either hasn’t been studied enough, or there are conflicting opinions and research on the topic. When the US Preventive Services Task Force last November (during the battle over health care), said that it no longer recommends mammography for women in the 40 to 50 age bracket, well, . . . emotions ran very high to put it mildly. The Health and Human Services Secretary had to, in essence, publicly denounce the finding and promise women in their 40s that they would still be able to get their annual mammograms.
Opponents of mammography for women in certain age groups point to the risk of false positives, which are nerve wrecking for patients, as well as the cost of performing and reading the mammogram. There is also the specter of “overdiagnosis” of breast cancer. Meaning that thousands of women may be being treated for breast cancer which wouldn’t have killed them in the first place, possibly because the human body naturally “shoots down” early cancers.
And as new medical advances keep breast cancer patients alive longer, some argue that mammography may offer little benefit for very young, or perhaps very old women. Nonetheless, the American Cancer Association currently recommends that women 40 and above begin having annual mammograms.
Personally, I believe that mammography screening for breast cancer is a good idea for women in their forties and above, with the big caveat being that all women should be allowed to make these decisions on their own.
A flood of new research findings seem to have muddied the issue further as the results have been viewed as contradictory by some. A recent Swedish study concludes that women in the 40s can lower their risk of dying from breast cancer by 26% through the use of mammography. However, a study published in the New England Journal of Medicine showed “only” a ten percent reduction in breast cancer mortality in women in the 50 to 69 age group bracket.
Previously I considered that anyone who didn’t support mammography screening for women was off their rocker. However, there are real trade offs and different women have a different risk for developing breast cancer, those with the highest risk of breast cancer undeniably benefit from mammography or some other form of early detection such as MRI which is more commonly used in younger women with a known high genetic predisposition for breast cancer.
For many women, they would rather run the risk of having a false positive than missing a breast cancer which could potentially kill them. In this case, a doctor could reasonably say to a 40 year old woman that there is some evidence that says that if she has a mammogram it could save her life, and here are what the drawbacks are. To do anything less would be to tell a patient, “I’ve read all (or some) of the research and I am going to make a decision for you even though experts are feuding over this.”
Usually this is exactly what doctors do in many cases. An elderly man I saw in the hospital as a medical student had a rare condition called “tertiary syphilis”, which is due to undiagnosed long term infection with syphilis, which had begun to affect his mental processes. He was prescribed the appropriate antibiotic, penicillin, to treat this condition. There wasn’t any discussion with the patient about the risks and benefits of starting the antibiotic as the therapy is proven and very low risk. In the case of controversial screening programs, such as mammography, doctors are forced to have a discussion with patients which isn’t that routine, the “this may or may not save your life and it is up to you to decided” type conversation.
It goes without saying that the detection and treatment of breast cancer will change significantly in the coming decades. As 40,000 women still die each year from this disease, new forms of chemotherapy and possibly different types of screening, such as using MRI instead of older X-Ray technology, could do much to prevent these deaths.
One thing that likely won’t change is the reality that as more is understood about breast cancer risk among different groups of women, doctors will increasingly need to have meaningful conversations with patients so that they can make the decisions which are right for them.
Probably the best advice for women would be to discuss their risk of breast cancer with their doctor and to ask questions about the risks and benefits of mammography.