Category Archives: Medical Economics

Report finds illicit drugs bought on Internet could be poison (Ya think?)

HealthDay reports, “A case study of two men who were poisoned and turned blue after ingesting what they thought was a recreational drug that they had bought on the Internet highlights the dangers of such purchases,” according to a study in the Morbidity and Mortality Weekly Report, published by the US Centers for Disease Control and Prevention. Continue reading

Many physicians foolishly treat self, family members

American Medical News reports, “Professional ethics policies have long warned about the perils of physicians treating themselves or family members,” and yet, “a 2011 survey of more than 1,000 physicians in North Carolina found that nearly half had treated themselves and that 85% had treated an immediate family member, significant other or close friend.” Continue reading

Scientists argue sugar should be regulated like alcohol, tobacco

In a front-page story, the San Francisco Chronicle, “Like alcohol and tobacco, sugar is a toxic, addictive substance that should be highly regulated with taxes, laws on where and to whom it can be advertised, and even age-restricted sales, says a team of UCSF scientists” in a commentary published in Nature. Continue reading

Campaign to publish list of overused tests, treatments

The AP reports, “Chances are you’ve heard that many expert groups say cancer screening is overused, too, from mammograms given too early or too often to prostate cancer tests that may not save lives,” but “some of the nuts-and-bolts tests given during checkups or hospital visits are getting a second look.” Continue reading

PSA screening for prostate cancer. The debate continues.

ABC World News reported, “An earthquake in the debate over men and prostate cancer” regarding a “simple blood test called a PSA. Twenty million men use it to find out if they show a sign of risk, yet today, a government task force is saying healthy men should skip that test, arguing that the treatment that often follows the test may not be worth the consequences.” Continue reading

The PSA Controversy: A view from family physicians.

The U.S. Preventive Services Task Force, or USPSTF, has once again rejected the status quo, following the evidence to propose a recommendation some likely will find controversial. Here’s a viewpoint from the American Academy of Family Physicians (AAFP) that I find very convincing: Continue reading

The PSA Controversy: A view from the American Cancer Society.

To screen or not to screen for prostate cancer, that is the question. Or is it? Here’s the viewpoint of my friend, J. Leonard Lichtenfeld, MD, the Deputy Chief Medical Officer for the American Cancer Society.  Continue reading

Task force recommends “D” rating for PSA screening for prostate cancer

TV and print media have extensively covered the US Preventive Services Task Force’s (USPSTF) decision to give a “D” rating to PSA testing. What’s this mean for men? I’ll cover this controversy in the next few blogs. Continue reading

Is the US infant mortality ranking “shameful”? I say, “no,” but here’s the debate:

Of the over 2000 blogs I’ve posted, one of the most popular was Health Myth #1: “The U.S. has one of the highest infant mortality rates in the developed world.”. Now, in an editorial, USA Today points out that the US has now dropped “to 41st worldwide in newborn death rates.” Is it really that bad here? Continue reading

Palliative care may prolong life, reduce suffering

Do you know the difference between “palliative care” and “hospice care”? I must confess that for sometime I did not. Now that I’m more educated on the topic, I’m finding that many patients – and even many doctors – confuse palliative medicine with hospice (a form of palliative care for people in the last six months of life). Other patients mistakenly worry that doctors won’t work as hard to cure them if they ask for palliative care. Continue reading

Investigator Planned to Make Vast Profit From Autism/MMR Vaccine Scare

Andrew Wakefield, the lead author on the 1998 study that reported a link between the measles-mumps-rubella (MMR) vaccine and a new condition of regressive autism and bowel disease called autistic enterocolitis (AE), was planning to market a prestudy diagnostic testing kit with expected yearly sales of 28 million pounds (43 million US dollars), a new paper published online in the BMJ reports. Continue reading

Obama Pushes to Rescind Conscience Rights For Pro-Life Doctors

A national organization of Christian doctors is strongly concerned about the Obama administration’s effort to rescind conscience protections the Bush administration put in place for medical professionals. The regulations provide additional protections and support for those doctors and nurses who don’t want to be involved in abortions and may face pressure from medical institutions receiving federal funds. Here are the details from LifeNews.com:

Documents the Obama administration filed in November and December have Obama administration attorneys admitting the administration wants to finalize a rescission of the conscience rules but has been delayed because of other business — likely due to the HHS working on implementing the provisions of the ObamaCare law.

That greatly concerns Jonathan Imbody, the Vice President for Government Relations at the Christian Medical Association.

“When the Obama administration announced plans to get rid of the only federal regulation protecting conscience rights in health care, CMA swung into action and organized a coalition of nearly 50 organizations into a new entity, Freedom2Care,” he said in an email to LifeNews.com.

“Our groups helped enable healthcare professionals and patients to flood the U.S. Department of Health and Human Services (HHS) with approximately 340,000 regulation-supporting comments, which, by law, HHS officials must review before getting rid of the regulation.”

“Such efforts apparently delayed the administration acting on its threat until now,” Imbody said.

The advocate for medical professionals said medical workers and the pro-life people who support them need to act now to try to save the regulations.

“The government is now telling the court, in response to a lawsuit by several states against the conscience-protecting regulation, that HHS plans to eliminate or replace the conscience regulation by as early as January 31,” Imbody added. “That means we must act again to raise awareness of this threat to conscience rights, which has the potential to push life-affirming healthcare professionals out of medicine and strand the patients who depend upon them for care.”

“Whether you are a student or a doctor, federal conscience protections will have a significant impact on your ability to continue to practice ethical medicine. Don’t wait for someone else to stand in the gap on this one—take action yourself to protect your rights,” he added.”Share your story if you’ve experienced overt or subtle discrimination, contact your legislators, tell your patients and engage your colleagues.”

Imbody warns of potential fallout in the medical industry if those doctors and nurses who don’t want to violate their conscience are pressured or forced to do so.

“Millions of patients nationwide depend upon faith-based healthcare institutions and professionals. Our national poll revealed that 95 percent of faith-based physicians will leave medicine if forced to compromise their ethical convictions,” he said.

David Stevens, MD, the CEO of the Christian medical group, also weighed in on the news of the impending Obama administration actions.

“This regulation was designed to put teeth into the laws that protect our First Amendment rights. Unfortunately, the administration has not enforced it in the interim and now they plan to eliminate it altogether,” he complained. “As the case of the nurse who was forced to participate in a late term abortion in New York City demonstrated, presently healthcare professionals have no legal recourse when they are discriminated against unless this regulation is kept in place and enforced.”

Stevens is referring to the case of Cathy Cenzon-DeCarlo, who lost a federal court ruling saying she doesn’t have the right to sue the hospital that forced her to participate in an abortion.

In 2008, the Bush administration issued a rule that prohibited recipients of federal money from discriminating against doctors, nurses and health care aides who refuse to take part in medical procedures to which they have religious or moral objections, such as abortion.

The rule implemented existing conscience protection laws that ensure medical professionals cannot be denied employment because they do not want to assist in abortions.

Although federal law has long forbidden discrimination against health care professionals who refuse to perform abortions or provide referrals for them, the regulation required institutions that get federal funding to certify their compliance with laws protecting conscience rights.

It also promoted education within the medical community regarding their rights and provided an avenue of recourse in the event of discrimination through the Office of Civil Rights within HHS.

At the end of February 2009, the Obama administration announced it began “reviewing” the regulations implementing conscience laws, the first step toward rescinding the rule altogether.

In 2009, Obama told students at Notre Dame he wanted to find common ground on abortion and used the conscience clause as an example. But he came under criticism from pro-life lawmakers who said he was working to remove the protections.

U.S. spending millions to see if herbs truly work

People have been using herbal supplements for centuries to cure all manner of ills and improve their health. But for all the folk wisdom promoting the use of such plants as St. John’s wort and black cohosh, much about their effect on human health remains unknown. Therefore, I’m delighted that the federal government is spending millions of dollars to support research dedicated to separating the wheat from the chaff when it comes to herbal supplements. Here are the details from USA Today:

“A lot of these products are widely used by the consumer, and we don’t have evidence one way or the other whether they are safe and effective,” said Marguerite Klein, director of the Botanical Research Centers Program at the U.S. National Institutes of Health. “We have a long way to go. It’s a big job.”

In August, the U.S. National Center for Complementary and Alternative Medicine and the Office of Dietary Supplements awarded about $37 million in grants to five interdisciplinary and collaborative dietary supplement centers across the nation.

The grants were part of a decade-long initiative that so far has awarded more than $250 million toward research to look into the safety and efficacy of health products made from the stems, seeds, leaves, bark and flowers of plants.

Reliance on botanical supplements faded in the mid-20th century as doctors began to rely more and more on scientifically tested pharmaceutical drugs to treat their patients, said William Obermeyer, vice president of research for ConsumerLab.com, which tests supplement brands for quality.

But today, herbal remedies and supplements are coming back in a big way.

People in the United States spent more than $5 billion on herbal and botanical dietary supplements in 2009, up 22% from a decade before, according to the American Botanical Council, a nonprofit research and education organization.

The increase has prompted some concern from doctors and health researchers. There are worries regarding the purity and consistency of supplements, which are not regulated as strictly as pharmaceutical drugs.

“One out of four of the dietary supplements we’ve quality-tested over the last 11 years failed,” Obermeyer said. The failure rate increases to 55%, he said, when considering botanical products alone.

Some products contain less than the promoted amount of the supplement in question — such as a 400-milligram capsule of echinacea containing just 250 milligrams of the herb. Other products are tainted by pesticides or heavy metals.

The U.S. Food and Drug Administration warned supplement makers that any company marketing tainted products could face criminal prosecution. You can read my blog on this — “FDA targets manufacturers of tainted supplements.”

FDA targets manufacturers of tainted supplemen

The agency was specifically targeting products to promote weight loss, enhance sexual prowess or aid in body building, which it said were “masquerading as dietary supplements” and in some cases were laced with the same active ingredients as approved drugs or were close copies of those drugs or contained synthetic synthetic steroids that don’t qualify as dietary ingredients.

But even when someone takes a valid herbal supplement, it may not be as effective when taken as a pill or capsule rather than used in the manner of a folk remedy. For example, an herb normally ground into paste as part of a ceremony might lose its effectiveness if prepared using modern manufacturing methods, Obermeyer said.

“You move away from the traditional use out of convenience, and you may not have the same effect,” he said.

Researchers also are concerned that there just isn’t a lot of evidence to support the health benefits said to be gained from herbal supplements. People may be misusing them, which can lead to poor health and potential interactions with prescription drugs.

“Consumers often are taking them without telling their doctor, or taking them in lieu of going to the doctor,” Klein said.

Botanical research efforts that received recent federal funding include:

  • Pennington Biomedical Research Center in Baton Rouge, to investigate how supplements such as artemisia and St. John’s wort can reduce a person’s chances of developing metabolic syndrome.
  • University of Illinois at Chicago, to examine how the body processes herbal supplements.
  • University of Illinois at Urbana-Champaign, to investigate the safety and efficacy of such botanical estrogens as wild yam, soy and dong quai, and particularly their potential to contribute to cancer in women.
  • University of Missouri, Columbia, to look at the molecular pathways used by supplements such as garlic and elderberry to affect human health.
  • Wake Forest University Baptist Medical Center, Winston-Salem, N.C., to study the potential of botanical oils to boost the immune system and reduce inflammation.

Despite the concerns of the medical community, researchers believe there are a lot of valid health benefits that can be derived from botanical supplements. These benefits just need to be proven in the lab.

“We wouldn’t be supporting a multimillion-dollar program if we didn’t feel there was potential,” Klein said.

You can learn more about the current research supporting or refuting various natural medications (herbs, vitamins, and supplements) in my book, Alternative Medicine: The claims, the evidence, the options, how to choose wisely. Signed copies are available here.

Alternative Medicine - 2009

Obama Admin Working to Rescind Conscience Rights on Abortion

The Obama administration is still working to overturn conscience rights for medical professionals on abortion that were put in place at the tail end of the Bush administration. Here are the chilling details in a report from LifeNews:

In 2008, the Bush administration issued a rule that prohibited recipients of federal money from discriminating against doctors, nurses and health care aides who refuse to take part in medical procedures to which they have religious or moral objections, such as abortion.

The rule implemented existing conscience protection laws that ensure medical professionals cannot be denied employment because they do not want to assist in abortions.

New information about the state of those protections and efforts to repeal them comes from legal papers the administration filed in a case the state of Connecticut launched against the conscience protections.

In a document filed in federal court in November, Obama administration attorneys admitted that the administration wants to finalize a rescission of the conscience rules but has been delayed because of other business — likely due to the HHS working on implementing the provisions of the ObamaCare law.

HHS “hope[d] to have an internal draft final rule prepared in the near future, but that the schedule is necessarily tentative given the possibility of unforeseen delays and the need to devote time and resources to other agency priorities,” the November legal paper said.

Responding to the paper, the federal court asked for more information about the delay.

The Obama administration filed another legal paper December 1 stating “HHS still cannot be certain of a date for completing the rulemaking” but added “HHS expects to have a final rule published in the Federal Register within sixty to ninety days – i.e., as early as January 31, 2011, and no later than March 1, 2011.”

Obama officials asked the court to not mandate a time by which the rescission is made and said they hope to complete the rescission of the conscience rights prior to the court issuing a decision related to the Bush rules in the Connecticut challenge.

The Alliance Defense Fund, a pro-life legal group, points out that the papers make it clear the Obama administration intends to repeal the conscience protections on abortion, citing language saying the administration would notify the court “when the final rule regarding the proposed rescission is published.”

ADF Legal Counsel Matt Bowman said the Obama administration “wants to dismantle” the conscience protections “leaving little defense for the regulation and for health care workers.”

“Medical professionals should not be punished for holding to their beliefs, and they should not be forced to perform abortions against their conscience,” he told LifeNews.com. “Those pursuing this lawsuit, including organizations such as Planned Parenthood, would like nothing more than to deny health care workers the only means that exists to defend their federally protected right to opt out of abortions.”

ADF has been defending the rights of a nurse who was forced to assist in an abortion and is she is now seeking to join the lawsuit to oppose Connecticut’s efforts to overturn the Bush rules.

As LifeNews.com reported in November, Cathy Cenzon-DeCarlo lost a federal court ruling saying she doesn’t have the right to sue the hospital that forced her to participate in an abortion.

Now, the Alliance Defense Fund has filed a motion to intervene in State of Connecticut v. United States of America.

ADF is currently involved in a lawsuit in New York state court to defend Cenzon-DeCarlo’s conscience rights under state law, but the U.S. Court of Appeals for the 2nd Circuit upheld the dismissal of her federal lawsuit, leaving only an ongoing investigation by the U.S. Department of Health and Human Services as the means to defend her rights protected under federal law.

That investigation relies upon the conscience regulations implemented by former President George W. Bush that direct the department to conduct such investigations.

If Connecticut is successful or the Obama administration overturns the rules, “this case may cause Mrs. DeCarlo to again be illegally compelled to assist in abortions by her federally funded employer due to the removal of all her protective measures,” ADF legal papers say.

“Moreover, that Regulation has helped empower Defendant HHS’ Office of Civil Rights to actually and presently be investigating that violation on her behalf, explicitly telling Mrs. DeCarlo that the investigation is being pursued at least in part under the Implementing Regulation.

Yet in this case, Plaintiffs seek to invalidate that Regulation and Defendants have worked with Plaintiffs to stay the case based on their intent to rescind the Regulation,” the papers add.

ADF attorneys, working together with the Christian Legal Society’s Center for Law and Religious Freedom, are simultaneously attempting to intervene in the Connecticut case on behalf of several pro-life medical associations.

The judge cleared the motions from his calendar for now but determined that they can be considered once the case, which is currently on hold, moves forward.

Although federal law has long forbidden discrimination against health care professionals who refuse to perform abortions or provide referrals for them, the regulation required institutions that get federal funding to certify their compliance with laws protecting conscience rights.

It also promoted education within the medical community regarding their rights and provided an avenue of recourse in the event of discrimination through the Office of Civil Rights within HHS.

At the end of February, the Obama administration announced it began “reviewing” the regulations implementing conscience laws, the first step toward rescinding the rule altogether.

In 2009, Obama told students at Notre Dame he wanted to find common ground on abortion and used the conscience clause as an example. but he came under criticism from pro-life lawmakers who said he was working to remove the protections.

Now, it’s clear that the President was either being less than truthful or has changed his mind. I doubt the latter.

As Healthcare Reform Takes Hold, 74% of Physicians Will Retire or Seek Other Alternatives

Healthcare reform, should it survive legal challenge, repeal, and/or non-funding, will usher in a new era of medicine in which physicians will, according to a report in Modern Medicine, “largely cease to operate as full-time, independent, private practitioners accepting third party payments. Instead, they will work as employees, as part-timers, as administrators, in cash-only ‘concierge’ practices, or they will walk away from medicine altogether.” Here are the details from Modern Medicine:

These are some of the findings of a new report commissioned by The Physicians Foundation entitled “Health Reform and the Decline of Physician Private Practice”.

The report outlines provisions in the Patient Protection and Affordable Care Act (aka “Obamacare”) and examines economic, demographic, and other forces impacting the way doctors structure their practices and deliver care.

The report offers a road map for where medical practice is headed in the post-reform era, says Lou Goodman, PhD, president of The Physicians Foundation and chief executive officer of the Texas Medical Association.

Concern about patient care

“The private practice physician is rapidly disappearing,” Goodman notes. “Both market forces and the health care reform law are forcing physicians to find new ways of running a practice. We are extremely concerned about how this will affect patient care.”

Drawing on the perspective of a panel of healthcare experts and executives, the report projects physicians will follow one of four courses:

  • Work as employees of increasingly larger medical groups or hospital systems
  • Establish cash-only practices that eliminate third party payers
  • Reduce their clinical roles by working part-time
  • Opt out of medicine altogether by accepting non-clinical positions or by retiring.

Survey results in agreement

The projections are backed by results of a national physician survey included in the report.

Of some 2,400 physicians responding, only 26 percent said they would continue practicing the way they are in the next one to three years. The remaining 74 percent said they would:

  • retire,
  • work part-time,
  • close their practices to new patients,
  • become employed and/or
  • seek non-clinical jobs.

Based on the survey and other data, the white paper projects health reform will worsen the ongoing physician shortage and make it harder for many patients to access a physician.

In order to illustrate medical practice trends, the report includes case studies of medical practice models likely to proliferate post-reform, including studies of a medical home, an accountable care organization, a concierge practice, a community health center, and a small, hospital-aligned practice.

All-in-all, if this survey is accurate, the evolution of healthcare reform should be very interesting.

ObamaCare Repealed in the House

The House of Representatives resumed debate this morning on H.R. 2, legislation to repeal ObamaCare. A final vote came this evening, and it, as expected, passed easily with the new GOP majority in control. Also, in the “breaking news” category is a headline from American Spectator saying CBO Says Repealing ObamaCare Would Reduce Net Spending by $540 Billion. Haven’t heard that from the liberal news media, have you?

Unfortunately, Senate Democrat Leader Harry Reid called today’s vote “partisan grandstanding,” and again said that he won’t allow a vote to take place in the Senate. Reid is using the same tactics that resulted in this lousy law being rammed down the throats of the American taxpayer to begin with.

Here are some interesting facts from my friend, Gary Bower, founder and President of the Campaign for Working Families:

Yesterday, 200 economists sent a letter to congressional leaders calling for ObamaCare’s repeal. In the letter they warned, “We believe [ObamaCare] is a threat to U.S. businesses and will place a crushing debt burden on future generations of Americans.” But it’s not just economists who are worried.

A Thomson Reuters survey released this week found that 65% of doctors fear ObamaCare will cause healthcare to deteriorate. Just 18% of doctors believe ObamaCare will improve healthcare in America. Who do you trust most when it comes to your healthcare — Harry Reid or your own doctor?

The concerns of so many doctors should not be dismissed. Consider some markers of the quality of healthcare in countries with socialized medicine. A 2008 study found that the United States “had the highest five-year survival rates for breast cancer, at 83.9% and prostate cancer, at 91.9%.” But in Great Britain’s National Health Service the figures were dismal: “69.7% survival for breast cancer … and 51.1% for prostate cancer.”

Writing in today’s New York Post, Sally Pipes of the Pacific Research Institute notes that ObamaCare is already having a negative impact on healthcare in America. Here are some of the emerging problems she cites:

  • Because of ObamaCare mandates, construction at 45 hospitals around the country has been halted.
  • 40% of doctors said they plan to “drop out of patient care in the next one to three years.”
  • 60% of doctors said they will close or significantly restrict their practices. (How are the 30 million folks supposedly insured under ObamaCare going to get healthcare if 40-60% of doctors quit or restrict their practices?)

On the House floor today, Rep. Mike Pence (R-IN) said, “You know there is a lot of talk these days around here about where Members of Congress are going to sit during the State of the Union Address.  …I learned a long time ago it doesn’t really matter where you sit.  It matters where you stand.  And today House Republicans are going to stand with the American people and vote to repeal [the Democrats’] government takeover of health care lock, stock and barrel.”

Despite what happened today, it won’t be the end of this fight. If the Senate refuses to act on repeal legislation, House conservatives are determined to defund ObamaCare. Just as importantly, the House is scheduled to vote soon on a resolution instructing various House committees to start drafting free market alternatives to ObamaCare — alternatives that Nancy Pelosi, Harry Reid and Barack Obama refused to consider last year.

No doubt this story will continue to evolve.

Lower-Priced Resveratrol Supplements Pass Quality Tests While Some Higher-Priced Brands Flunk

Nature’s Code ResveratrexConsumerLab.com has reported that tests of supplements containing resveratrol — a compound promoted as “life-extending” — revealed that two products provided only 43.4% and 86.7%, respectively, of their listed amounts of resveratrol. These two products were among the most expensive supplements of the ten products selected for testing by ConsumerLab.com.

Surprisingly, ALL of the lower-priced products fared well in the tests.

Results for all ten products are now published in ConsumerLab.com’s Review of Resveratrol Supplements. An additional nine products that passed the same testing through ConsumerLab.com’s Voluntary Certification Program are included in the report as well as one product similar to one that passed testing but sold under a different brand name.

Resveratrol products have proliferated following reports in 2006 of life-extending and athletic endurance-enhancing effects of resveratrol in animals. Sales of resveratrol supplements were estimated at $31 million in the U.S. in 2009 by Nutrition Business Journal.

Laboratory research has also shown antioxidant, anti-inflammatory, anticancer, and other effects. Human studies of resveratrol’s effectiveness have NOT been reported, but many are underway.

At least one researcher in the field, Dr. David Sinclair at Harvard Medical School, is noted as taking resveratrol personally at a dose of approximately 350 mg per day.

In addition to quality issues, ConsumerLab.com found the daily suggested dosage among resveratrol products to range from 50 to 1,020 mg of resveratrol. The cost to obtain 100 mg of resveratrol from products ranged from $0.15 to as much as $2.76 — more than a 17-fold difference.

Based on a daily dose of 400 mg of resveratrol, the daily cost would range from $0.60 to $11.04.

None of the products were contaminated with lead or cadmium, which can occur in plant-based supplements, and all tablets were able to properly break apart in solution.

“There is still much to learn about resveratrol,” said ConsumerLab.com’s president, Tod Cooperman, M.D.  “At least those who choose to use it can now find out which products contain what they claim, which do not, and how to save money buying resveratrol.”

Brands covered in the new report are:

  • Bioforte (Biotivia),
  • Country Life,
  • Finest Natural (Walgreen),
  • Life Extension,
  • Life Smart,
  • Nutralife,
  • Perfect ResGrape,
  • Protocol for Life Balance,
  • pureandhealthy Res98,
  • Puritan’s Pride,
  • ReserveAge Organics,
  • Resveratrex (Nature’s Code),
  • Resveratrol Max,
  • Resveratrox (Garden Greens),
  • Resvinatrol,
  • Solaray,
  • Solgar,
  • Swanson,
  • Transmax (Biotivia), and
  • Vitamin World.

The two products that failed testing were:

  • Nature’s Code Resveratrex
  • Resvinatrol Complete

The report also provides information regarding dosage and possible side-effects, and comparisons of active and inactive ingredients in the resveratrol products.

ConsumerLab.com is a leading provider of consumer information and independent evaluations of products that affect health and nutrition. Their reviews of popular types of vitamins, supplements, and generic drugs are available here. Subscription to ConsumerLab.com is available online.

The company is privately held and based in Westchester, New York. It has no ownership from, or interest in, companies that manufacture, distribute, or sell consumer products.

“Mammography Saves Lives” Slogan Doesn’t Tell Full Story and May Mislead Many Women

The current “Mammography Saves Lives” campaign in the United States and previous campaigns promoting screening for breast cancer are not providing balanced information, because they underreport, or don’t mention at all, potential harms from the procedure, say critics.

One expert says the advertising for a screening mammogram should say something like this:

MAMMOGRAPY HAS BOTH BENEFITS AND HARMS … THAT’S WHY IT’S A PERSONAL DECISION. Screening mammography may help you avoid a cancer death or may lead you to be treated for cancer unnecessarily. But both are rare; most often mammography will do neither.

That’s why screening is a choice.

Women who want to do everything possible to avoid a breast cancer death should feel good about getting mammograms (every year if they wish).

Women who don’t like the procedure or the prospect of unnecessary testing and treatment should feel equally good about not getting mammograms (or getting them less often or starting them later in life).

You can see a sample of the ad in another post of mine, New Evidence-Based Mammography Ad Suggested. Here are the details behind the ad:

Some experts now estimate that a 10-year course of screening mammography for 2500 women 50 years of age would save the life of 1 woman from breast cancer.

At the same time, up to 1000 women would have had a “false alarm,” about half of those would undergo biopsy, and breast cancer will have been overdiagnosed in 5 to 15 women, who would have been treated needlessly with surgery, radiation, or chemotherapy, alone or in combination.

Ouch!!!

In other words, over a decade of annual testing of 2500 women at 50 years of age, there would be one life saved and 1000 women harmed (1000 false alarms or false positives). And, 5 to 15 women would be the most harmed by having cancer overdiagnosed.

Ouch, again!!!

Here are more details about this concerning story in a report from Medscape Medical News:

This campaign slogan is 1-sided, several critics told Medscape Medical News , and it oversells the benefits of mammography.

When asked for a more accurate headline, H. Gilbert Welch MD, MPH, from the Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Lebanon, New Hampshire, had the following tongue-in-cheek suggestions: “Mammography could save your life, but it’s a long shot” and “Chances are it won’t, but mammography could save your life.”

Dr. Welch recently wrote an editorial in the New England Journal of Medicine discussing the benefits and harms of screening mammography, in which he reviews new data from Norway that — he says — confirm that “the decision about whether to undergo screening mammography is, in fact, a close call.”

Public information campaigns about mammography should reflect this, he told Medscape Medical News.

Another critic of the promotional campaign is John D. Keen, MD, MBA, from the Cook County John H. Stroger Jr. Hospital in Chicago, Illinois. Explaining to Medscape Medical News that he is a diagnostic radiographer and breast imager with no conflicts of interest and no axe to grind, he said he is very concerned about physicians getting a balanced picture of mammography screening for breast cancer.

In a recent communication in the Journal of the American Board of Family Medicine , Dr. Keen writes that “the premise of a near universal life-saving benefit from finding presymptomatic breast cancer through mammography is false.”

Statistically, there is only a 5% chance that a mammogram will save a woman’s life, he points out. And that chance has to be balanced against potential harms, which vary with age, Dr. Keen continues. For instance, women who are 40 to 50 years of age are “10 times more likely to experience overdiagnosis and overtreatment than to have their lives saved by mammography,” he writes.

Dr. Keen told Medscape Medical News that he is concerned that much of the ongoing debate about mammography has been dominated by screening advocates, but pointed out that many of these experts have professional and financial interests in mammography. He is concerned that they are promoting screening without presenting the whole story.

This point has also been raised by others, including the authors of a recent article published in the New England Journal of Medicine entitled “Lessons From the Mammography Wars.”

There is no regulation of marketing in healthcare, they point out — “the same group that provides a service also tells us how valuable that service is and how much of it we need, as when the Society of Breast Imaging sets the recommendations for mammography.”

New Campaign in the United States

The new Mammography Saves Lives campaign is produced by the American College of Radiology, the Society of Breast Imaging, and the American Society of Breast Disease. It is currently running on television and radio across the United States, and features testimonials from several women who report that mammography saved their lives.

“In fact, there is no way of knowing if an individual was indeed ‘saved’,” Karsten Juhl Jorgensen, MD, from the Nordic Cochrane Center in Copenhagen, Denmark, told Medscape Medical News.

The Nordic Cochrane Center group, which includes Peter Gøtzsche, PhD, has developed an evidence-based outline of the harms and benefits of mammography. They have been very vocal in criticizing information sent out to the general public in national campaigns for breast screening in many countries in Europe, and in Australia, New Zealand, and Canada.

The leaflets sent out to invite women for mammography screening in these countries have not contained adequate descriptions of the harms and benefits, they argue; their fierce criticism led to a very public controversy in the United Kingdom last year when a government-produced leaflet was withdrawn and redesigned.

“The situation in the United States is different, in that there is no national screening program to set a common standard for information at invitation,” Dr. Jorgensen said. “It is much harder to tease out what information is given in the United States, as this may vary considerably across health plans and physicians,” he told Medscape Medical News.

“There is no doubt that screening mammography has generally been oversold” in invitations to screening and in campaigns from cancer societies and other interest groups everywhere in the world where this has been studied, Dr. Jorgensen said.

The result is that women “trust screening to reduce their risk of dying from breast cancer to an extent that is in no way scientifically justified,” he continued.

We would all like to believe that a woman’s life will be saved by mammography “if a cancer that she did not know about is detected at screening,” he said. “But in fact, the likelihood that the woman in question will be diagnosed with breast cancer unnecessarily is 10 times greater.”

“There is no way of knowing if the symptom-free cancer she was diagnosed with would ever have developed into clinical disease. And if it was destined to do so, we cannot know if the screen-detection changed the prognosis in her particular case. She may very well have survived her disease without screening or died from relapsing breast cancer 10 years later,” he said.

Estimates of Harm Not Universally Accepted

However, a leading advocate of mammography, Carol Lee, MD, chair of the American College of Radiology Breast Imaging Commission, who is quoted on the MammographySavesLives.org Web site, suggested that the estimates of harms used by Dr. Keen and Dr. Jorgensen are not universally accepted, and have been questioned by others in the field.

Some of the numbers used are “very debatable,” Dr. Lee said in an interview with Medscape Medical News. The view from the Nordic Cochrane Group is well known to be at the extreme end of a very polarized debate, she added. “We all have different perspectives and different ways of looking at data,” she said.

Dr. Lee emphasized that there is absolutely no doubt that screening reduces breast cancer mortality. In the United States, there has been a nearly 30% reduction in breast cancer mortality since the introduction of widespread mammography screening in the mid-1980s. Although there have been improvements in treatment during this time, she “cannot believe that at least part of this reduction is not due to screening.”

“Screening is not perfect,” she noted. “There are harms; there are harms with every test,” Dr. Lee acknowledged. But the discussion of benefit and harm is a very complex one. It is different for each individual woman, and the place for that discussion is in the doctor’s office, Dr. Lee insisted. Every person needs to have that discussion with their healthcare provider whenever any tests is ordered, she emphasized.

“The Mammography Saves Lives campaign does tell women to talk to their doctor,” she said, “but the bottom line is that mammography does save lives and we need to get this message out, because mammography can’t save lives if women don’t utilize it.”

The message needs to be clear, she continued. “We can’t say you might do it, or you might not’,” she said. And the proposition that “if you are 40 years old you should have a discussion but if you are 50 years old you should have a mammogram doesn’t make sense to me.”

Dr. Lee was referring to last year’s recommendation from the US Preventive Services Task Force (USPSTF) that made that age distinction, sparking outrage from screening advocates.

That USPSTF recommendation has been generally interpreted as questioning the efficacy of mammograms, Dr. Lee explained, adding that she has heard women around the world saying that the US government thinks that mammograms are not worthwhile. “This is very frustrating to me,” she said, because “here we have a public health measure that works.”

One of the stated aims of the new campaign is “to clear confusion.”

The message has to be clear or it will just create more confusion, Dr. Lee emphasized. Something along the lines of “mammography saves lives but it may not be a good thing for you individually” would just add to the confusion that is already out there, she argued. The campaign emphasizes the point that screening does reduce breast cancer mortality, but whether it is right for each individual woman is for her to discuss with her healthcare provider, she said.

Better Than Previous Campaigns, But Still Unbalanced

The current campaign is better than some of the previous campaigns promoting breast cancer screening, said Dr. Welch.

Both he and Dr. Jorgensen were critical of the American Cancer Society’s campaign in the 1980s, which declared: “If you haven’t had a mammogram, you need more than your breasts examined.”

This is an example of a 1-sided campaign — it mentions nothing about the harms of screening, Dr. Jorgensen pointed out. “The truth is that mammography screening today has marginal benefits and serious harms, and that a decision not to get screened can be as sensible and responsible as the decision to get screened.”

Dr. Welch echoed this sentiment in his recent editorial, entitled “Screening Mammography — A Long Run for a Short Slide?”. It was prompted by new data from Norway that appeared in the same issue, which highlighted the fact that the mortality benefit from mammography is modest.

The benefit seen was smaller than that previously reported in clinical trials, he explained to Medscape Medical News, but in the meantime, there have been improvements in the treatment of clinical detected breast cancer, and an increasing awareness among women to report any breast abnormalities. “There is no debate about the value of diagnostic mammography in these circumstances,” Dr. Welch emphasized, but there are questions about the value of screening mammography in healthy women.

“These new data from Norway are probably the best representation we have of effectiveness in clinical practice,” Dr. Welch said. They confirm the view that “the decision about whether to undergo screening mammography is, in fact, a close call.”

There is “a delicate balance between modest benefit and modest harm,” Dr. Welch wrote in his editorial, using data from the Norwegian study to illustrate his point.

Dr. Welch estimated that a 10-year course of screening mammography for 2500 women 50 years of age would save the life of 1 woman from breast cancer. At the same time, up to 1000 women would have had a “false alarm,” about half of those would undergo biopsy, and breast cancer will have been overdiagnosed in 5 to 15 women, who would have been treated needlessly with surgery, radiation, or chemotherapy, alone or in combination.

“Although the current campaign doesn’t suggest that women who forgo mammography need their head examined, it remains 1-sided,” Dr. Welch told Medscape Medical News. It still focuses only on the benefit of mammography, which is why he suggested alternative tongue-in-cheek slogans, such as “Mammography could save your life, but it’s a long shot.”

“What we really need to do is develop a more balanced campaign that respects the fact that different women can make different choices,” he explained. “Since there is no single ‘right answer’ about screening mammography, our goal should be to encourage women to feel good about the answer that’s right for them,” he said. To that end, Dr. Welch suggested that the promotion of screening mammography should reflect this, and offered the following as an example of the way in which the message could be publicized.