This article is from the source 'guardian' and was first published or seen on . It last changed over 40 days ago and won't be checked again for changes.

You can find the current article at its original source at http://www.theguardian.com/commentisfree/2014/feb/14/mammograms-arent-useless-but-we-need-to-employ-them-with-more-care

The article has changed 2 times. There is an RSS feed of changes available.

Version 0 Version 1
Mammograms aren't useless, but we need to employ them with more care Mammograms aren't useless, but we need to employ them with more care
(7 months later)
“Mammograms do not “Mammograms do not reduce breast cancer deaths.”
reduce breast cancer deaths.” This headline felt like a heart-sink moment for me because the word “mammogram” frequently populates my medical vocabulary, along with the exhortation, “make sure you have one”. In this topsy-turvy world of modern medicine where our assumptions not only about cancer but also a range of other diseases are being routinely routed, recommending a mammogram has always seemed like a reliable piece of advice.
This headline felt like a heart-sink moment for me because Last year on medical rounds, I met a 55-year-old academic, who presented with severe abdominal pain that thankfully turned out to be gastroenteritis. “Thank God it wasn’t cancer,” she said, a perfect segue to introduce the concept of health promotion to a group of medical students. We went through a checklist. She didn’t smoke, drink or take illicit drugs. She ate healthily and walked briskly to her office. On weekends, she played bowls with her octogenarian mother. We ought to have commended her for it all when a keen student asked, “And when did you have your mammogram?”
the word “mammogram” frequently populates my medical vocabulary, along with the
exhortation, “make sure you have one”. In this topsy-turvy world of modern
medicine where our assumptions not only about cancer but also a range of other
diseases are being routinely routed, recommending a mammogram has always seemed
like a reliable piece of advice.
Last year on medical rounds, I met a 55-year-old academic,
who presented with severe abdominal pain that thankfully turned out to be
gastroenteritis. “Thank God it
wasn’t cancer,” she said, a perfect segue to introduce the concept of health
promotion to a group of medical students. We went through a checklist. She
didn’t smoke, drink or take illicit drugs. She ate healthily and walked briskly
to her office. On weekends, she played
bowls with her octogenarian mother. We ought to have commended her for it all
when a keen student asked, “And when did you have your mammogram?”
“Oh”, she frowned. “I haven’t.”“Oh”, she frowned. “I haven’t.”
“It doesn’t have to very recent,” I added helpfully.“It doesn’t have to very recent,” I added helpfully.
“No, I mean I have never had one.”“No, I mean I have never had one.”
You could have heard the collective gasp of our disapproval You could have heard the collective gasp of our disapproval all the way to the next floor. I cringe to recollect the well intentioned but sanctimonious advice we dispensed, but suffice to say, she soon felt that she had done her entire family a disservice by never having a mammogram to detect the breast cancer that might be lurking beneath the surface.
all the way to the next floor. I cringe to recollect the well intentioned but Months later, she tracked me down. Her mammogram had demonstrated a small abnormality. She had needed a second mammogram and found both experiences very painful. But worse was to come. A surgeon advised that he could not exclude cancer. The initial biopsy was extremely bruising yet inconclusive. She was advised she could let it be, chance a repeat biopsy, or have it removed for a definitive answer. Her strongest instinct was to do nothing but ridden with guilt and foreboding, she consented to surgery.
sanctimonious advice we dispensed, but suffice to say, she soon felt that she Unlike the breast lump, which was benign, her postoperative course was anything but. She developed complications from the anaesthetic followed by a serious wound infection that took weeks to heal. A painful deep vein thrombosis followed, which in turn caused swelling and disfigurement of her arm. True, the extent of her post-operative troubles was unexpected but she summed up her experience thus: “If I had had any hint that I wasn’t just signing up for a mammogram but all of its serious implications, I would have given it more thought. But when you hear ‘cancer’, it seems ridiculous to think about over-diagnosis: you just want it out.”
had done her entire family a disservice by never having a mammogram to detect To my genuine regret for my role in her ordeal, she replied graciously, “Doctor, you are only going by the evidence.” I can’t help imagining her reaction to the new evidence that supports her testimony while giving oncologists like me pause for thought. A Canadian study of nearly 90,000 women, performed meticulously over 25 years, has shown that screening mammography for women under the age of 60 does not improve survival but vitally, leads to over-diagnosis of breast cancer in one in five women.
the breast cancer that might be lurking beneath the surface. This means that one in five screen-detected cancers (yes, cancers) would not have reduced a woman’s life expectancy if left undetected. This in turn means that one in five women did not need invasive surgery, chemotherapy, radiotherapy or the burden of psychological illness or the broader family turmoil attached to a cancer diagnosis.
Months later, she tracked me down. Her mammogram had Since this news broke, the media has been filled with stories of women who swear by their mammogram. And indeed, I too meet patients whose timely mammogram did them a favour. So how should we view this latest research? It would be a catchy headline but overly simplistic to declare that mammograms are useless. No, their utility just needs to be more carefully defined. Instead, we should seize the opportunity offered to doctors and patients alike to soberly contemplate the twin traps of over-diagnosis and over-treatment that are rife today.
demonstrated a small abnormality. She had needed a second mammogram and found Medicine has evolved dramatically over the past decades. Modern doctors, oncologists chief amongst them, are taking the fight to diseases that once attracted trenchant pessimism. It is gratifying to be able to offer a patient not one kind of scan but three; not just a handful of blood tests but a series of genetic scorecards too; not one surgeon’s opinion, but that of an entire team of experts. Patients often respond with alacrity, alas, often succumbing to the false hope that more tests, more diagnoses, more opinions and ultimately, more interventions must necessarily mean better outcomes.
both experiences very painful. But worse was to come. A surgeon advised that he I recently saw a patient who was grateful for the prompt treatment of nausea he received but took issue with the “too many tubes of blood they took”. Out of curiosity, I counted the tests. He was right. There were dozens, apparently reflexively added to a battery. But tellingly, the only abnormal test in the slew had gone unnoticed – a urine infection that could have rendered him septic. Any patient intervention comes with the responsibility of deliberately checking every result and being aware of uncommon but potentially serious implications; it is not difficult to appreciate how good intentions go amiss.
could not exclude cancer. The initial biopsy was extremely bruising yet Quite apart from physical and psychological harm to patients exposed to unnecessary medical interventions, there is the mounting cost of care associated with these practices. The Australian Medical Association today released its annual report card showing marginal improvement in public hospital performance. But there is growing disquiet that healthcare spending seems a bottomless, thankless pit and the implied suggestion is that doctors must curb the expenditure.
inconclusive. She was advised she could let it be, chance a repeat biopsy, or But the responsibility to use healthcare judiciously belongs to doctors and patients. Doctors must spend time obtaining a patient’s history and examining them thoroughly. Rarely does a test or intervention replace the old-fashioned art of listening to the patient. The reasons for performing tests must be thought through beforehand and not after the fact.
have it removed for a definitive answer. Her strongest instinct was to do Increasingly, patient care also means tolerating uncertainty, not a natural fit for doctors who like to nail answers.
nothing but ridden with guilt and foreboding, she consented to surgery. In turn, patients must understand that despite all its advances, there are limits to what medicine can achieve. A screening test does not always detect disease. A detected disease is not always harmful. Treatment can be worse than doing nothing. So patients too need to come to terms with uncertainty. “I am not sure,” does not signal a doctor’s failing, it can be an invitation to engage meaningfully in what should happen next. Patients must speak up to be partners in care.
Unlike So much conventional wisdom has been uprooted in my short career as an oncologist that by now, I should have learnt to expect the curveballs. For this important addition to our knowledge that will hopefully safeguard the health of future patients we should thank the Canadian researchers. In the meantime, there is one failsafe piece of advice that it is worth holding on to even though it originated at a time when our forebears had little to offer patients:
the breast lump, which was benign, her postoperative course was anything but.
She developed complications from the anaesthetic followed by a serious wound
infection that took weeks to heal. A painful deep vein thrombosis followed, which
in turn caused swelling and disfigurement of her arm. True, the extent of her
post-operative troubles was unexpected but she summed up her experience thus: “If I had had any hint that I wasn’t just signing up for a mammogram but all of
its serious implications, I would have given it more thought. But when you hear
‘cancer’, it seems ridiculous to think about over-diagnosis: you just want it
out.”
To my genuine regret for my role in her ordeal, she replied
graciously, “Doctor, you are only going by the evidence.” I can’t help
imagining her reaction to the new evidence that supports her testimony while
giving oncologists like me pause for thought. A Canadian study of nearly 90,000
women, performed meticulously over 25 years, has shown that screening
mammography for women under the age of 60 does not improve survival but
vitally, leads to over-diagnosis of breast cancer in one in five women.
This
means that one in five screen-detected cancers (yes, cancers) would not have
reduced a woman’s life expectancy if left undetected. This in turn means that
one in five women did not need invasive surgery, chemotherapy, radiotherapy or
the burden of psychological illness or the broader family turmoil attached to a
cancer diagnosis.
Since this news broke, the media has been filled with
stories of women who swear by their mammogram. And indeed, I too meet patients
whose timely mammogram did them a favour. So how should we view this latest
research? It would be a catchy headline but overly simplistic to declare that
mammograms are useless. No, their utility just needs to be more carefully
defined. Instead, we should seize the opportunity offered to doctors and
patients alike to soberly contemplate the twin traps of over-diagnosis and
over-treatment that are rife today.
Medicine has evolved dramatically over the past decades. Modern doctors,
oncologists chief amongst them, are taking the fight to diseases that once
attracted trenchant pessimism. It is gratifying to be able to offer a patient
not one kind of scan but three; not just a handful of blood tests but a series
of genetic scorecards too; not one surgeon’s opinion, but that of an entire
team of experts. Patients often respond with alacrity, alas, often succumbing to
the false hope that more tests, more diagnoses, more opinions and ultimately,
more interventions must necessarily mean better outcomes.
I recently saw a patient who was grateful for the prompt
treatment of nausea he received but took issue with the “too many tubes of
blood they took”. Out of curiosity, I counted the tests. He was right. There
were dozens, apparently reflexively added to a battery. But tellingly, the only
abnormal test in the slew had gone unnoticed – a urine infection that could
have rendered him septic. Any patient intervention comes with the
responsibility of deliberately checking every result and being aware of
uncommon but potentially serious implications; it is not difficult to
appreciate how good intentions go amiss.
Quite apart from physical and psychological harm to patients
exposed to unnecessary medical interventions, there is the mounting cost of
care associated with these practices. The Australian Medical Association today
released its annual report card showing marginal improvement in public hospital
performance. But there is growing disquiet that healthcare spending seems a
bottomless, thankless pit and the implied suggestion is that doctors must curb
the expenditure.
But the responsibility to use healthcare judiciously belongs
to doctors and patients. Doctors must spend time obtaining a patient’s history
and examining them thoroughly. Rarely does a test or intervention replace the old-fashioned art of listening to the patient. The reasons for performing
tests must be thought through beforehand and not after the fact.
Increasingly, patient care also means tolerating
uncertainty, not a natural fit for doctors who like to nail answers.
In turn, patients must understand that despite all its
advances, there are limits to what medicine can achieve. A screening test
does not always detect disease. A detected disease is not always harmful. Treatment
can be worse than doing nothing. So patients too need to come to terms with
uncertainty. “I am not sure,” does not signal a doctor’s failing, it can be an
invitation to engage meaningfully in what should happen next. Patients must
speak up to be partners in care.
So much conventional wisdom has been uprooted in my short
career as an oncologist that by now, I should have learnt to expect the
curveballs. For this important addition to our knowledge that will hopefully
safeguard the health of future patients we should thank the Canadian
researchers. In the meantime, there is one failsafe piece of advice that it is
worth holding on to even though it originated at a time when our forebears had
little to offer patients:
Primum non nocere – first do no harm.Primum non nocere – first do no harm.