Early cancer tests, surgeries questioned

Was this mastectomy necessary? It’s a question few breast cancer survivors want to ask, and one that few are likely to answer absolutely. But after years of aggressive emphasis on early diagnosis and treatment, some previous imperatives are being called into question. Noting that breast biopsy has long been considered the “gold standard,” a report in today’s New York Times addresses the new rethinking:

As it turns out, diagnosing the earliest stage of breast cancer can be surprisingly difficult, prone to both outright error and case-by-case disagreement over whether a cluster of cells is benign or malignant, according to an examination of breast cancer cases by The New York Times.

Advances in mammography and other imaging technology over the past 30 years have meant that pathologists must render opinions on ever smaller breast lesions, some the size of a few grains of salt. Discerning the difference between some benign lesions and early stage breast cancer is a particularly challenging area of pathology, according to medical records and interviews with doctors and patients.

Diagnosing D.C.I.S. “is a 30-year history of confusion, differences of opinion and under- and overtreatment,” said Dr. Shahla Masood, the head of pathology at the University of Florida College of Medicine in Jacksonville. “There are studies that show that diagnosing these borderline breast lesions occasionally comes down to the flip of a coin.”

Much of the current finger-pointing is toward pathologists, where their money comes from, whether they are ‘certified’ or not and in general, how good a job they do.

In 2006, Susan G. Komen for the Cure, an influential breast cancer survivors’ organization, released a startling study. It estimated that in 90,000 cases, women who receive a diagnosis of D.C.I.S. or invasive breast cancer either did not have the disease or their pathologist made another error that resulted in incorrect treatment.

After the Komen report, the College of American Pathologists announced several steps to improve breast cancer diagnosis, including the certification program for pathologists.

For the medical community, the Komen findings were not surprising, since the risk of misdiagnosis had been widely written about in medical literature. One study in 2002, by doctors at Northwestern University Medical Center, reviewed the pathology in 340 breast cancer cases and found that 7.8 percent of them had errors serious enough to change plans for surgery.

This space has argued occasionally for reconsideration of yearly mammograms and for longer, stronger consideration of other options before a mastectomy is performed. Especially in the case of older women.

Would I insist on further studies or opt for less radical treatment if I were diagnosed with breast cancer today? Probably. Can I undo the mastectomy I had at 72? Not exactly. Second-guessing is beside the point for someone who is healthy and fit, but asking questions won’t ever hurt.

Earliest Steps to Find Breast Cancer Are Prone to Error – NYTimes.com.

New Cancer Guidelines: One Good Message

News about changing guidelines for cervical and breast cancer screening have some women cheering, a lot of women fuming, and most women feeling confused. Or betrayed, or mistreated or worse.

There is one universal message in it all: every woman has to be her own advocate.

For most of us, that is no big deal. We’ve known for a long time that no two of us (and surely no four collections of breast tissue or no two histories of sexual activity) are alike, and most of us have gotten used to asking a lot of questions. It’s unfortunate that so many changes have been announced at almost the same time, and especially that the issue has become politicized.

New York Times health writer Denise Grady summed up the latest developments, and the issues that have caused confusion and anger in a November 20 article:

New guidelines for cervical cancer screening say women should delay their first Pap test until age 21, and be screened less often than recommended in the past.

The advice, from the American College of Obstetricians and Gynecologists, is meant to decrease unnecessary testing and potentially harmful treatment, particularly in teenagers and young women. The group’s previous guidelines had recommended yearly testing for young women, starting within three years of their first sexual intercourse, but no later than age 21.

Arriving on the heels of hotly disputed guidelines calling for less use of mammography, the new recommendations might seem like part of a larger plan to slash cancer screening for women. But the timing was coincidental, said Dr. Cheryl B. Iglesia, the chairwoman of a panel in the obstetricians’ group that developed the Pap smear guidelines. The group updates its advice regularly based on new medical information, and Dr. Iglesia said the latest recommendations had been in the works for several years, “long before the Obama health plan came into existence.”

She called the timing crazy, uncanny and “an unfortunate perfect storm,” adding, “There’s no political agenda with regard to these recommendations.”

Dr. Iglesia said the argument for changing Pap screening was more compelling than that for cutting back on mammography — which the obstetricians’ group has staunchly opposed — because there is more potential for harm from the overuse of Pap tests. The reason is that young women are especially prone to develop abnormalities in the cervix that appear to be precancerous, but that will go away if left alone. But when Pap tests find the growths, doctors often remove them, with procedures that can injure the cervix and lead to problems later when a woman becomes pregnant, including premature birth and an increased risk of needing a Caesarean.

Still, the new recommendations for Pap tests are likely to feed a political debate in Washington over health care overhaul proposals. The mammogram advice led some Republicans to predict that such recommendations would lead to rationing.

It boils down to this: every woman will need to pay close attention to her own health care. That is bad news for the less educated, the less aggressive, and those with less access to care, and not particularly good news for many older women who grew up with “The doctor knows best” excuse for not paying attention.But it’s good news for those of us, particularly older women, who have questioned what sometimes seemed too-frequent testing and screening.

Asking questions just got more respectable.

Guidelines Push Back Age for Cervical Cancer Tests – NYTimes.com.

Skip mammograms, quit breast self-exams, and maybe lighten up on 'defensive medicine' while we're at it

All those mammograms, self-exams and dutiful attention to catching breast cancer at the very first sign? Forget it. Might even do more harm than good.

As summarized by Associated Press writers Stephanie Nano and Marilynn Machione late Monday,
Most women don’t need a mammogram in their 40s and should get one every two years starting at 50, a government task forcesaid Monday. It’s a major reversal that conflicts with the American Cancer Society‘s long-standing position.

Also, the task force said breast self-exams do no good and women shouldn’t be taught to do them.

For most of the past two decades, the cancer society has been recommending annual mammograms beginning at 40.

But the government panel of doctors and scientists concluded that getting screened for breast cancer so early and so often leads to too many false alarms and unneeded biopsies without substantially improving women’s odds of survival.

“The benefits are less and the harms are greater when screening starts in the 40s,” said Dr. Diana Petitti, vice chair of the panel.

The new guidelines were issued by the U.S. Preventive Services Task Force, whose stance influences coverage of screening tests by Medicare and many insurance companies.

But Susan Pisano, a spokeswoman for America’s Health Insurance Plans, an industry group, said insurance coverage isn’t likely to change because of the new guidelines. No changes are planned in Medicare coverage either, said Dori Salcido, spokeswoman for the Health and Human Services department.

Maybe, just maybe, a clearer look at breast cancer screening could be accompanied by a good look at a little of the other possibly unnecessary and extraordinarily pricey “defensive medicine” going on around the country. What a fine way that would be to hold down costs and save a lot of time and angst. In another recent article (November 5) published in the San Francisco Chronicle, Associated Press reporter Steve LeBlanc wrote of how the costs of “defensive medicine,” along with malpractice insurance and lawsuit awards, are adding significantly to the soaring costs of health care.

LeBlanc illustrates the issue with a story that rings sadly true:

Dr. James Wang says he tries to tell his patients when medical procedures aren’t necessary. If they insist, though, he will do it – not so much to protect their health as his own practice.

After being sued for allegedly failing to diagnose a case of appendicitis, Wang says he turned to what’s known as “defensive medicine,” ordering extra tests, scans, consultations and even hospitalization to protect against malpractice suits.

“You are thinking about what can I do to prevent this from happening again,” he said, adding that he did nothing wrong but agreed to a minor settlement to avoid a trial.

We have, LeBlanc explains, doctors battling malpractice premiums and lawyers saying malpractice suits discourage bad medicine — meanwhile, the costs of it all add up to some ten percent of health care expenditures.

We the public, healthy and sickly alike, are caught in the middle. Could we not somehow declare a truce? We’ll quit rushing to sue, lawyers back off from chasing ambulances, doctors go about the business of practicing medicine according to patient need rather than fear of consequences. Seems like a good idea to me, but I’m not holding my breath.

I’m also not having any more mammograms any time soon.

New advice: Skip mammograms in 40s, start at 50 – Yahoo! News.