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How does any woman know before she decides to have a mammogram which of those little icons representing 10 women will represent her personally?
Consider the 940 "unnecessary biopsies". The only way to determine that a biopsy was "unnecessary" is to do the biopsy. If there were a way to know ahead of the biopsy that it was "unnecessary", no "unnecessary" biopsies would ever be done. Biopsies are not necessary or unnecessary they are indicated or not indicated, and that decision must be left to the patient and her doctor. That no cancer was found does not make a biopsy unnecessary.
Of the 302 with cancer, how do you tell me, before I have my mammogram, whether I will be included in that icon for 10 women who would have death prevented or one of the icons in the other groups? Note that the 57 "overdiagnoses" are still cancer. They are included in that 302 figure, right? Before I book my mammogram appointment, which group am I in? Normal? False positive? A negative (unnecessary) biopsy? One of the ten that will have death averted? One of the 57 that are "overdiagnosed"? One of the 62 that cannot be saved with current treatments? If one of the 173 who survive regardless of screening, how many of those who were unscreened required more extensive treatment, say mastectomy versus lumpectomy, than they would have if the tumor had been picked up by screening at an earlier stage?
The fact is that there is no way to categorize me before I decide to have a mammogram. All of those numbers are derived after the mammograms (and biopsies) have been done. In particular there is at this time no way to predict the biologic behavior of a breast tumor and tell a woman whether her cancer is potentially fatal or one of the "overdiagnosed" ones that would never kill her. That is why the "overdiagnosed" tumors get treated.
Post hoc statistics are useful for epidemiologists. They cannot be applied to individuals.
I repeat what Dr. Gorski said in the link I posted earlier:
"There is no difference, mammographically, between breast cancers that are overdiagnosed and those that will progress to endanger the life of the woman. No matter how well trained the radiologist is, he or she can’t tell the difference. All the radiologist can tell is that there’s a suspicious mass, bit of architectural distortion, or cluster of microcalcifications requiring biopsy. All the pathologist can tell is whether, on histology, there is DCIS or cancer there, or not."
"I am a breast cancer surgeon and I don’t know of any test in everyday use that is reliable enough to tell me which mammography-detected breast cancer or DCIS lesion is safe to watch and which needs immediate treatment. All the pathologist looking at the biopsy of that mammographic abnormality can tell histologically is that it is breast cancer. What neither of them can tell is if it is overdiagnosed breast cancer (i.e., cancer that will never progress or will progress so slowly that it never becomes a problem in the patient’s lifetime) or breast cancer requiring treatment. As a breast cancer surgeon, when confronted with a biopsy-proven histological diagnosis of cancer in a patient, I have no choice but to treat that cancer as though it threatens the life of the patient because I have no reliable test to tell me which ones are safe or not. I am aware that some cutting-edge surgeons (if you’ll excuse the term), like Dr. Laura Esserman do sometimes use watchful waiting for low grade DCIS, but most surgeons don’t (yet) have the intestinal fortitude for that, and I doubt that even Dr. Esserman’s intestinal fortitude is up to the level where she would use “watchful waiting” as the initial management of an invasive cancer."
How does any woman know before she decides to have a mammogram which of those little icons representing 10 women will represent her personally?
Consider the 940 "unnecessary biopsies". The only way to determine that a biopsy was "unnecessary" is to do the biopsy. If there were a way to know ahead of the biopsy that it was "unnecessary", no "unnecessary" biopsies would ever be done. Biopsies are not necessary or unnecessary they are indicated or not indicated, and that decision must be left to the patient and her doctor. That no cancer was found does not make a biopsy unnecessary.
Of the 302 with cancer, how do you tell me, before I have my mammogram, whether I will be included in that icon for 10 women who would have death prevented or one of the icons in the other groups? Note that the 57 "overdiagnoses" are still cancer. They are included in that 302 figure, right? Before I book my mammogram appointment, which group am I in? Normal? False positive? A negative (unnecessary) biopsy? One of the ten that will have death averted? One of the 57 that are "overdiagnosed"? One of the 62 that cannot be saved with current treatments? If one of the 173 who survive regardless of screening, how many of those who were unscreened required more extensive treatment, say mastectomy versus lumpectomy, than they would have if the tumor had been picked up by screening at an earlier stage?
The fact is that there is no way to categorize me before I decide to have a mammogram. All of those numbers are derived after the mammograms (and biopsies) have been done. In particular there is at this time no way to predict the biologic behavior of a breast tumor and tell a woman whether her cancer is potentially fatal or one of the "overdiagnosed" ones that would never kill her. That is why the "overdiagnosed" tumors get treated.
Post hoc statistics are useful for epidemiologists. They cannot be applied to individuals.
I repeat what Dr. Gorski said in the link I posted earlier:
"There is no difference, mammographically, between breast cancers that are overdiagnosed and those that will progress to endanger the life of the woman. No matter how well trained the radiologist is, he or she can’t tell the difference. All the radiologist can tell is that there’s a suspicious mass, bit of architectural distortion, or cluster of microcalcifications requiring biopsy. All the pathologist can tell is whether, on histology, there is DCIS or cancer there, or not."
"I am a breast cancer surgeon and I don’t know of any test in everyday use that is reliable enough to tell me which mammography-detected breast cancer or DCIS lesion is safe to watch and which needs immediate treatment. All the pathologist looking at the biopsy of that mammographic abnormality can tell histologically is that it is breast cancer. What neither of them can tell is if it is overdiagnosed breast cancer (i.e., cancer that will never progress or will progress so slowly that it never becomes a problem in the patient’s lifetime) or breast cancer requiring treatment. As a breast cancer surgeon, when confronted with a biopsy-proven histological diagnosis of cancer in a patient, I have no choice but to treat that cancer as though it threatens the life of the patient because I have no reliable test to tell me which ones are safe or not. I am aware that some cutting-edge surgeons (if you’ll excuse the term), like Dr. Laura Esserman do sometimes use watchful waiting for low grade DCIS, but most surgeons don’t (yet) have the intestinal fortitude for that, and I doubt that even Dr. Esserman’s intestinal fortitude is up to the level where she would use “watchful waiting” as the initial management of an invasive cancer."
What you are stating is, on one level, obviously true. Obviously, you cannot know what is in the closed box of the future until you open it. Obviously, no one can know ahead of time what is going to happen to them. Obviously, no woman can ever know ahead of time whether she will be one of the lucky ones who has her deadly breast cancer detected through screening.
But there are (at least) two different additional issues here:
I only have time for one now (but will post the other when I have more time).
First, you are wrong in insisting that population-level statistics are useless for the individual. Smart people use population-level statistics all the time to make decisions about their lives, about the risks they are willing to take. I choose not to play the lottery because the odds are against me. I do not have a crystal ball. I don’t know and I cannot possibly know if I would have been a winner or not, but I can clearly see that the expected value of my “investment” in a lottery ticket is negative (Usually on the order of $50 for every $100 spent.) Wise people know they will never know what the future would have held for them if they don’t play ... and yet they still don’t play.
Here is a different example: How do you know ahead of time, when you get on a plane that you won’t be on one of those rare planes that crashes? You have no way of seeing into the future. You have no way of knowing until you get on that plane and see what what happens. And yet you get on the plane, precisely because you have population-level statistics to reassure you and you know your expected value is really quite high.
Why do people decide to make a huge investment in going to college and getting a bachelor’s? Sure, some just love going to school just to go to school (end in itself). But a lot of people look at the expected value of an education and see that it is a good bet. They have no way of knowing ahead of time what the future might hold. But they know a good bet when they see it.
Similarly, I cannot possibly know ahead of time what a mammogram will reveal and yet I apply the same kind of reasoning. I look at the odds and decide what is best based on those odds. I see that the expected value is quite low, even potentially negative (if you take into consider all cause mortality plus the time, inconvenience, psychologically and physical pain involved in false positives, biopsies, overtreatment, etc.)
Really, there is nothing at all strange about thinking like this. In fact, since the future is always a black box (not just in BC screening, but for every single thing in our lives), we always kind of bet whether or not we are aware of it.
Last edited by Jill_Schramm; 09-26-2020 at 05:50 AM..
You seem to feel that having a mammogram involves some tremendous amount of time and emotional energy in going to the doctor and/or medical environment. I have to disagree with that assessment. Aside from updating my medical records online for pre-registration, my mammogram took a total of 25 minutes this year in a pleasant womens imaging center about 7 minutes from my house. The wait was 5 minutes to get in to see the technician, making the entire appointment approximately half an hour. Since both my mother and sister had breast cancer (successfully removed and treated), I consider 30 minutes of my "quality time" a paltry investment to try and keep myself as healthy as possible.
I know, right? What is the big deal? It can’t be a fear of the actual procedure, but more about being afraid of a scary result.
I know, right? What is the big deal? It can’t be a fear of the actual procedure, but more about being afraid of a scary result.
Well, some people fear the pain of the procedure, but it's so brief that, to me, it's negligible. There are also posters here who have stated they fear the mammogram itself, while "smashing" the breast, will damage the breast tissue and/or spread any existing cancer cells throughout the body. I don't subscribe to that theory; however, that is apparently their fear.
I know, right? What is the big deal? It can’t be a fear of the actual procedure, but more about being afraid of a scary result.
It’s funny because I tend to see those who insist on their screening mammogram as being driven by fear - the largely irrational fear that they will die of breast cancer if they don’t have their mammogram.
You say getting a screening mammogram is “no big deal.”
First, it doesn’t matter if it’s a “big deal” or not if there is no good proof that screening mammograms are actually effective in doing what they are supposed to do — saving lives and preventing overtreatment. There is instead lots of evidence that 1) although they do save a precious few women from a death specifically from breast cancer, we are talking about many fewer women than originally thought 2) if they actually have an effect on all cause mortality, is it extremely small - like 1 in 200,000 women and 3) women who have mammograms are much more likely to have bc treatment (and not just lumpectomies) than women without screening mammograms although the overall death rate is extremely similar.
If then there is little point to getting them and in fact evidence suggests that for most women mammograms actually negatively effect their health, why should I take an entire precious morning of my life for nothing or worse than nothing?
This might seem surprising to you. After all, patient-oriented literature offers cheery encouragements like: “Mammogrsms save lives. Get yours today!” What they don’t say is: 1) We actually have no great evidence they save lives, we just think so. Trust us. 2) They might save someone’s life but it is vanishingly small that this life will be yours 3) If you get a mammogram, you are much more likely to be diagnosed and treated for BC than if you don’t”
Why is this the case?
Screening mammograms were introduced many decades ago back when the medical model of cancer was much different than it is today. Back then, the idea was that cancer started off as tiny and treatable, but then steadily and predictably grew larger and metastasized and became deadly, so it was seen as extremely important to “catch it early.” Now, though, oncologists and cancer researchers know that the situation is much more complex and it is much more a question of the biology of a woman’s individual cancer than it is how large a cancer is when they catch it. So the entire idea of screening mammography is founded on an out-dated paradigm.
Unfortunately, although the paradigm is terribly outdated, the medical-industrial complex around mammograms has grown over the years so there are many, many medical professionals whose livelihoods depend on screening mammogram programs. And if your livelihood depends on something, sure as water is wet you’re going to squint hard at the data until you can tease out some evidence of some effectiveness even if it is for very few women.
Second point: Getting a mammogram does frequently turn into a “big deal.” You say it is so easy. You just go and get your mammogram. A little compression of the breast. Doesn’t hurt that much. One and done. But what happens if something suspicious is found and you need to come back for more testing. Already not so simple. Do you have to take more time off work? Give up lunch with a friend? Give up a lovely walk in the park so you can sit around in some medical waiting room again? (You are already playing the odds. You are giving up X hours of your life for some hypothetical return.) Then let’s say you get a potential positive (not so positive, if you know what I mean). You may think that this won’t happen to you. However, unlike the possibility of having your life saved due to screening mammograms which is very low (probably way under .05%), if you get tested every year for ten years, your chance of having a false positive is actually very high — close to 60%. So. It’s no big deal to get your boobs squished and radiated, but when you do that you are putting yourself on a slippery slope where you are much, much more likely to end up harmed in some way than helped.
Sorry about no links. I included links to articles and data in previous posts.
What you are stating is, on one level, obviously true. Obviously, you cannot know what is in the closed box of the future until you open it. Obviously, no one can know ahead of time what is going to happen to them. Obviously, no woman can ever know ahead of time whether she will be one of the lucky ones who has her deadly breast cancer detected through screening.
QED.
Quote:
Originally Posted by Jill_Schramm
It’s funny because I tend to see those who insist on their screening mammogram as being driven by fear - the largely irrational fear that they will die of breast cancer if they don’t have their mammogram.
I see those who choose mammograms as being proactive about their own health care, based on conversations with their doctors and a personalized estimate of risk.
“QED” means you proved something. However, you didn’t prove anything (and interestingly ignored the rest of my post).
Quote:
I see those who choose mammograms as being proactive about their own health care, based on conversations with their doctors and a personalized estimate of risk.
Oh, for crying out loud, let me solve this one for you. Almost everyone’s risk of hurting their health by not getting a mammogram is extremely low. Good luck finding a doctor who will tell you that though (in other words, have fun with that “conversation” with your doctor). Even though a lot of doctors are aware of the very serious problem of overtreatment specifically related to screening programs, they will not discuss it with their patients. Why? Mostly because they would like to keep their jobs (not get in trouble with insurance companies).
Again, almost every doctor is going to tell you that you should get a mammogram if you are in the screening age range (50 to 69) no matter what your risk and no matter what you say, Why? Because they are essentially required to tell you that.
Last edited by Jill_Schramm; 09-26-2020 at 08:49 PM..
“QED” means you proved something. However, you didn’t prove anything (and interestingly ignored the rest of my post).
Oh, for crying out loud, let me solve this one for you. Almost everyone’s risk of hurting their health by not getting a mammogram is extremely low. Good luck finding a doctor who will tell you that though (in other words, have fun with that “conversation” with your doctor). Even though a lot of doctors are aware of the very serious problem of overtreatment, they will not discuss it with their patients. Why? Mostly because they would like to keep their jobs (not get in trouble with insurance companies).
The QED was because you finally admitted there is no way to tell that specific woman is being overtreated.
The rest of the post became irrelevant after that.
No doctor will get fired or get in trouble with an insurance company for discussing pros and cons of mammography with a patient.
Th idea that mammograms are harmful is only your personal opinion, despite your long posts attempting to justify it.
The QED was because you finally admitted there is no way to tell that specific woman is being overtreated.
The rest of the post became irrelevant after that.
Did you even read the rest of it? Did you think about it?
Quote:
The idea that mammograms are harmful is only your personal opinion, despite your long posts attempting to justify it.
No. It is not my personal opinion. It is clearly there in the statistics.
Let me explain it to you another way,
You are clearly concerned about the fact that you cannot tell if you may or may not have your life saved by a mammogram beforehand. This is true, is it not? You insist again and again that you do not know ahead of time what the mammogram may reveal. I assume that when you say this, you are primarily concerned about the possibility of not getting beneficial treatment. You are not primarily concerned that you are missing out on your big chance to have unnecessary radiation therapy. I mean, of course! right?
But you are myopically choosing to only look at one side of the equation.
The gist of what I was saying was this: While it is obvious that you cannot tell what the future will be like if you don’t get a mammogram, it is equally obvious that you cannot know what the future will be like if you do get a mammogram. The future is sealed to us period. Full stop. We can not know what we are gaining or losing either way. Since we cannot know that, we use statistics.
Scenario #1:
So, it is true that a woman’s life may be saved due to a screening mammogram. Obviously, she won’t know if this is the case until after she does the mammogram (actually she probably won’t know it after either). This is highly unlikely, but it may happen.
Scenario #2:
However, it is also true that a woman may lose her life due to overtreatment (or other reasons) precisely because she had a mammogram. This is also something you do not know ahead of time. Just like the previous scenario this is highly unlikely, but it may happen.
Why do you, along with most women, myopically focus of Scenario #1 and completely ignore Scenario #2, which is about as likely according to statistics (I.e. not my opinion.)
And yes, doctors do have financial pressures on them place by insurance companies to get a certain number of women into screening programs. If they do not, they will be penalized. So, sure they say “discuss the harms and benefits.” However this is usually “harm and benefit” theater, not a frank discussion of harm and benefits.
Did you even read the rest of it? Did you think about it?
No. It is not my personal opinion. It is clearly there in the statistics.
Let me explain it to you another way,
You are clearly concerned about the fact that you cannot tell if you may or may not have your life saved by a mammogram beforehand. This is true, is it not? You insist again and again that you do not know ahead of time what the mammogram may reveal. I assume that when you say this, you are primarily concerned about the possibility of not getting beneficial treatment. You are not primarily concerned that you are missing out on your big chance to have unnecessary radiation therapy. I mean, of course! right?
But you are myopically choosing to only look at one side of the equation.
The gist of what I was saying was this: While it is obvious that you cannot tell what the future will be like if you don’t get a mammogram, it is equally obvious that you cannot know what the future will be like if you do get a mammogram. The future is sealed to us period. Full stop. We can not know what we are gaining or losing either way. Since we cannot know that, we use statistics.
Scenario #1:
So, it is true that a woman’s life may be saved due to a screening mammogram. Obviously, she won’t know if this is the case until after she does the mammogram (actually she probably won’t know it after either). This is highly unlikely, but it may happen.
Scenario #2:
However, it is also true that a woman may lose her life due to overtreatment (or other reasons) precisely because she had a mammogram. This is also something you do not know ahead of time. Just like the previous scenario this is highly unlikely, but it may happen.
Why do you, along with most women, myopically focus of Scenario #1 and completely ignore Scenario #2, which is about as likely according to statistics (I.e. not my opinion.)
And yes, doctors do have financial pressures on them place by insurance companies to get a certain number of women into screening programs. If they do not, they will be penalized. So, sure they say “discuss the harms and benefits.” However this is usually “harm and benefit” theater, not a frank discussion of harm and benefits.
You have already admitted that when a woman and her physician sit down one on one and discuss the issue there is no way to determine whether that individual patient will be one whose potential cancer would be deadly before the mammogram is done. After a biopsy is done, there is no way to tell whether a particular tumor will be indolent or aggressive.
Your entire argument is based on numbers generated after all of the mammogram and treatment decisions have been made.
Game over.
Goodbye.
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