Category: science-based medicine

What Orac has to say about the new USPSTF recommendations on breast cancer screening:

Whether the cost is worth it or not comes down to two levels. First and foremost, what matters is the woman being screened, what she values, and what her tolerance is for paying the price of screening at an earlier age, such as a high risk for overdiagnosis, excessive biopsies, and overtreatment in order to detect cancer earlier and a relatively low probability of avoiding death from breast cancer because of screening. Then there’s the policy level, where we as a society have to decide what tradeoffs we’re willing to make to save a life that otherwise would have been lost to breast cancer. Although screening programs and recommendations should be based on the best science we currently have, deciding upon the actual cutoffs of who is and is not screened and how often unavoidably involves value judgments.

That’s putting it well. Somewhere in the comments on the post, he also states that he wishes the whole “anxiety” thing weren’t being so generally overplayed. That I agree with as well, since it’s the thing that many women have grabbed on to, and it also the source of the accusations that the recommendations are “patronizing.” Considering that the detrimental effect of anxiety is not being played up in the recommendations, but rather that’s coming from the reporting, I think it’d be more fair to say that the press is being patronizing. Which isn’t a surprise for anyone.

Anyway, a good post. And unlike me, Orac knows what he’s talking about. His second post on the subject is also very worth reading.

From Skepchick: No, Ladies, the New Breast Cancer Guidelines Aren’t Patronizing

I mean, not a lot for me to say here. I agree. The guidelines aren’t patronizing. From the AP article about this:

“Overall, I think it really took courage for them to do this,” she said. “It does ask us as doctors to change what we do and how we communicate with patients. That’s no small undertaking.”

Considering the reaction that this is getting, courage is a fairly reasonable word to use. I did go look over the recommendations myself, just to see what kind of impression I got. It certainly wasn’t patronizing or patriarchal. I tend to think of myself as a woman with a big feminist chip on her shoulder, but the reaction to the recommendations has just left me stunned.

I think the issue is over the use of the word “anxiety.” As in, the panel that came to these conclusions feels that earlier screening causes a lot of unnecessary anxiety to go with the false positives and unnecessary biopsies. Perhaps the women who have latched on to the word “anxiety” are probably imagining an avuncular stand-in-for-the-patriarchy sort of doctor, telling us to not worry our pretty little heads over things, because anxiety causes wrinkles. While I think the assumption is understandable***, and perhaps the use of “anxiety” could be a bit better explained, the women who are saying bitter, nasty things about the patriarchy need to chill the hell out. The anxiety we’re talking about here is the soul-crushing, sleep-killing fear that comes with a false diagnosis or (even worse) a false positive off of a biopsy. Fear and anxiety like that could significantly affect the health of the person feeling it, particularly when we’re talking about an age group that’s moving in to the chronic conditions of later life (e.g. hypertension) that can be severely exacerbated by stress.

Another quote from the AP article:

“The task force advice is based on its conclusion that screening 1,300 women in their 50s to save one life is worth it, but that screening 1,900 women in their 40s to save a life is not, Brawley wrote.

On its face, I almost agreed with this quote before I sat down and really thought about the anxiety question. If there are negative effects and even mortality associated with the added stress of breast cancer screening, and if those negative effects mean that more women of this hypothetical 1900 suffer and die than the one woman who is saved… then yes. The numbers would say that it’s more beneficial for the population to stop the screening. If you’re that one woman in your 40s, that’s not a lot of comfort, though – and that’s how these things tend to work. (Very similar to vaccinations… it’s not comforting if you’re the 1 in a million that has a rare adverse reaction to the vaccination, but ultimately more people are saved when the population is vaccinated.)

The real stunner for me was the recommendation in regards to breast self-examination. I grew up in a time when that was really big. When I lived with my parents, my mom always had a card hanging from the shower head on how to do the self-exam. And recently, I also read The Cancer Journals by Audre Lorde. While there are many things in that book I disagreed with Lorde about (particularly her stance on alternative treatments) I was right there with her on the importance of exams. From what the report says, the practice apparently just doesn’t have enough efficacy and carries too many of the anxiety/false positive risk factors. Still, I have a hard time just letting the self-exam go as easily as the idea of having my boobs smashed wafer-thin between two plates of glass. In many ways, I think the self-exam has become a little ritual women do to ward off the specter of breast cancer – and if the recommendations are true, it’s about as effective as throwing salt over your shoulder to ward off bad luck.

*** Consider, for example, the way women are both demonized and patronized in regards to abortion. Laws that require women to view ultrasounds, or have multiple consultations, are certainly patronizing since the implicit assumption is that we’re incapable of understanding what an abortion functionally does.