This is a blog by a former CEO of a large Boston hospital to share thoughts about negotiation theory and practice, leadership training and mentoring, and teaching.
Wednesday, November 18, 2009
Caught between mammograms
Here is a great commentary by WBUR's Rachel Zimmerman about the uncertainties raised by recent articles about mammograms.
It is worth reading the reports. http://www.annals.org/content/151/10/738.full (The report.) http://www.annals.org/content/151/10/716.full (The recommendation statement.)
The recommendation that would follow from the analysis depends on the objective. Careful reading of the report shows that the biannual screening from 50 to 74 is the answer that follows if the objective is to achieve the greatest reduction of breast cancer deaths for a given number of screenings. The answer might be different if the objective is to increase the available life-years of women stricken with breast cancer.
There are some important results of the analysis that don't make the news, or that don't support the TV commentary. 1. The radiation from modern breast cancer screening is small and a negligable consideration (contrary to the TV hype from supporters of the new recommendation). 2. The top end limit of 74 is largely based on the conclusion that many women beyond that age have a high liklihood of dying from something else, with the effect being reported as "overdiagnosis". 3. There is evidence in the report, not mentioned in the TV commentaries, of a median 33 life-years gained per 1000 women screened by extending the starting point of annual screening to 40 years rather than 50 years. I suspect that life-years gained for a woman stricken with breast cancer in her 40s would be pretty important to her and to her family.
I agree, confusion all over the place with the new mammogram guidelines. It states that women who have had the BRAC Analysis do not fall under the guidelines, in other words the test that look for the genes.
That test runs about $3000 and some insurance carriers are now scrutinizing who gets to have it and who does not and require a bit of documentation before they will approve.
Just my own personal opinion here, but I think this test would carry additional use now that the screening process guidelines are going to be changed, and also there's the company that does the tests having an exclusive patent here. The science world is complaining about that too as they feel they could use the genetic processes for further research.
It's kind of mixed up world here on this as again I think the testing might have more value now, and affordability, access and the scientific challenges wait at Myriad's (company that does the gene testing) door to answer here.
How do you find the women who do not meet the guidelines without a test is the question and once more who's going to pay for it and we kind of come around to the question on what's in a patent in healthcare, if you will and is there more importance to have this test done?
This is an incredibly gray zone analogous to the PSA testing debate. I saw lots of breast cancer in women in their 40's during my pathology practice - but also lots of big, benign hunks of biopsied breast tissue. Also people need to know that pathology itself is a sampling procedure. There is huge debate in pathology whether every single piece of tissue should be submitted for microscopic examination - and even if that's done, one slide of each piece is still only about 5 thousandths of a millimeter thick. To truly look at every millimeter of breast tissue would take thousands of slides for each case. Obviously, this is not done. Even with needle biopsies, not every single micron of tissue is viewed. In addition, there are "benign", "malignant" and "indeterminate" types of calcifications on mammograms.Of course, there are not rigid cutoffs between each category. If you're a radiologist who might get his pants sued off for missing something, how confidently will you dismiss "benign" calcifications? The public just has to get used to it - there is NO TEST in medicine which is 100% specific and 100% sensitive. Dealing with false positives and false negatives is just a fact of life. Each woman must decide, based on her individual risk factors, breast density, family history, ethnic group, etc. I just wish they hadn't come out with this now, when it can be seized upon by both sides politically and completely distorted - like everything else in this debate.
I can't comment on whether the recommendations are right. What I worry about is that we will never have the political will to change government-funded treatment decisions based on actual science if the treatment is popular or perceived to be important. If we can't do that, we'll never be able to control costs.
-------
Yesterday, but the U.S. Treatment Services Task Force announced that leeches aren't a particularly good treatment for most ailments. While noting that leeches might still be useful for certain specific circulation disorders, the USTSTF recommended against their use in other situations, like halitosis and appendicitis.
You can imagine the outrage. Although the Task Force has no power to make anyone do anything, Rep. Dave Camp (R-Mich) was heard on NPR's Morning Edition saying, "This is an even better example than death panels to illustrate the insidious encroachment of government into the health decisions made between a doctor and a patient." Camp also neglected to address the facts that overuse of leeches is (1) expensive, and science-based recommendations about appropriate use would save the government money without harming patients, and (2) can lead to negative side effects, such as upsetting the body's natural humoral balance.
Widespread concern of regular citizens that leeches would no longer be offered by their doctors, was shared by industry leaders. "I am deeply concerned about the actions of the USTSTF in severely limiting access to leeches. These recommendations, in combination with recent Medicare cuts to leech reimbursement, jeopardizes access to both long proven and cutting-edge bloodletting technologies," stated James H. Thrall, M.D., FACR, Chair of the American College of Bloodletting Board of Chancellors. Dr. Thrall neglected to note that the USTSTF did not limit access to anything, and merely made a recommendation.
Fortunately, the Secretary of Health and Human Services rushed to the microphone to pledge for the record that there would be no changes to Medicare or Medicaid coverage while she was on the job. "My message to patients is simple. Leeches have always been an important life-saving tool in the fight against pretty much any sickness they still are today. Keep doing what you have been doing for years -- talk to your doctor about your individual history, ask questions, and make the decision that is right for you."
Few commentators highlighted the rigorous science-based process of the USTSTF, the evidence against leech use in most cases, and the harms caused by the excessive use of leeches to treat illnesses ranging from fever to flatulence.
It is worth reading the reports.
ReplyDeletehttp://www.annals.org/content/151/10/738.full (The report.)
http://www.annals.org/content/151/10/716.full (The recommendation statement.)
The recommendation that would follow from the analysis depends on the objective. Careful reading of the report shows that the biannual screening from 50 to 74 is the answer that follows if the objective is to achieve the greatest reduction of breast cancer deaths for a given number of screenings. The answer might be different if the objective is to increase the available life-years of women stricken with breast cancer.
There are some important results of the analysis that don't make the news, or that don't support the TV commentary.
1. The radiation from modern breast cancer screening is small and a negligable consideration (contrary to the TV hype from supporters of the new recommendation).
2. The top end limit of 74 is largely based on the conclusion that many women beyond that age have a high liklihood of dying from something else, with the effect being reported as "overdiagnosis".
3. There is evidence in the report, not mentioned in the TV commentaries, of a median 33 life-years gained per 1000 women screened by extending the starting point of annual screening to 40 years rather than 50 years. I suspect that life-years gained for a woman stricken with breast cancer in her 40s would be pretty important to her and to her family.
I agree, confusion all over the place with the new mammogram guidelines. It states that women who have had the BRAC Analysis do not fall under the guidelines, in other words the test that look for the genes.
ReplyDeleteThat test runs about $3000 and some insurance carriers are now scrutinizing who gets to have it and who does not and require a bit of documentation before they will approve.
Just my own personal opinion here, but I think this test would carry additional use now that the screening process guidelines are going to be changed, and also there's the company that does the tests having an exclusive patent here. The science world is complaining about that too as they feel they could use the genetic processes for further research.
It's kind of mixed up world here on this as again I think the testing might have more value now, and affordability, access and the scientific challenges wait at Myriad's (company that does the gene testing) door to answer here.
How do you find the women who do not meet the guidelines without a test is the question and once more who's going to pay for it and we kind of come around to the question on what's in a patent in healthcare, if you will and is there more importance to have this test done?
http://ducknetweb.blogspot.com/2009/11/mammogram-guidelines-change-screening.html
This is an incredibly gray zone analogous to the PSA testing debate.
ReplyDeleteI saw lots of breast cancer in women in their 40's during my pathology practice - but also lots of big, benign hunks of biopsied breast tissue. Also people need to know that pathology itself is a sampling procedure. There is huge debate in pathology whether every single piece of tissue should be submitted for microscopic examination - and even if that's done, one slide of each piece is still only about 5 thousandths of a millimeter thick. To truly look at every millimeter of breast tissue would take thousands of slides for each case. Obviously, this is not done. Even with needle biopsies, not every single micron of tissue is viewed.
In addition, there are "benign", "malignant" and "indeterminate" types of calcifications on mammograms.Of course, there are not rigid cutoffs between each category. If you're a radiologist who might get his pants sued off for missing something, how confidently will you dismiss "benign" calcifications?
The public just has to get used to it - there is NO TEST in medicine which is 100% specific and 100% sensitive. Dealing with false positives and false negatives is just a fact of life. Each woman must decide, based on her individual risk factors, breast density, family history, ethnic group, etc.
I just wish they hadn't come out with this now, when it can be seized upon by both sides politically and completely distorted - like everything else in this debate.
nonlocal (and female) MD
I can't comment on whether the recommendations are right. What I worry about is that we will never have the political will to change government-funded treatment decisions based on actual science if the treatment is popular or perceived to be important. If we can't do that, we'll never be able to control costs.
ReplyDelete-------
Yesterday, but the U.S. Treatment Services Task Force announced that leeches aren't a particularly good treatment for most ailments. While noting that leeches might still be useful for certain specific circulation disorders, the USTSTF recommended against their use in other situations, like halitosis and appendicitis.
You can imagine the outrage. Although the Task Force has no power to make anyone do anything, Rep. Dave Camp (R-Mich) was heard on NPR's Morning Edition saying, "This is an even better example than death panels to illustrate the insidious encroachment of government into the health decisions made between a doctor and a patient." Camp also neglected to address the facts that overuse of leeches is (1) expensive, and science-based recommendations about appropriate use would save the government money without harming patients, and (2) can lead to negative side effects, such as upsetting the body's natural humoral balance.
Widespread concern of regular citizens that leeches would no longer be offered by their doctors, was shared by industry leaders. "I am deeply concerned about the actions of the USTSTF in severely limiting access to leeches. These recommendations, in combination with recent Medicare cuts to leech reimbursement, jeopardizes access to both long proven and cutting-edge bloodletting technologies," stated James H. Thrall, M.D., FACR, Chair of the American College of Bloodletting Board of Chancellors. Dr. Thrall neglected to note that the USTSTF did not limit access to anything, and merely made a recommendation.
Fortunately, the Secretary of Health and Human Services rushed to the microphone to pledge for the record that there would be no changes to Medicare or Medicaid coverage while she was on the job. "My message to patients is simple. Leeches have always been an important life-saving tool in the fight against pretty much any sickness they still are today. Keep doing what you have been doing for years -- talk to your doctor about your individual history, ask questions, and make the decision that is right for you."
Few commentators highlighted the rigorous science-based process of the USTSTF, the evidence against leech use in most cases, and the harms caused by the excessive use of leeches to treat illnesses ranging from fever to flatulence.