Health care cost skyrocket, recommendations for screening women reduced

From the NY Times:

For nearly three generations, women have been taught that annual Pap smears, mammograms and visits with their doctor were essential to good health.

Now all that is changing. National guidelines are urging less frequent screening for breast and cervical cancer. The declining use of menopause hormones means that older women no longer need to check in with their doctors to obtain annual refills. Women are delaying childbirth, and some birth control methods are effective for five years, giving women even less incentive to schedule a regular appointment.

I have very mised feelings about this.  I’d love to know what others think.

I do think that the early introduction to the gynocologist that so many young women experience can easily become part of the pathologizing of the female body.  There are so many bits, and they need constand vigilance because they can turn against you at any monent.  And that’s just day to day life; if you become pregnant, little choices you make can ruin two lives, or indeed more.

On the other hand, I do not really understand the argument that the yearly screening is bad because there are a number of false positives that cause a lot of stress.  Doesn’t a human life typically involve facing the possibility of really bad news?

For example, at the age of 16 children’s brains are  not yet developed enough to give their owners the self control that adults more typically have.  And that’s when they can get control of a car to drive around.  Now there’s stress.  Or how about the stress of having a mean boss or getting demoted, turned down or even ridiculed in a social context.  What’s worse:  getting a really nasty review or having to go back to have the mammo redone just in case?  Or even having a biopsy because there is a lump.

And then there’s the suspicion that the reductions are occurring just when health care costs are receiving so much attention.

So what do you think?  I’m really interested in hearing what people think about the early pathologization of the female body.  It would also be great to hear from people not from the medically self-conscious USA.

I do remember Michael Dummett claiming that American concerns with, e.g., smoking argued a national narcissism about perfecting the individual.

Please let us know your views.

18 thoughts on “Health care cost skyrocket, recommendations for screening women reduced

  1. I’m no expert on this issue, but my understanding is that false positives cause a lot more than “stress”: often they entail further invasive and even dangerous medical procedures (biopsies, more x-rays and radiation, and extreme cases unnecessary treatment such as surgery, chemotherapy, etc.).

    Also, even putting aside these risks, the argument suggested above can over generalise. If there’s no harm in testing, why not have Pap smears every month, rather than every year? We have to draw the line somewhere, it’s not quite clear why the current status quo in the US (which, btw, is different in other countries) is the ideal way to go.

  2. Yearly screening was done away with ages ago in Canada. Americans seem over tested, over medicated, etc. that is those with health care coverage.

  3. It’s irrational, but I never go for any tests and wouldn’t go to a doctor unless I was seriously injured or very, very sick.

    Again it’s irrational, but concern for health has always seemed to me part and parcel of traditional femininity, and so puts me off. When I was a kid one of the big topics amongst grown up women was disease and operations. Women’s magazines even now are full of articles on health issues.

    It bothers me because it seems that the new presbyter is the old priest writ large: all the stuff that came out during the 1960s about “our bodies ourselves,” all interest in health issues and what was going on with one’s body just seemed an extension of the same old thing: women obsessing about their health, about their bodies and talking about operations.

  4. Jane expressed my understanding. Overtreatment is a huge and obvious problem:

    A study published in the Annals of Internal Medicine earlier this year found that, over a 10-year period, one in every two women who gets a mammogram will receive a false positive. Aside from the psychological impact of a cancer scare, one in 11 will actually be treated for breast cancer that does not require immediate treatment – undergoing biopsies, radiation and surgery.

    (Note that even the non-false positives are not likely to be women who benefit from the early detection.)

    But I’d really like to stress that medical stress can have surprisingly severe effects. Take monthly breast self exams. Turns out they are completely unnecessary. But I know lots of women who regularly felt guilty and worried about not doing them and put up with lots of well meaning nagging from concerned friends and relatives. It just wears on one. Given that it has no clinical benefit, that stress adds up to quite a bit of waste.

    I have arthritis. One of the things I shared with my arthritis buddy when I had one is commiserating after going even for routine checkups. Going to the doctor can be a really miserable experience. I remember getting exhausted by just having to take pills. Pills every damn day. 3 times a day, forever and ever. Stupid stupid pills.

    This is all in addition to the point of unnecessary consumption of scarce medical resources.

  5. As a 31 year old woman in the UK, where we have the free healthcare (for now), I’ve never seen or indeed had the opportunity to see a gynocologist. I’ve had a few minor gynocological issues, but I’ve always seen my GP or a nurse. When I got my Mirena fitted (bit like an IUD), it was a GP who fitted it. We get a smear once every three years from the point we become sexually active.

    I’ve always found the idea of seeing a gynocologist every year – or at all, if you’re in good health – a bit weird and yes, pathologising. To me, a gynocologist is a highly trained specialist doctor who is there when you have something seriously up with your tubes. It seems a waste of their expertise (let alone the cash that goes with that, whoever’s paying) to have them simply check everything is in working order.

    It’s strikes me as a bit like having to talk about your appetite and digestion to a gastroenterologist every year.

  6. Let me stress that this site is sharing the views of usually highly educated, very well informed people, but I don’t think any of us is trying to be a medical authority. Where one gets sound medical advice remains a puzzle for me.

    Let me stress two things that are being said; the lives saved by screening itself are much fewer than is often suggested, and the number of questionable procedures is too high.

    Still, there are some complications that might be mentioned. First, even the no 1 (in standard rankings) breast cancer center recommends self- exams for women with very dense breasts. Mammograms are much less effective in their cases.

    Secondly, there are a couple of reasons for unnecessary surgery and one is more benign, as it were, than one might think. Most breast cancer starts as lcis or dcis. For our purposes the “is” is important, because it means “in situ” and it is not malignant. Some specialist say it isn’t really cancer. However, some of it will become malignant, and there is now no way to tell which is which. If you have either, you need to have it out or do watchful waiting.

    Lots of women do not want to get a mammogram each year to find out if its turned maglignant. In addition, broadly speaking, the have it out, the better your quality of life will be. Chemo really, really sucks and it can do horrible things, but if you get it very early you won’t need that.

    If you miss the line between its turning maglignant and its getting to the lymph nodes, you may be in for a life time of unpleasant complications, even if it hasn’t spread to any where else. And once it has spread to the lymph nodes, you have to worry about mets.

    Once it metastisizes, your chance of living for over five years is 25%.

    A lot of women then choose what may well be unnecessary surgery because the consequences of leaving in stuff that is going to turn maglignant can be really bad.j

  7. Hi Anne,

    Hmm. I guess the key point, regardless, is that the amount and sort of screening should be based on evidence of benefit vs. harm. I trust that’s uncontroversial (though, it’s often not! people have a bias toward doing more).

    Wikipedia has a rather good discussion.

    From my reading, it’s not clear that the scenario you posit is benign, much less helpful, in real practice. Dr. Susan Love:

    The real issue is not whether mammography can find cancers but whether it can find them at a point that will make a difference in the outcome. The problem is that it is really the ability to find all cancers early that is being questioned. We now know that there are at least five different kinds of breast cancer and that some are so slow growing that it doesn’t matter when you find them, they would never kill you. Others are so aggressive that they will have spread before you can see them on a mammogram. It is only some of the kinds where you can make a difference with screening and it is mostly in women over 50.


    Recommendations on mammography screening must also take into account our new understanding of the biology of breast cancer. We used to think that all cancers were the same, that they all grew at the same pace, and that there was a window when all breast cancers could be caught before they spread. We now know that there are at least five different kinds of breast cancer based on their molecular biology. Some breast tumors are so slow growing and are so unlikely to spread that they will never do any harm. Others grow and spread very quickly. The idea that they all can be “caught early” is wishful thinking. In fact screening is best at finding the “good ones” that might even disappear if left alone.

    Things are different for high risk individuals, of course.

  8. Bijan, Love’s is the argument that yearly screening doesn’t save many lives. That seems right. But I was trying to point out that some of the seemingly unnecessary precdures might be more rational than one might think. I gather, for example, that about 70% of tumors start as dcis. Somewhere between 20 and 40% of these become invasive, and, as things are now, it is very hard to tell which is which. So suppose you are told that you have a condition that will kill somewhere between 20 and 40% in 10 to 15 years.

    If every one decides too have it out, that’s a huge numbers of unnecessary operations. But honesty, I couldn’t say to a friend, much less a loved one, that she should be happy with a 60 to 80% percent chance of, e.g., livivg to see her first grandchild. For women with relatively young children stll living at home, the thought of an early death is often agonizing. Plus dying of breast cancer is really, really hard on families and can take quite a while.

  9. Ps, I am so sorry to hear about the arthritis. It sounds as though it is rheumatic, which is worse than the plain one, I believe. If it isn’t i’d strongly recommend clucosamine, even though the latest evidence is not positive. It made an amazing difference to me.

  10. But I was trying to point out that some of the seemingly unnecessary precdures might be more rational than one might think. I gather, for example, that about 70% of tumors start as dcis.

    Obviously, it’s all down to the numbers. I’m having trouble making yours add up. For example, even if 70% of tumors start as dcis, it makes a difference if we’re talking 2% of dcis becoming tumors or 20%.

    Somewhere between 20 and 40% of these become invasive, and, as things are now, it is very hard to tell which is which. So suppose you are told that you have a condition that will kill somewhere between 20 and 40% in 10 to 15 years.

    Suppose we have 1000 women positive for dcis. If 2% of the dcis become tumors, that’s 20 tumors (9 more tumors will have other starts, so these 20 represent 70% of all tumors). If 20-40% of those tumors become invasive, then that’s 4-8 invasive tumors, let’s be pessimistic and say 8. That means that the risk is 8/1000 * 100, i.e., a 0.8% chance of having an invasive tumor, not a 20-40% chance.

    (If it’s 20%, then 200 tumors, 40-80 invasive, then 80/1000*100=8%. That’s obviously much more significant, but still much less than 40% chance of having an invasive tumor. Which is still not necessarily a 40% chance of dying.)

    There are risks to the surgery as well, of course.

    My further understanding is that the reviews show that at-screening treatment even of those 8 doesn’t improve outcomes. (If we’re talking about general population. High risk women have much different numbers.)

    (Apologies if I’ve gotten confused about your numbers. Obviously, some of my analysis was speculative and not related to the actual biology. I did do some googling around to try to find more about DCIS, but it wasn’t going very well. I did find these two articles are interesting. The first, even while suggesting fairly aggressive treatment, seemed a bit mixed to me. A key bit, “The increase in prevalence is largely the result of the increased use of mammographic screening, they explain, noting that DCIS now accounts for about 25% of all new diagnoses of breast cancer.” This is going to distort the survival (and treatment) rates. (I’m sure they dealt with these in the paper itself, the article isn’t so clear.) In the second, we have a reported doubling of women having a double mastectomy in spite of having DCIS in only one breast and having a very small risk of developing DCIS in the other breast.)

    If every one decides too have it out, that’s a huge numbers of unnecessary operations. But honesty, I couldn’t say to a friend, much less a loved one, that she should be happy with a 60 to 80% percent chance of, e.g., livivg to see her first grandchild.

    I do think the calculus is rather different at 20-40% risk of death. But we also need to know how many people are actually saved by the early treatment. It’s arguably worse to have treatment and die at the same point anyway.

  11. Dcis is often discussed in terms of being a tumor. It and lcis form 80-85% of initial stages of cancer. For DCIS, it is 20-40% that turns malignant, and unfortunately biopsies are inconclsive, because the tumor may have only a small part that’s become malignant. I’m not sure where your 2% came from. Perhaps a mistake of mine?

    One problem with a breat cancer diagnosis is that there are just about no options that are what would normally be acceptable. A very standard pattern of treatment is slash, burn and poison, though the poisoning can also precede other treatments. Honestly, the slash part can seem the easiest, though a mastectomy leaves one numb over one side of one’s chest, with phantom pain and itching, and a frozen shoulder. If lymph nodes come out, it can be much worse. There are a large number of exceptionally brave women bearing such burdens.

    I am pretty sure that if I were told I have so far non-malignant BC, I’d choose to wait and see. It’s really not clear that’s sensible. I’m going to stop for a bit and see if I can find a comments by a woman whose advice is highly regarded by the contributors of

  12. The 2% was just to illustrate what seemed to be a missing number, but I see it was just my following the wrong pronoun.

    One confusing bit about googling around is that a lot of the more obvious stuff is about post-treatment risks and risks of recurrence. But this article is interesting:

    “For every 1,000 women in their 50s who undergo a 10-year course of annual mammography, under a best-case scenario, two would avoid a breast cancer death or have a breast cancer death delayed — that is the credit side of the balance sheet,” Welch says. “On the debit side, 250 to 500 of these women will have at least one false-positive result they will worry about. And about four of these women will be diagnosed with breast cancer unnecessarily — four women will be overdiagnosed.”

    (In most recommendations, women over 50 are still recommended to get regular mammograms. So we should expect the balance to shift a bit in younger women.)

    Obviously, death is a big deal, but I don’t think the debit side is negligible. It depends a lot on the outcome of the unnecessarily treated women. I’ve different intuitions about the credit/debit when considering screening vs. say infliciting suffering to cause a cure. I.e., if 250 women being similarly anxious plus four being operated causally healed two women, would it be permissible? Required? I guess it matters if all the women are sharing the risk. In the screening case, you don’t know if you are in the helped or harmed pool, whereas with the causal story, presumably the ones in the harmed pool would have no risk…

    Re: prediction, this is cheering.

  13. Here’s Beesie, from She seems exceptionally well informed. One important point she makes is that the 20 to 40% risk applies to low grade cancer. Cancer cells get a 1, 2, or 3. That’s suppose to give you a sense of the aggressiveness:

    – DCIS is always Stage 0 breast cancer – whatever the grade, whatever the size.  DCIS is the earliest stage of breast cancer, with the best possible prognosis. DCIS is always non-invasive; there is no such thing as “invasive DCIS”.  DCIS can evolve to become invasive cancer but at that point, the diagnosis changes and becomes IDC.

    – Despite what you may read, Nobody knows what percent of DCIS will eventually evolve to become invasive cancer and nobody can predict which cases of DCIS will become invasive and over what period of time.  Some studies of low grade DCIS not removed surgically have suggested that perhaps 20 % – 40% will become invasive over 5 to 10 years but other studies have shown that low grade DCIS, left untreated, can evolve to become invasive cancer even after 25 or 30 years.  For those with high grade DCIS and DCIS with comedonecrosis, it is believed that the percentage that will become invasive is very high. However because these types of DCIS are almost always removed and treated, there is no way to know what percentage would become invasive if allowed to progress naturally.  It is known that after treatment (i.e. when the DCIS is surgically removed), if there is a recurrence, in approx. 50% of cases the recurrence will not be found until the DCIS has progressed to become IDC. 

  14. Bijan, Fernandes’ work is encouraging, but controversial, and, many feel, too early to use without more clinical trials. I don’t know. If, by the way, you know someone struggling with these issues personally, I’d say there does seem reason to be increasingly hopeful. It is definitely not fun, though.

    Psoriatric arthritis is really unfair.
    Do you know about Dennis Potter’s “the Singing Detective?”. Potter himself had very extensive psoriasis, and this show draws on that in a fairly hysterical British way. I just recommended it to a friend with psoriasis.

  15. That’s an interesting post. Unfortunately, the 20%-40% doesn’t tell us what the benefit is of treating it earlier, i.e., whether it improves morbidity and mortality outcomes. This post quotes an article saying:

    In the case of DCIS, there is a lack of convincing data that early treatment reduces mortality, Dr. Esserman said. Furthermore, finding DCIS has not led to a decrease in invasive breast cancer rates, she added.

    “There are now 60,000 new cases a year of DCIS in the United States. But we haven’t seen any drop in invasive cancers, despite treatment of DCIS as if it were early cancer,” she explained.

    In arguing for a change of approach to DCIS, Dr. Esserman said that screening for precancerous tissue works in some other cancers – it has led to a decrease in cervical cancer – but evidently not in breast cancer.

    Of course, this doesn’t say anything about morbidity…perhaps those invasive cancers are more effectively or easily treated early. But then balancing 20%-40% of women who have easier treatment vs. 80%-60% who have worse (because strictly unnecessary) treatment is tricky.

    I love the Singing Detective. Fortunately, I don’t have any active psoriasis, “just” the arthritis part.

  16. Bijan, apologies for the spam detector, which decided your link was suspicious. So irritating!

    I’m getting distracted by the idea of cancer as making one trashy or like a leper…

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