Feel free to skip your next mammogram then.

Incorrect...radiation contributes to cancer. However mammograms use such low doses of radiation that the benefits definitely outweigh the risks.

Your body has a way of shutting down when its being attacked.

stuffyhead

It appears that you confuse the mammogram with chemotherapy. Mammograms are low dose; chemo is high dose.

Yeah you got a 1 in 3 chance of "Winning". I'd take those odds anytime!

This is just a repeat of British propaganda combined with news-media skewing what the chief of cancer research said in the first place. He said that there were some breast cancers that would never need treatment but he also said that he did not know which ones at this point. This writer then extrapolated that to mean that there was no need to treat some breast cancers and implies that there is overtreatment. I do not understand why AP and Newsvine continue spreading misinformation. The UK has the highest death rates for breast cancer in all of Europe and North America. It sounds like they are justifying not treating breast cancer appropriately rather than the rest of the Western Countries over treating it.

I dont think the screening is the issue.

I think it's what happens next that is the problem.

Im really curious as to how they figured out, after the fact, that women received treatments for cancers that were never life threatening...but they couldnt figure that out PRIOR to giving the treatment?

Or are they saying that they knew, prior to treatment, that these were non-life threatening cancers...but the patients just hear the word cancer and ignore their doctors advice and go through treatment anyway, just to be safe?

Jack - Please familiarize yourself with the literature on this subject. When women are diagnosed and treated who would never in their lives have gotten sick from cancer, that is overtreatment, by definition. This has been shown to occur. Since there is no way of knowing which women those are, that does not imply that any person who has chosen to get screened and has had a putative cancer detected should choose not to treat it, and this article certainly did not say that.

I'll let my 39 year old daughter, mother of two about your educated assumption. she is now entering her 5th year cancer free following breast cancer - surgery, chemo and a lot of love.

Jane, I am a Board Certified Medical Oncologist in a clinic that is in the top 10% for survivals for stage III breast cancer. I KNOW the literature. What are your qualifications?

This is the same junk published by the Brits to justify not spending more to provide adequate care through their single-payor, public health system. It has been regurgitated once again by a writer for AP who does not understand whereof she writes.

Hey Board Certified Jack, single-payer is how it is spelled. I guess they did not teach you spelling in roughly 20 years of school?

jack,

Jane is a poster who I have gone back and forth occasionally. She is a very bright PhD candidate who reads scientific literature at a high level. Unfortunately, she is somewhat blinded by her strong bias against current medical practice, and she lacks any real clinical knowledge of medicine. This bias, and her inability to place what she reads in the context of treating patients severely limits her insight.

My two cents is that the public and media are very rightly clamoring for more and more preventative medicine. However, the more people we screen and treat the more false positives we may find. And as Jack correctly points out, the definition of "unnecessary testing" is somewhat unclear

To illustrate this point, think of diabetes. Currently, if your fasting blood glucose is less than 126, you are not diabetic. If its over 126, you are diabetic. Is there some cosmic significance to that number? Not at all---it was set somewhat arbitrarily by people. If we set it lower, we'd catch more diabetics and probably reduce some complications of the disease. However, we would also end up overtreating some people.

robiscoole,

Ive actually seen it spelled both ways. Not only that, but if all you can post about is spelling errors and grammar mistakes, just save everyone some time and skip it

Eric,

You've seen it spelled both way !!!

Really ?

You've seen "single-payor" often ?

It would be funny if it wasn't so sad.

jo,

oh boy. You should feel pretty darn foolish...

http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/single-payor-healthcare-what-could-it-do-on-the-national-stage.html

http://www.uua.org/statements/statements/115807.shtml

http://laborweb.afscme.org/sites/CA_C_57/CA_C_57_L_2428/index.cfm?action=article&articleID=3a25c084-fddb-4706-a795-f24c6d1c50e3

I rarely get to absolutely 100% prove someone wrong in black and white so thank you for this rare opportunity

Better luck next time...

jo,

Im going to pile it on you just because you chose to cop such an attitude from the get-go

http://www.merriam-webster.com/dictionary/payer

Merriam-webster lists "payor" as an alternative to "payer"

Definition of PAYER

: one that pays; especially : the person by whom a bill or note has been or should be paid

See payer defined for English-language learners »

Variants of PAYER

pay·er also pay·or

"Payor" is correct in this situation. Don't feel bad, Jo, it's usually only people who work in the health care industry that know this convention. It DOES give credence to Jack's claim that he is an oncologist.

Please, carry on. This is actually interesting- usually I dismiss those with Jack's viewpoint, but interesting to hear it come from a physician.

I stand corrected, my apologies to you eric.

I thought this was in the same vein as "should of" and such common error.

I'll plead the "English is not my first language" excuse your honor.

Jane, I am a Board Certified Medical Oncologist in a clinic that is in the top 10% for survivals for stage III breast cancer. I KNOW the literature. What are your qualifications?

Me too. As is everyone that posts on the newsvine.

Jack - I remember well that you have stated you are an oncologist who treats breast cancer. If you were not, I certainly would not have demanded that you read up on the subject. Overdiagnosis is a fact. Long-term mammographic screening results in the diagnosis, over a lifetime, of a significantly larger number of cancers. Either some fraction of screen-detected cancers would not have progressed to be detected otherwise, or mammography itself causes far more cancer than most of us would expect it to cause. Nobody is saying that a woman known to have stage I cancer should not be even conservatively treated because she might have been overdiagnosed, nor are they saying that nobody should ever get a mammogram. But if you move from the extreme position of "nobody ever getting a mammogram" towards the extreme position of "everybody getting a mammogram once a month from the age of menarche onward", there is some point at which the harms of added screening exceed the benefits. That point cannot be honestly estimated if the fact of overdiagnosis is ignored.

As for Dr. Eric, he is or claims to be a cardiologist. For some reason, Dr. Eric seems to be obsessed with the fact that I have a Ph.D. in a scientific field, even though my degree is not in a biomedical field and does not qualify me as any kind of expert on this subject. I think perhaps it angers him to know that I am as educated as he is and can't be told I am too ignorant to be allowed to read and think about medical literature whose conclusions don't support his beliefs.

Dr. Eric seems to be obsessed with the fact that I have a Ph.D. in a scientific field,

Ha..don't flatter yourself. A comment on the internet is far from obsessed. Also, please quote where I said you PhD to be is in a scientific field...i'll wait.

does not qualify me as any kind of expert on this subject

we actually agree on this

I think perhaps it angers him to know that I am as educated as he is

So you did college, medical school, residency, a fellowship, and a sub-fellowship? Hmmm...I suspect college at the most.

But angry? No... i meet people like you every day. Armchair docs who fancy themselves experts because they spend half their waking hours on webmd.

and can't be told I am too ignorant to be allowed to read and think about medical literature whose conclusions don't support his beliefs.

Messy sentence Jane. I think ive deciphered it though. You are welcome to read whatever you want. You do it well. You just apply it poorly. You do not know how to use relative risk properly. You do not understand the limitations of absolute risk. You do not know what constitutes significant tricuspid regurg. Etc, etc, etc.

Cute! I don't plan to prove my academic bona fides any more than you do. Yours are more relevant, since you demand special consideration as an expert and I do not, but you'd also have a greater potential loss of income from being outed, if your current and future patients could Google you and find about your ignorance of recent research and contemptuous attitudes towards health care consumers and their values. So from now on, why don't you just pretend I only have a high school diploma, and I'll pretend you're only an EKG tech, and we'll each judge the other's comments based on content rather than credentialing?

I understand one major limitation of absolute risk, which is that it's a limitation on doctors' income. When patients are presented with decision aids that give the absolute risks of various harms without treatment or screening and with treatment or screening, they are usually less willing to consent to treatment or screening. No wonder that so many doctors just happen to speak of relative risk for benefits and absolute risk for side effects.

Some Guy, No everyone posting is not a board certified oncologist but there certainly are a lot of jerks. Nor is the topic a spelling contest.

This article does not even define what over-treatment is. Is a biopsy of Ca-in-situ over-treatment or over-diagnosis? It might be in an 80 year old but what about a 30 year old? What about wide excision of an invasive ER/PR positive breast cancer in a 75 year old who has palpable axillary nodes? Does it matter if she is healthy vs. having heart failure and kidney disease? Is that over-treating?

Secondly, it is not just the genes that are being studied, but also antigens on the cancer cells, like the HER2neu antigen that predicts response to a monoclonal antibody. For a patient to be treated properly, a biopsy or wide excision needs to be done to get this information. Is all of that over-diagnosis/over-treatment.

People purporting to know whether a breast cancer will ever become invasive, metastasize and kill the patient vs. not ever needing treatment are speculating and gambling with patients' lives at this point in time. I doubt that there will ever be a time when a biopsy will not need to be performed and that, in itself may be treatment as well...and maybe even the only treatment necessary, but again define over-diagnosis and over-treatment. Jane your comment about monthly mammograms is just plain ridiculous. Yes, there are patients that I do not send for mammograms. They are ones that I would not treat if they had a positive one, or patients that I would only consider treating if there were physical evidence of breast cancer. An example would be a patient who already has breast cancer and is on treatment. Another example would be an elderly sick patient who I did not think would survive long due to other disease processes. There are a lot of reasons to not do a diagnostic test but YOU, Jane, do not have to look a patient or a family in the eye and tell them how their specific case should be handled. I suspect, from your comments, that you would like to be able to do so. I do not question your education, just your motives and your judgement, just as I sometimes question the judgement of certain doctors. Yeah there are MDs who are profiting from unnecessary procedures and treatments but I contend that in Britain the public health service is trying to discourage mammograms in order to save money. That sounds like a "death panel" to me. There are people in this country who would do the same thing, and that is wrong.

By the way, Britain does not have a true single payor (or payer) system. A lot of people there go outside the public health service for medical care and quite a few come to the U.S. for their care...if they are rich.

The argument that U.S. health care over-diagnoses and over-treats cancers is specious. The reason that the death rates from cancer is lower in a lot of other countries is because people there do not live long enough to get it OR their record keeping is bad or absent as in say Peru or China. There are likely a lot of people in those countries and others who never see a doctor for their lymphoma, prostate cancer. breast cancer or pancreatic cancer. Just like the reported infant mortality rates. If a child does not survive at least 24 hours in some countries, it does not count as a live birth. In other countries where labor and delivery are done at home, a stillbirth or a short-lived birth never gets reported and depending on religious custom, or the income of the family, there may not be a proper burial. Did you know that in my lifetime I have seen the dead infant of an unwed mother buried beneath the road of a cemetery in a small town in an unmarked grave? I doubt that infant ever got counted in the infant mortality stats.

This country is becoming (in)famous for having panels and committees who "oversee" medical care and over-document what they determine to be inappropriate care or unnecessary care. They consider themselves experts but have never actually worked in the field they are criticizing. They provide nothing of substance to the well-being of others (in most cases) and yet they get paid to do it.

The point is, Jane, that one can stand back and shout "Over-diagnosis" and "Over-treatment", but you sound more like Chicken Little than a cancer expert.

jane,

nothing in your post is worth replying to. Also, seems like youre the one jack slapped upside the head...

:-) Jack, overdiagnosis is statistically proven to exist. Regular mammography will lead to a greater number of total lifetime diagnoses of breast cancer. Since nobody dies of breast cancer without being diagnosed, by definition the excess number of cancers are ones that would not have killed the women diagnosed. The only way to avoid calling that overdiagnosis is to suggest that mammography itself causes a significant fraction of the cancers that a regularly screened group will suffer. Ad hominems will not help you escape these facts.

The more you screen, and the lower-risk the people who are screened, the more overdiagnoses and false positives you will have for every life saved. Yes, monthly mammography for all females would be ridiculously overdone. But you speak as if the evidence-based European standard of mammography once every two years for women over fifty is ridiculously underdone. Do you have any scientific evidence in favor of your preferred screening level, or is your belief just propped up by ideology and profit motive? I'm sure you as a doctor, and Eric as a doctor or EKG tech, read the New England Journal of Medicine. Today's issue has a fine editorial by Woloshin et al on cancer screening, freely available online, that notes:

"A simple recipe for persuasion is to make people feel vulnerable and then offer them hope, in the form of a simple strategy for protecting themselves. The standard approach is to induce vulnerability by emphasizing the risk people face, often framing statistics so as to provoke alarm, and then offer hope by exaggerating the benefit (and ignoring or minimizing the harms) of a risk-reducing intervention."

That is what you are doing when you pretend there is no overdiagnosis.

Jane, the opposite of overdiagnosis is underdiagnosis. Which do you think is worse?

I never said anything one way or another about "overdiagnosis". Define "overdiagnosis". How do you overdiagnose cancer??? I concede that it can be overtreated and often is. Do you over diagnose it the same way you overdiagnose pregnancy or an MI?

All European countries do not screen for breast cancer the same way. This article is about the UK and how they are trying to convince people that their way of screening is the right way. I disagree with them and so do a lot of other doctors who belong to ASCO. How is my ad hominem attack any different from calling Eric an EKG tech when you do not know for a fact that he is not who he claims to be. I said you sounded like Chicken Little with your circuitous logic but you may have insulted him by denying the fact that he might just be what he claims and yet you call him an EKG tech.

Heh, Jack, neither of you could have such lousy reading comprehension or you wouldn't have made it through med school, so I can only assume that your misrepresentation of what I said to Eric is deliberate. To address your substantive argument, I also presume you are smart enough to understand that, if the total number of cancers diagnosed over the whole lifetime of a screened group is 25% higher than would have been diagnosed in the same group during their whole lives if they had not been screened, then one-fifth of the cancers in the screened group never would have made them sick. This is overdiagnosis, and it's been thoroughly proven to exist. I personally would not accept any type of screening from a doctor who pretended that he'd never heard of it. It's the same old FUD (Fear, Uncertainty and Doubt) tactic to keep women flocking to the doctors' offices - "Oh, screening can't do any real harm! Those people who recommend less screening are just afraid women worry too much about the false positives."

There's no such thing as underdiagnosis - "missing" a cancer that is temporary or will never make a person sick does no harm (except to oncologists' bottom lines and cure rates). There is such a thing as late diagnosis, i.e., failing to catch a potentially curable cancer before it has spread. Whether late diagnosis is better or worse than overdiagnosis, at a population level, depends entirely on the numbers involved. Overdiagnosis seriously reduces quality of life, and even kills. One late diagnosis is certainly worse than one overdiagnosis. One late diagnosis would not - by average women's values, at least - be worse than a hundred overdiagnoses. Informed consent for random screening requires that women have some idea of what the odds actually are, given their age and screening frequency.

http://www.bmj.com/content/332/7543/689

Rate of over-diagnosis of breast cancer 15 years after end of Malmö mammographic screening trial: follow-up study

Cancer progression is heterogenous. Some do not progress. Some regress.

Jane, Semantics. Also, if a person dies from a cancer for whatever reason, like failure of a doctor to diagnose a brain stem glioma or as a secondary consequence of cancer, like a pulmonary embolus from an occult malignancy, that is under diagnosis (since having a malignancy increases one's chance of PE).

Are you seriously espousing treating individuals purely on statistics, which can be manipulated and which may not even be totally accurate? That is a cold, hard hearted attitude toward people. Each person is an individual and the decision to run diagnostic tests and to treat has to be based on more than what is posted in a journal article that is often tainted by the author's bias.

Your argument about over diagnosis is not totally absurd, just mostly. It like the tests run to diagnose influenza. By the time the test results are back the disease is running its course and the treatment for the most part is palliative. Same thing applies for over treatment. It occurs all the time by your definition. Everyone with TB will not die from it or become contagious yet it is universally treated because the risk of it doing harm is great. I suspect that the problem is that you want to be an MD but have not made it that far. Maybe, like a few of the "Cancer Experts" you intend to make a name for yourself by posting contrarian ideas, or archaic ones, like "Man will never fly.",which is sort of what you are doing with your argument about cancer diagnosis and treatment. There are obviously people who are diagnosed with cancer who will never die from it but there is no definite way to know whether they will die from it or not unless they are gasping their last breath or have a near terminal illness. The same goes for treating it unless one is clairvoyant. I have had one patient killed by a train and another killed in a plane crash just after completion of adjuvant chemotherapy therefore those patients did not benefit from the treatment. I have seen several women who had carcinoma-in-situ breast cancer who should never have had a recurrence after local excision and local treatment who developed metastatic disease. What you are arguing is that we should use statistics purely to determine how to manage individual cases. While that may work on a computer or in theory, there is more to diagnosis and treatment of cancer than that. Every patient is an individual and deserves to be treated as one rather than just being a statistic. Like I stated earlier, your theories might apply well to a "death panel" and that is a frightening thing toward which I fear we are headed. It is easy to say that an unnamed person on the other side of the world should not be diagnosed or treated for a cancer but if it is your wife or son I seriously doubt you would look at it the same way.

Robert, I agree, some cancers do regress. Melanoma is an example. Yet if you are diagnosed with melanoma the surgeon is going to recommend an excision, most likely a wide one with skin graft. There is no definite way to treat local melanoma other than that and not to offer it would be considered negligence.

Well, I guess I know how you're voting next Tuesday. "Death panels" indeed. :-) Firstly, you have put up another pitiful straw man. It appears that only a minority of screen-diagnosed breast cancers are overdiagnosed (though a recent letter in Archives of Internal Medicine suggests that the percentage is even higher than suggested here). Therefore, given that an individual had been diagnosed, "statistics" would say that it was wise to be treated, at least with surgery. The exception would be if she was old or sick enough that she would likely die before suffering serious illness from the cancer, and people who are in that category should not be getting random screening anyway. But they do.

Look, breast cancer is not the only disease in the world. There are other doctors out there pushing thyroid screening (the "incidence" of thyroid cancer and treatment-associated harm has skyrocketed). Others push ovarian cancer screening (the PLCO trial has shown that this subjects huge numbers of women to needless major surgery and saves no net lives). Shall we all get CAT scans annually to see if we might be getting pancreatic cancer (never mind the increasingly large numbers of cancers that will be caused from all this scanning)? And then there is heart disease, which kills far more women than breast cancer; screening of asymptomatic people is reported to convert many into cardiac patients without reducing event rates. There are potentially hundreds of diseases for which we could screen. Since it is not rational to spend one's whole life in obsessive efforts to find disease, one should accept only those screening tests which, given one's age, sex and risk factors, have a meaningful chance of being useful and are likely to do more good than harm.

ovarian cancer screenin

Jack, correct me if Im wrong, but ovarian cancer is very deadly precisely because there is no good screening tool, and thus cases are usually discovered in the advanced stage. I imagine thats the reason why no net lives are saved. Not because screening doesn't or wouldn't work, but because we can't screen effectively

Jane, you need to take off your biased blinders. You are so dead set that screening is useless you fail to consider other possibilities. You allude to whole body CT screening which I think everyone would agree at this point is not beneficial. But this doesn't mean screening for other illnesses is always bad all of the time.

The measure of a good clinician is a good differential diagnosis, and the ability to think critically. Most clinical failures I see result from locking in to a diagnosis too early, and failing to consider other possibilities. I think you may be doing that here.

And then there is heart disease, which kills far more women than breast cancer; screening of asymptomatic people is reported to convert many into cardiac patients without reducing event rates.

There is no such thing as screening for heart disease. We look for risk factors, and treat those that are known to cause things like heart attacks. And this has been shown many times to reduce event rates. If you feel different, please show evidence

I suspect the only thing you'll try to show is statin use in low risk individuals. Although this has been clearly shown to reduce event rates, I concede the numbers are small, and with the relatively new found risks of diabetes its not unreasonable to defer treatment on a patient by patient basis. However, for even moderate risk individuals, the choice is usually very clear in favor of treatment

Please do not claim to be experts on Cancer. With the thousands of years of school under your belts, all of you professionals have found no cure. These numbers are statistics to you not lives. Your profession is hocum-- snake oil -- and pharmys. I cannot cure your pain but here is something to make it go away for now. Please pay the nice lady at the front desk when you leave.

I'll take overdiagnosis over underdiagnosis any day. I've had 3 maternal aunts and one maternal great-aunt survive breast cancer. I am my son's primary (almost sole) care provider, and primary financial support. If there is something suspicious on my mammo, I want a definitive diagnosis, even if it involves a biopsy that someone not caring for or supporting my child deems "unnecessary". Considering the number of single mothers, I imagine an awful lot of women feel the same, regardless of the stats. Tell their orphaned kids that their mothers' lives were sacrificed in the name of questionable statistics from a nation with poor breast cancer survival rates, making recommendations about how, and how often, to screen.

Wow, Dr. [or EKG Tech, whatever] Eric thinks there is no such thing as screening for heart disease? I am glad to hear that he does not rake in big bucks performing stress tests or cardiac CT scans on asymptomatic people. Good for him - for once, I mean that sincerely. Sadly, other cardiologists do, and low-risk individuals who are screened end up getting more drugs and far more invasive procedures than those who are not, but without better health outcomes (see McEvoy et al., Archives of Internal Medicine 2011;171(14):1260-1268).

Sandy - For you, mammograms are a better deal. Though your absolute risk of having cancer on your next mammogram is still very small, your family history means that you might be at higher risk than an average woman, and the likelihood that screening would benefit you would then be higher. If you instead had a strong family history of colon cancer, you would probably care more about having some type of regular screening for that disease. In other words, you are rationally trying to avoid the health problems that are of greatest concern for you personally.

But as a general principle, don't be fooled by talk of survival rates that excludes talk of population-wide death rates. Overly aggressive screening that leads to high overdiagnosis rates artificially inflates the percentage of "victims" of a disease who are cured or survive long-term. Also, of course, if survival is discussed only in terms of measures like "five years after diagnosis," rather than age at death, earlier diagnosis would make survival look much better even if treatment had no effect whatsoever. (This "lead-time bias" is well understood yet still ignored to this day by some radiologists.)

rake in big bucks performing stress tests or cardiac CT scans

These tests are not indicated for asymptomatic patients, thus, as I correctly stated, they are not screening tests. They are indicated for symptomatic patients for the diagnosis, not screening, of heart disease

These (diagnosis vs screening) are important terms to learn to use correctly

ther cardiologists do, and low-risk individuals who are screened end up getting more drugs and far more invasive procedures than those who are not,

This is clearly against current ACC/AHA guidelines. Do some docs practice this way? Surely. Is it as many as you think/imply? No. If you have evidence to the contrary, please provide it.

rtificially inflates the percentage of "victims"

If they are screened and eventually diagnosed with a disease, then they have it and should be included in the denominator.

(This "lead-time bias" is well understood yet still ignored to this day by some radiologists.)

This is not at all ignored by clinicians. Every 2nd year med student knows this term.

rather than age at death

clearly this depends on age at diagnosis at least as much as efficacy of the treatment or screening tool

@jane,

I find your attacks on eric to be immature and to contradict the educational level you claim. Most especially immature is your threat in a later post to report him to the medical board - for what, exactly? I'll take my medical advice from someone whose degree IS in the biomedical sciences, thanks. Not from an organization trying to justify delayed treatment of potentially fatal illnesses.

jack, thank you for your description of the differences in which infant mortality is calculated in other countries. I had heard the same regarding not reporting the birth of a child who dies within 24 hours. An excellent illustration of how statistics can be twisted and used to malign the US health care system in comparison to other countries.

Obviously if two single individuals are diagnosed with incurable cancer, one at 45 and one at 65, the former will have a lower age of death. We are talking about populations here. Suppose a group of women all have cancers start when they are 60, that without treatment would become detectable at 67 and kill them at 70. If some are screened and diagnosed at 63, then if treatment were entirely worthless that group would all still die at 70. Yet their five-year survival rates would be 100%, compared to 0% in the unscreened group. There was a paper pushing mammography by a bunch of Oregon radiologists a year or two ago that deliberately ignored this well-known fact. There was also a recent study that found most doctors believed a large increase in five-year survival rates to be stronger evidence for screening than a small decrease in total-population death rates, even when they were coached otherwise, whereas the opposite is true. So if doctors are taught about this sort of math in school that does not mean that they will reliably apply it later.

Now, suppose that you add in another bunch of 63-year-old women who have cancers/DCIS that would never have harmed them. Some will not be harmed because they are fated to die "early" of something else; others will live to 80 or 90 yet the cancer will never spread, and may even disappear. Suppose these are detected by screening. The average age of death in the screened women will then be higher than 70. It is not tenable to then say "Look, screening adds several years to your life expectancy!" Those women's lives were not extended by treatment, and may even have been shortened, yet their inclusion makes early treatment look more effective. That is why studies of screening need to include total disease-specific and all-cause death rates. Those numbers are what allows us to know that only a minority of breast cancer deaths can be prevented by screening mammography. The death rate in screened groups is smaller, but only modestly so.

We really can't argue about this and a cardiology issue simultaneously - too messy - but if you are saying that asymptomatic people should not get stress tests or cardiac scans, it sounds like we have nothing to argue about anyway. Great to have a point of agreement.

Eric, you are correct. There is no really good screening test for ovarian Ca. The most common symptom is bloating. Most patients present with stage II or III disease.

As far as Jane, she would be dangerous if most people listened to her but fortunately they listen to practicing MDs instead.

Heh! Thanks! I don't ask anyone to listen to me on this issue. I ask them to listen, if it is consistent with their values, to the U.S. Preventive Services Task Force.

sandy,

thanks. i think things got a bit out of hand, and Im not completely innocent either. How's life?

jack,

thanks for the info. Im not familiar with the study jane cited--i wonder if they were using ca-125 or some other biomarker for screening. Just seems like that would be the major issue. I think if there was a good screening test for ovarian cancer like we have for cervical cancer, we'd have the same reduction in mortality.

jane,

i understand lead time bias. I just think that age of death is also a troublesome stat to use, even on a population scale. Just too many confounding factors other than efficacy of screening (age of diagnosis, efficacy of treatment, etc)

I think the actual correction factor used is a statistical tool honestly above my pay grade

Eric, CA125 was used as a screening test for ovarian ca. It did not increase early detection/cure. CA125 can be elevated by ascites, peritonitis and even pleural effusion.

Robiscoole: NOT! More cancers are being cured all the time. The research is being done. Everyone that treats cancer is not necessarily in research. It's not that simple. Do some reading.

If there is no way way of knowing if a cancer is harmful or not, how did anybody reach the conclusion that it is over diagnosed?. This article does nothing but add to the confusion. If there are tests (and I know that some exist) to determine cell proliferation speed, for example, why aren't they routinely used? There may be a lot of substance and research that led to the conclusions of this article, but they are not mentioned here to make an informed decision.

As always in the case of cancer such news add to the general feeling of fear. If research identified so many cases where treatments were not necessary or even harmful, please be specific and stop treating us as idiots!!! For many of us who had, have or live in fear of developing breast cancer it is essential to have serious and well documented information.

@Insider!

The "unnecessary" part is entirely in hindsight. By comparing the speed of cancer growth in treated and untreated patients, they can see that 3 out of every 4 breast cancer cases are "non-clinical" meaning that the patients did not benefit from treatment, but were exposed to the risk of treatment (which are well-known and well-documented.) The point would be to develop better tests and diagnostic procedures that distinguished between those who would benefit and those who wouldn't.

I have exactly the same situation with prostate cancer. I am 68 and have a high PSA and high PSA velocity. The odds are quite high that I have prostate cancer since over half of all men my age do. But the situation with prostate cancer is even worse. About 19 out of every 20 prostate cancer cases are exactly the same --- they are non-clinical --- and there is no benefit to treatment, only the lifelong persistent side effects to the urinary, bowel and reproductive processes. There is even evidence that at least some lethal prostate cancers might be caused/exacerbated by biopsies. But there is no test (including biopsy) that can distinguish between clinical and non-clinical prostate cancers, so urologists treat 19 men unnecessarily, almost always causing serious side effects, to catch one lethal prostate cancer. And with prostate cancere, there is absolutely zero evidence (including ALL major studies) that screening, biopsies, and treatment (surgery/chemo/radiation/hormone) extends life by even a second, including cases of lethal (fast-growing) prostate cancer.

But this puts patients in a horrible position. I can tell you that first hand. On one hand you have a urologist telling you lurid tales of the painful death that supposedly (and falsely) awaits all prostate cancer victims and demanding an average of $300,000 to "save your life." And on the other hand you have all the scientific data that tells you that there is absolutely zero evidence that treatment will extend your life, but that treatment could possibly shorten it and will almost certainly cause side effects --- ED, incontinence, and loss of bowel control --- that will last you the rest of your life. There are even studies that say that PSA tests are so improperly administered by physicians that they are less accurate than a coin toss.

Luckily, my wife is a gerontologist and I was able to both have guidance in examining the literature for myself and the access to some of the sharpest people in the field. So I chose to forego biopsy and have limited future PSAs to one a year. But the threat of the "Big C" is something in itself to be reaconed with. The psychological damage from overdiagnosis, not even to mention the cost to the medical system of unnecessary treatment, is something that should make people stop, get in touch with someone knowledgable who has nothing to gain financially from the diagnosis, and carefully evaluate the situation prior to jumping into serious and potentially damaging treatment.

One aspect that this article (and most physicians) completely ignore is that cancer treatment involving chemo, radiation, or hormones are serious KNOWN causes of cancer. Most people "cured" of cancer will eventually die of causes related to the treatment. Physicians consider this a "fair tradeoff." People dieing of their second cancer have doubts.

I don't think they know enough about breast cancer yet. I have a relative who was one of the "overdiagnosed" and chose to have it monitored. The next screening scheduled showed it had progressed to a Stage IIb which required chemotherapy and radiation therapy. Had they just removed it when it was low grade, it would have been a small lumpectomy with possible radiation, but no chemo.

Why are unnecessary treatments a bad thing? Because every year some women die from the treatments. The problem is from what I have seen of friends and relatives that have had cancer and then successful treatments almost all of them have had a reoccurrence and most eventually died. Just lost a friend last week at 39 she had been fighting cancer for 5 years. She go it the same time as my aunt who died ont he second occurrence. My friend had been treated for about 3 different cancers before it got her. Two other friends are on their second occurence of breast cancer. One study seemed to indicate that there were two types of cancers, those that kill you and those that don't. Treatment only delayed death for those that were fatal. This is backed up by the fact that even though more cancers are found earlier and treated, the overall death rate has not gone down. We just need to find better treatments.

Chris749391 - it's not that three out of four cancers are overdiagnosed, but that the majority of breast cancers fall into two other categories: ones that are potentially harmful but don't spread well, which probably would someday have been found and treated but would still have been curable at that point, and ones that spread very fast, which are often or usually already incurable when they are discovered by mammography. That's different from the situation with prostate cancer where it really is the case that a huge proportion of the men who could be treated never would have needed it.

Women should also notice that this was the estimated overdiagnosis rate for women in their fifties receiving screening less than once per year. It has elsewhere been estimated that two to ten women are overdiagnosed for every woman saved when women in their forties are screened annually (again, this does not address the huge false-positive and needless-biopsy rate for younger women). If you have an ultimately harmless small abnormality, it may disappear over time, and the more frequently you are screened, the more likely it is that that abnormality will be spotted during its limited period of existence.

"But some cancers will be treated that would never have caused any harm

and under Obamas death panel, some cancers will not be treated that will cause harm by denying mammograms until too late.

Chris 749391, Subclinical means that a cancer has not caused symptoms yet. That is usually the time when it can be cured. In addition, there are studies from St. Jude childrens hospital that refute what you claim concerning a high incidence of cancers due to chemotherapy. The fact that a person develops a second cancer can not be proven to be due to the chemotherapy. A lot of lymphoma patients develop a second lymphoma or leukemia but their immune system is already altered and this means that the 2nd cancer may develop because their own immune system does not catch it early.

In addition, comparing breast cancer to prostate cancer is like comparing apples to oranges. The death rate from untreated breast cancer is far higher than that for untreated prostate cancer. A lot more men die from other causes than their prostate cancer, not so with women who have breast cancer.

Excellent point although the statement quoted in the article isn't correct. We know something about the cancer based on histologic grade. The more undifferentiated the greater the chance of metastasis. If the author is right and it was your cancer what would you do? Roll the dice?

@Chris

I don't understand the rationale of getting a yearly PSA. You've already got a high PSA and PSA velocity and you're not doing anything about it. What does this test change?

Second. PSAs aren't administered by physicians, it's a lab draw. What studies (citation please) showed an "improperly administered test by a physician" led to overdiagnosis?

At Jack, of course the untreated death rate is much higher. The untreated death rate comes from those who received no testing or too late testing. By the time it is discovered it is inevitably fatal and likely would have been fatal no matter what treatment they received. For those who have a non-aggressive form of breast cancer it is often never discovered so we never know about it. Without this survuving comparative group of curse the non-treated rate is sky high. Again, what the research is saying is that women are receiving unneccessary treatment for cancer's they would never die from and some die from the treatment. If they were never tested we would never know they had it in the fist place. Again, we can twist the statistics however we want....

They have the ability to sequence the dna of the cancers. Hopefully, physicians can recommend treatment based on this in the near future.

The hindsight arguement doesnt make a whole lot of sense to me.

Do we know of women who've been diagnosed with cancer and have skipped treatment, and 3 out of 4 of them ended up just fine?

Short of that, im confused on how it's proven?

No, it's NOT true that three-quarters of breast cancers are harmless. The ratio of overdiagnosed people to lives saved is elevated because most people who are diagnosed with cancer because of screening do not have their lives saved as a result. One fairly good estimate is that there may be about a 25% overdiagnosis rate in middle-aged women. If that's true, it's closer to three-quarters of screen-diagnosed breast cancers that would eventually become dangerous if you lived long enough. (That's very likely not true of DCIS, which is a special case that many authorities think should not even be called "breast cancer.") Not having a diagnosed "real" cancer at least treated with conservative surgery would then, if you have a long life expectancy, give you a 75% chance that it would come back to bite you in the keister; that's worse odds than Russian roulette, though less likely to kill you. But that is an argument for taking action if you are appropriately screened and an abnormality is found, not an argument for screening younger and lower-risk women with higher frequency.

Oh I have a great idea. Since we can't tell which cancers will lead to death, let us just stop treating all cancers. Of course, the 25% whose cancer will lead certainly to their deaths, will die. However, think of all the money we can spend on bombs. The same savings can be made in postrate cancer, too.

@Miki Howcroft,

You're not as far off as you imagine. I am not as informed about breast cancer (since my risk is extremely low) but with prostate cancer, if you ceased all screening, biopsies and treatment (surgery, radiation, chemo, and hormones) you would not cause even the slightest change in life expectancy or death rates from all causes --- not even a day. And that applies to deaths from prostate cancer as well. But for every $300,000 spent to "save" one life, $5,700,000 would be saved by not trying to treat patients who would not benefit from treatment. I would think that if you then spent the almost $6 million appropriately and wisely, you could save far more than one life.

These are complicated issues that are highly influenced by money. Instead of money, the decisions should be made on the basis of quality of life and what really and truly can extend life or maintain/improve quality of life.

Modern medicine will become more and more about the allotment of finite resources, trying to put the resources where they will do the most good instead oif broadcasting them in the hope that something will "take." Remember M*A*S*H? Hot Lips did "triage" on casualties to try to save the ones that were the most "savable". Triage is what it is about.

Eventually Obamacare will incorporate these findings into breast cancer care. It's expensive to do so many tests, and doing less will save money.....you got to expect some losses.

....Never mind that the US has the highest cancer survival rate of any country...

mer44

....Never mind that the US has the highest cancer survival rate of any country...

This not true. It only appears true because we have such high detection rates. If every country found it at the rate we did they would probably be pretty similar. Many of the people who survive in low detection countries are just not known to ever have it and die of something else first. Those who are known to die of it are detected very late and would have likely died anyway no matter what actions had been taken earlier since some people never recover no matter how early it is detected and no matter how aggressive the treatment.

Statistics are a tricky thing, you can spout them however you wish to make your point....

Statistics are a tricky thing, you can spout them however you wish to make your point....

Just to show you, even though our survival rate is high, which is the rate of survival after it has been discovered, our actual death rate whether discovered or not is nowhere near as good. Again, statistics are a tricky thing...

Sorry, breast cancer screening is more available under Obamacare. However, if Romney is elected we will have fewer places to get screening since he will, "get rid of Planned Parenthood".

Miki Howcroft....Planned Parenthood doesn't do Mammograms....

Obama's Medical Advisory Board had recommended Women in their 40s should stop routinely having annual mammograms and
older women should cut back to one scheduled exam every other year....

Till the Sh!t hit the fan.....then they backed off....If Barry-0 gets re-elected there's no telling what he will do when he doesn't need the woman vote anymore....

@Mike in Delray,

The Planned Parenthood/mammogram issue is a lot more complicated than that. GOP-inspired restrictions on PP cliunics have pretty much stopped them from being able to have the equipment available to do them. For example, in Florida, PP has to have no less than FOUR physician-radiologists for each machine if it also performs "reproductive services." But if no reproductive services are performed, then only one part-time radiology tech is required. So PP does what it can for free and refers the rest to "friendly" providers who do the mammograms mostly pro bono.

It was the Preventive Services Task Force started by Bush who recommended that women under 40 not have mammograms unless there are other indications such as a family history of breast cancer. And ditto for the every other year exam for women over 40. It is not rocket science to look at frequency of examination and its effect on cancer survivability. Why do procedures that don't benefit anyone except the people charging for the procedure.

These recommendations came from task forces set up by the BUSH administration and have nothing to do with Obamacare or with the Obama administration. No one backed off --- the recommendations still stand as originally expressed.

Great spin attempt --- but very bad information!

Mike-O - The recommendation to reduce the number of lifetime mammograms for average-risk women is consistent with European guidelines that are based on the best available science. A disinterested task force determined that frequent screening of younger low-risk women leads to so much additional, unnecessary harm (including premature deaths) that it outweighs the expected benefits. I see no reason to distrust their conclusions more than those of a group of radiologists and surgeons who derive hefty incomes from doing these tests and procedures. But that is the conservative view now, is it not - that whoever is wringing the most profit out of a particular activity should have carte blanche to decree how and when it should be used?

Okay, so let's allow the one person die, instead of letting 3 others just worry about it. Does that work for everyone?

That's an illogical argument and non critical statement. It's about informed choice.

Or you could look at it as forcing 3 to be treated unnecesarilly to hypothetically save one.

Yes, other tests and testing measures exist, but they are not as widespread or available as the basic mammogram

The argument is not saying get rid of mammograms. Its stating the fact that there is inherent and dangerous problems with population screening. Which is different than clinically suspecting cancer and then ordering a mammogram. It's about telling people to get screened just because they are a certain age or gender. It's population medical policy. It has inherent problems.

Thank you for accurately pointing out the gist of the article. I would add that certainly technology already exists that can help determine during biopsy whether the lump is aggressive or a slow-growing, non-aggressive lump. It was after mine was removed that an Onco-type-DX test was performed on a thin-slice, determining that my cancer was 0% non-aggressive (would not be spreading outside the breast), eliminating the need for chemotherapy. Certainly this can be adapted to a biopsy setting. For those who think, oh, well, radiation/chemotherapy at age 70 isn't any big deal...think again. And I must add that I have felt totally ill-informed by the doctors all along this process and have had to self-educate, expecially about the long-term risks of radiation that no one talks about.

@zapper,

But taking a "wait and see" attitude and momnitoring a breast cancer closely to see if it indeed grows quickly is not a "death sentence" as you imply. In fact, waiting for a short while, at very low cost can improve diagnosis without adding significantly to risk. The problem is that the medical system is set up more along the lines of an "in and out" assembly line with little patient insight and there is no path to a closed monitoring loop that would make wait-and-see more effective, for both breast and prostate cancers.

My wife is a gerontologist, meaning that she studies aging. Gerontologists consider prostate cancer and, to a slightly lesser degree, breast cancer, not as acute illnesses, but as conditions of aging. These things are just part of the aging process and some part of the aging process will eventually envelope us all. At 68 this is a lot easier to see than it was at 25.

My mother is 83, she's had two rounds of breast cancer, both found with mammography and early detection. She's still going like the energizer bunny. Without the mammography, she would be DEAD. It's quite one thing to have a false positive and follow up procedures to find out if the diagnosis is truly cancer. (One doesn't usually jump from a positive mammogram reading to surgery or a full mastectomy or chemotherapy, without some more tests and followup.) It's another if no report is given due to the test being denied because it isn't always absolutely accurate. Personally, I'd rather be safe, than sorry, even if a little bit of worry was added in.

Zapper - Unless you can tell us that she had an extremely aggressive tumor type, you don't know that. For all we know, she might have had DCIS, which would likely never have harmed her. No doctor who has just put you through major surgery is going to say "Guess what, it looked pretty harmless." No, it's always going to be "We caught it JUST IN TIME." Since mammography only reduces the death rate from breast cancer by about 15% (while large percentages of diagnosed women survive no matter how it is detected), we know that in most cases of screen-detected disease, it's been caught either earlier than necessary or too late.

Chris - I would like to respectfully disagree with your "catch-all" solution of "wait and see". I was diagnosed in August of 2011 - 2 weeks after my 38th birthday - with stage Ib Triple Negative Breast Cancer. By the time I had my lumpectomy two weeks later, I was at a stage IIb because of the extremely aggressive pathology of my tumor. It had more than doubled in size in those two weeks. My situation is not an uncommon one, unfortunately. Do your homework on triple-negative, Her2+ and Inflammatory breast cancers. Young women are dying...daily. Ironically, the younger the individual is at diagnosis, the higher the chances are of her having a more aggressive, deadly breast cancer. Now, if this were your daughter, wife, mother...would you be willing to "wait and see" if hers was the variety that went from curable to potentially manageable at best in two weeks time? Concievably, had I waited another two weeks, I could have been at a stage III or even IV and that is not a risk I am willing to take with the live of my childrens' mother.

I can say absolutely that I am here today because of mammograms. My breast lumps could not be felt by both a nurse practitioner and a surgeon. My tumor marker test showed up as normal. I felt fine at the time of diagnosis. Despite this, I had stage III breast cancer. That was almost five years ago now.

Lead time bias is also factor. Survival rates are calculated based on 5 years. Cancers can be detected earlier which means the person lives longer after being diagnosed, not necessarily just living longer. Stage 4 breast cancer survival rates are about the same as they were 50 years ago.

Again, it's a numbers game. If mammography saves 10 lives a year, is it worth it? I say yes. I don't know about the rest of the world, but I do know that breast cancer, left undiscovered and untreated, has killed more women than I can count. If it inconveniences a few people with a false positive, so be it. That's why we have "more tests" to figure out what is what. Until someone has been through that wringer, I would suppose they don't think it will happen to them. I don't like playing the numbers against my life. I'll have my mammography, thank you very much.

If it inconveniences a few people with a false positive, so be it.

You're misunderstanding. This doesn't even count the many false positives. This is talking about overtreatment.

I would like to know how it is determined that 75% of breast cancers would not kill the patient. Is this determined by the number of women with breast cancer who die due to other causes like car accidents? Or stroke? Absent a crystal ball to determine the patient's future cause of death, we MUST treat breast cancer when we find it. Breast cancer is not a systemic disease until we give it enough time to spread to other parts of the body. Once it has gone systemic, it is deadly.

During the Viet Nam war we lost 58,000 Americans in the war and we lost 300,000 American women to breast cancer. There was not a whisper about those 300,000. There was no mammography, no early detection, breast cancer was virtually a death sentence. Very few people cared, but some of us got on a soapbox and started fighting the establishment. Forty five years later we have the ability to find breast cancer when it is the size of three grains of salt. At such an early stage we use a needle to extract susoicious cells, and yes, many of them are benign to the great relief of all involved. So those with benign cells go home with a bandaid and their lives go on as usual. For those whose extracted cells are malignant, a surgeon will consult with them to determine their course of treatment. ONLY WITH YEARLY MAMMOGRAMS DO WE HAVE THE ABILITY TO FIND CANCERS WHILE THEY ARE VERY SMALL.

What I find disturbing is that mammography seems always to be under attack. By whom? A government panel with no cancer doctors on it? And no radiation doctors on it? Are we to lower our standards to comply with European Health care, mammorgams every three years, then stopped at age 70? For those of us who live in the world of mammography, saving lives is not open for negotiation.
To Readers: PLEASE AVAIL YOURSELVES OF THE EXCELLENT DIAGNOSTIC TOOLS YOU HAVE IN YOUR COMMUNITY.

http://www.washingtonpost.com/wp-dyn/content/article/2007/04/06/AR2007040601955.html

Finding More Cancer Isn't the Answer

Zapper - The false positives - which will eventually be a sizeable percentage of those who follow the self-interested recommendations of American radiologists - are only subjected to a little more radiation and/or to minor surgery that very rarely causes lasting harm or death. Then they are told that they don't have cancer ... though of course they will "need more follow-up." They'll be fine. The "three women" we are talking about here are women who are told that they DO have cancer and need major treatment. You dismiss their experience above as "worry", but it's much worse. They will have surgery - the number of mastectomies goes up with frequent mammographic screening, not down, because of the rate of overdiagnosis - and perhaps a lifetime of lymphedema. They may be pressured to take chemo that reduces their cognitive ability or causes heart failure, and/or radiation that can cause heart damage or future cancers. A few will actually die of that damage, which may be why frequent early mammography does not seem to improve all-cause mortality rates. Then there are the financial burdens on their families, the lifetime of worry, stress and follow-up care, the risk of discrimination against those believed to have pre-existing conditions. These harms must be counted in the estimation of the net benefit of a screening program. Nobody is saying that nobody should ever be screened; what they want to do is find the point where more aggressive screening of lower-risk people causes more additional harm than it prevents, and stop just before that point.

Lesley - Thank you for your comment. My mom was one of those 300,000 women who died of breast cancer during the Vietnam War era. She was 44 years old. Because of the advances made since that time, I have a good chance of not having a recurrence and actually seeing old age!

Robbie,

That has always been our goal. Thanks for your comment, you made my day!

Thanks, again, Robert. My perception is that surgeons know only about surgery, oncologists know only about oncology, and radiologists know only about radiology. Therefore, the patient gets only part of the picture, and no one cares about recovery...what to do to re-build the immune system, how to detox the anesthesia, etc. I'll definitely check out this book.

@Robert,

I was lucky enough to be able to have Dr. Welch consult on my prostate cancer issues. (My wife is a well-known gerontologist, so I had the connections.) He has a very clear insight into the issues. If you are not up to the book, here is a short youtube video in which he discusses it.

http://www.youtube.com/watch?v=3WocLvpfFcA

My decision, after several such consultations and a very thorough, grad student-assisted lit review, was to forego biopsy, to forego future DREs and to restrict future PSAs to one a year.

One thing that even Dr. Welch does not mention is that around 90% of PSAs are so poorly administered that they are less accurate than a coin toss. For a PSA to be meaningful, the man should not have ejaculated for 3-5 days prior to the test. If the man has had a vascetomy in the past, he should abstain for 2-3 weeks prior. If this is not done, the PSA results are meaningless, but the current office practice system does not allow for patients to be so warned prior to a "routine" test.

Excellent!

@Marilyn - you are very accurate with your statement that surgeons know surgery, oncologists know application of chemo, radiologists know application of radiation treatment, etc.

A WWII vet I knew had prostate surgery, followed by some chemo and I think one radiation treatment. While having an outpatient saline IV to treat his subsequent dehydration, he died from cardiac arrest (his potassium levels were practically zero.) The oncologist apologized because she did not know the medication could deplete his potassium electrolytes. So sometimes the specialists do not even know the effects of their favored treatments.

With no treatment at all for his prostate, he likely would have lived to see the dedication of the WWII Memorial.

With a hammer in your hand, everything looks like a nail - this applies to surgeons more than any other specialty.

@mailman,

Your story, however anecdotal, is exactly why it is bad medicine to treat people unnecessarily. 19 out of 20 men who are treated for prostate cancer do not benefit from the treatment. But 20 out of 20 men are subjected to the risks, the side effects, and the possibility of death from treatment.

Urologists see prostate cancer as "a guaranteed revenue stream" and little else.

Those are not mutually exclusive options.

REad the book. It will give questions to your observation and possibly erroneous conclusion.

Exactly right: to save money; lots of money. Millions of dollars for EVERY middle-aged or senior female saved. A society will fall apart if the old are allowed to feed off the bones of the young. Cancer is a normal part of aging. Everyone isn't going to make it to 100, or 80 or even 70. The senior citizens, physicians, medical community and politicians should be ashamed of themselves. The government allows seniors and physicians to use the American taxpayer to pay to keep every senior alive for months at any given cost. Seniors are happy to take advantage because, "We paid for this our entire working lives through our Social Security." Funny how senior citizens don't know when they actually started paying for Medicare (that it was LBJ who set it up in 1965), what percentage they paid or how much they paid. They just feel they have a blank check to use however they feel.

Janedoe-how old are you? How old and how healthy is your mom? Would you euthanize her to save your inheritance?

I am forty. My mother has already been killed by a doctor who did not prescribe an antibiotic for strep throat. But, let's go with my 77 year old grandmother. She smokes, has Type II diabetes and Alzheimer's disease. Complications of the diabetes include blindness in one eye, stage 3 kidney failure and nerve damage that leaves her unable to walk unassisted and in debilitating pain. Last year she had a knee replacement. At the time, surgeon said he would wait a year for her to recover so he could do her hip replacement but the surgery had to be postponed this year because she required a quadruple bypass. Sure enough, as soon as she healed, they did the hip replacement. This woman is barely alive. There have got to be limits! My husband and I are self employed and cannot find, on the private market, any reasonably priced insurance (less than $1500/month premium with a $5000 deductible). When I got pregnant I hired a midwife because I couldn't afford a $25000 bill for a doctor who weighs you and has you pee in the cup once a month to tell you nothing is wrong. A pediatrician wants $500 cash to tell you your child is fine.

So, yes, I would happily euthanize my grandmother to go see a doctor and take my children to the doctor.

JaneDoe, i have the feeling you wouldn't have any objection to euthanizing me, either. I was diagnosed with prostate cancer at age 54, and had the surgery. It seemed effective for about 7 years, when my PSA began to rise. It had metastasized to my lung, and cost me a lobe during the biopsy. I am now on hormone therapy either for the rest of my life, or until it fails, at which point the treatment options become very expensive, and may or may not prolong life beyond what no treatment would result in. My total costs for this disease are probably over $400,000, most of it paid by insurance. I have survived since diagnosis almost ten years. Have I fed off the bones of the young too long for you? Just asking.

Jane Doe is right. There is a point where we need to say "enough is enough." It is not only a financial issue, but a quality of life issue. Breathing isn't life, it is just breathing. My grandma thinks her quality of life begins and ends with her cigarettes. But there are other seniors (my great-aunt and adopted-step great-grandma) who make a positive difference, or at least actually live, that deserve to keep on living if possible.

And yes, if I had to choose between giving an organ to a young person or an eighty-year old invalid, I would give the organ (or money for medical expenses) to the person who has more time and ability to enjoy their good health. Unfortunately, resources are limited. Reality is full of tough, non politically correct decisions. Sometimes that means just making people comfortable.

Yes, there's a point where enough is enough, but who is JaneDoe to say we should just let people die from cancer, because it's a normal part of aging? Strep is a pretty normal infections, too, but it apparently wasn't the strep, but the doctor's inaction that killed her mother. So, we treat strep, but not cancer?

My dad is 64, and had his cancerous prostate removed 2 years ago. No signs of recurrence since. At the time, he was jogging 45 minutes on his treadmill most days, and still plays golf every day the weather allows. He still cuts and stacks all the firewood for his and mom's primary source of heat. He is likely to live a lot longer, with a very high quality of life, yet, according to JaneDoe, he shouldn't have been treated.

If he'd had some other disease likely to end his life soon, I'd agree that he shouldn't have been treated for his prostate cancer. But he didn't - he was healthier than many men in their 20's, otherwise.

Suppose you have a big group of women and you split them into two groups of identical size, have half get annual mammograms and half not, then follow them for many years. Let's say by the time they reach old age 100 women have been diagnosed with breast cancer in the no-screening group and 125 in the screening group. Since the groups were identical at the start, they should have had identical cancer risks, so where did those extra 25 cancers come from? The nicest and most likely explanation is that they are overdiagnoses of "cancers" that would never have done harm (probably including most DCIS, which used to be rare but has skyrocketed in "incidence" since the screening era began). Unfortunately, there is no way to know in advance, if ever, which apparent cancers need some kind of treatment and which don't.

The incidence of DCIS has not skyrocketed. The ability to detect DCIS, while the breast is still attached to the patient, has increased with the improvement of imaging. When DCIS was first perceived on mammograms, the tendency was to watch it closely. Usually it didn't change much leading us to believe that it was not a threat to life. When it began to change it was removed.

Now we've had many more years to observe the behavior of "innocuous" DCIS. It turns out it's not so innocuous after all. Lazlo Tabar, M.D. has demonstrated that when we see DCIS, there is often a much larger area of involvement that we cannot see...yet. He has also demonstrated that, given enough time, it will grow and spread. DCIS is taken much more seriously now than it was twenty years ago,and rightly so. I am not an advocate of sitting around watching a cancer grow.

The first occult (not palpable) breast cancer was found in 1916 by a German surgeon, Dr. Salamon. He had removed the breast because he had felt a mass within. The mass turned out to be a cyst, absolutely benign. But he also found a tiny cancer which would not have been palpable for many years. So that patient lucked out, her life saved because of a cyst.

One last detail is that DCIS is not a cell type. It only means that the cancer has not yet broken through the wall of the duct. Ductal Carcinoma In Situ will remain just that, until it becomes IDC, Invasive Ductal Carcinoma. You may feel free to roll the dice when your life, or quality of life, is on the line. I prefer to find cancer early and deal with it.

There is no test to determine which cancer is dangerous. Cancer IS dangerous. The sooner it's found and removed, the better the outcome. This article is inaccurate and, in my opinion, is a disservice.

Lesley - I agree that the true incidence of DCIS has not skyrocketed, hence the quotation marks. The rate of diagnosis has skyrocketed. You imply that it's just a matter of time before DCIS becomes invasive ("will grow and spread"), but that's been strongly questioned by other authorities. Most invasive breast cancers start as a single lump, while DCIS is diffuse and often widespread (which means that many women diagnosed with DCIS end up with mastectomies). Are we supposed to believe that it regresses everywhere else in the breast while it is turning into a palpable lump in just one spot?

Another point that has been made is that screening programs don't reduce the number of cancer diagnoses in later years to correspond to the increased diagnoses in early years. If you screen a bunch of women this year and surgically treat everyone who has DCIS, then if the DCIS "would have become cancer" you would expect the rates of invasive cancer ten years later, say, to be substantially lower in the screened group, because you removed all that DCIS before it could become cancer. What actually happens is that they keep having new cancers diagnosed at pretty near the normal rate.

You speak of rolling the dice; well, every option is a dice roll. An average-risk woman is more likely to be harmed than helped by mammographic screening, so you're gambling when you do it, too - but those few women who are helped win really big. If you are told you have cancer and your doctor recommends radiation or chemo, you're either rolling the dice for some increased risk of recurrence or for a risk of heart failure and chemo brain. I make a hobby of pointing out to doctors that these are value judgements, not scientific judgements that have only one right answer. My own values include the feeling that an iatrogenic illness one has paid to suffer from is less tolerable than a natural illness that causes equivalent suffering. Therefore, my decision-making is biased towards refusing interventions that have not been proven in randomized trials to do more good than harm. YMMV.

i disagree with nearly everything in the above post--from DCIS being as benign as you claim, to cancer rates not dropping.

Id like to see sources for all of that

You should read Peter Gotzsche's book on the subject. You may find some of the discussion of statistics hard slogging, if your dismissive remark about absolute risk is representative, but it will be well worth your effort.

You should read Peter Gotzsche's book

No thanks. My education came from school--not amazon.com

if your dismissive remark about absolute risk

Recognize limitations, which is what I said, is different than dismissing outright. If you can't tell the difference, just give up now

Arm your patients with the information they need to make a decision. You don't have to love your patients...treat them like people who have a right to know what the risks are (in ALL the treatments) and you may find that these women are capable of making decisions, based on knowledge, not fear! Been there. Done that.

Er, the standard of care for breast cancer used to be to chop out a woman's chest muscles, and then to leave the muscles but chop out all of her lymph nodes. Then it turned out, oops, neither of those makes a substantive difference. It might be a very bad idea to let the (often local, often not evidence-based) standard of care "dictate" what happens to one's body. There are usually multiple treatment options (including that of doing nothing), and patients need to know the number needed to treat (with what expected benefit) and the number needed to harm (with what expected harm) for each option so that they can make decisions consistent with their values and life circumstances. You as a doctor are expected to know and explain the technical facts, but you are no longer expected to "dictate" the decision that best suits your own values.

@Kenneth,

The proper way to proceed --- as always --- is to regard a mammogram as data only. The patient should be given ALL the data, including the risks of unnecessary treatment of "non-clinical" breast cancers --- and very complete informed consent and assisted in the decision-making process. Some people are much more scared by cancer than others.

But as an example of a bad process, I would recount my similar experience with prostate cancer. My physician started doing PSAs on me without informed consent. This also meant that he was so improperly administering the PSAs that the odds of a correct one was less than that for a coin toss. I have had an "enlarged prostate" since at least age 25 and am 68. My physician was alarmed at a 4.2 PSa and started doing them at monthly "recall" visits, but telling me that he was monitoring my blood pressure meds. Then one visit he announced to me that I has a 12 PSA and a high velocity and that I must see a urologist immediately if I wanted to stay alive. That will make your blood turn to ice water in an instant --- the only comparable time in my life was when I heard the sound of a bullet hitting the guy next to me in Vietnam. He told me that I "almost certainly" had a lethal form of prostate cancer that would kill me within months if left untreated. He never once inquired as to the date of my last ejaculation --- a key factor usually omitted by poorly-trained physicians.

I went to the urologist. He showed up with a drug company rep --- a tall blond from the cheerleading squad at the University of Kentucky with a PPT presentation on treatments for prostate cancer. The urologist paid a great deal more attention to her butt than to me. Then he took over and, in very lurid detail, described how horrible it is to die from prostate cancer that has matastasized to the spine. He concluded his speel with "Now when can we schedule your biopsy?" I said I'd have to think about it.

Luckily my wife is a gerontologist and the director of a academic center on gerontology, so I had the right connections. She loaned me a couple of grad students who helped me do a complete lit review and set up phone consultations with a number of serious researchers in the area as a professional courtesy. The end conclusion was precisely the same as the USPSTF on Prostate Cancer Screening that came out about 8 months later. I bet my money that I am in the 19 out of 20 that are non-clinical prostate cancer.

I stopped all DREs and told my family doc that he could only do one PSA a year and no more DREs ever. Now he thinks I am suicidal and keeps wanting to put me on SSRIs so I'll come to my senses and get that biopsy. He seems to resent that I am still here 2.5 years later and that my last PSA was a 3.7 --- "normal" for my age.

The reality is that you realize as you grow older that aging is a natural process and that no one is going to live forever. You realize that some cancers (and lots of other conditions) are a natural part of the aging process and do not effect longevity in the slightest. And you realize that life is not fair --- otherwise why would Kieth Richards still be alive? In the end, you realize that life is not abpout how long you live, but about what you doi with your life and the quality thereof. I couldn't see that at 25 because I wasn't supposed to, but now it is time to conclude that life does have a definite end and it is not that far away.

When I was diagnosed almost five years ago, the lumps were initially found via mammography. The radiologist wanted to confirm this, so I was sent for a needle biopsy. They also used those tumor samples to learn more about my cancer, such as, whether it was her2- or hormone positive. This information helps to guide the oncologist's treatment plan. Once my cancer was confirmed, believe me, I asked them to throw every treatment they had at me, and I followed my doctor's instruction to the letter. So far so good.

At least in my case, there was no "guessing," no "We think it's a tumor so we're going to subject you to four months of chemo just to be sure." If you have questions about whether a lump is cancerous or not, demand a needle biopsy or further testing, but for god's sake, don't just go your merry way, assuming that you may have a cyst or something.

Robbie, no ethical and competent oncologist would EVER treat based on a mammogram without biopsy. It just isn't done.

I was one of the four whose life was saved. Thank you.

It's impossible to say for certain. You can not prove a negative. Hence no one knows who is being saved and who is being overtreated. If they are alive and were treated then they believe they were saved. This is one of the many positive feedback loops that leads to more belief in screening.

Whiskey Foxtrot Tango???? So you're saying we women like to have mammograms? Perhaps you have never had one, but it's not something women 'like' to have. Mammograms squeeze your breasts to the point of pain.

As for other things we women get done that men don't, take the pap smear. KY jelly is applied to your outer vagina as a speculum (usually the coldest they can find) is inserted and cranked open with the delicate grace of drunk opening another can of beer. Then a thin Q-tip like instrument is inserted. The nurse or ob/gyn then scrapes around. All the while you feel this going on. It feels horrible and creepy.

Pap smears and mammograms save lives. Sorry you guys don't get to experience these 'wonderful' tests and that we are so lucky. By the way, men do get breast cancer too. Perhaps, you should experience the wonder that is a mammogram for yourself.

See above. Where is this woman? No one knows for certain. You can not prove a negative. 100% of the women diagnosed in this manner believe that their life was saved or the treatment mattered. In reality only 25% were saved while 75% were not "saved" but were merely overtreated and then believed they were saved.

This doesn't take into account of all of the false positives who were told they have cancer and had to go through unneccesary biopsies and anxiety for something that was never there in the first place.

Seems to me if 25% were actually saved, it doesn't make much difference which ones they were. I'll take my chances on the mammogram, and a treatment that might or might not be of benefit.

cancer treatment can be very dangerous, sickening, or permanent. It's nothing to take lightly. Especially if your prognosis is wrong and it turns out you never needed it. But with breast cancer nobody knows.

With more screening your chance of diagnosis goes up but not necessarily your chance of survival.

robert,

youre confusing screening with treatment. The value of screening is a bit controversial, though I think the data supports it.

However, with a known diagnosis of breast cancer, especially advanced, treatment is life-prolonging and even life saving

youre confusing screening with treatment. The value of screening is a bit controversial

uhh, this is what the article is about, Eric. Screening. Value. Harms. Controversy. Duh.

I would rather undergo a biopsy and find out I didn't have cancer than not have a biopsy and be wrong. Have you ever known anyone who died of breast cancer? My mother died of it, and it's a grueling, horrible, painful death.

I've never smoked, drank only lightly, didn't do drugs, ate a high-fiber, vegetable-based diet, took vitamins, exercised daily, had the vitals of a healthy 20-year-old, and felt terrific when I was diagnosed at age 48. So much for your theory.

Good luck to you.

Was it written by Seinfeld?

The report itself says the report is about nothing;

It's not about nothing. It's about 75% of screening detected breast cancer being overtreated. Meaning it wasn't going to cause harm.

Robert - read the story. It's not known until after the fact if the treatment was necessary.

No! It's more like the opposite ratio. What they aren't explaining here at all is that if your cancer is slow-growing, you could probably have waited to find it later and still been okay, and if it's aggressive, when they find it on the mammogram there's a good chance you're already doomed. Therefore most diagnosed cases are neither overdiagnosed NOR saved. They don't want to say that, because it makes mammography look not terribly effective, which is true.

We are told that the American-aggressive approach, annual screening for average-risk women in their 40s, will save the lives of about 1 in 2000 women that age over ten years of annual mammograms. During the same time several hundred will get at least one call-back and two to ten will be overdiagnosed and needlessly treated. For my part, these odds aren't good enough to seem very appealing.

Robert - read the story. It's not known until after the fact if the treatment was necessary.

That's not true. They never know who is actually overtreated and who is saved.But 100% who are still alive after treatment "believe" they are the one who was actually saved even though the statics dictate it's only a 1 in 4 chance it is. This creates a positive feedback loop of more screening "believers".

What part of this sentence do you not understand?

"But some cancers will be treated that would never have caused any harm and unfortunately, we can't yet tell which cancers are harmful and which are not."

Only someone looking to get out of paying for the treatment would try to ignore or twist that fact.

What part of this sentence do you not understand?

I understand it completely. You are not comprehending the message. I read the story and I already knew this issue with population screening.

we can't yet tell which cancers are harmful and which are not."

Read it again. It doesn't say they cut it out and stare at it and then decide "Oh that's a killer cancer right there"or "yup that's a harmless little critter".

They know through epidemiology that many of the screening diagnoses will not kill. They don't actually know in any particular individual case because they aren't prophets, have a crystal ball, or can accurately tell the future. So all breast cancer diagnoses get treatment. In this particular method of catching a diagnosis they determined about 75% are unnecessary treatment.

Do you understand that?

Jane is exactly right. She knows her stuff.

hat they aren't explaining here at all is that if your cancer is slow-growing, you could probably have waited to find it later and still been okay, and if it's aggressive, when they find it on the mammogram there's a good chance you're already doomed.

This is a gross overgeneralization to the point of being completely ridiculous

Dr. Eric, I've seen an estimate that regular mammography only reduces the death rate from breast cancer by 15%. That means that most of the women who would have died without annual screening die anyway, either because they have very fast-growing interval cancers or because their cancer had already spread when it was found on the mammogram. Of course, many women who have life-threatening cancers are saved by treatment. But this is also true of many whose cancers are detected by other means than screening. Improvements in treatment appear to account for most of the improvement in breast cancer death rates over time. I do believe that a majority of those who are diagnosed through other means than random screening enjoy long-term survival. Why don't you give Dr. Jack a little pat on the back for that fact, rather than trying to deny it?

Dr. Eric, I've seen an estimate..

Post it. If its like the other studies you posted, it consists of a case series of a dozen patients that you would like to apply to every woman on earth

whose cancers are detected by other means than screening

Thats the problem--how else are cancers detected? They rarely hurt, or cause noticible bumps until way too late.

Why don't you give Dr. Jack a little pat on the back for that fact, rather than trying to deny it?

a)please quote where I denied that

b) why are they mutually exclusive in your mind?

Heh! People who have been watching us go at each other for a while will know whether that's a fair description or not. If you're interested in learning about this subject, and don't have time/energy to get through Gotzsche's book, you should read the paper by Jorgensen et al. (Radiology 2011;260:621-7) that a commenter named Robert provided a link to on the second page of comments. This is an extremely helpful link - thanks, Robert, if you're still around! This paper provides two citations for the estimate of a 15-16% reduction in mortality due to screening. One is a publication by the Cochrane collaboration; the other is a publication in Annals of Internal Medicine about evidence considered by the U.S. Preventive Services Task Force. If you wish to have a tantrum and insult me some more for being so st00pid as to consider Cochrane or USPSTF as valid sources, go ahead, I can take it. :)

If it were true that cancers that are not screen-detected are "RARELY" detected before it is "WAY too late," then a sizeable majority of women who found lumps that turned out to be cancer would already be doomed to die of it. If that were the case, why would or should they submit to attempted curative treatment that would very likely just extend and increase their suffering while preventing them from completing life goals, dying with dignity, or leaving their families free of debt? Fortunately, you're wrong. Maybe Dr. Jack will break the thin white line long enough to smack you upside the head for your abysmal ignorance of his specialty.

! People who have been watching us go at each other for a while will know whether that's a fair description or not

This brings up an interesting point. Whenever you post a response to me, you direct it at some imaginary audience, like youre the keynote speaker at some convention. In reality, I doubt anyone but us two has read any posts. Anyway, just an observation

Either way, its probably better to stick to what I said rather than you would have like to pretended that I said. I know it will make debating harder, but TS.

you should read the paper by Jorgensen et al. (Radiology 2011;260:621-7) that a commenter named Robert

haha..robert is an antivaccine nut that posts here all the time. Good company.

If you wish to have a tantrum and insult me some more for being so st00pid as to consider Cochrane or USPSTF as valid sources, go ahead, I can take it. :)

More pretending by you. You have a wild imagination.

Fortunately, you're wrong. Maybe Dr. Jack will break the thin white line long enough to smack you upside the head for your abysmal ignorance of his specialty.

So Im the tantrum throwing insulting one? Just checking

I cannot follow your run-on sentences. Im sure you'll blame my reading comprehension, knowing you, but what am I wrong about?

if you think Im wrong about self exam being useful for detecting cancer early, then you have a lot to learn. Allow me to give you your first lesson...

http://jama.jamanetwork.com/article.aspx?articleid=365753

breast cancer self exam has a sensitivity of 20%. Yeah, missing 4/5 isn't that bad...

Good Lord, you boggle my mind. The sensitivity of a single self-exam has nothing to do with the proportion of non-screen-detected cancers that are curable. You just throw out these things at random as if one fact refutes a totally different fact - hey, they both have numbers in them, right? And you are a doctor? As for my writing style, which you keep grousing about, I suppose I should feel obliged to thank you for the feedback. Since most of my writing (outside internet bickering) is for scientific journals, I do tend to write lengthy complicated sentences that some laypeople might find hard to read. I will try to simplify my style a bit.

You only embarrass yourself when you offer childish ad hominem arguments. I don't follow the endless vaccine debates - there's no point - so I have not encountered Robert in that context. He linked to an article that was published by a major, mainstream radiology journal. If you want to discuss mammography in an informed way, you need to have read either this article or some other article that includes similar information.

Good Lord, you boggle my mind

Doesn't seem all that difficult. Interesting. For example:

The sensitivity of a single self-exam has nothing to do with the proportion of non-screen-detected cancers that are curable

Well, kind of hard to treat a cancer that you don't find through screening, and can't feel yourself. This goes directly to my point that outside of screening by a physician, it is difficult to detect cancer. I really shouldn't have to explain this to such an accomplished PhD candidate who somehow gets asked to write for journals..

there was nothing else in that self-agrandizing post worth responding to. If you can't see the connection between this statement you wrote:

then a sizeable majority of women who found lumps that turned out to be cancer would already be doomed to die of it.

and my citation you are hopeless. Also, this:

Since most of my writing (outside internet bickering) is for scientific journals

is hysterical. Just hilarious. You make a point of stating that your PhD is not in a science related field, yet you write for scientific journals?

At least be consistent with your fantasies

Good night

Dear God, how can you directly lie with a straight face about things that have been said in the same thread? Are you actually mentally ill? I'd almost agree to have us both post our CVs if you would go along with it, because if I knew who you were I'd report you to your state medical board as potentially impaired. (That is, assuming that you are a doctor and not an EKG tech.)

For anyone else - with regard to Eric's bizarre straw man, not all breast cancers are detected either by mammograms or by formal Breast Self Exams. The USPSTF specifically recommends against BSE, because it is not very effective but generates huge numbers of false positives. Simple awareness is responsible for finding many cancers. And as for his earlier claim that if you have found a lump it is probably "way too late" if it is cancer - Utter bull. Get yourself a doctor who actually knows what she's doing.

again, nothing worth replying to.

Also, this is your last warning about ad hominem. I will report you next time for violation of the CoH

Oh, my goodness, you are so cute! If we took away all use of ad hominems, you'd hardly have an argument left, and in the past I've seen you directly namecall several posters. Flag me for saying that if you like. I still will not stoop to flagging you every time you insult or slander me. People who love to dish it out but can't take it are infantile.

Anyone still reading? Scan through the messages above, make your own judgement about Eric's reading comprehension, and then think of him next time some cardiologist you've just met is agitating to cram a pacemaker, ICD, or bunch of stents into you or one of your elderly relatives.

reported.

Grow up.

Jane knows the facts of this topic. You are intellectually over your head on this Eric. It's obvious just in this thread alone. You have replied with nothing but ad hominems and personal insults.

It's really scary if Eric is a real cardiologist.

haha..robert is an antivaccine nut that posts here all the time.

You call anyone who doesn't agree with you a nut. Just like you are portraying Jane. How is this a not a COH violation but when Jane questions you it is?

Questioning the safety of a vaccine or the neccesity of say a Hep B vaccine for a non risk newborn doesn't make someone a nut. But your attempt to marginalize people who question medical policy has been noted.

You are a medical injury denier. You are hellbent on the ideological and indiscriminate use of medical technology on the population. Anyone who critically takes a stance against that policy or questions it is labeled anti-science luddite, uneducated, killer, etc.,

That is not scholarly or collegial debate. That is strawman logical fallacies and propaganda techniques.

Robert - He doesn't call everyone a nut. If you've been interacting with him for a while, you ought to know that he has a variety of names to call people, many of which are much harsher than the criticisms he runs to complain about. It's an interesting mentality. Actually, it's that apparent belief that he is entitled to belittle others while never being challenged himself that makes me think he may really be a doctor, whatever the state of his continuing education. I have seen the same sort of rage in cardiologists who were questioned face-to-face while in the process of committing life-altering malpractice on one of my loved ones. Those guys were shown enough red flags that they should have known they were making a big mistake, but because they were emotionally committed to the idea that patients and families had no right to question them and nothing of value to say, they were unable to consider the possibility of changing course. I believe that doctors who get angry when patients read and ask about medical literature present a huge risk of harm and should be avoided at all costs.

. I believe that doctors who get angry when patients read and ask about medical literature present a huge risk of harm and should be avoided at all costs.

I agree!

jane,

when i first saw you post on here, I thought you may be different from most of the people on here. Most posters clearly have no idea what they are talking about, and write purely ad hominem stuff with very little fact. I think mostly because they are likely meek individuals in real life but on the internet they get a dose of courage from the anonymity.

However, look at your last 2 or 3 posts. They are vile, spiteful, and of really little value. You clearly wouldn't say those things in real life face to face, so you need to ask yourself why you so easily do it on the internet

Does this somehow make you feel better? Is this a release of your tensions from life?

I suggest you find more effective ways to deal with frustrations and these anger issues. However, if this is how you are in real life too, than Im not sure that is better

If Im incorrect you have my sincerest apologies

Yeah, I'm angry. Life-altering malpractice has that effect on not only the victim but the relatives who have to nursemaid him through it. If you don't think I'd go toe-to-toe with an allopath and tell him to his face that he is wrong on the facts, think again. I didn't speak up with enough confidence to talk my loved one out of submitting to that malpractice, which he now bitterly regrets. But later, I learned. I had to get in a doctor's face and argue repeatedly to make sure that he was not subjected to at least three different further needless harms. Now, though he no longer sees a cardiologist and does not plan to do so ever again, if any doctor makes a claim to me that blatantly contradicts published literature, I will be quite capable of handing him a PDF and demanding an explanation.

My loved one does not want to sue, and these days, posting negative reviews of that particular pack of quacks could allow THEM to sue US. So, my way of dealing with the post-traumatic stress I suffered is to try to reduce the number of future victims, not just of those individuals, but of an entire industry that is often dedicated to turning healthy people into patients, telling sick people that they can "only get worse," and telling those who are being harmed by interventions that their only hope is more interventions. I criticize scientifically questionable or values-driven American medical dogmas in online forums in the hope that just a few other people with values similar to mine might thereby find out that there are questions to ask before they have submitted to something that may alter their lives forever.

Did I think about spending my time in that way before? Certainly not. So it was your incompetent and malevolent colleagues in your stated profession that made me your enemy. Next time you find yourself rejecting some piece of research because it doesn't support a dogma you favor, ask yourself whether harms caused by your practice just might be making more enemies among your ex-patients or their relatives or next of kin.

Yeah, I'm angry.

Clearly. But getting pissy and attacking others is not the answer. You can be passionate and respectful at the same time

Youve mentioned that he got a pacemaker when he didn't need one...i wouldn't mind hearing the whole story when you have time. I honestly have seen unnecessary procedures more than a few time, though still the small minority of the time

Just one suggestion from the other side of the curtain--docs are people first. I never have any problem with questions from a patient, but if I feel that im being attacked/interrogated rather than questioned, I get a bit defensive too. Its only human

I don't want to give all the appalling details, for the sake of anonymity; I HOPE that the totality of the intervention cascade he suffered was extremely rare. Briefly: While suffering from acute heart failure, he had telemetry-detected episodes of nocturnal bradycardia (corresponding with episodes of symptoms that I think might qualify as "paroxysmal nocturnal dyspnea", a concept his doctors never mentioned). Only after he signed the consent form for a pacemaker, after several days in the hospital, did they double his Lasix dose; then he lost 15 pounds in two days, and suddenly had no more nocturnal bradycardia - just before the procedure was to take place. A resident who had lied to our faces about several issues told him that the arrhythmia "could never get better" even as it was getting better. Well, I told him that if I were in his shoes, I would not go through with the procedure - but he went ahead, in part because he feared that if it turned out later he "really needed it," he might be mistreated for having canceled before. As it was, they both implanted the thing incompetently and programmed it incompetently, resulting in severe complications and further hospitalizations and procedures (at a different hospital, yet badly complicated by the initial unwillingness of the second batch of doctors to recognize that the pacemaker was responsible for his new problems).

We actually have particular rage against two electrophysiologists who did him no physical harm, but made repeated attempts to bludgeon him into submitting to not just a pacemaker but an ICD. An ill, exhausted man was literally shouted at and told that he was stupid if he refused and that our values were bad and wrong. He told me just recently about having a nightmare about these two; their abuse was so brutal as to leave scars years later. I asked these two, look, might he not get better if he changed his lousy diet, took meds consistently, exercised, lost weight? Oh no, they said, he would NEVER get better! Then as soon as they left his room, I'd yell "Bull****!" What a destructive message for patients - no, don't change your lifestyle, it won't help! His ejection fraction was then 35%; in less than a year, which included months of disability caused by the pacemaker, it was 55-60%. Living well is the best revenge. :-)

so nocturnal bradycardia is the bane of my existence...i get calls all the time at 2 am because either some resident or nurse saw a patient's heart rate in the 30s--i always tell them 5 min before my pager went off my heart rate was probably 30--everyone's hr is 30 overnight. We are all just not hooked up to tele

That being said, if he was symptomatic with it, thats a different story. But it would have to be symptoms like lightheadedness, dizziness, syncope/presyncope. Just shortness of breath would do it for me, since he was known to have a reduced EF

In my experience, PND and bradycardia really aren't linked. At all. Sleep apnea can cause bradycardia, but not just PND

I agree with you though, in total, if his bradycardia was only at night and his symptoms weren't presyncope or something clearly linked to a slow heart rate, a pacemaker is not indicated

Though if he had an EF of <35% and a left bundle, he may have qualified for a biventricular pacemaker, which is a different story

As for the ICD, he only qualifies if his EF was <35% for at least 3 months on maximal medical therapy. If his docs were saying differently, they were looking for a payday. This would not be the first time Ive seen something like this

The only exception would be sustained VT--that automatically buys you a device

I can't imagine how suboptimal programming could lead to such devastating symptoms. No doubt Ive seen people who are pretty symptomatic if they lose AV synchrony or something like that from the device settings. But those type of things are easily diagnosed and treated with modern devices. With an EF of 35%, its hard to determine what is due to the pacemaker, and what's due to the underlying myopathy

Anyway, just my 2 cents

The institution, it turns out, has a seriously money-grubbing leadership, another thing we did not know. And though the thing had been deliberately set to maximize needless ventricular pacing, that was not the only or the worst problem with the device by a long shot. Trust me, it was the device and not his then-low EF that put him back in the hospital. Then when that was all over and we were trying to get the thing turned down so he wouldn't get further pacing, there was some delay due to incompetence there too. I don't want to give details in case one of the involved parties should happen to see this and recognize himself or herself.

Yes, he had respiratory symptoms during his acute illness, which were comparable to episodes he used to have with his sleep apnea before he got CPAP - but since they went away when he finally received appropriate diuresis - which we later discovered should be treatment numero uno for acute heart failure - and never came back, he plainly did not "need" the device. As I said, he is now healthy (if still too fat) with no symptoms of heart failure. And we were unhappy to find that the device couldn't be turned totally off or set below 30, since as you note, a lot of us normally have heart rates slower than that during sleep and would not see a net benefit from ventricular pacing!

Another infuriating (and probably tortious) thing is that no consent form mentioned any of the long-term risks of pacemakers, such as tricuspid regurgitation, endocarditis, and lead-induced arrhythmias. If we had been given truthful information on those risks upfront, I could certainly have persuaded him to demand a delay for a second opinion, since the "incurable condition" had gone away. If we'd been given them later, we might have dug in our heels and held out for an explantation when the thing was nearly killing him. Electrophysiologists continued to lie and dismiss published research - oh, those are very rare, you're not at risk - except of course that you'll "need" follow-up care for the rest of your life to see if you are about to succumb to them. Which he has chosen not to submit to, to my great pride. And that, combined with a series of incidents of dishonesty related to drug options, is why I will always say that there is no such thing as informed consent in American cardiology and patients had better do their own research.

The institution, it turns out, has a seriously money-grubbing leadership, another thing we did not know. And though the thing had been deliberately set to maximize needless ventricular pacing,

Its almost difficult to set a pacemaker to maximize v pacing. Everyone knows this should be minimized in patients with a cardiomyopathy, and there are many settings built into the device to do just that. Medtronic has MVP, Bosci has search av+, etc. Not trying to be argumentative, but I do find it hard to believe an EP would knowingly maximize v pacing. Why? Whats his motivation? Readmission rates look bad and are a ding for the hospital--not worth the reimbursement--which may even be denied.

but since they went away when he finally received appropriate diuresis - which we later discovered should be treatment numero uno for acute heart failure

Yeah, again, Ive never seen a cardiologist who doesn't order lasix. And Ive worked at a few institutions. Im beginning to think your experience was atypical. Please do not judge american medicine by that hospitalization

nd we were unhappy to find that the device couldn't be turned totally off or set below 30, since as you note, a lot of us normally have heart rates slower than that during sleep and would not see a net benefit from ventricular pacing!

I know you don't believe me, but you can easily set the device to ODO. That essentially makes it a very expensive paperweight. It will not sense or pace in either chamber. Its what I do when someone has passed, so the family doesn't continue to see pacer spikes on grandma's tele.

Alternatively, you can set the AV delay to something very prolonged, like 350 ms. Since a normal PR interval is <200 ms, he'll never pace as long as he doesn't have an outrageous 1st degree AVB.

o consent form mentioned any of the long-term risks of pacemakers, such as tricuspid regurgitation, endocarditis, and lead-induced arrhythmias.

Your point about TR is valid. I myself honestly never have mentioned it in informed consent, but you may be happy to learn that after our discussions, I may start. I don't think it happens as often as you contend, but you have convinced me it happens at least often enough to bring up.

I cannot believe the consent does not say anything about infection though. Its on every consent form ive ever seen, from a central line, to a catheterization. Its just standard. I make a big deal of it since in my mind this is the most serious complication

As far as lead induced arrhythmia, im honestly not worried about that. Firstly, im not convinced it happens often. If a lead is going to cause arrhythmia, itll probably do it when I place the lead in the lab, and I'll just move it. I think it would be pretty rare to just happen suddenly one day after the lead is fibrosed into the endocardium.

Secondly, if it was a big enough issue, and happened within the first year, the lead could be repositioned with minimal difficulty

there is no such thing as informed consent in American cardiology and patients had better do their own research.

While i disagree with the spirit of that statement, I agree with the ultimate conclusion. Being an informed patient is almost never a bad thing...i say almost because the information out there is confusing and not always accurate or reliable. Docs aren't the only dishonest people on earth

Eric, I sincerely appreciate your thoughtful responses here. I would agree that our experience was worse than usual, taking into account not just the excessive treatment inflicted but the immediate complications suffered and the incompetence of the individuals involved. His second bunch of doctors said things about the first electro's surgical and programming choices like "I don't see any medical reason for doing it that way" - which coming from a doctor means "This was plainly malpractice, but I can't use the M word 'cause you might ask me to testify against him." The first bunch displayed such blatant anger toward him for refusing an ICD, and such contempt for our hope that he might recover, that I actually wondered at the time if they had not deliberately set him up to get worse so that he would come crawling back to admit that he was incurably defective and put himself totally in their hands. His next/last cardiologist - a much younger, politer and smarter guy, though not numerically inclined - thought that was ridiculous, and I suppose now that he was right. But it is the sort of thing that goes through your mind when things are done so amazingly wrong by a doctor who is supposed to be a big-shot with a great reputation.

"I don't see any medical reason for doing it that way" - which coming from a doctor means "This was plainly malpractice, but I can't use the M word 'cause you might ask me to testify against him.

hahaha...this is true. I have said it myself , and then gone back to my colleagues and talked about what an effin idiot the last doc was

I believe it is upwards of 75% false positives for prostate cancer Wis. I will never get tested and not because of the "finger." I'll take my chances and only get tested if there is serious pain unless they get their crap together and come up with a test we can trust.

LOL...bad,bad leroy brown won't take the butt-er-finger. I looked over my shoulder and asked...'Haven't they come up with a blood test for this yet?' Doctor says nope (glove snap). BTW...by the time there is serious pain....you have about 6 months.

You just like the test don't you Wis? C'mon, you can tell us!

LOL...my favorite part of the physical...not