On breast cancer screening. Guest post by Dr. Elaine Schattner
Mammography screening. Should you? Or shouldn’t you?
A few weeks ago, I received a letter in the mail from the clinic where I get my mammography. Rather than the expected ‘all is fine,’ the clinic was requesting that I call to schedule another screening due to abnormal findings. Not only was this not the way that I wanted to receive news that something might be wrong, but, I opened the letter at 4 pm on a Friday afternoon, giving me little time to get over the initial shock and then get on the phone to see if I could learn a bit more before the clinic closed for the weekend.
Mammography screening has been in the news quite a bit over the past year, with lines being drawn between experts who say that screening doesn’t save lives and women who want their mammograms regardless of the facts. I happen to fall on the latter side of the aisle and while I suffered a lot of anxiety before I had a second screening, not knowing would have been even worse. (FYI – it turned out fine.)
Recently, my friend Dr. Elaine Schattner, a trained oncologist, hematologist, educator and journalist, wrote about a new review that I believe that every woman should read before deciding whether or not to have a mammogram. It puts some of the controversy into perspective and also provides a much more balanced viewpoint on the risk-benefit ratio. And rather than reinvent the wheel, I asked Elaine if I could re-run the post on Flashfree. Please share it far and wide; it’s important.
With little fanfare, the NEJM published a feature on breast cancer screening in its Sept 15 issue. The article, like other “vignettes” in the Journal, opens with a clinical scenario. This time, it’s a 42 year old woman who is considering first-time mammography.
The author, Dr. Ellen Warner, an oncologist at the University of Toronto, takes opportunity to review updated evidence and recommendations for screening women at average risk for the disease. She outlines the problem:
Worldwide, breast cancer is now the most common cancer diagnosed in women and is the leading cause of deaths from cancer among women, with approximately 1.3 million new cases and an estimated 458,000 deaths reported in 2008.(1)
On screening:
The decision to screen either a particular population or a specific patient for a disease involves weighing benefits against costs. In the case of breast-cancer screening, the most important benefits are a reduction in the risk of death and the number of life-years gained….
She breaks down the data for mammography by age groups:
For women between the ages of 50 to 69 the evidence is clear, she says. For those over 70, there are little data to support breast cancer screening. There’s a consensus that screening isn’t appropriate for women with serious coexisting illnesses and a life expectancy of less than 5–10 years.
For those between the ages of 40–49, Warner challenges the revised 2009 USPSTF recommendationson several counts. She critiques those authors’ weighting of data from the Age trial of 161,000 women, emphasizing the use of an antiquated (single view) mammography technique and flawed statistics. She considers:
…However, this change in remains highly controversial,22, 23 especially because of the greater number of years of life expectancy gained from preventing death from breast cancer in younger women. According to statistical modeling,19 screening initiated at the age of 40 years rather than 50 years would avert one additional death from breast cancer per 1000 women screened, resulting in 33 life-years gained.”
What I like about Warner’s analysis, besides its extreme attention to details in the data, is that she’s not afraid to, at least implicitly, assign value to a procedure that impacts a young person’s life expectancy relative to that of an older person.
She goes on to consider digital mammography and the Digital Imaging Screening Trial (DMIST [NCT00008346]) results. For women under 50 years, digital mammography was significantly more sensitive than film (78% vs. 51%).
The article is long and detailed; I recommend the full read including some helpful tables, with references to the major studies, and charts.
In concluding, the author, who admits receiving grant support from Amersham Health (a GE subsidiary), consulting fees from Bayer and lecture fees from AstraZeneca, returns to the hypothetical patient, and what might be said to a woman in her 40s who lacks an outstanding risk (such as a genetic disposition or strong family history):
…Mammography screening every 2 years will find two out of every three cancers in women her age, reduce her risk of death from breast cancer by 15%. There’s about a 40% chance that further imaging (such as a sonogram) will be recommended, and a 3% chance for biopsy with a benign finding.…
In my opinion (ES) this is key – that the chances of a false positive leading to biopsy are only 3% for a woman in her 40s. If those biopsies are done in the radiology suite with a core needle, every 2 years for women of average risk, the costs of false positives can be minimized.
About the author…Dr. Elaine Schattner is a trained oncologist, hematologist, educator and journalist who writes about medicine. Her views on health care are informed by her experiences as a patient with scoliosis since childhood and other conditions including breast cancer. Elaine is a Clinical Associate Professor of Medicine at Weill Cornell Medical College in New York City where she teaches part-time. Her blog, Medical Lessons, is geared towards dissecting and providing commentary on how healthcare news is comunicated in order to foster learning and help bridge the gap between patients and doctors.
Wednesday Bubble: chase the midlife blues away with a cup of java?
Coffee. The morning elixir that oh, so many of us rely on. Did you know that caffeine is the world’s most frequently ingested psychoactive substance?!
We’ve heard a lot about the blues and depression during midlife and menopause, with some experts saying that the two are connected and others, that they are not. However, regardless of whether or not menopause increases the risk for depression, it is clear that depression affects twice as many women as men, and at least 20% of all US women at some point during their lifetime. Hence, if there is an easy way to boost the success of antidepressants or behavioral or other strategies, I’m all for it. And it appears that coffee may be the part of the solution.
Coffee? Really?
In a newly published study in the esteemed Archives of Internal Medicine, researchers say that they followed over 50,000 women and examined their food intake including how often they drank caffeinated and decaffeinated coffee, tea and soft drinks and and ate chocolate. During the 10 years of the study, researchers identified slightly over 2,000 cases of depression. However, it appeared that drinking two to three cups of coffee daily reduced the risk of developing depression by 15% compared to drinking one cup a day or less. Women who drank four or more cups a day had a decreased risk of 20%. And decaffeinated beverages? No dice.
In so far as this study goes, it’s not conclusive and it could be possible that mildly depressed women drink less coffee. And keep in mind that too much of a good thing is well, too much. Studies have shown that long-term consumption of caffeine can lead to tolerance, meaning that you need greater amounts to achieve the effects that many of us crave. Nevertheless, so far, the results show that coffee may very well be mildly protective against depression.
English playwright and theatre director John Van Druten once said, “I think if I were a woman I’d wear coffee as a perfume.” I think I’d rather just drink it than wear it!
Read MoreTalk health to me, baby…on ePatient Conference, Seduce Health and menopause
When was the last time talking health was considered sexy? Or creative? Or passionate? Well, if you are a long time reader of Flashfree, you know that I don’t mince words and I don’t attempt to turn menopause or aging into a steamy soap opera (unless we’re talking steamy as in night sweats and hot flashes). However, I do try to approach the ‘what you need to know’ with humor, integrity and candor and stay away from fear mongering. That’s why I was excited to meet a lot of people last week who not only shared my passion for healthcare but more importantly, for conversing about it.
If you have not heard of ePatient Conference, you may want to check it out next year. It’s two solid days of engagement, exchange and networking. But if you take away the buzzwords, you are left with an opportunity to put creativity back into the way that healthcare is approached, managed and talked about.
Among the many incredible experiences — from hearing Seth Godin’s keynote to witnessing the VGo Robot take photos of the audience — none were quite as inspiring as meeting Google’s Chief Health Strategist, Roni Zeiger. And while Roni is undoubtedly doing some very cool things with Search and Trends over at the Google Headquarters, I was most impressed when he started telling me about Seduce Health. Along with co-founder Alexandra Drane, Roni started the site “to get a public conversation started about how we can reframe how we ask people to change their behavior, to live healthier and therefore happier lives. To move from fear and lecturing to passion and dreams, hope and beauty.”
It’s not a bad goal. But is it achievable?
It’s fairly clear that health messaging often falls on deaf ears and that sometimes, the individuals, experts and organizations leading the charge are the ones who are also misleading the very public they seek to educate. Take overweight and obesity for example, problems affecting an estimated two out of three American adults and at least 17% of all children. Obesity is the elephant in the room, acknowledged but rarely discussed without fear or lecturing, under- or misestimated and frequently inadequately addressed. Menopause is also a good example, a natural transition in a woman’s life that has been turned into the disease of the 21st century, medicalized by many health practitioners, manufacturers and the media, and mongered to the point where we have a burgeoning Menopause Industrial Complex based on greed, profit, fear and self-loathing rather than empathy and education.
When it comes to women’s health, I do believe that can be sensuous and passionate, not dry and stale. Along these lines, I recently wrote that:
taking control doesn’t have to mean that the aging process is denied, stopped or obliterated, medicalized or industrialized. Rather, it means taking charge to feel better, more vibrant, healthier so that you/we/I can live the best life I can live while we are alive. For me personally, that doesn’t mean hormone replacement or botox or lipo; it means trying to make more healthier decisions, control or address my symptoms with evidence-based alternatives and accept the transition as a natural part of my journey. I consider this time an opportunity for shifting priorities and interests that open all sorts of possibilities. And, I want to take the experience out of the closet and foster discussion and sharing. Ultimately, I’d like the see a more natural course driven by women themselves, as opposed to societal expectations and stigmatization of the aging process and as opposed to the Menopause Industrial Complex.
I’ve said it before and I’ll say it again. Let’s crowdsource menopause. Let’s make it a goal to seduce our peers and practitioners into talking about it, embracing it and not trying to change it into something its not: a four letter word. Aging can be a hopeful, positive experience.
What do you say? You in?
p.s. If you are curious about ePatient Conference, organizer Keven Kruse has graciously posted presenter slides here.
Read MoreMidlife metamorphosis: for da guyz
Yes, this one if for da guyz. Who may or may not be dealing with their own aging issues. Who says that Flashfree isn’t an equal opportunist when it comes to gender issues?
This one’s a redux. Because men? You’re worth it.
[Used with permission. Dan Collins. http://www.dancollinscartoons.com]
In Laura A. Munson’s poignant “Modern Love” post, ‘Those aren’t fighting words, dear” she writes about the crisis of self that may seem familiar to many in midlife who are watching or have watched their husbands or partners implode. In the post, (which I highly recommend if you’ve not read it) Laura writes:
And I saw what had been missing: pride. He’d lost pride in himself. Maybe that’s what happens when our egos take a hit in midlife and we realize we’re not as young and golden anymore. When life’s knocked us around. And our childhood myths reveal themselves to be just that. The truth feels like the biggest sucker-punch of them all: it’s not a spouse or land or a job or money that brings us happiness…
The premise that happiness comes from within is not a new one. However, the midlife spin on it can be a wake-up call of epic proportions, when we start reaching for a gold ring that actually resides out of sight. Yet, why are we yearning for what was rather than what is to be? Aren’t life’s many transitions, including the one that our partners and each of us are facing, movements into the next phase of productivity or change or growth, rather than a loss of self?
I’ve had many conversations with women who are facing or have faced situations that are similar to Laura’s. Overwhelmingly, they say that women tend to themselves a little at a time so that the crises never quite reach the precipice. That many women are able to deal with their physical and emotional changes incrementally so that the ultimate metamorphosis — who they are during and at the end of their lives — is not a monumental shock.
Dick Roth, in his wonderful book “No, It’s Not Hot in Here,’ devotes a chapter to men in midlfe. He says that men should repeatedly ask themselves three questions:
- What won’t pass away when my youth does?
- Who will I be after my career is over?
- Who would I be if everything else was gone but my mind and feelings?
Referencing the book The Diving Bell and the Butterfly, Roth adds that the protagonist’s lack of self-pity and ability to cherish his soul provided him with the foundation to overcome his physical confinement (the author, who was completely paralyzed by a stroke except for a single eyelid, was only able to communicate by blinking this one eye).
Cherish your soul. Sounds a lot simpler than it is. Or does it?
As much as we expect our partners to understand what we are going through as hormonal changes wreak havoc on our psyches and our bodies, we must also be willing to offer the reverse, to acknowledge the changes and struggles that our partners are going through, their self-confinement, and perhaps their inability to cherish or tap into their souls.
Midlife doesn’t have to be a four-letter word. What rings true for women, also rings true for men.
Seize it.
Read MoreWednesday Bubble: working the transition
I’ve been absent for about a week now. The reason? I’ve been in transition, not menopausally-speaking but literally and physically. I’ve moved about a mile away from my last home. However, it feels as though it’s taken miles to get here.
I spend a lot of time on Flashfree discussing how the transition (and midlife) affects our wellbeing, our general health and our moods. And I would like to offer that this stage of life comes with a set of challenges that feel unlike any other. Whether it’s a change from full house to empty nest or a divorce or a new career, it’s tough. Throw a move into the mix, and well, it’s enough to get a person out of sorts.
The last time I moved, I was in another sort of transition. You can read about that here. This time, the move was again, out of my control but it was in my hands and on my terms. And as such, this transition, albeit difficult, holds promise for all good things to come.
Sheer exhaustion permeates the rambling words on this page and yet, underlying them is a hope that I’ve not felt in quite some time. So, I am taking a mental break this week. Friday’s post will be a guest post and next week Flashfree will be back to business as usual.
I’ll be working this transition to the fullest. Hope you’ll stick it out with me.
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