VIDEO: The Truth about Mammograms - Adam Ruins Everything

Here's a great, brief explainer about the problems with mammography (and most cancer screening)  - 2:43

A slightly longer/better version is here on TruTV's website: The Truth About Mammograms - Full Episode (4:30)

Source: http://www.trutv.com/shows/adam-ruins-ever...

Mammogram Theater: A Visual Aid For Medical Decision-Making

With a title like "mammogram theatre" you would wonder if this post is meant to poke fun at the elaborate song and dance of mammography; we have spent years promising women that "early detection is key," only to realize that screening mammography cannot do what we originally hoped it could (but many still pretend it can).

Of course women want their breasts and lives saved. But the information on the benefits of mammography has been largely overstated in part due to cognitive biases (like lead-time bias, base-rate fallacy, etc), and the risks are too often left out of the conversation.

Every test has risk and benefits, but it can be challenging to decide if a test or treatment is right for you or your patient when there is too much information, experts disagree when they review the same studies, and the media has a constant see-saw back and forth of "yes" and "no" headlines that seem only to confuse. It can feel a bit like ping-pong, following the discussion back and forth. It's not really fair to ask patients to make sense of all this.

So yes, the promise of benefit of mammography may have been a bit of dramatization, but the theatre I speak of is a literal one. 

Dr. Andrew Lazris is an American internist who partnered with environmental scientist Erik Rifkin to popularize a simple, easy way of showing how many are helped and harmed by common tests and procedures.

Lazris and Rifkin have developed a tool to give people a realistic way of evaluating 'hope and worry;'

Their "benefit-risk characterization theater" images vividly show the odds, based on solid research. (read more on NPR)

This is a tool to help doctors and patients have informed discussions about the risks and benefits of breast cancer screening with mammography, to engage in shared-decision making on the topic. Take a look:

This tool has been added to the "hands-on tools" section of this website, where you can find other tools like it.

Source: http://www.npr.org/sections/health-shots/2...

​Choosing diagnostic tests wisely: Doing the little things well

* RESEARCH FIRST LOOK *

There was such a wonderful response to the Choosing Surgery Wisely paper from Dr Roland Grad and medical students Nicholas Meti and Mathieu Rousseau, that they have submitted another!

Dr Grad's poster at PODC2015

Dr Grad's poster at PODC2015

You may remember Dr Grad, a family physician and researcher at McGill University, from his poster on harnessing InfoPOEMS to find potential topics for the Choosing Wisely Campaign, which he also presented at the Preventing Overdiagnosis conference this year (PODC2015). [click to view the more recent poster in PDF format]

Again, Rousseau and Meti worked with Dr Grad to extend this work and look at InfoPOEMs that dealt with three topics in diagnostic testing: stable TSH measurements, screening mammography, and mid-stream urine collection. Guided by clinical questions pertaining to these topics and the best available evidence, they make a clear case that we need to choose very wisely when considering 'routine' testing. There are some apt qualitative insights provided by physicians reflecting on the practice-changing POEMs (Patient-Oriented Evidence that Matters) included in this research, which will undoubtedly help it to resonate with readers.

Please feel free to leave questions or comments below or contact the authors directly. If you would like to submit a guest-post for consideration, email lessismoremedicine@gmail.com.


Choosing diagnostic tests wisely: Doing the little things well

Rousseau, M., Meti, N., Grad, R. Faculty of Medicine, McGill University, Montreal, Canada.
 

Introduction
 

As clinicians, do we challenge the appropriateness of our diagnostic test ordering? To achieve shared decision-making in health care, it is up to clinicians to communicate both the harms (as well as the benefits) of diagnostic testing. Within the concept of shared-decision making, there are three core practices: 1) Identifying that a decision must be made; 2) Communicating the potential benefits and harms of options to patients; and 3) Incorporating what is important to patients within the decision. The latter may require us to consider other questions: What would be the impact of this test on the patient’s quality of life? What about the interval between follow-up tests? What is the impact on the economy when diagnostic tests and follow-ups are considered at scale? When clinicians think about ordering a test (or not), we suspect their decision is based on “routines” and “experience”. The point of this post is not to argue against the “art of medicine”, but to raise awareness of new research that can inform decisions about diagnostic testing.

In this post, we highlight the findings of three recent diagnostic test studies. Study findings were disseminated to Canadian physicians as ‘POEMs’. For those unfamiliar with this acronym, POEMs are tailored synopses of primary research or systematic reviews, selected in a process that involves searching over 100 journals. [1] Since 2005, the Canadian Medical Association (CMA) delivers one POEM to their members by email on weekdays. As described in a prior guest post (Choosing Surgery Wisely), we identified the following POEMs by analyzing the ratings of all daily POEMs (n=255) collected from physician members of the CMA in 2014.
 

CLINICAL QUESTION: “How much do seemingly stable thyroid tests vary over time? / POEM Title: Stable TSH can be rechecked in 2 years”

In a cohort study, the authors asked how frequently do patients with treated hypothyroidism need to have their TSH measured. [2] From a sample size of over 700 persons treated with levothyroxine, they were able to identify a subgroup that would benefit from less frequent TSH monitoring based on their dose of levothyroxine. They report that patients receiving less than 125 micrograms per day could have their TSH rechecked in two years instead of annually. Importantly, this study highlights that once TSH has normalized, the frequency of subsequent monitoring can be stratified based on dosing.

Monitoring frequency is a relevant issue in the clinic setting. In the absence of evidence, many clinicians assume default rates for all manner of diagnostic test and treatment plans. We read the free-text comments submitted by CMA physicians about this POEM. Some of these physicians expressed surprise at the association between dose and frequency of monitoring. Others reported the following: had they known about this approach, they would have spread out the visits for their healthier patients. This would save time and provide costs savings for the healthcare system. Although not addressed by this study, one physician even raised the question of whether we need to be checking TSH levels at all in an asymptomatic patient.

 

CLINICAL QUESTION: “What are the trade-offs of benefits and harms for women considering a mammogram to screen for breast cancer? / POEM Title: Numbers to help women understand the benefits/ harms of screening mammography”

Welch et al. believe primary care physicians should have more balanced discussions with their patients about the benefits and harms of screening mammography. [3] Their premise is that the majority of discussions focus on the possibility of avoiding death from breast cancer, and do not include a discussion of false alarms nor overdiagnosis. The authors used currently available data from trials of screening mammography to give a range of estimates for harms and benefits with the hope that this information would help decisions about screening. Their results are summarized in this table. Note that the numbers are per-one-thousand women, screened yearly for 10 years:

Figure 1: Estimates of harms and benefits of screening mammography

We received mixed feedback from physicians who read this POEM. Some physicians were grateful to have empiric data to help them in their discussions with patients. One wrote it is “helpful to have the actual numbers presented in such a way that I can share info with the patient when discussing mammograms and screening - always easier when there are numbers that we can look at”, and these numbers “make discussion around breast cancer more objective”. However, others wrote that even though “it is much easier to communicate this information to a patient by simply selecting the age group she falls into, and presenting the numbers for that group [...], I have not yet had a patient who didn't just simply choose the mammogram”. It seems that numbers do not tell the entire story… “because this is an emotional issue, most women we counsel opt for the regular screening”.

The importance of this topic to primary care is high, because as one CMA member wrote “the harms of false positives are seen first-hand in primary care”.
 

CLINICAL QUESTION: “How accurately does a midstream urine culture predict the results of a catheterized urine culture? POEM Title: Interpretation of midstream urine cultures in healthy young women with suspected UTI”

What about the practice of empirically treating suspected urinary tract infection in otherwise healthy women without relying on culture? In a diagnostic test evaluation study, midstream urine cultures with any evidence of E. coli or K. pneumoniae strongly suggested a true infection, while the presence of enterococci or group B streptococci had little predictive value. [4]

Feedback from physicians who read this POEM showed appreciation for the findings and included comments such as this one: “As a walk-in clinic doctor, urinary symptoms are a very common reason for visits. I routinely treat women on spec for these UTI's and don't send their urine for culture unless it is a complicated UTI, the patient has significant comorbidities, or the patient has recently been on antibiotics.”

The practice of empirically treating suspected urinary tract infection in otherwise healthy women without relying on culture was recommended in a recent review by Grigoryan et al. [5] Her group reviewed the optimal approach for treating acute cystitis in young healthy women and analyzed studies totalling 259 397 patients. This showed that “immediate antimicrobial therapy is recommended rather than delayed treatment or symptom management with ibuprofen alone”.

This choosing-wisely-approach to a common infection was perfectly summarized in this comment submitted by another physician: “great info [in this POEM]. Sometimes we just do too much testing”.
 

Conclusion
 

As we reflect on all this, we see that even if one test “can’t hurt”, at scale the impact can be large for publicly funded health care systems. This point has been made by others. For example, Kale et al showed how “routine” diagnostics tests cost large sums of money. [6] Primary health care faces a big challenge in reconsidering how diagnostic testing is used, to ensure better value for all.
 

References
 

1. Grad RM, Pluye P, Tang DL, Shulha M, Slawson DC, Shaughnessy AF. 'POEMs’ suggest potential clinical topics for the Choosing Wisely Campaign. Journal of the American Board of Family Medicine 2015;28:184-189. http://www.jabfm.org/content/28/2/184

2. Pecina J, Garrison GM, Bernard ME. Levothyroxine dosage is associated with stability of thyroid-stimulating hormone values. Am J Med 2014;127(3):240-245 http://www.amjmed.com/article/S0002-9343(13)01021-8/abstract

3. Welch HG, Passow HJ. Quantifying the benefits and harms of screening mammography. JAMA Intern Med 2014; Dec 30 http://archinte.jamanetwork.com/article.aspx?articleid=1792915

4. Hooton TM, Roberts PL, Cox ME, Stapleton AE. Voided midstream urine culture and acute cystitis in premenopausal women. N Engl J Med 2013;369(20):1883-1891 http://www.nejm.org/doi/full/10.1056/NEJMoa1302186

5. Grigoryan L, Trautner BW, Gupta K. Diagnosis and Management of Urinary Tract Infections in the Outpatient Setting. JAMA. 2014;312(16):1677-1684. http://jama.jamanetwork.com/article.aspx?articleid=1917443

6. Kale MS, Bishop TF, Federman AD, Keyhani S. "Top 5" lists top $5 billion. Arch Intern Med 2011;171(20):1856-1858

RADIO INTERVIEW: Dr Iona Heath: Too much medicine is making us sick

Dr Iona Heath is one of the foremost voices of the movement that confronts overdiagnosis and medicalization. She is in Australia to deliver a Sydney Ideas talk, "Too Much Medicine: Exploiting Fear for the Pursuit of Profit," on August 5th.

Testament to her ability to draw a crowd as she speaks frankly, humanly, and persuasively about this controversial subject, it has been moved to a larger venue!

While the Sydney Ideas talk may not be made available online, she has also given an interview with ABC Radio Conversations in Australia.

In the discussion, she frames the problem of 'too much medicine' and helps to define the difference between illness and disease, explaining how we make well people into patients.

With reference to A Fortunate Man and drawing on experience and connection with patients from her own 30 years in practice, she speaks about the role of the general practitioner and our inability to address the social determinates of health - the real underlying risk factors for poor health. 

Challenge by an interviewer who is not familiar with the science behind risks and outcomes of screening mammography for breast cancer, Iona emphasizes that the key message is not that a test or treatment is wrong for everyone, but that patients must be given informed choice. They must be fully informed of the potential risk and benefits of any intervention, and think about how it may impact them personally.

When the interviewer sticks to the common rhetoric 'prevention is better than cure' and insists that listeners should not run out and cancel their mammogram, Iona answers this bravely and personally. She shares that she, being in a low risk category, has decided that the harms of a mammogram outweigh the benefit for her. The paper she wrote in the BMJ in 2009, It is not wrong to say no, summarizes the arguments fully.

Iona does not state this explicitly, and I'm not sure it is fair to suggest it is implied, but our professional oath guides us such that: where there is risk but no benefit, the medical expert has a duty not to harm and so will encourage avoidance of the unnecessary test or treatment.

I am hopeful the lecture hall tonight is bursting at the seams with contemplative fence-sitters who may be persuaded by her words. Every event like this brings us closer to transforming the culture of care and being able to improve the lives of our patients.

Source: http://www.abc.net.au/local/stories/2015/0...

Better informed women probably less likely to choose mammography

Screen Shot 2015-02-19 at 8.53.24 PM.png

An interesting article was published in the latest Lancet: Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial.

In brief, women who got information about the risk and possible harms of breast cancer screening (by mammography) were less likely to intend to be screened. The study didn't go on to look at what the women actually chose (only what they intended to choose). However, it still confidently suggests that women who have all of the information are less likely to get screened.

Contrast this informed approach with the classic approach from the well-intentioned doctor: "You need a mammogram to screen for breast cancer. Here is the requisition."

It is not wrong to say no. (These are the words of Dr Iona Heath - well ahead of the curve - in the title of a  BMJ paper in 2009 regarding this same topic).

It is not wrong to say no. And the more you know, the more likely you'll say no. 
 

Not sure what to do for yourself?
Not sure how to start discussing this with patients?
 

- Here is a Canadian resource to help you decide if Mammography is right for you; it's not perfect but it is a start

- Below is an icon array from the Harding Center for Risk Literacy that helps visually represent the benefits vs. harms of mammography:


Source: http://www.thelancet.com/journals/lancet/a...