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)
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)
Families, doctors, nurses, patients, people all:
Everyone knows someone with cancer. Cancer is unfortunately inevitable unless something else gets you first. It may sound awful to talk that way but because of what cancer is - essentially the unchecked growth of progressively more abnormal cells - and the fact that our cell's replicating machinery gets a little wonky as it wears out over time, the older we are the more likely we are to develop cancers.
Cancer is horrible. It devastates happiness, bodies, minds, families, plans, and dreams. We want to do everything possible to treat it and prevent it. Although I've written a lot about the futility of aggressive care in the end of life, the harms of delaying a palliative approach, and our misplaced trust in screening (which often harms more than it helps: PSAs or mammograms, for example), I also advocate strongly for patient access to the things that do work.
There are things you can do to lower your risks, robustly backed by the evidence:
There is a great summary of some specific examples of dietary items in the "Summary of global evidence on cancer prevention" from the World Cancer Research Fund International.
As much as we want them to work, natural supplements, diets, 'miracle' clinics overseas, and homeopathy just don't.
Billions of dollars are made in scaring people into taking 'natural' remedies that are meant to prevent or treat cancer. Let me tell you: if these remedies were effective, they would be patented, put into pill form, and your family physician would be nagging you to take them. Heck, we might even lobby the government to put cancer-preventing agents in the drinking water! And if there was such thing as a miracle clinic, curing cancer constantly, well I would like to work there because that sounds amazingly rewarding.
Sadly, despite our dearest hopes, turmeric and elimination diets, cannabis oil, black fungus like that growing at Chernobyl (Fox News), and a whole host of other things continue to be proven useless at preventing or treating cancer. Most of these 'remedies' are harmless, but some have real side effects and none of them help the wallet.
In fact, while people are wasting their time, money, and hope on these snake oils, they are depriving themselves of the opportunity to focus on what matters:
Optimism is not wrong - optimistic people probably live longer. If you trust that (scientific) statement, then you should also trust that the optimism should be directed towards scientifically-backed things that work.
Learn more about Tackling cancer treatment myths, from clean eating to cannabis
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.
Many of you will be familiar with the hilarious and helpful work of Dr Mike Evans and his team. Their white board videos are a great blend of up-to-date evidence, patient perspective, and useful advice.
In Do More Screening Tests Lead to Better Health? you'll find more than just the answer to that question ("No.").
With a focus on healthy, well-feeling, average risk individuals, the video emphasizes that the harms of doing a test (and the sequelae of that test) may be greater than the benefit. This is a tough bit of information to accept particularly if you've already had lots of 'preventative tests' done and have felt reassured by them. However, it's really time to re-evalute their usefulness.
It's not that we should do nothing to prevent disease; instead of wasting a person's time and resources on unnecessary tests, the time can be better spent devoted to support around lifestyle choices that we know will lead to better health. Take a 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!
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 email@example.com.
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.  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.  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.  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:
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. 
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.  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”.
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.  Primary health care faces a big challenge in reconsidering how diagnostic testing is used, to ensure better value for all.
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
Yes, it's true, even the popular 'internet news media company' Buzzfeed is hosting an article highlighting the issues that arise with the current practice of disease screening. Known for horribly-titled and irrelevant news-utainment, with headlines like "The 21 Erotic Moments From The First Time You’re In A Bulk Barn," the site does have over 200 million viewers monthly. They must be doing something right, and hopefully this Buzzfeed Community post, Misconceptions about Screening, will be a viral hit, just like "These American Tourists Were Delightfully Puzzled By Awesome Canadian Road Signs."
In the post, Sense about Science, a UK-based organization that 'equips people to make sense of scientific and medical claims in public discussion,' wrote:
There’s a huge amount of discussion about screening programmes from celebrities, campaigners and emotive media case studies. Unfortunately, a lot of this discussion is filled with misconceptions, misinformation and unrealistic expectations of what screening programmes are and what they can deliver. This has real lasting implications for patients and healthcare professionals. This needs to stop.
They go on to review 6 key issues with broad-based screening campaigns, highlighting the grey areas in screening test results, the costs and harms of these tests, the different role they play as compared with diagnostic tests for symptomatic individuals, and the idea that screening must be employed only for the right population and the right diseases.
Much of the culture of screening has been created by the medical industry and by health care practitioners, but the celebrity 'experts' have not helped. This article reminds Buzzfeed readers, many of whom follow celebrity news, to think twice about listening to this unscreened advice.
Read Making Sense of Science's 'MAKING SENSE OF SCREENING: A guide to weighing up the benefits and harms.' Other similar tools can be found in the health care provider section, the patient section, and the 'hands-on' section (mostly tools for shared decision-making) on this site.
At the Preventing Overdiagnosis conference last year in Oxford, I heard Dr Margaret McCartney speak. This is a passionate woman, one who advocates tirelessly for patients and follows the motto "Think critically and demand evidence." She is an outspoken leader, holding the NHS, her patients, her peers, and herself to high standards, eschewing conflict of interest and junk science.
I was lucky to meet her and when we talked further, Margaret handed me a copy of her book, The Patient Paradox: Why sexed-up medicine is bad for your health. Travel and work got in the way of me opening it, but when I did, I devoured it, underlining and folding and marking key points that resonated with me.
I have read many essays and a few books in the area of "too much medicine," and agreed with most of what they had to say. This book was different. It gained my trust by talking about things I already knew and accepted (more is not always better in medicine) and pushed me just outside my comfort zone, to question things I take for granted (eg the importance of pap tests). I admire the bold way in which she can push the already skeptical to challenge assumptions we didn't even know we had. Since I felt the need to share this book with others, I wrote it up.
You can buy the book from the publisher, Pinter and Martin here. If you want to read other reviews or get a copy on Kindle, Amazon.ca can help.*
If you like the idea of reading more on the subject of "Less is More in Medicine," there are about 20 books in the Read section of the site, ranging in focus from cancer screening or overdiagnosis in psychiatry to patient-centered care, achieving evidence-based medicine, and turning healthy people into sick.
* I don't receive any kickbacks here, just hoping to make it easy to get the book in your hands
The word about 'overdiagnosis' is a regular feature in medical journals, stories are found at least weekly in major newspapers, and patients are starting to question whether cancer screening tests are really right for them.
Ok, no no, we are a long way from finding the right balance of too much and too little medicine. But now that we accept that 'too much medicine' is a real thing, we need to figure out just how big the problem is.
He has attempted to lay out the way in which we can quantify (and clarify) the times where we inappropriately give a person the label of 'cancer.'
He states clearly that misdiagnosis, while unfortunate, isn't overdiagnosis. He also says that false-positives, while they can lead to harmful results, are not overdiagnosis.
What is is then? Whole conferences (eg. Preventing Overdiagnosis) have been devoted to defining it.
Overdiagnosis, according to Ubel, occurs when we detect things that would never have caused a problem for the patient. He gives the example of a tiny breast cancer that would never have been noticeable in an elderly woman (who would undoubtedly die of something else first). When trying to change the culture to encourage people to stay away from screening tests that will lead to overdiagnosis, we are up against several challenges. One of those is the fact that early diagnosis can sometimes make it seem like we live longer if we detect the cancer earlier, though finding it early doesn't improve or save our life (lead-time bias, which is explained in the article).
Ultimately, in order to quantify the prevalence of overdiagnosis, we will need population-level data after a screening program has been introduced, and the data will need to be measured for long enough that any of the lead time bias effect will have passed.
Read more of Dr Ubel's explanation, How Much Are We Over-Diagnosis Cancer? in Forbes.
In February, an excellent systematic review article appeared in JAMA as part of their "Less is More" series. Patients’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review by Drs Tammy Hoffman and Chris Del Mar provides a comprehensive overview of patients views of the risks and harms of various tests, procedures, and treatments.
Their Conclusions and Relevance section explains the take-away it nicely:
The majority of participants overestimated intervention benefit and underestimated harm. Clinicians should discuss accurate and balanced information about intervention benefits and harms with patients, providing the opportunity to develop realistic expectations and make informed decisions.
This week, the NY Times Upshot - a source I'm finding myself reading more and more often - posted their reflection on the article, If Patients Only Knew How Often Treatments Could Harm Them. They beautifully wove together some of the data from the article to make it easier to digest and understand.
For example, they highlight the 2012 Annals of Family Medicine study that looks at patient estimates of the benefits of screening for bowel cancer.
94% of patients overestimated the benefits of bowel cancer screening.
Simple and persuasive examples like that help explain the problem with our current care, and the article culminates in a summary written by Drs Frakt and Carroll that is completely in line with the principles that drive the Less is More in Medicine approach:
Many of the studies in the systematic review show that people report that they would opt for less care if they better understood benefits and harms. Improved communication could better serve patients and might improve the efficiency of our health system if patients focus on getting the types of care for which the benefit outweighs risk of harm.
Since they've done such a great job expounding the article, I feel no need to provide my own explanations or reflection.
These kinds of articles come into my email and RSS reader and across my twitter landscape in droves; being overrun with articles and action in the field of overdiagnosis/testing/treatment is a delightful problem to have.
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.
- 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: