February 14th, 2014

The mammogram study and the NY Times

Here’s an article in the NY Times about a new mammogram study that’s gotten a lot of attention.

And here’s the study itself.

Compare and contrast.

The first sentence of the Times article:

One of the largest and most meticulous studies of mammography ever done, involving 90,000 women and lasting a quarter-century, has added powerful new doubts about the value of the screening test for women of any age.

From the study’s abstract:

Objective: To compare breast cancer incidence and mortality up to 25 years in women aged 40-59 who did or did not undergo mammography screening…

Conclusion: Annual mammography in women aged 40-59 does not reduce mortality from breast cancer beyond that of physical examination or usual care when adjuvant therapy for breast cancer is freely available.

There were many more details, of course. Both articles are long, especially the study. But the Times article never even mentions the age limitations of the study, and that first sentence in the Times implies that women of all ages were part of the study, which they were not. The study explicitly dealt only with woman between the ages of 40 and 59.

I wonder what the Times’ agenda might be here, although never underestimate the possibility of mere shoddy and slipshod reporting.

The study itself offers some evidence that annual mammograms in those age groups don’t reduce mortality significantly as compared to regular breast examination (not as compared to nothing). There are the usual problems with methodology in large epidemiological studies of this type, and there are other studies of the subject that agree and disagree. But this one should certainly add to the amount of information that we have, as well as the amount of confusion.

Why does age matter so much? Breast cancer is not a unitary disease. There are many types, and the disease in younger women often works somewhat differently than in older women. Let’s not forget, by the way, that 1 in 100 cases of breast cancer occur in men.

24 Responses to “The mammogram study and the NY Times

  1. Sergey Says:

    My experience of science writer and observer is that no scientific study ever gets adequate review in mass circulation media. Most of these popular presentations contain egregious errors and distortions. This is in no way a peculiar trait of NYT, but a very general and almost universal phenomenon.

  2. T Says:

    Furthermore, last night on the Kelly File Charles Krauthammer pointed out that the study compares mammography results with the results of a physical exam. It says that the mammogram is no more valuable than a physical exam, not no more valuable than no exam at all. That’s a big distinction.

  3. artfldgr Says:

    big deal
    not like people want ot know valid answers
    i should know.. they HATE valid answers

    they will blithly and happily discuss nothings they think are something and get all emotional over them and not give a twiddle bugs arse as to whether what they talk about is valid, invalid, useful, useless, etc…

    like the labor theory of value, they just dont get that you can actually go through the cargo cult motions of debate and discussion and never say anything nor every get to some conclusion…

    its infinite due to its meaninglessness
    its important cause how it feels
    its socially desireable, as it pleasures us

    but its a waste of time as we kill time till we die.

    personally, i care not any more
    my life is deemed over and i am waiting to die
    no reprieve.
    no help
    no hope.

    par for the course…

  4. Susanamantha Says:

    I believe this study and the resulting news reporting is bent on turning women away from annual mammograms – a subtle and passive rationing, if you will.

    After decades of insisting on free, ubiquitous mammograms, (just ask Planned Parenthood!), we are now starting to hear faint murmurings that maybe they are not really worth it.

    Same with medication instead of cardiac stents. Soon to follow, all sorts of treatments for Medicare patients. Need that knee ‘scoped? Maybe not. Just take a pill, as Obama said a few years ago. Buy a cane. Sit down and shut up.

  5. artfldgr Says:

    Intelligent discussion is work, and often unrewarding, since the same errors and dodges come up again and again and resist correction. Even if someone wants to understand a position it takes a great deal of imaginative effort to do so if he doesn’t already almost agree with it. If someone hears an assertion, he thinks of what it would be for him to make it. If he believes that “gay marriage” advances the purposes of public recognition of marriage and hears opposition, what he hears is “I want to pick on gay people.” That’s what it would mean if he took such a view and all his other beliefs remained the same. Such barriers can be quite difficult to overcome.
    To make matters worse, the very diversification of opinion and information promoted by the Internet has put a premium on more effective ways of dismissing disfavored views. All too often people don’t want to understand because it would complicate matters to do so. To maintain the stability of their intellectual and social world in an age without legitimate authority they find ways to exclude whatever doesn’t fit. The result is that the more open public discussion seems to be the more partisan and taboo-ridden it becomes. Opposing positions are not described fairly or understood correctly, and what’s presented is less argument than insult, sophistry, bludgeoning, and half-truth or outright fiction. Issue is never joined, and discussion goes nowhere. At times in the past there has been a conception of honor that demanded a certain standard of honesty and good faith in public discussion. Those who violated it were discredited and ignored. In today’s marketplace of ideas that’s disappeared, and cheating pays off as long as it supports the answers people want.

    (“non in dialectica complacuit Deo salvum facere populum suum” Saint Ambrose

    you realize your commenting about a paper who decided to keep a pulitzer for helping people starve and that they did not diserve?

    Susanamantha: your correct… its just another part of eugenics programs like feminism, and rationing care, and upping race hate, and so on…

    puerto rico is a disaster now that the feminist latinas idnt have children… as many other places.. but i have tried to start that conversation, but no one wants to put things together.

    ie. we have a 2500 piece puzzle, and rather than put it together, we prattle about how each part is like separately as if they are not connected

    taking money and providing abortion is eugenics when the parents ultimately have ot pay for kids..

    removing parents rights, tends to make parents loathe to be parents.

    on the medical side, they are pulling soviet crap…
    ie. giving you the definition technically but screwing you out of the substance of things (which is why i said to read the soviet constitution to get an idea of the process)

    you now have insurance, but its too expensive, and the deductible is so high you might as well not have any…

    your going to find hard paper work, long lines and anything that discourages you from what you are told you have a right to. that way they can claim to provide you X, but no one ever gets it.

    i could fill you in
    and others
    but why bother
    as nothing of substance gets anywhere here
    its babble without the different languages.

    There would have been a time for such a word.
    Tomorrow, and tomorrow, and tomorrow,
    Creeps in this petty pace from day to day,
    To the last syllable of recorded time;
    And all our yesterdays have lighted fools
    The way to dusty death. Out, out, brief candle!
    Life’s but a walking shadow, a poor player
    That struts and frets his hour upon the stage
    And then is heard no more. It is a tale
    Told by an idiot, full of sound and fury
    Signifying nothing. — Macbeth (Act 5, Scene 5, lines 17-28)

    bring in da noise, bring in da funk, but waste time as the thing discussed is impliemented, and then discuss how no one stopped it, and so on.

    lex rex is dead
    long live rex lex, long live the Czarish king…

  6. neo-neocon Says:

    artfldgr:

    Of course I realize those things about the Times. I’ve even written about them. I mentioned the Times because in this case the omission of the ages in the study seemed especially egregious, obvious, and probably significant.

  7. Lizzy Says:

    I agree with Susanamantha that this appears to be designed to convince people that they don’t really need that mammogram. Next HHS will alter its recommendations, and then health insurers (if they’re still in business!) will quietly adjust there coverage. I expect all medical decisions will now become politicized.

    Oh, and my mom and my sister in law both discovered their breast cancer from mammograms long before the growths were big enough to be found during a breast exam.

  8. holmes Says:

    I saw it on Twitter, but someone made the comment that one of the worst traits of nationalized healthcare will be turning every single medical decision into a national fight. Should be fun.

  9. q6Elms Says:

    Accuracy in science and media reporting seems challenging generally. But as far as the value of mammography goes there is plenty of robust and meaningful data against the general use of this procedure (as described in “The Mammogram Myth” by Rolf Hefti).

  10. Don Carlos Says:

    Rolf Hefti? You must be kidding.

  11. Sam L. Says:

    My wife was diagnosed with breast cancer in ’90. Died in ’96. She was 40. Her mom survived breast cancer,

  12. J.J. Says:

    I saw this discussed on one of the Fox News casts. The doctor, a woman, was of the opinion that family history was very important. Her opinion was that those who have breast cancer in their family should be screened with mammograms much earlier and more often than those who don’t. She also stressed the need for both regular self and annual medical examinations for all. Seemed a sensible answer.

    The problem is, as I see it, the government and big medicine would like patients to be pretty much the same. Each of us is different and those differences make it hard to come up with “standard” treatments. Yes, 60% of the population might do well on standard protocols, but there are outliers. That’s why I see the IPABs and other government edicts as damaging to the doctor patient relationship.

    In theory, the computerized medical records make sense. I remember Newt Gingrich holding forth at length about how wonderful it would be if your medical history was stored electronically and at your beck and call anywhere you might move or travel. That argument has some appeal. One of the most efficient doctors I’ve ever come in contact with – twenty years ago while traveling – was using a computer routinely to record his notes and diagnosis. It was clear that he had set this system up on his own volition and knew how to use it well. My family doc started using a computer 2 years ago. It has hampered his efficiency, but he’s a believer in Obamacare, so he soldiers on.

  13. Don Carlos Says:

    Breast cancer familial genetics ain’t an opinion. It’s a fact.

  14. Oldfyer Says:

    Two thoughts about mammograms.

    I lost my Mother at the age of 45 to breast cancer. That was in 1954 and they probably did not do mammograms back then.

    My wife just had a lumpectomy and radiation treatment for DCIS, a form of breast cancer that is not detected by examination.

    She had gone three years between mammograms, because 1. she hated them 2. She thought that Medicare was only covering–recommending them– every other year; and we were moving cross country at the time hers was due; and 3. she hated them.

    This year her PCP insisted.

    Her surgeon said that DCIS was the best form of breast cancer to have, if you were going to have cancer; but, we have to believe that it was well to find it when it was found, and that would not have happened without the mammogram. Of course she is 77, so the study does not apply anyway.

  15. Beverly Says:

    Sister died of breast cancer metastases in 2009. Grandmother died of it.

    Mine was found in 2012 from, yes, a routine mammogram: stage 0, thank God. Had a lumpectomy and have been keeping an eye on it ever since.

    Would it have progressed from stage 0? who the heck knows? and who wants to find out? not Me.

  16. Ymarsakar Says:

    Remember, the Left says we are engaging in a war on women.

  17. parker Says:

    Fuck these people with a rusty shank of iron. This is just a ‘study’ to bolster the ‘death panals’. My daughter (age 39 at the time) was diagnosed with breast cancer via a routine mammogram which lead to treatment which after much angst for her, her husband, and of course her parents wa successful.. She is now 2+ years cancer free to our great relief. Anyone who stands between me and my children and grandchildren has a death wish that I am more than ready to fulfill.

  18. Don Carlos Says:

    The difference between the Western Left and that of Cambodia and Russia and China is fundamentally a difference in speed, not motivation.
    Not an original thought, I know, but still I ponder it.

    Cambodia under Pol Pot is way too analogous for comfort. We are dumbing down our population; educated Cambodians were killed (it’s quicker). We are being forced to use less, drive less, live less well, do away with best medical practice, centralize and centralize. Cambodians were just driven out into the fields (it’s quicker).

    It’s the old frog thing. I can’t stop it, you can’t stop it, and together we can’t stop it either as long as we’re stuck on stupid and don’t change our ways.

  19. Don Carlos Says:

    I have now read the paper,
    -published in the Brit Med J, which has become highly politicized
    -a very flawed study, begun 1980, that comports to find no survival difference between the mammo and non-mammo groups ( no attention to treatment apparently needed; treatment is assumed to be a black box standard, apparently, same for both groups)
    -but the average tumor found in the mammo group was T1 size, and was T2 in the non-mammo group. This size difference is the difference between Stage I and Stage II. So Stage doesn’t matter? No survival difference? Au contraire: this further suggests that treatment in the canadian health system is not up to par. Either that, or the Staging system is wrong; take your pick.
    - An “excess” of cancers was found in the mammo arm, and I quote:
    “an excess of 142 breast cancer cases occurred in the mammography arm compared with control arm (666 v 524) (fig 4⇓). Fifteen years after enrolment, the excess became constant at 106 cancers. This excess represents 22% of all screen detected invasive cancers—that is, one over-diagnosed breast cancer for every 424 women who received mammography screening in the trial”.
    I cannot speak to this ‘logic’.

  20. sergey Says:

    “One size fits all” approach does not work in medicine. Familial history of health problems is important not only for breast cancer, but for cancer in general and in a lot of other diseases. Alas, this is the only practical approach in all forms of socialized health care. Only when people make their own decisions in choosing doctors and diagnostic tools these individual family histories can be properly considered. It is always better if your family doctor knows your family medical history.

  21. neo-neocon Says:

    Don Carlos:

    Yes, I read the entire study too (quickly, but I did read it). I was puzzled by many things in it but decided not to spend 5 hours figuring out a specific critique of the methods. Large epidemiological studies like that virtually always make a lot of assumptions (such as the ones you mention; and I know this is your field of expertise) that are just that: assumptions. Hopefully the assumptions are at least logical ones, but I was struck also by the fact that in this study (if I’m recalling it correctly) they were just assuming treatment was equal because health care is available to everyone in the Canadian health care system, and because the mammo/no-mammo subjects were randomly chosen.

    Those supposedly “over-diagnosed” cases in the mammo group (again, I’m doing this from memory) were assumed, as best I can recall, because of the fact that more people were diagnosed with breast cancer in the mammo group compared to the other group. At least, that’s what I took from the study; it seems so odd a definition of “over-diagnosed” that I keep thinking I’m interpreting it wrong. Perhaps you can explain to me how they arrive at this “over-diagnosed” figure?

  22. Don Carlos Says:

    Neo-
    Since it is not defined in the paper, at least to my reading, I cannot speak to the “over-diagnosed” figure or its meaning. I looked, but did not find.

    The big tell is in the ‘average’ (not median) size of the cancers found. Of course smaller cancers are less often feel-able. That is the whole darn point of earlier detection. The study, begun 1980, was in the relatively primitive part of the mammogram era, so detecting cancers at an average diameter of 1.91cm, versus 2.10 in the “control” group is not nearly reflective of current state-of-art mammographic detectability.

    Nevertheless even then a prognostic difference was appreciated as a function of tumor size, and the study shows the Canadian system could not deliver that for the women in the study.

    Finally, a word about the Brit. Med. J. – during the GWB era it published an (ahem) peer-reviewed paper that purported to show an enormous Iraqi death toll caused by the USA. Based on “reports’, extrapolations, etc. Disgusting. Basically all made up. Controversial articles in that journal but also New Engl J Med and J AMA must be understood to have passed the Leftist editorial bias screen.

  23. neo-neocon Says:

    Don Carlos:

    That’s certainly interesting about the political bias of the journal. I remember that Iraq article, but didn’t remember the journal (or maybe I’m confusing it with one in Lancet). It lends more credence to the idea that the left might be pushing fewer mammograms as a cost-saving device.

    I also noted that the current study reflected treatment from decades ago, even though it followed the cohorts in later years. But the experimental intervention occurred during the 80s.

    If it is well-documented that breast cancer tumor size at detection is correlated with survival rates, even at size differentials involving fairly small tumors, then that could cast some doubt on these results, since the mammo group had tumors which were smaller.

    I seem to recall reading somewhere, though, that the type of tumor was more important than size differentials, especially if the size differentials were small. I assume you know whether that’s the case or not?

  24. Don Carlos Says:

    My error-It was Lancet, not BMJ. You’ve a better memory, Neo!
    Comparing cancer type- for example ductal v. lobular, and claiming that is more important than cancer size is apples/oranges, pure and simple. When you throw two variables into the pot, conclusions become elusive. Yes, some types, e.g. ductal carcinoma in situ, are prognostically better to have, size for size. But never forget we do not get a menu from which to pick, and infiltrating ductal remains the most common.

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Previously a lifelong Democrat, born in New York and living in New England, surrounded by liberals on all sides, I've found myself slowly but surely leaving the fold and becoming that dread thing: a neocon.
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