Thursday, December 17, 2009

Do NOT Go Spelunking in Sub-Saharan Africa! (Plus Mammogram Stuff.)


PS--As a follow-up to the news on CT scans and people misoverestimating its dangers (as Bush 43 might say), a good comparison can be found in the recent brouhaha about the US Preventive Services Task Force revised recommendations about when women should obtain mammograms. In mid-November, the USPTS rolled back the recommendations for annual mammograms for women under 50, and for women over 50, they recommended mammograms every other year.

There was a firestorm, with outraged women calling up congressfolk and other government people howling about how women's lives are worth less than men's. Even prominent academics took to the airwaves and cyberspace to pile on, as this piece by the University of Pennsylvania's Center for Bioethics Arthur Caplan demonstrates. "Screening is what responsible and health-conscious women do to take control of their bodies and prevent disease," Caplan wrote. Those are commendable and powerful virtues, and...more compelling than a pile of bland data...there is no reason to doubt the accuracy of the scientists' findings...but there is every reason to doubt that the numbers they compiled will be sufficient to overturn a medical practice that carries so much ethical weight for women." [my emphasis]

Ladies and gentlemen, a nominee for Most Cowardly Writing By An Academic For 2009! That little pile of bland data suggested that, whatever "ethical weight" pre-50 mammograms may have for women, it would lead to unnecessary amounts of radiation, agonizing trials for women awaiting biopsies of tissue that didn't need to be biopsied, and, in some cases, completely useless mastectomies. Could a guy like Caplan maybe have considered it his responsibility to use his status as Big Time Academic to try to help explain this data, and give it the proper context it deserved because the data indicate a better way to treat women? He will have to answer for that. In the meantime, a nice counter-example can be found in this NYT op-ed by the very awesome mathematician John Allen Paulos, who tried his best to explain to women the potential benefits of the USPTS recs, at least in terms of the mathematics of the probability of a "positive" mammogram being a "false-positive" due to the relatively low prevalence of breast cancer in the 40-50 group.

The US Senate, which has shown remarkable ineptitude thus far in getting even the most modest health care bill passed, rushed to include an amendment to cover the mammograms its own USPTS no longer recommends...pleasing wild-eyed constituents and providing just the kind of unnecessary radiation discussed in the cat scan studies that so freaked people out! (Though yes, a mammogram has far less radiation than a standard cat scan.)

So I say of this: you can't have it both ways!

Perhaps the USPTS might have been more media-savvy about announcing their new recs, and perhaps they might have more shrewdly thought out how to get this information out. But the notion--which seems to have been uncritically bandied about by people in positions of authority in both government and academia--that this is part of science's ongoing war against women is not merely short-sighted, it may well harm women! This may be the final irony of what medical historians in the coming years might call the "Radiation Flap of 2009." Too much radiation from CTs, not enough radiation for mammograms...and not enough people with a bully pulpit brave enough to try to help show people the way.

I do want to note that the issue gets stickier when one considers African-American women under 50. Please--for the few people who read this blog, pass this information on to African-American women! They are at higher risk of having breast cancer before age 50 compared to white women. The problem is that it's not fully clear that earlier mammography will put a dent in the excess mortality rate, because the most lethal types of breast cancer, and the kind that AA women are more likely to have, grow more rapidly than the kind of cancers that mammograms are good at detecting and thus "pop up" in between screens due to their rapid growth and can be found simply by feeling them. A good discussion of the problem can be found here at the Science-Based Medicine blog. In short, African-American women aged 40-50 need to take special care and not simply take the USPTS recs at face value. Not that anyone is, but still.

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