Wednesday, November 18, 2009

Take With a Grain of Salt

Tell Me, Did We Just Get Punked?

Just the other day, my colleague and I were talking about certain drugs we used to use for patients in the ICU. These were drugs that had no evidence of really making a difference, but more or less, drugs that we pumped into a patient in a sort of Hail Mary pass. This exchange was part of a broader discussion of being grateful that we work in a more modern environment of evidence based medicine where clinicians prefer proof (evidence) that drugs (or treatments) work the way we're told they will before we use them. I can tell you that in 25 years of nursing, I've given medications that were ordered by the doctor only because that's the way it's always been done, and I've given medications because studies have proven those drugs to work for the condition being treated. I much prefer the latter.

In the news this week is the controversial recommendation regarding breast cancer screening that is based on a computer model. I'm a bit shocked at the outcomes of this new study that recommends no routine screening until after the age of 50. And no self breast exam? Are you kidding me? I personally know of 3 women who found their own cancers with their very own hands. I personally know 5 women under the age of 50 who have breast cancer--one of whom had a negative mammogram, but a positive breast coil MRI she had to fight to get insurance approval to have. She was in her mid-thirties at the time of diagnosis and the only thing that bothered her was a pain in her breast.

Do these computer models really provide the evidence that doctors need to make intelligent and informed decisions about what tests they order? Do the statistics that show improved outcomes for those diagnosed early even matter? How about the decline in deaths for women in their 40s because they got screened early? Does that count? The new recommendations state that women with a high risk history should have early mammography, but how about the 75% of women who have no history to speak of, but have breast cancer none the less? Should they wait until their disease is so advanced, the only available treatment will be hospice at the time of diagnosis? Don't think this doesn't (still) happen all the time. It does, and I really don't want to see it happen more.

How many radiologists specializing in mammography screening sat on the panel that came up with these new suggestions? It's a trick question, because a wise person would guess that at least one of them was a specialist in this field, right?

Here is the American Cancer Society response to the recent recommendations.


sapphireblue said...

I saw this on the news last night. I hope no one takes this serious, and the insurance continues to pay for these routine exams.

Winifred said...

We don't get routine screening on NHS until after 50 but we are encouraged to self examine. However like you say how many cancers are picked up by mammograms when they are too small to be found by self examination? My friend's did.

On the other hand my doctor told me years ago that he wasn't happy for his patients to have mammos too early and too often as he worried about the radiation risks. I really trusted him as he often bot into hot water with the NHS arguing about things he believed in like ordering tests when he felt it necessary rather than limiting his referrals to what he was allocated by NHS. Things have changed since then.

I agree with you, better to have the evidence than computer models.

Brenda said...

Yes, I heard this on the news last night. What really floored me personally, was the number of women that cancelled their appointments after hearing this on the news. People need to use their own gut instincts and brains to make decisions, and only pay attention to media news AFTER checking into it ALOT. Computers make our lives easier sometimes, but they malfuntion and give wrong information too often.

Ruth said...

In Australia they recomend self examination of breasts. We have Breast Screen that provides free mamograms to everyone over 50 till 79 every 2 years(not that everyone takes up the offer)Thye have busses that travel the country and it is a very efficient service thye send out reminders.I have been having yearly mamograms with them since age 40 as Mum had breast cancer a few years back. I am happy to continue to do this. On a different note we have the Pap Smear Registry that tries to contact you if you don't have a pap smear after 3 years or so. These interventions are gove funded and do not depend on the whim of any insurance company.

Blue bird said...

We lost contact for a while Rudee!
My opinion about mammograms is that if you did not have a problem you can have one with the frequet xray which takes quite a long time to be exposed to radiation! In addition to the rough treatment you can get with a not very qualified tech. help.

Now I have a message for the coming holidays: It's about "Nature's Beauties". Greetings: Bluebird :-)

Gail said...

I'm gonna keep checking, my mother did not raise a fool.

Rose said...

Thanks for the link; I added it to my blog and linked back to you too. How typical that health care is putting women in the back seat yet again. Blood pressure has been rising since this came out; similar to how insurance pays for Viagra but not oral contraception. Coincidence? I don't think so.

Anonymous said...

There was not a single Mamo radiologist on that panel. This is ridiculous.

Kathleen said...

A scientist/epidemiologist I work for says we're in the midst of a "pandemic of modeling." He's all about evidence-based everything and despises modeling b/c you can't ever account for every variable.

Rositta said...

That's been the standard (two years) in Canada for a long time. Is it wrong, I don't know. I do know I had a false positive which caused all kinds of stress. I think every woman must decide for herself

laurie said...

i'm not a nurse, and i don't understand all this stuff, and everything i hear is making me more an dmore confused.

my sister died at age 52 of breast cancer that was discovered when she was 47. she knew she had a lump and ignored it. she died.

my sister-in-law is cancer-free four years after finding a lump during a routine self-examine. (she, too, was under 50 when it was found.) yes, she found a lump and went right to the doctor. she lived.

now i'm hearing from doctors--doctors!--on the radio that there is no point to either mammograms or routine self-exams because by the time you find something it's been growing for years, has probably metastasized, and is basically "too late."

i wanted to smash my car radio when i heard this.

Miss T said...

I really, really wonder about some of these studies.

Rudee said...

Miss T--don't wonder about the studies, for they're clear--early diagnosis saves lives. What isn't clear is how this group of statisticians input data and came up with what they did.

Laurie, we should all worry if physicians and insurance companies follow these guidelines of new "evidence".