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[collegekidsmom]

Thank you, Biomancer for that information. It adds to my contention that there should not be a "one size fits all" recommendation for some screening test. Mammograms include exposure to radiation. I have no risk factors(except being female-although males are at some risk too), even though that does not mean I  will not get breast cancer of course. When I was younger, they recommended annual mammograms after age 30 or 35, then upped it to 40-then older. So, should I have had 20+ years of annual radiation exposure? So, when I just went for a mammogram, I asked about the radiation exposure to healthy breast tissue. The wonderful answer from the mammogram person was "there was a lot more radiation in them in the past!" Oh, perfect-that there was MORE for all the women before, including me. I would just prefer to assume I am healthy than expose myself to unnecessary radiation.
I would prefer to worry about the diseases for which I  actually might be at risk. Lipitor is supposed to be the magic bullet for those.

[kedves]

Thread is interesting-- let me ask a question along a similar line: I like my primary care MD (who does double as a cardio, though I do not (thankfully) need these services yet).  I do have ongoing issues for which I take meds, and I get bloodwork prior to my appts. with him.  We have several decisions pending as to the long-term direction of my treatment.  I last saw him in March, and he wanted me back in June, but the day of our appt., he cancelled, secretary saying there was an emergency he needed to attend to in hospital.  He told her to just schedule me another appt. in the queue, that he did not need to see me asap unless I felt sick (I didn't), so we scheduled next available appt., which was mid-August.  The day of this appt. his sec cancelled again for same reason, again only making next available appt. for mid-Oct.  I feel now that I really do need to have him keep this appt., or, if he ends up unable to do so, that he should get me in asap thereafter, rather than wait for the two+ month queue to free up space again ( I am thinking, based on my visits to his office, etc., that a big part o fthe problem is that he likely has too many patients), but, should he have to cancel again and the secretary does try to reschedule according to the queue, potentially weeks later, what, if anything, should I say?  Also, when, if ever, might I decide that:

1) he really maybe does not want to be my doctor anymore
or 2) I should look for another primary myself

Kay, I think the big question I'd be asking in your situation is:  what is the time frame for an appointment when it's you that has the emergency?  For example, if you came down with flu (normal, swine, bird, whichever) tomorrow, could your doctor fit you in fast enough to get you on the appropriate medication (tamiflu, relenza) within the 72 hour window that the drug actually works?  If the answer to that is "no" then it's definitely time for a different doctor.  Part of why I liked my doc in SLACville so much is that she could always get me in within 24 hours, and often the same day.

I agree with that, but other people's emergencies are why routine appointments get canceled, so it is hard to know what will happen until you are the one in the emergency.  If you are comfortable with the doctor except for this, I would take a wait-and-see approach.  If he does cancel a third time, remind appointment scheduler that it is the third time and see what their policy is.  Even for an odd series of chances in a routine situation, they shouldn't keep pushing an appointment back.  But I have bad luck with doctors, so when I find one who's okay, I would always prefer to stay with him or her. 

[unspoiled]

Congrats on the physical therapy progress. Here's hoping you'll be painfree and fully functional soon!

Thanks, that is sweet of you!

But this brings us back to the issue that standard practice is sometimes wrong. The standard now, as you mention, is that women over 40 should have regular mammograms. (I believe this is the AMA standard.) However, there has been some very credible research that shows that this standard should be questioned

This report on the Cochrane meta analysis discusses some of the complexities of screening recommendations -- and does a fine job unpacking the statistics.

... risk. That's kinda tiny, actually when you think about it. And that doesn't even factor in the risk of false positives, the call-backs for repeated tests, the worrying, the money spent on exams, the time taken off work, etc.

Your social and statistical analysis seems flawed to me (let's leave the practice of clinical medicine aside as we can debate just fine without it).  For one thing, impact of the illness is not necessarily milder if the risk is "tiny" but nevertheless you (or me, or her, or someone you know and care about) end up being the ones afflicted after all.  It can be very lonely and selfish at the top, both as cancer patients and as primary caregivers of cancer patients (personal experience here), even if they denied themselves prevention and treatment for the most unselfish reasons in the world (self-effacing sacrifice for family which is big in some cultures, especially when women are concerned etc.)  

Second, the physician is indeed obligated to abide by the ethical/religious/ethnic/cultural convictions/traditions that prevent the patient from receiving test X, procedure Y and treatment Z and make a note of this in the chart, but while the physician does have to abide to the set of beliefs and arguments (including statistical arguments) the patient bought into, or worked herself into, s/he doesn't have to buy into them as well.  To hold certain convictions as to be applied to one's own body is one thing, and to question the standard of practice for all women based on one's convictions is another thing.  

First, according to statistical calculators on line,

The on-line calculators,

Which on-line calculators did you use?  The one in the Cochrane meta-analysis report you quoted?  I haven't got to reading the entire study yet because I'm focusing on your use of this calculator for now.  

The low-risk figures you come up with are contingent among other things on "the woman not having had a history of ductal carcinoma in situ or lobular carcinoma in situ".  I'm not discussing anyone's particular medical circumstances here, but statistical variables which in epidemiology reflect upon diagnostic tools, and unless I'm missing something big it is unclear to me how the woman in question, who attempts to estimate her own risk, can be so sure she has never had a history of either DCIS or LCIS as long as she did not have a mammogram or a biopsy performed, respectively.  Did you research how DCIS and LCIS are diagnosed in the first place, as well?

there is more life-long exposure to radiation

And that doesn't even factor in the risk of false positives, the call-backs for repeated tests, the worrying, the money spent on exams, the time taken off work, etc.

Again, it's one thing to be concerned about cumulative lifetime exposure to radiation (which can be a medical adverse side effect of the mammogram) and quite another thing to worry about non-medical inconveniences (time, money, stress).  I am as concerned as you are about cumulative lifetime exposure to radiation.  I am not as concerned as you are about the rest, because I happen to believe that time, money and stress expenditures would be way higher should I actually become ill, and furthermore instead of one person putting herself through a series of inconveniences, an entire family would become tragically affected.  

[unspoiled]

The low-risk figures you come up with are contingent among other things on "the woman not having had a history of ductal carcinoma in situ or lobular carcinoma in situ".  I'm not discussing anyone's particular medical circumstances here, but statistical variables which in epidemiology reflect upon diagnostic tools, and unless I'm missing something big it is unclear to me how the woman in question, who attempts to estimate her own risk, can be so sure she has never had a history of either DCIS or LCIS as long as she did not have a mammogram or a biopsy performed, respectively.  Did you research how DCIS and LCIS are diagnosed in the first place, as well?

This is what I'm referring to (on of the caveats the calculator comes with):

The tool's risk calculations assume that a woman is screened for breast cancer as in the general U.S. population. A woman who does not have mammograms will have somewhat lower chances of a diagnosis of breast cancer.

So in other words, the calculator warns us that if the woman has never had regular mammograms and biopsies as per the guidelines of screening in the general US population, she cannot answer "no" to the question "does the woman have a medical history of DCIS or LCIS" AND expect an accurate estimation of risk at the same time.  A woman in that category, designated here as "a woman who does not have mammograms,"  will therefore underestimate her risk to a certain extent ("will have somewhat lower chances of a diagnosis of breast cancer").  This calculator is a projection in the future which works best for women who get screened regularly in the present and past, not for women who do not believe in regular screening.  It works to a certain extent for the latter as well.  But not as well as for the former category, and it does come with that recommendation.  

[treehugger1]

Second, the physician is indeed obligated to abide by the ethical/religious/ethnic/cultural convictions/traditions that prevent the patient from receiving test X, procedure Y and treatment Z and make a note of this in the chart, but while the physician does have to abide to the set of beliefs and arguments (including statistical arguments) the patient bought into, or worked herself into, s/he doesn't have to buy into them as well.  

OK. But no matter what the doctor believes, I, at least, think they should be forthcoming about the complexities of screening. I've only spoken with three different M.D.s about this. However, in each case the message was: "You must get tested." Period. No cost/benefit analysis whatsoever, when, in fact there are costs. I understand why they do this. I think the M.D.s truly believe in screening's ultimate benefit for most women (no matter how equivocal the results of certain studies may have been) and are afraid that if they seem to be hedging women won't make the effort. In fact, M.D.s made precisely this objection when the Cochrane study came out and/or when the guidelines were being revamped -- "If women are confused or if the importance of the test seems iffy, then they'll be less likely to get tested." Well, yeah! How's that for circular reasoning.

My personal hunch is that these screening exams are truly important for a small minority of women -- women who have quite a few risk factors, or have a family history -- but the medical establishment tries to get as many women as possible to go through screening in order to support the system, as it were. But, like I said this is merely an unsubstantiated (and probably a little paranoid) suscipion.

The low-risk figures you come up with are contingent among other things on "the woman not having had a history of ductal carcinoma in situ or lobular carcinoma in situ".  I'm not discussing anyone's particular medical circumstances here, but statistical variables which in epidemiology reflect upon diagnostic tools, and unless I'm missing something big it is unclear to me how the woman in question, who attempts to estimate her own risk, can be so sure she has never had a history of either DCIS or LCIS as long as she did not have a mammogram or a biopsy performed, respectively.  Did you research how DCIS and LCIS are diagnosed in the first place, as well?

Well, speaking personally, I have had mammograms in the past -- at the ages of 41 and 43. The first mammo was supposedly "ambiguous" (see below) and the second (accompanied by an ultrasond) was negative. So I have no particular reason to believe that I have either a DCIS or LCIS. But, speaking generally, a women doesn't need to know that in order to have some good idea of her risk as there are many other factors out there. And, speaking personally again, I only have one of many risk factors. Although I've had no pregnancies (risk factor), I have no cancer at all --of any kind -- in my immediate family, I eat well (ask me about the quinoa kale soup we just had for dinner), maintain a "healthy" weight, exercise every day, rarely drink, have never smoked, have never used BC pills, had a relatively late onset of menstruation, have what seems to be early menopause, etc. Any yet, all three of the gynecologists I have seen have almost hysterically insisted on my getting mammograms every year. (Back four years ago, when I let myself get hounded into getting my first mammogram, the results came back "ambiguous" and they wanted me to follow up with a better(?) or more detailed(?) mammogram, I decided that I had made a mistake and decided not to pursue that matter any farther. At that point, the clinic started aggressively calling me -- insisting that I come back for another exam. When I refused, they sent me a registered letter (which I had to take time off from work to pick up, unaware, as I was, of the sender.) Their response felt almost like harassment.) In any case, here's my attitude: sure, I can get BC, just like everyone else, but its just not *that* likely. At this point, given my medical history, it's much more likely that I'll eventually die of diverticular complications and, given my family history, it's much more likely that I'll die of heart problems/stroke.

Again, it's one thing to be concerned about cumulative lifetime exposure to radiation (which can be a medical adverse side effect of the mammogram) and quite another thing to worry about non-medical inconveniences (time, money, stress).  I am as concerned as you are about cumulative lifetime exposure to radiation.  I am not as concerned as you are about the rest, because I happen to believe that time, money and stress expenditures would be way higher should I actually become ill, and furthermore instead of one person putting herself through a series of inconveniences, an entire family would become tragically affected. 

Well, this is just a question of personal philosophy. Personally, I think life is life. Unless you particularly like going and getting mammograms, biopsies and whatnot, you have used up a morning or afternoon of your life everytime you go. I read somewhere that the average woman gains 3 days of life by getting screening mammograms. I know, this is a silly statistic. Who's the average woman? Which three days? etc. But still, there is some cost/benefit analysis to be done (in my book). At the very mimum (if you are never called back for more tests, which is highly unlikely) you will spend 25 days of your life getting mammograms if you following the current screening recommendations (and live to 65).

But like I said, this is very much a personal question. Yesterday, I had long heartfelt conversation with my sister and my mother about the issue. Both sis and Mom would agree with you, sis somewhat and Mom strongly. Mom was so angry she nearly hung up on me. She religiously gets every test possible (although she resists taking medication long term). My sister said the same, but said that it was because of her children. She feels a responsibility to be around for them. She said (but perhaps she was only being diplomatic) that if she were in my situation (sans kids) she would be more nonchalant about the whole thing.

Anyway, one of the points I'm trying to make is the following: It's fine if doctors feel strongly about the importance of mammograms and strongly encourage most of their patients to go get the test. All well and good. On the other hand, I also feel that a woman has a right both to opt out of screening or any kind of follow-up after a screening and have her wishes treated with respect (at least once she has made clear her rationale). That is -- she should not be bullied, humiliated, sneered at etc. But, of course, as everyone on the Fora knows, I live in la-la land. :-)


OK. Now I will descend from my soapbox and get back to work.

[bookishone]

Anyway, one of the points I'm trying to make is the following: It's fine if doctors feel strongly about the importance of mammograms and strongly encourage most of their patients to go get the test. All well and good. On the other hand, I also feel that a woman has a right both to opt out of screening or any kind of follow-up after a screening and have her wishes treated with respect (at least once she has made clear her rationale). That is -- she should not be bullied, humiliated, sneered at etc.

treehugger, I think you and I are in total agreement on these two points!

[biomancer]

Thank you, Biomancer for that information. It adds to my contention that there should not be a "one size fits all" recommendation for some screening test. Mammograms include exposure to radiation. I have no risk factors(except being female-although males are at some risk too), even though that does not mean I  will not get breast cancer of course. When I was younger, they recommended annual mammograms after age 30 or 35, then upped it to 40-then older. So, should I have had 20+ years of annual radiation exposure? So, when I just went for a mammogram, I asked about the radiation exposure to healthy breast tissue. The wonderful answer from the mammogram person was "there was a lot more radiation in them in the past!" Oh, perfect-that there was MORE for all the women before, including me. I would just prefer to assume I am healthy than expose myself to unnecessary radiation.
I would prefer to worry about the diseases for which I  actually might be at risk. Lipitor is supposed to be the magic bullet for those.

If you're referring to the statistical risk-analysis, I think Treehugger provided that.  Risk analysis is indeed good food for thought.

[inthelab]

Anyway, one of the points I'm trying to make is the following: It's fine if doctors feel strongly about the importance of mammograms and strongly encourage most of their patients to go get the test. All well and good. On the other hand, I also feel that a woman has a right both to opt out of screening or any kind of follow-up after a screening and have her wishes treated with respect (at least once she has made clear her rationale). That is -- she should not be bullied, humiliated, sneered at etc.

treehugger, I think you and I are in total agreement on these two points!

I agree with both of you.  I stopped getting routine mammograms when I switched employers and no longer had access to a mammography unit, where the radiologists only read mammograms.  This is key to obtaining the true value of mammograms.  Absent this, I no longer go, and I've told my internist why.  Most recent epidemiological research seems to bear out my personal practice in terms of value for women.  There's no history of breast cancer in my family; I started menses relatively late, and ended early.  Never used the pill, exercise regularly (though my weight is not where it should be, granted).

[collegekidsmom]

As others, I have practically had to fight to stay away from mammograms. I do not preach to others about this, or even discuss it, but have been similarly threatened, bullied, laughed at, you name it-by physicians, insurance companies, and others over this issue. I have received letters in the mail. I just don't think that radiation and breast tissue are a good combination.

I do tell them that I am going to die from something, and I know that and can accept it and I will instruct my family not sue anybody in the medical profession when it happens (due to disease). However, I have had the same issues with things like unmedicated childbirth, lack of flu shots even when they're free(!), and other such things. I think too much medicine is fear-based anyway. In my own way, if I feel good, then I am going to presume I am healthy.
If I don't feel good, I will investigate.
Thanks to all for statistical information. 

[unspoiled]

Mammograms include exposure to radiation. I have no risk factors(except being female-although males are at some risk too), even though that does not mean I  will not get breast cancer of course. When I was younger, they recommended annual mammograms after age 30 or 35, then upped it to 40-then older. So, should I have had 20+ years of annual radiation exposure? So, when I just went for a mammogram, I asked about the radiation exposure to healthy breast tissue. The wonderful answer from the mammogram person was "there was a lot more radiation in them in the past!" Oh, perfect-that there was MORE for all the women before, including me. I would just prefer to assume I am healthy than expose myself to unnecessary radiation.

I just don't think that radiation and breast tissue are a good combination.

Thanks to all for statistical information. 

Here's more statistics:

Radiation exposure from mammography

The modern mammography machine produces breast x-rays that are high in image quality but uses a low radiation dose (usually about 0.1 to 0.2 rads per picture). In the past there were concerns about radiation risks. Today if there is a risk, it is very small.

Strict guidelines are in place to ensure that mammography equipment is safe and uses the lowest dose of radiation possible. Many people are concerned about the exposure to x-rays, but the level of radiation from mammography today does not significantly increase the risk for breast cancer.

To put dose into perspective, if a woman with breast cancer is treated with radiation, she will likely get a total of around 5,000 rads (a rad is a measure of radiation dose). If she has yearly mammograms beginning at age 40 and continues until she is 90, she will get a total of 20 to 40 rads. To put it another way, the dose of radiation that she gets during a screening mammogram is about the same amount of radiation from her natural surroundings (background radiation) she would average in a 3-month period.

(American Cancer Society)

[inthelab]

Many people are concerned about the exposure to x-rays, but the level of radiation from mammography today does not significantly increase the risk for breast cancer.

Don't know if NCI would agree with that statement. 

[unspoiled]

Many people are concerned about the exposure to x-rays, but the level of radiation from mammography today does not significantly increase the risk for breast cancer.

Don't know if NCI would agree with that statement. 

Tell us more if you know more.  I'm also concerned about the cumulative lifetime radiation risk.  I haven't run exhaustive searches on the NCI website but so far I haven't found statements of dissent with the ACS. 

# What is the best method of detecting breast cancer as early as possible?

Getting a high-quality screening mammogram and having a clinical breast exam (an exam done by a health care provider) on a regular basis are the most effective ways to detect breast cancer early. As with any screening test, screening mammograms have both benefits and limitations. For example, some cancers cannot be detected by a screening mammogram but may be found by a clinical breast exam.

Checking one’s own breasts for lumps or other unusual changes is called a breast self-exam, or BSE. Breast self-exams cannot replace regular screening mammograms or clinical breast exams. In clinical trials (research studies), breast self-exams alone have not been found to help reduce the number of deaths from breast cancer.

# What are the benefits of screening mammograms?

Several large studies conducted around the world show that breast cancer screening with mammograms reduces the number of deaths from breast cancer for women ages 40 to 69, especially for those over age 50. Studies conducted to date have not shown a benefit from regular screening mammograms, or from a baseline screening mammogram (a mammogram used for comparison), in women under age 40.

Radiation exposure—Mammograms (as well as dental x-rays and other routine x-rays) use very small doses of radiation. The risk of any harm is very slight, but repeated x-rays could cause problems. The benefits nearly always outweigh the risk. Women should talk with their health care provider about the need for each x-ray. They should also ask about shielding to protect parts of the body that are not in the picture. In addition, they should always let their health care provider and the technician know if there is any possibility that they are pregnant.

[wegie]

Somewhere around (although I can't find it at the moment) is the UK data on whether yearly mammograms are either useful or cost effective. The last time I read anything about it, the general viewpoint was that the money is better spent extending the age-range of women who get mammograms rather than the frequency.

For comparison, here in the UK we have a [ur=http://www.cancerscreening.nhs.uk/breastscreen/index.htmll]national screening service[/url]. Every woman between the ages of 50 and 70 who is registered with a GP (there's no exact figure for what percentage of the UK population is registered with a GP, but figures well in excess of 95% are common) is invited for a three-yearly mammogram. From 2012, the age range moves to 47 to 73, in conjunction with most of the country having access to digital mammography. Of those women invited for a mammogram, approximately 75% attend. If you are in a high-risk group (mother or sister had early cancer, BRCA1 and 2 genes), you are advised to have yearly mammograms after the age of 40 and yearly MRIs if you're under 40.

Aha. Here we are. Link on the NHS breast screening programme website to the 2002 study that basically says that moving from a 3 year screening cycle to a yearly cycle isn't cost effective (this is a service paid for out of general taxation after all) and the change in the number of cancers detected isn't statistically significant. I've even seen some more recent research that suggests that the problems caused by false positives on annual screening outweigh the numbers of extra lives saved.

So, for all you women with pushy doctors. Just tell them to do it every three years and to do it right.

[inthelab]

So, for all you women with pushy doctors. Just tell them to do it every three years and to do it right.

Thank you Wegie, that sounds like the NCI data I recall.

Doing it right = having it done at a facility dedicated to mammography, read by a radiologist who specializes in reading mammograms.

[menotti]

What happens now is that even when you do not have any health concern, there are all of these tests offered to find out just what MIGHT be wrong with you. So, do you have a colonoscopy, with its possible risks, just to find out that you don't have colon cancer, or mammograms with radiation exposure to find out that you don't have cancer? Do you have an escalating number of immunizations foisted on your kids? It doesn't make sense that everyone needs to have their breasts, prostates, and colons checked,while the rest of their bodies may be the ones growing some kind of cancer.

Although I'm apparently in the minority on this thread, I have to comment here, probably a bad idea. It's not  excessive for a physician to urge any patient to have an appropriate screening test. The millions of standard cholesterol tests, mammograms, and colonoscopies ordered and performed in this country save lives as well as health care dollars. If you're a female over 40, or under 40 with a family history of breast cancer, it's your gynecologist is certainly not out of line in urging you to get a mammogram, even just a baseline mammogram. It's up to you whether or not to get one, of course.

I won't comment on your doctor's bedside manner, but it doesn't seem out of the question that a cholesterol test when you come in with concerns about menopause might be appropriate.  Your risk for heart disease increases after menopause, after all, and cardiovascular disease is the #1 killer.  If you are coming in asking about your health at that point, finding out some more about your heart disease risk doesn't seem unreasonable.