Emotions, as they say, run high, especially about “health.” There is a great deal of superfluous, extraneous, and irrelevant discussion taking place with regard to the new mammogram guidelines. Yesterday, many organizations rushed to the microphone to say, “Don’t worry! We still recommend every women gets mammograms as frequently as possible.” They were worried lest women think they did not care. Let’s examine this phenomenon.
There is a range in how much people care about their own physical being, from hypochondria to indifference. I’ll use the term hypochondriac to mean not just those who suffer from the mental disease of ridiculous concern, but also for those who worry disproportionately to the actual risk of any malady. Antibacterial-goo-carrying hand washers are in this category, as are mothers who fearfully drag their tot to doc every time it sneezes. The indifferent eat and drink whatever the hell they want and say, “A short life, but a merry one.”
The reactions of those at either caring extreme to those at the opposite end is not symmetric. That is, hypochondriacs regard the indifferent in a manner that is wildly different than how the indifferent think about hypochondriacs.
The indifferent think hypochondriacs are nuts, and that they’d be better off if they just wouldn’t worry so much. But the indifferent are inclined to think that if the hypochondriacs want to run to the doctor for every perceived symptom, let them; as long as they leave us alone.
Hypochondriacs—and their close cousins the worrywarts, hand-wringers, and fretters—think the indifferent are nuts, too. But in general the hypochondriacs cannot abide the indifferent and want to change their behavior. Misery loves company, and the misery caused by constant concern should be enforced, even mandated, for all. Hypochondriacs rally under the banner, “Something might be wrong with you!”, which is a true statement, but an empty one, because it contains no information beyond the fact that some people get sick and some don’t. It doesn’t tell you the odds.
Very well. Hypochondriac females desire, as early as they are allowed, to have a mammogram, and have them often, “so that they know.” The indifferent look at these females and say, “Go ahead, but I don’t want to take the chance of a false positive.” But the hypos can’t stomach this, don’t care at all about false positives—they might as well not even exist—and so they browbeat the indifferent until they agree, at least verbally, with the hypos’ concerns.
But there is middle ground.
All the new mammogram recommendations did was to seek a balance between the admitted inaccuracies of mammograms—and they are very inaccurate—with the chance of developing breast cancer (which is small), all while attempting to account for the average person’s feelings about false positives and false negatives. The average person is not a hypochondriac nor is she indifferent. Further, there are many more in the middle than at the extremes.
The study—and my own work—highlighted four things which were previously unemphasized, and which every woman thinking about a mammogram should consider.
- False positives exist and are common. And they have serious consequences. The costs involved with the mammogram’s mistakes should, and almost never are, considered before deciding to have the test. Women should be better advised.
- The doctor’s costs are not the same as the woman’s. Obviously, the doctor doesn’t suffer at all if the mammogram gives a false positive. In fact, his billing increases as he calls the woman back for further tests. It’s not his breast being squeezed under glass, nor his breast being cut open to extract a possible unnecessary biopsy, nor his breast being exposed to additional radition.
- The age at which to begin mammograms is not set in stone. To those who condemn the new guidelines, I ask—seriously—why not recommend mammograms at 13 or 14? Why not get them twice yearly, or even once every quarter? The answer you give cannot be “Don’t be silly.” You must base your response on quantitative data. That is what the study (and my work) tries to do.
- Not all cancers are equal. Some breast disease can be lived with and won’t kill, and some of these, sometimes, are better left alone. Read the original paper (linked here) for a more thorough discussion.
That last point need emphasis. It might not be that 50 is the right age for healthy, otherwise not-at-risk women (at risk women include those with family histories of cancer, etc.) to commence screening, it might be that it is 52 or 48. It also might not be best for tests to be annual or semi-annual. What is best and how do we tell? To explain that requires the math I pointed to yesterday. The point to take away is that this is a question that can be answered empirically and quantitatively—and not politically. The correct age and timing will be different for each woman—and there are tools to help her decide what these numbers are.
One more thing: I heard some docs say, “The data used in the study were not all current. Treatment methods have changed.” This is true, but largely irrelevant. Breast cancer treatment is not at issue: the accuracy and usefulness of mammograms is, and these fallible instruments have not improved much through time.