Thursday, November 19, 2009
The mammogram panic: or, false positives are no picnic
Inhale through your nose (be sure your abdomen moves, not just your chest). Exhale through your mouth. Slowly, now ...
OK, let's talk about the U.S. Preventive Services Task Force's recommendation that women begin getting mammograms at age 50 instead of 40, and that we space them two years instead of one year apart.
I'm not going to argue that the USPSTF is right or wrong about this. I'll probably keep on getting my annual mammogram, and the HHS secretary assures me that this should be no problem. But I do understand the Task Force's wish to cut back on unnecessary procedures. As satirical columnist Gail Collins wrote this morning, "Whatever happens, we do not want the government conducting any studies on whether current health practices actually do any good. Let this continue and soon you will not be able to get your hands on a good leech when you need one."
The USPSTF's recommendations are not exactly outlandish. Beginning mammography at age 50 and thereafter at two- (or even three-) year intervals is already the standard in the European Union and Japan. Breast cancer, however, is one of the few diseases with higher survival rates in the United States (especially for white women) than anywhere else. Is this due to early detection, better treatment, fewer smokers, or a different approach to statistics? People have theories, but no one knows for sure. So, until they figure this out, I imagine I'll opt for the annual mammogram.
Still, there are good reasons to be concerned about false positives. I've had two false positives, and here's what happened to me.
I had a worrisome mammogram on July 25, 1999. The doctor didn't like what he saw, so he sent me for a second mammogram on July 29. It did not make him any happier, so I went immediately for an ultrasound. On August 18--after nearly three weeks of what the USPSTF, with classic understatement, calls "anxiety"--I went to the hospital for one-day surgery.
First, however, I had yet another mammogram to mark the tiny mass through needle localization. While the breast is compressed, a needle bearing a small wire is inserted. This does not feel good. Also, it somehow affects the vagus nerve, and some women pass out while it is being done. I came very close to being one of them. Fortunately, the technicians started hollering and someone brought a bed to catch me. Eventually they found what they wanted, and I was taken to the operating room for a surgical biopsy. It left me very sore for several weeks and slightly disfigured forever. Nothing whatsoever was wrong with my breast.
Two years later I had another false positive. This time I went directly to an oncologist, whom I will bless forever. She did not ask for a second mammogram, and she did not do a needle biopsy. Instead, in her office, she did an ultrasound followed by a fine needle aspiration. Again, nothing was wrong.
A number of my friends have been sent for breast biopsies too. Most of them had stereotactic biopsies (if you're in a grisly mood, see Mayo Clinic's descriptions of different kinds of biopsies). None of them had anything wrong either. They had a lot of anxiety, discomfort, and expense, though.
I'm not saying mammograms should be done later, or less frequently. I don't know. I'm just saying that false positives are nothing to sneer at. If yearly mammograms really do provide better results, then false positives may be an unpleasant, expensive, but necessary side effect. If yearly mammograms make little or no difference, then we need to consider that false positives carry their own risks, not the least of which is infection.
I suppose I'm going to carry on with yearly mammograms. Maybe they contribute to the U.S.'s good survival statistics. Maybe I'm superstitious: if I skip a year, I will surely be punished. But if Blue Cross or Medicare someday decides not to fund annual mammograms, or if I move from Wheaton to Paris or Geneva, I won't panic. At least not as much as I did when I had the false positive mammogram results.