Screenings

Today’s New York Times Article

2/12/2014

In today’s New York Times on the front page there is an article about a long-term Canadian study involving mammographic screening for breast cancer. It looked at over 90,000 women randomized to get mammographic screening vs. those who only had a breast exam by a nurse without mammography. It lasted 25 years. It was published in the British Medical Journal. It found that there was no difference in deaths from breast cancer in either group (about 1 death per 90 women enrolled over the 25 year period). While I have not yet seen the full article I feel compelled to make some observations.

 

  • Clearly breast cancer is not “one disease”. Some forms are clearly more virulent than others.

 

  • In this study, the death rate in the non-screened group was probably lower than it might have been because of improved treatments that we now have even for later stage breast cancers that present because they are large enough to feel.

 

 

  • In the screened group, my biggest concern is that people (i.e. patients, the government) think mammography is a “laboratory test”. What do I mean? If I order a blood count on my patient and she goes downstairs and has blood run through a machine called a Coulter Counter that is well calibrated, and let’s say her blood count is 39.4, and I were to send her for a similar test at Hackensack Hospital with a well calibrated machine perhaps it would be 39.7, but it would not be 25 or 48. Those are highly reproducible laboratory tests. Mammography is only as good as the equipment employed and the people performing and interpreting the study. I know little about the Canadian system of health care, but I guarantee that the 45,000+ women were not getting the quality of mammographic screening that most of my patients are receiving. The mammography facilities that I recommend do not simply have a technician do a study and then later have a physician come by and read images, and then having to decide if it is necessary to call the patient back for further evaluation. The best facilities (the ones I recommend) do not let the patient leave until all issues have been reconciled and this often involves a spot film or compression film or ultrasound when necessary. Most good facilities will have a “double read” (two physicians) and some even include a clinical breast exam and the doctor speaking to the patient. I have no doubt that some of the deaths that occurred in the screened group in this study were “false negative” studies where people with early cancers went undetected. That has not been my experience when patients of mine are in the hands of top mammography facilities.

 

This is not unlike my concerns about those who feel that transvaginal ultrasound cannot detect early ovarian cancer. Transvaginal ultrasound is even more operator and equipment dependent than mammography. So while the United States Preventative Services Task Force (USPSTF) may recommend against routine screening of ovaries that recommendation is based on very flawed population data. I take care of patients myself, one at a time, and perform my own transvaginal ultrasound exams with top-of-the-line equipment.  

 

So…bottom line is do not consider changing your mammographic screening…unless the facility you use is not one of the highest quality.

 

As usual, if you have any issues or questions do not hesitate to call. I remain yours in health.

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Letter to The New York Times

05/01/2013

An article appeared in yesterday’s NY Times Science section about the lack of benefit and even potential harm of the routine bimanual pelvic examination in gynecology. It is so inaccurate and one sided that I have sent a letter to the Times which I have reproduced for you. (I am not optimistic that they will choose to run it.) This is such important information you may want to share it with friends, colleagues and family…

All reporters and most readers appreciate there are two sides to every story. So usually if I disagree with some of a given story I accept a divergence of opinion. But some of the misstatements and glaring inaccuracies of “An Exam with Poor Results” by Jane Brody (4/30/13) mandate a response.

I can agree that a blindly performed bimanual pelvic examination is extremely crude and may yield limited information. However, the statement by Dr. George Sawaya of UCSF that after finding an enlargement during a bimanual pelvic examination he gets “follow-up with a sonogram which shows a mass but I can’t tell what the mass is without surgical exploration. Yet nearly always it is benign.” must be commented on. The field of gynecologic ultrasound with the introduction of vaginal probe sonograms in the last 30 years has refined gynecologic diagnosis to the point where the overwhelming majority of masses detected are clearly benign and can be left alone without surgery. It seems that Dr. Sawaya, and unfortunately many other physicians and patients, do not understand that benign ovarian growths do not become malignant. Perhaps this misconception is a result of the fact that virtually all other gynecologic cancers (cervix, uterus, and breast) have well defined premalignant stages that we attempt to identify before they become frank malignances. I also believe that another major reason that the rate of surgery for ovarian cysts and hysterectomy in the United States is twice as high as European countries is because their ability to better understand that gynecologic ultrasound can reliably suggest “benign” is far ahead of most doctors in the United States. Further proof of this is underscored by the United States Preventive Services Task Force’s (USPSTF) refusal to recommend routine ultrasound screening for early detection of ovarian cancer partly because there were 30 surgeries for every malignancy detected in the PLCO  (prostate, lung, colon, ovary) study. This stems from that study having used a definition of a “positive” screen for entities that many of us, even in 1993 when it was designed, and surely today, would clearly recognize as benign and avoid surgery.

You can click here for the original NYT article. http://well.blogs.nytimes.com/2013/04/29/an-exam-with-poor-results/?smid=pl-share

Pap Smear Screening

There was an article in the New York Times by Tara Parker-Pope entitled “The annual appointment loses some relevance”.  It was about the highly publicized, but not so very different, pap smear guidelines by the USPSTF (United States Preventative Services Task Force).  The guidelines had already been changed several years ago making the recommendation for less screening in some women.  At that time, as a member of the Editorial Board of Contemporary ObGyn, I wrote a piece entitled “If it ain’t broke, why are we fixing it”.  The pap smear is one of the single biggest success stories of modern medicine (barely behind the discovery of polio vaccine).  The number of cases of invasive cervical cancer in this country has fallen dramatically over the last 60 years mainly because of the pap smear.  Currently, 50% of new cases of cervical cancer today are in women who have never had a pap smear and another 10% in women whose pap smear is abnormal, but have never bothered to follow-up!  In my 25 years of practice I have had two cases of invasive cervical cancer and both of those women walked into my office with the disease already.  No one who has been under my care has developed invasive cancer.