Why I’m Opting out of Mammography

Christie Aschwanden

doi:10.1001/jamainternmed.2014.6394

Inside Story

February 2015

Why I’m Opting out of Mammography

Christie Aschwanden¹

Author Affiliations Article Information

¹Independent journalist

JAMA Intern Med. 2015;175(2):164-165. doi:10.1001/jamainternmed.2014.6394

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At a routine appointment a few days after my 40th birthday, my gynecologist gave me a prescription for a mammogram. There was no discussion, no explanation. Just a slip of paper, handed to me without a word as I left the examination room. When I asked the doctor what she’d just given me, she told me it was an order for a mammogram. I could call the number to schedule an appointment.

“Wait—why should I get a mammogram?” I asked.

“Because it could save your life.” Her voice conveyed a note of impatience.

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3 Comments for this article

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December 2, 2014

Opting out of screening mammography

Barbara C. Cavanaugh | retired

This is an excellent discussion of this complex and confusing topic. I specialized in breast cancer diagnosis during my 30 years of practice, always interested in studying the effects of breast cancer screening since its inception in the late 1970s- early 1980s. I have an additional point to add to Ms. Aschwanden's discussion. The original premise of screening mammography was that we could prevent breast cancer deaths by decreasing the numbers of women presenting with Stage 3-4 breast cancer, if we could detect these cancers while still clinically occult. Very logical. Enter screening. However, a look at the SEER data from the last few decades shows that this premise appears incorrect. Although the incidence of breast cancer presenting as Stage 1-2 has skyrocketed, the incidence of breast cancer presenting as Stage 3-4 is unchanged. (Fortunately, advances in treatment have greatly improved the prognosis for Stage 3-4 cancers.) So these Stage 3-4 cancers, which were the original targets of screening programs, have not been affected by the detection of all of these early stage cancers and may be completed unrelated to them biologically. This information has important implications aside from the personal decision to undergo screening. If late stage breast cancer is unaffected by screening programs, then we are directing a lot of our research effort and money into the wrong place. Similarly, the vast sums of our health care dollars that go to screening programs, with their attendant costs of diagnosis (and misdiagnosis!), could be directed to more useful health care programs. And lastly, the time and stress and morbidity that women experience while participating in screening programs, again with their downstream effects, is incalculable.

CONFLICT OF INTEREST: None Reported

December 2, 2014

lack of data

Steven Yarows | IHA

I truly think this is an unfortunate conclusion to a lay journalist review of the evidence. Lack of evidence does not mean lack of benefit. I agree that this individual would have benefited from a separate appointment to discuss the physician's interpretation of the medical evidence rather than how it was handled. This is not a simple question for the telephone/email for some individuals. The conclusion that she will never get a mammogram based on her review of the lay journals is unfortunate and I truly hope not a deadly decision. I have been practicing Internal Medicine for 33 years. When I began practicing death from breast cancer was a common occurance perhaps 5/year. Now, fortunately, I rarely have a death from breast cancer, perhaps only every 3-5 years. The medical literature has confirmed this observation.I cannot emphasize enough that proper discussion is imperative. Different patients have different expectations of how they wish to make medical decisions. Most of my patients wish a short discussion and will commonly wish my opinion on the subject and follow this. Others, perhaps like this individual, wish a detailed discussion which should be performed face-to-face. This is accomodated also, within my practice

CONFLICT OF INTEREST: None Reported

February 4, 2015

bravo!

Jennifer Russell | layperson - female, age 43

Ms. Aschwanden, thank you for laying out the factual data regarding the known (quantified) risks and benefits of population screening for breast cancer in a way that is logical and easy to understand. I am pleased to know you are with me among the growing ranks of women who reject out-of-pocket paternalistic orders from the medical establishment, where the possibility of benefit, no matter how miniscule, outweighs the risk of harm, no matter how great.Dr. Cavanaugh, how refreshing to hear from someone who devoted a career to understanding and treating breast cancer, in the pursuit of averting deaths from disease; and who is also open to challenges to the assumptions that drove much of that work!Dr. Yarows, please consider re-reading this piece with a more open mind. You are correct that lack of evidence doesn't mean lack of benefit; but in this case, there IS evidence that clearly points to a lack of benefit from population-based breast cancer screening. Ms. Aschwanden laid out that evidence elegantly. Perhaps your practice has shifted over the years so that you are seeing fewer women who ultimately die of breast cancer. Or perhaps, as has been shown in many publications on the subject, awareness of cancer symptoms is improved, social acceptance of talking about breast cancer (or even saying its name!) has dramatically increased, and breast cancer treatments are more effective, thus saving some lives that might have been lost decades ago. The fact that you have over 30 years of experience practicing medicine doesn't mean that your personal opinion, based on 30-year-old information, trumps knowledge gained and facts established in the intervening decades. Intelligent women who take the time to inform themselves regarding evidence may not want to demur to their \"physician's interpretation\" of that same evidence. That is the beauty of evidence - it is fact based. Facts do not require interpretation; rather, individuals must weigh the known facts against their own personal values, risk aversion, personal and family health history, and inherent (illogical) biases. Discomfort and fear are not good underpinnings for important health-related decisions when fact-based evidence is present to guide them.Please read the articles Ms. Aschwanden references, which inform and support the logic she presents; here are two more:\"Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence\" N Engl J Med 2012; 367:1998-2005\"A systematic assessment of benefits and risks to guide breast cancer screening decisions.\" JAMA 2014 Apr 2;311(13):1327-35

CONFLICT OF INTEREST: None Reported

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