Thursday, November 19, 2009

What Mammography and Continuous Electronic Fetal Heart Rate Monitoring Have in Common

by Melissa Garvey, Writer and Editor

Earlier this week the U.S. Preventive Services Task Force (USPSTF) issued revised breast cancer screening guidelines: women in their 40s who have no unusual risk factors for breast cancer should not receive routine mammograms for early detection of breast cancer and should instead begin routine screening at age 50.

This is proving upsetting especially to women who were diagnosed with breast cancer at a young age, which is understandable. At the same time, I can't help but wonder…is routine mammography for women in their 40s who have no risk factors for breast cancer akin to continuous electronic fetal heart rate monitoring (EFM) for all women with low risk pregnancies?

Fetal heart rate monitoring during labor is essential, but continuous EFM may send up red flags where none are needed. EFM readings vary by machine and clinician. Jump on an abnormal reading too quickly and you may end up with an unnecessary cesarean section—major abdominal surgery that carries heightened risks for both mother and baby.

In fact, ACOG recently revised their EFM guidelines and put it into perspective in a press release containing this insightful statement:
“Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002," says George A. Macones, MD, who headed the development of the ACOG document. "Although EFM is the most common obstetric procedure today, unfortunately it hasn't reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions."
So, what about these revised breast cancer screening guidelines? Here’s a snapshot of the National Breast Cancer Coalition (NBCC) analysis of the revisions :
“Mammography can miss cancers that need treatment, and in some cases find disease that does not need treatment, leading to overtreatment with toxic therapies. Harms for healthy women who do not have cancer can include unnecessary imaging tests and biopsies, unnecessary exposure to x-ray radiation, and psychological trauma and anxiety.”
“All breast cancers are not equal. Some patients will have fast-growing, aggressive tumors while others will have slower-growing, less aggressive tumors that are less likely to metastasize and, therefore, have a better prognosis. Screening is more likely to identify the slower-growing, less aggressive tumors because of longer asymptomatic periods. This “length-time” bias can make screening appear more beneficial than it is.”
Notice any similarities to continuous EFM?

What do you think? Are these revised guidelines a step toward backing off of our nation’s overuse of technology and interventions? Or was this a bad public health move?


Joy said...

My mom died from a VERY aggressive breast cancer at 47 yrs old. She was diagnosed at 42. Cancer is not akin to low risk pregnancy. I think women should start screenings in their 30's.

Jenny said...

I see what you mean, but due to personal experience I feel some sort of early detection measures (not necessarily mammography) are necessary. I blogged about this a few days ago. My mom was in her mid-fifties when she had her yearly mammogram and found that she had stage II breast cancer. She'd had a clear mammo the year before. If she'd waited another year (the second part of the new recs) she might be dead now.

On the other hand, I had to have my first mammo at 19 to diagnose a lump my gynecologist found. They couldn't see much of anything because of my dense breast tissue, so they did an ultrasound and saw it perfectly clearly. I don't get WHY they can't do ultrasounds instead on these young women, especially when a lump is felt. I also think that telling women that breast self-exams do no good is just one more way they are teaching women not to trust themselves.

I agree with Joy, though. Pregnancy is NOT an illness, but breast cancer is. And it's an illness that seems to be more and more common in young women.

Simone C. said...

This has been a busy week for ACOG. After making these changes they went on to announce less stringent guidelines for pap smears and cervical cancer screenings. Is it possible that cancer isn’t as big a threat to women as we’ve been told? I doubt it.

It’s my understanding that in Maryland (my home), the state foots the bill for uninsured women over 40 to get annual mammography screenings to catch breast cancer as early as possible. I wonder if this regulatory change will have any effect on the disproportionately high number of poor women who die from cancer each year.

rj said...

I think this is an excellent post.

The women who comment on these articles typically will be in opposition due to anecdotal evidence/their personal histories, as you know. At a time in which evidence-based medicine is so often overlooked, and so desperately needed, especially regarding women, these findings ultimately stand to protect us.

Can you look at some stats that would depict whether you can make an accurate comparison between cancer and low-risk pregnancy?

And of course cancer could be less of a threat than we are told. Look at all the advertising! Whomever this blog author is, knows that the number one cancer killer is lung cancer, and the number one killer of women is heart disease. Furthermore, not every "cancer" that women report, or even their doctors "report" to have "saved" them from can be assumed to have been malignant. Remember, these stats and stories are only based on what we are told.

Melissa Garvey said...

It was so great to come back from vacation to all these wonderful comments! "Pregnancy is NOT an illness, but breast cancer is." Great point, Joy and Jenny.

Ethel said...

Pregnancy may not be directly related to breast cancer but the outcome is the same, increased monitoring gives no improvement in care and with mammograms the increased radiation could also increase the death rate for women - not just with cancer but damage to tissues.

I think that we need to make an informed decision with mammograms, with low risk women (no BRCA1 mutation, no history in family of cancer, pregnancy before 30s, extended breastfeeding, appropriate BMI) there really is no good reason to start screening until they are 50, and then every other year. Those of use in the middle perhaps every other year, and indeed ultrasounds have been proven to be as useful as mammograms for detecting cancer as well.

I personally had my first mammogram this summer, I knew it was going to find nothing, but there was concern because of my age and having just miscarried (pregnancy makes cancer go into hyperdrive). I consented not because I wanted to, but because it would calm the care givers but having more x-ray exposure then necessary fills me with dread, I have been exposed when my kids have their lungs x-rayed (pneumonia), hips (worry about a growing hip joint), and etc... and then to add dental images on top of mammograms really really scares me.

Besides more women die of heart disease then breast cancer, shouldn't we be more worried as women about heart disease then breast cancer? If breast cancer is scarier then heart disease perhaps we need to look at why that is and really start considering our true risks to our health.

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