Though I found the 2009 recommendation credible, I have to admit I didn’t follow it. Mammograms were still the standard of care. The American College of Radiology opposed the recommendation. I felt too vulnerable. I worried I would be responsible if a cancer was missed. I, like most doctors, continued to refer all female patients over 40 for mammograms. But this new study may actually change my practice. I will probably still offer every woman over 40 a mammogram, but I won’t do it on autopilot. I will feel compelled to explain to my patients what the risks are, which is hard to do in the allotted 15 minutes. (It’s hard enough to explain it in an article.) Until we reach a tipping point, until the medical establishment as a whole decides that mammograms are not all that helpful, we doctors feel too vulnerable to be on the cutting edge.
Every patient has a mom or a friend or a cousin whose life was “saved” by treatment. Itʼs hard to tell someone that momʼs double mastectomy may not have saved her life. The breast cancer survivor is a modern heroine, clad in pink, surrounded by family, walking for the cure. It won’t be so easy to recast her as a stooge of bad medical information.
What makes this harder is that there are camps fiercely interested in one side or the other. H. Gilbert Welch, one of the lead authors of the new study and a known screening skeptic, published the book Overdiagnosed: Making People Sick in the Pursuit of Health in 2011. (He is the same researcher who worked to debunk the use of PSA screenings for men and prostate cancer.) “Overdiagnosis causes harm ranging from unnecessary worry to death in rare instances,” Welch once told Time. Welch’s skepticism about screening tests makes him a radical in the world of preventative medicine. He asks uncomfortable questions that threaten the equanimity of both patients and doctors.
And to be clear, my equanimity is sufficiently threatened by this study. I need to figure out how to integrate this new data into my practice. I suppose I will tell my patients:
We know a mammogram finds early cancer, but we have no way of telling if this early cancer would have killed you without treatment. Every mammogram may put you at risk for getting cancer treatment you don’t need. However, not getting a mammogram also has risks. We may not find a rare, early cancer that may become deadly.
In the past, when I would put that kind of decision to a patient, she would say, “Doc, what should I do?” In this case, I’ll have to say, “I don’t know.” But of course I won’t be able to leave it at that. People expect their doctors to have an opinion. People are looking for guidance. So I guess I’ll have to say, “It depends on what makes you more uncomfortable: the idea of unnecessary treatment or the idea of a missed cancer.”
But when she asks me if she’ll be OK if she skips the mammogram, I’ll be back to, “I don’t know.”