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Should You Get A Mammogram?

A recent mammogram study in the New England Journal of Medicine was so controversial that the authors (Drs. Welch and Bleyer) decided to make a YouTube video to defend and explain their conclusions. Now that’s a first, isn’t it? Well kudos to the study authors for their creative approach to getting ahead of a controversy. However, their video (created for the “general public”) is still a bit too technical in my opinion. I’d like to take a crack at distilling it further.

A question on most women’s minds (as they turn 40 and beyond) is whether or not they should get a screening mammogram (x-ray of the breasts). If you have found a lump in your breast or you have a family history of breast cancer the answer is yes. No need to read any further. However, for the majority of us lumpless, family-history-free women, a screening mammogram is far more likely to expose us to unnecessary follow up testing than it is to catch a tumor early.  Dr. Welch explains that screening mammograms aren’t very good at identifying aggressive breast cancer early enough to make a difference in whether one lives or dies anyway. That’s very disappointing news.

Dr. Welch goes on to explain that most of the gains we’ve made in breast cancer survival have been because of improved breast cancer treatments, not because of early detection with mammograms. He estimates that every year in the U.S. 1.3 million women are “over-diagnosed” with breast cancer because of screening mammograms, subjecting women to unnecessary biopsies, surgical procedures, and further follow up studies. In the video, Dr. Welch doesn’t explain exactly what these “over diagnosed” cancers end up being exactly (Cysts? Benign calcifications? Early non-aggressive cancers that the immune system kills on its own?) But suffice it to say that they don’t contribute to the cancer death rates.

So, given the fact that you are more likely to suffer through a false alarm than to discover a cancer early (and even if you do find it early, if it’s the “bad” kind you may not survive) are you willing to undergo a screening mammogram? That’s a personal question that we each have to answer for ourselves. As time goes on, however, I suspect that the answer will be made for us since health insurance companies (whether public or private) will begin to balk at paying for tests that do more harm than good overall. I think this issue is really at the heart of the controversy (the perception of rolling back a health benefit that women currently “enjoy”). Eventually screening mammograms may become an out-of-pocket expense for women who simply prefer the peace of mind that a normal test can give – even at the risk of going through a false alarm.

That being said, it sure would be great if we could find a screening test that identifies breast cancer early – especially the aggressive kind. Perhaps a blood test will do the trick one day? At least it is comforting to know that we have made great strides on the treatment side, so that fewer women than ever before die of breast cancer. More research is needed on both the screening and treatment sides of course.

As for me, I do regular breast self exams – though because I have no family history of breast cancer I’ve opted out of screening mammograms because I feel the cost/benefit ratio is not in my favor. I certainly hope that a better screening test is developed before I face a potential diagnosis. I respect that other women will disagree with me – and I think they have the right to be screened with the only option we currently have: the mammogram. I’m not sure how long it will continue to be covered by insurance, but at a price point of about $100, most of us could still afford to pay for it out-of-pocket if desired.

The bottom line of this controversial research study is that screening mammograms don’t actually catch death-causing breast cancers early enough to alter their course. Even though it makes intuitive sense to be screened, long term observations confirm that overall, mammograms do more harm than good. So now we wait for a better test – while some of us continue with the old one (as the National Cancer Institute recommends), and others (like me) don’t bother.

***

Thanks to ePatient Dave and Susannah Fox who brought the issue to my attention on Facebook. Isn’t social media grand?

The Epidemic Of Sedentary Behavior

“I never worry about action, but only about inaction.”  — Winston Churchill

Winston Churchill was right: Experts are saying sedentary behavior is an epidemic, with the resulting health effects potentially devastating.

Lack of muscular activity is associated with higher incidence of obesity, cardiovascular disease, diabetes and cancer, as well as a heightened risk of death. And this is regardless of one’s level of structured physical exercise, according to the authors of an article published [recently] in the British Journal of Sports Medicine.

The team from Stockholm, Sweden, says that sedentary behavior has become synonymous with lack of exercise, but that this is inaccurate and misleading. Rather, sedentary behavior should be defined as whole body muscular inactivity. Read more »

Each Hour Of Daily TV-Watching Increases Your Risk Of Death

If you’ve spent anytime on The Happy Hospitalist in the last two years, you know I am a strong believer in lifestyle as the only solution to an economic disaster we find ourselves in.  One recently reported television health statistic confirms, once again, the strong correlation between lifestyle and early death.

I blogged previously about studies showing an 80% reduction in heart disease, strokes, cancer and diabetes by adhering to lifestyle choices proven to save lives.  America is a nation of couch potatoes.  Everyday I see families, doctors and nurses taking the elevator up on story to the next floor above.   What ever happened to using the stairs for a little self sacrifice?

The television health statistics in this country are alarming.  How many hours a week do Americans spend watching television? 1  How does 31 hours a week sound.  That’s amazing.  I have one or two shows a week that I watch, if I’m lucky. Read more »

*This blog post was originally published at The Happy Hospitalist Blog*

Why You’re More Likely To Die On Saturdays and Sundays

Patients don’t choose the days they get sick.

There are several studies, specifically dealing with heart attacks, showing that the mortality rate increases when a patient visits the hospital during the weekend.

It appears that the same goes for upper GI bleeding. MedPage Today discusses a recent study showing that “patients with nonvariceal upper gastrointestinal hemorrhage had a 22% increased mortality risk on weekends, and those with peptic ulcer-related hemorrhage had an 8% higher risk.”

Staffing issues, leading to delayed endoscopies, appear to be chief culprit. Minutes count in cases of GI bleeding, so the delay is a likely explanation for the higher mortality rates.

Especially in community hospitals, doctors often cover for one another, and in general, there are less physicians available. Short of having more doctors on call, a prospect that faces long odds as hospitals are loathe to pay specialists for additional call, I’m not sure what can be done to rectify this statistic.

One suggestion is to have so-called “bleed teams,” where staff can be quickly mobilized to respond solely to acute GI bleeds. But again, this likely would require more staff, and it’s dubious that hospitals are willing to bear the additional cost.

**This post was originally published at KevinMD.com**

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