Cancer Survivor or Victim of Overdiagnosis?
By H. GILBERT WELCH
Hanover, N.H.
FOR decades women have been told that one of the most important things they can do to protect their health is to have regular mammograms. But over the past few years, it’s become increasingly clear that these screenings are not all they’re cracked up to be. The latest piece of evidence appears in a study in Wednesday’s New England Journal of Medicine, conducted by the oncologist Archie Bleyer and me.
The study looks at the big picture, the effect of three decades of mammography screening in the United States. After correcting for underlying trends and the use of hormone replacement therapy, we found that the introduction of screening has been associated with about 1.5 million additional women receiving a diagnosis of early stage breast cancer.
That would be a good thing if it meant that 1.5 million fewer women had gotten a diagnosis of late-stage breast cancer. Then we could say that screening had advanced the time of diagnosis and provided the opportunity of reduced mortality for 1.5 million women.
But instead, we found that there were only around 0.1 million fewer women with a diagnosis of late-stage breast cancer. This discrepancy means there was a lot of overdiagnosis: more than a million women who were told they had early stage cancer — most of whom underwent surgery, chemotherapy or radiation — for a “cancer” that was never going to make them sick. Although it’s impossible to know which women these are, that’s some pretty serious harm.
But even more damaging is what these data suggest about the benefit of screening. If it does not advance the time of diagnosis of late-stage cancer, it won’t reduce mortality. In fact, we found no change in the number of women with life-threatening metastatic breast cancer.
The harm of overdiagnosis shouldn’t come as a surprise. Six years ago, a long-term follow-up of a randomized trial showed that about one-quarter of cancers detected by screening were overdiagnosed. And this study reflected mammograms as used in the 1980s. Newer digital mammograms detect a lot more abnormalities, and the estimates of overdiagnosis have risen commensurately: now somewhere between a third and half of screen-detected cancers.
Study links mammograms to overtreatment
Breast cancer specialists reject findings, back testing
Researchers estimated Wednesday that mammograms caused more than 1 million American women over the past three decades to be diagnosed with early-stage breast cancers that would not have proved fatal if left undetected and untreated — a controversial finding sure to provoke more heated debate over the benefits of the screenings.
The study, published in the New England Journal of Medicine, concluded that these women were “overdiagnosed” and “overtreated” because few lives were saved.
“There’s been a dramatic increase in early-stage breast cancers that coincides with an increased use of mammograms,” said study co-author Dr. H. Gilbert Welch, a professor of medicine at the Dartmouth Institute of Health Policy and Clinical Practice in Hanover, N.H. “But it’s not enough to find early-stage breast cancer; it must translate into fewer women being diagnosed at a later stage, and we found this decrease to be remarkably small.” Tumors found later, after they have spread, are hard to cure and more likely to be fatal.
But breast cancer specialists heatedly disputed the findings, with some calling the study “junk science” and others questioning the size of the overdiagnosis harms estimated by the researchers.
A Failed Experiment
By NICHOLAS D. KRISTOF
In upper-middle-class suburbs on the East Coast, the newest must-have isn’t a $7,500 Sub-Zero refrigerator. It’s a standby generator that automatically flips on backup power to an entire house when the electrical grid goes out.
In part, that’s a legacy of Hurricane Sandy. Such a system can cost well over $10,000, but many families are fed up with losing power again and again.
(A month ago, I would have written more snarkily about residential generators. But then we lost power for 12 days after Sandy — and that was our third extended power outage in four years. Now I’m feeling less snarky than jealous!)
More broadly, the lust for generators is a reflection of our antiquated electrical grid and failure to address climate change. The American Society of Civil Engineers gave our grid, prone to bottlenecks and blackouts, a grade of D+ in 2009.
So Generac, a Wisconsin company that dominates the generator market, says it is running three shifts to meet surging demand. About 3 percent of stand-alone homes worth more than $100,000 in the country now have standby generators installed.
“Demand for generators has been overwhelming, and we are increasing our production levels,” Art Aiello, a spokesman for Generac, told me.
That’s how things often work in America. Half-a-century of tax cuts focused on the wealthiest Americans leave us with third-rate public services, leading the wealthy to develop inefficient private workarounds.
It’s manifestly silly (and highly polluting) for every fine home to have a generator. It would make more sense to invest those resources in the electrical grid so that it wouldn’t fail in the first place.
But our political system is dysfunctional: in addressing income inequality, in confronting climate change and in maintaining national infrastructure.
Administration affirms key mandates of healthcare law
The Obama administration proposes rules that leave the Affordable Care Act largely unchanged. Some adjustments are made to address industry concerns, however.
By Noam N. Levey, Washington Bureau
9:17 PM PST, November 20, 2012
WASHINGTON — The Obama administration reaffirmed key requirements of the new healthcare law Tuesday, setting out how insurance companies will cover nearly all Americans, even if they are already ill, and provide plans with minimum benefits.
Consumer advocates, insurers and business groups were looking for signs the administration might try to modify some of the law's requirements as the federal government races to implement the legislation by the end of next year.
But the proposed rules issued Tuesday hew closely to the Affordable Care Act that President Obama signed in 2010. At the same time, administration officials restated their commitment to move rapidly ahead, despite continued resistance from some Republican governors.
A stroll down health care’s memory lane
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Posted Nov. 21, 2012, at 1:33 p.m.
“The time is at hand this year to bring comprehensive, high quality health care within the reach of every American. I shall propose a sweeping new program that will assure comprehensive health insurance protection to millions of Americans who cannot now obtain it or afford it, with vastly improved protection against catastrophic illnesses.”
Barack Obama in 2009?
Hillary Clinton 1994?
Ted Kennedy 1969?
That was actually Richard Nixon in 1974 proposing a national health care plan that looks, in some key respects, like the American Affordable Care Act of 2009.
The more recent plan has been nicknamed “ObamaCare” and is adored by some, despised by many others, and sometimes labeled as either a socialist, Marxist or communist idea, with, of course, a few Nazi references for good measure.
That would no doubt surprise Nixon, who fought in World War II and was one of the most ardent Cold Warriors of his era.
It’s really not news that the Republican Party has traveled some distance from the sort of plan Nixon once suggested.
But it is interesting to read Nixon’s speech and see how we are dealing with the same problems in 2012 as we faced in 1974.
Only some have greatly worsened.
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