The USPSTF is changing their recommendations to once again push mammography to younger women. I know many of you dislike videos, but I promise this is worth your time. I go through a slide deck on mammography and combine the studies with my interpretation. If you are at all interested in mammography or cancer screening you will want to check it out.
Vinay, thank you for posting this work. Primary Care clinicians, such as myself, would benefit from more clear communication on these topics. Even better would be to have clear infographics produced that illustrate these concepts.
The USPSTF has a nice one for PSA screening but I haven’t seen others for mammogram, CRC screening, and pap. Patients would be better able to make choices aligned with their values if they could understand the balance of benefits and harms.
This may be Vinay's best video, and that's saying something.
Given this was inspired by USPTFs decision to add women in their 40s to these recs, it's probably helpful to look at some hard numbers. According to the CDC wonder database, there were a total of ~3000 breast cancer deaths annually from 2018-2020 in this age group, in 20 million individuals. Even by optimistic assumptions, the ceiling on number of lives saved by screening this age group is something in the hundreds, annually. This means the NNS (number needed to screen) per death avoided is on the order of 20,000-40,000. Given the average cost per screened individual in their 40s was estimated at ~$350 several years ago (let's say ~$400, conservatively, now for inflation), this is in excess of $10 million dollars per death avoided, at the minimum. It's not inconceivable that is actually 2-3x that figure.
On the one hand, this would be entirely indefensible from a medical or economic standpoint if it was a totally new program. On the other hand, a substantial portion of women in this age group already do get screened (about 25% I'd estimate), so it's a buffer against the marginal cost. Either way, there is no rational calculus that supports widespread screening women in their 40s.
Many of the articles I read quoted officials citing racial equity as a reason for the change. This is a sick joke. For one, if equity is your issue, can anyone think of better way to spend billions (with a B!) of dollars to decrease disparities? For another, is there any data that screening is more efficacious in averting death in any minority groups (I'm asking, but I doubt it)? Lastly, black people already have a similar rate of mammography to whites (actually higher, but marginally so), so the known disparity in mortality does not seem to be at all a function of screening. In my opinion, equity has likely entered this discussion as a shield from criticism. You might think the benefits of mammography are oversold, but you still can't be against it, because who can be against equity?
The weaponization of medicine against women has never really ended, just look at the history of hysteria, IVF, or even abortion and so-called "women's rights" from an actual objective perspective rather than an ideological. Whenever someone invokes "rights" (especially in lieu of replicable facts or data), hold onto your wallet.
Thank you so much for this, Vinay! After 17 years in primary care, I have become frustrated with screening mammograms; I have seen them cause a lot of meaningless anxiety without any significant benefits. This presentation was extremely helpful and aligns with my experience. But it is sacrilegious to speak ill of mammograms around administrators. Being so easy to quantify, mammogram screening rates are constantly used to rate the "quality" of primary care physicians. I used to think the USPSTF was our one honest source of screening information but I am sad to see them responding to political pressure to make this recommendation.
I am glad you are voicing concern on these matters. One year it seemed like all of my friends were having mastectomies. It didn't make sense, unless you consider that the mammogram equipment is improving so much that they can pick up the tiniest abnormalities.
Vinay, Begging for a transcript. This seems well worth running through an autotranscriber and integrating with the slides. Otherwise you will lose lots of important audience.
I wish I could “like” this a hundred times. What an absolute masterclass. But maybe I’m just saying that because I’m not that litigious.
I have a “meta” question inspired by your talk, and your mention that some of the papers were written by professors you’ve had: when you talk like this to your med students over the years, do they roll their eyes, or otherwise ignore you? Why aren’t there more doctors like this, in other words? If just half of the students you’ve taught, or your mentors taught, thought like this, we wouldn’t have all these problems (lack of informed consent, etc).
I'm not sure I agree entirely with Vinay on this one. There are two issues: the individual and the population. From the population perspective, there is no question in my mind that the impact of mammography on death from breast cancer or all-cause mortality is going to be very very small. After all, you are starting from an already small baseline : 10% of women will get breast cancer but if mammography only saves the life of only 1% of those 10%, you're down down a 0.1% effect which you're simply not going to pick up. But at the individual level, clearly picking up a cancer that is less than 1 cubic cm in a 40 year old is likely to save her life or more accurately to prevent her dying from that particularly tumor. Doesn't mean she wont get another tumor in the same breast if the treatment was a lumpectomy or in the other breast. Also doesn't mean that when she reaches the ripe old age of 80, she wont die of something else eventually. After all none of us is immortal. It therefore seems to me that the goal is to prevent premature death of individuals who are fit of mind and body. Clearly, therefore, screening mammography should be a personal and informed choice.
Fantastic video. Thanks for putting this together. I’m generally not one for videos (or even podcasts) and far prefer transcripts (I read TWIC rather than listen to dr. Mandrola’s podcast), but this was well worth the time.
In my area, I generally prefer USPSTF recommendations to those of various “societies “, as I find them to be more conservative wrt primary prevention and screening. It is disappointing to see the difference in this arena. And as dr. Mandrola likes to say, the biases may not be nefarious….but I’d submit that biases rooted only in human nature are biases all the same. That the cause of a bias is not nefarious does not lessen the effect of said bias. That fact will prevent me from impugning motives, but will not prevent me from discounting the work product.
What is truly concerning and alarming is that there are not enough subject area experts + practitioners of rigorous EBM, who are there to lay out the biases for all to see, in all fields. This is not my field and I was completely ignorant of the foundational research in this area.
Seems to me that instead of spending all this money on useless screenings, every woman could be given a free gym membership and healthy cooking classes. In my ideal “preventative medicine” world, the pharmacies we see on every corner these days would be replaced by gyms. Let’s compare outcomes of traditional preventive medicine to accessible healthy activities- true prevention.
Vinay, thank you for posting this work. Primary Care clinicians, such as myself, would benefit from more clear communication on these topics. Even better would be to have clear infographics produced that illustrate these concepts.
The USPSTF has a nice one for PSA screening but I haven’t seen others for mammogram, CRC screening, and pap. Patients would be better able to make choices aligned with their values if they could understand the balance of benefits and harms.
I’ve been aware of the fact that mammographies aren’t what they’re sold to be and have chosen not to get them.
One thing I wish you had included in this video is when it does make sense to screen for cancer according to the data.
This may be Vinay's best video, and that's saying something.
Given this was inspired by USPTFs decision to add women in their 40s to these recs, it's probably helpful to look at some hard numbers. According to the CDC wonder database, there were a total of ~3000 breast cancer deaths annually from 2018-2020 in this age group, in 20 million individuals. Even by optimistic assumptions, the ceiling on number of lives saved by screening this age group is something in the hundreds, annually. This means the NNS (number needed to screen) per death avoided is on the order of 20,000-40,000. Given the average cost per screened individual in their 40s was estimated at ~$350 several years ago (let's say ~$400, conservatively, now for inflation), this is in excess of $10 million dollars per death avoided, at the minimum. It's not inconceivable that is actually 2-3x that figure.
On the one hand, this would be entirely indefensible from a medical or economic standpoint if it was a totally new program. On the other hand, a substantial portion of women in this age group already do get screened (about 25% I'd estimate), so it's a buffer against the marginal cost. Either way, there is no rational calculus that supports widespread screening women in their 40s.
Many of the articles I read quoted officials citing racial equity as a reason for the change. This is a sick joke. For one, if equity is your issue, can anyone think of better way to spend billions (with a B!) of dollars to decrease disparities? For another, is there any data that screening is more efficacious in averting death in any minority groups (I'm asking, but I doubt it)? Lastly, black people already have a similar rate of mammography to whites (actually higher, but marginally so), so the known disparity in mortality does not seem to be at all a function of screening. In my opinion, equity has likely entered this discussion as a shield from criticism. You might think the benefits of mammography are oversold, but you still can't be against it, because who can be against equity?
The weaponization of medicine against women has never really ended, just look at the history of hysteria, IVF, or even abortion and so-called "women's rights" from an actual objective perspective rather than an ideological. Whenever someone invokes "rights" (especially in lieu of replicable facts or data), hold onto your wallet.
Thank you so much for this, Vinay! After 17 years in primary care, I have become frustrated with screening mammograms; I have seen them cause a lot of meaningless anxiety without any significant benefits. This presentation was extremely helpful and aligns with my experience. But it is sacrilegious to speak ill of mammograms around administrators. Being so easy to quantify, mammogram screening rates are constantly used to rate the "quality" of primary care physicians. I used to think the USPSTF was our one honest source of screening information but I am sad to see them responding to political pressure to make this recommendation.
I am glad you are voicing concern on these matters. One year it seemed like all of my friends were having mastectomies. It didn't make sense, unless you consider that the mammogram equipment is improving so much that they can pick up the tiniest abnormalities.
Vinay, Begging for a transcript. This seems well worth running through an autotranscriber and integrating with the slides. Otherwise you will lose lots of important audience.
Dr. Prasad, thank you so much. As a woman, this has given me a lot to think about.
I wish I could “like” this a hundred times. What an absolute masterclass. But maybe I’m just saying that because I’m not that litigious.
I have a “meta” question inspired by your talk, and your mention that some of the papers were written by professors you’ve had: when you talk like this to your med students over the years, do they roll their eyes, or otherwise ignore you? Why aren’t there more doctors like this, in other words? If just half of the students you’ve taught, or your mentors taught, thought like this, we wouldn’t have all these problems (lack of informed consent, etc).
I'm not sure I agree entirely with Vinay on this one. There are two issues: the individual and the population. From the population perspective, there is no question in my mind that the impact of mammography on death from breast cancer or all-cause mortality is going to be very very small. After all, you are starting from an already small baseline : 10% of women will get breast cancer but if mammography only saves the life of only 1% of those 10%, you're down down a 0.1% effect which you're simply not going to pick up. But at the individual level, clearly picking up a cancer that is less than 1 cubic cm in a 40 year old is likely to save her life or more accurately to prevent her dying from that particularly tumor. Doesn't mean she wont get another tumor in the same breast if the treatment was a lumpectomy or in the other breast. Also doesn't mean that when she reaches the ripe old age of 80, she wont die of something else eventually. After all none of us is immortal. It therefore seems to me that the goal is to prevent premature death of individuals who are fit of mind and body. Clearly, therefore, screening mammography should be a personal and informed choice.
Fantastic video. Thanks for putting this together. I’m generally not one for videos (or even podcasts) and far prefer transcripts (I read TWIC rather than listen to dr. Mandrola’s podcast), but this was well worth the time.
In my area, I generally prefer USPSTF recommendations to those of various “societies “, as I find them to be more conservative wrt primary prevention and screening. It is disappointing to see the difference in this arena. And as dr. Mandrola likes to say, the biases may not be nefarious….but I’d submit that biases rooted only in human nature are biases all the same. That the cause of a bias is not nefarious does not lessen the effect of said bias. That fact will prevent me from impugning motives, but will not prevent me from discounting the work product.
What is truly concerning and alarming is that there are not enough subject area experts + practitioners of rigorous EBM, who are there to lay out the biases for all to see, in all fields. This is not my field and I was completely ignorant of the foundational research in this area.
Seems to me that instead of spending all this money on useless screenings, every woman could be given a free gym membership and healthy cooking classes. In my ideal “preventative medicine” world, the pharmacies we see on every corner these days would be replaced by gyms. Let’s compare outcomes of traditional preventive medicine to accessible healthy activities- true prevention.