23 Comments

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.

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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.

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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?

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If you look at their rationale, they don’t really provide much of anything. They deem the evidence for almost every study they cite as “fair.” And provide nothing regarding the new screening recommendations specifically targeting or benefiting African Americans. Nor do they discuss how it will specifically benefit women under 50 for that matter. It is bizarre.

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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.

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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.

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I just have to add one more comment... right now I'm trying to get a patient in for a diagnostic mammogram, in a patient who is VERY LIKELY to have breast cancer on exam. All of the local mammogram centers are booked with screening mammograms for weeks! And this is in the SF Bay Area, not rural Oregon. The iffy-at-best recommendations for screening are getting in the way of something that is definitely beneficial, the diagnostic mammogram, causing real harm through delaying the diagnosis.

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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.

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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.

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Dr. Prasad, thank you so much. As a woman, this has given me a lot to think about.

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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).

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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.

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founding

Using your numbers, another way to consider the individual instead of the population, is that an individual would have a 99.9% odds of having absolutely zero benefit from subjecting themselves to the stress, the radiation, and a 10% odds of a false positive resulting in a biopsy. In short, it is literally 100 times more likely that an individual will be harmed vs helped.

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The dose from a mammogram is so low that any risk from that can be ignored. and those are Vinay's words not mine. With regard to stress/anxiety/biopsy surely that depends upon the individual. For example, let us say you palpate a breast mouse – you know with probably 95% certainty at least if not 99%+ that this is a benign fibroadenoma. Nevertheless, if I were the patient, I would want it removed. But that's just me. Others, of course, may feel very differently and that's their choice. The same arguments apply to colonoscopy which Vinay has also discussed at length in the light of the Nordic trial. If the prep were not so bad, I personally would be quite happy to have one once a year and feel good that nothing had been detected and equally good if some polyps had been detected and removed. But again that's just me. Others may be of the view that the bowel prep is so bad that it simply isn't worth it.

I think the real issue for the individual is whether one can prevent a premature death and it's up to the individual to decide the risk/benefit ratio for him/her providing all the facts are laid out on the table so that they can make a rational (at least in their mind) decision.

This is quite different from the case of smoldering myeloma where early treatment does not offer a cure and where multiple myeloma itself is not curable.

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founding

I agree that the most important aspect of all of this is fully informed consent.

I don't agree that radiation can be ignored, the radiation from a mammogram is the equivalent of 7 weeks of background radiation exposure concentrated into a few minutes, where are the studies that show this is harmless?

As it pertains to colonoscopy, if you knew that background rate of colon polyps in the population is roughly 33%, but life time odds of colon cancer is the low single digits, does it still make sense to look, snip, and if you are part of the 33%, subject yourself to the repeated stress of regular colonoscopy because you are deemed high risk due to a normal background rate polyps?

Again, I agree that this is all a personal choice, but the choice must be made with and clear risk/benefit descriptions. I personally wouldn't want to know about a benign tumor let alone take the unnecessary risk of surgery for a tumor that will never harm me. Too much of medicine today is driven by the industry using nefarious tactics to turn healthy people into patients by use of misleading statistics, fear mongering and outright lies. Why don't we know the background rate of all major diseases for all age ranges? It would be as simple as autopsy of a few thousand people that died in car accidents at various ages. For example, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4485977/ shows a surprisingly high background rate of prostate cancer in the population. By the age of 50 a man has 45% odds of having prostate cancer, yet the lifetime odds of dying from prostate cancer is roughly 4%. Screening a 50 year old for prostate cancer and being positive is pretty much a 50/50 coin flip (by age 70 it goes up to 82%) vs a 96% chance you will never have a problem from it. Full, easy to interpret risk/benefit explanations are imperative.

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People assume many things are harmless because no one ever has actually asked directly whether or not they are. People insert bullshit therein.

You are spot on here. To my knowledge, no one has done a meta-analysis to look at whether or not these tests cause harm themselves and there is zero incentive to because it's simply not profitable if you have a racket going where patient -> test -> treatment brings in hundreds of thousands of dollars per patient. This isn't medicine, it's extractive capitalism based on fancy statistics and arrogant, ostriching doctors.

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May 12, 2023·edited May 12, 2023

"I don't agree that radiation can be ignored, the radiation from a mammogram is the equivalent of 7 weeks of background radiation exposure concentrated into a few minutes, where are the studies that show this is harmless?"

Thank you for pointing this out. And I had a friend who ended up with them taking the photo 7 times. She ended up with breast cancer in that breast. Otherwise a very healthy woman (< 50yo) - very athletic and a healthy weight. Of course, it could be coincidence, but it makes you go Hmmmm.

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I'm not sure why the question would be different for a population vs. an average individual in that population. The only time it matters is if a) there is an externality, as in public heath for infectious disease, or b) the individual is known to have a different than average risk. But since that is not the case in your comment, the point stands just as a population: the BC mortality risk for a women in her 40s is so low (~1/10,000 annually), that the harms/costs, small as they might be, approach (if not exceed) the possible benefits.

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"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. "

I think he's said there wasn't evidence of that because the early testing didn't reduce the rate of metastatic cancers. I'm assuming that size doesn't dictate lethality, rate of growth does. So if she's had that cancer since she was 20 and if she had it for another 30 years but it didn't grow, then does she really want it out? The only argument I see is that operating on a 40 year old is safer than operating on a 70 year old, but in 30 years, she might have much better treatment options.

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That’s not what he’s saying.

The slides showed (from the best I could see in the video; I have looked at the studies) a dramatic increase in population-level early-stage and DCIS since mammography became widely available and recommended. However, decades on, we have almost exactly the same level of population level Stage 4 cancers. While he said we saw steady rates of mid- to late-stage cancers, I do think the slides showed a modest decline.

- This doesn’t mean that no one who gets an early stage cancer diagnosed in their 30s, 40s, or 50s, isn’t being saved from developing metastatic breast cancer or stage 3 breast cancer later. Many of these women are. The timeline for “later” is also quite varied, depending on the type of cancer. Could be months or a couple of years -- or it could be decades. Likely, lower nuclear grade DCIS in a 40 year old will grow slowly, but there is a lot of life left to live. Even a cancer that takes 20 years to grow still puts someone in working age.

- But generally speaking, younger people usually have more aggressive, faster growing cancers than older people. The types of breast cancers (aka “turtles”) he’s referring to are not those found in a 20 year old. Those are often DCIS (or stage 0, non-invasive cancers that can eventually turn invasive) in older patients. A 70 year old may die of other causes before DCIS turns invasive, so it may be better to watch and wait. This is much less likely for a younger patient. Size also matters. The larger the tumor, the the grading/staging of the cancer, which is predictive of the 5 year survival odds. 1 cm isn’t particularly large, but they keep growing

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But the USPSTF guidelines are specifically aimed at the population-level, not the individual. Breast cancer for women under 50 is relatively rare. Until recently, the guidelines were to specifically leave it up to the individual as to whether they chose to get a mammogram or not biannually starting at age 40. Cancer under 40 is rarer still, and there are no guidelines for this age group. They still get cancer -- and it’s often more aggressive.

Ideally, women would either know they have risk factors that would lead them to get one or have a discussion with their doctor about their medical history to know whether their were at increased risk or not. Many women who get screened earlier do so because they are at increased risk, and the guidelines are not written for them. They are written for the general population.

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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.

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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.

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