Tuesday, April 8, 2014

A Way to End the What Age for Mammograms Controversy?

Work with me here, what if everyone could agree on one option for the mammogram controversy? Wouldn't it make a lot more sense? I mean there has been so much ink about this single issue. On one hand is prevention and on the other is over diagnosis and false positives, with a lot of other data, crap, history, and arguments added on to each. So what is the real answer?

I believe JAMA has the right idea here. In the age of personalized medicine, why are we hung up on cross the board requirements? JAMA suggests that we "Stop One Size Fits All Mammography".

"A woman's decision to undergo mammography "should be individualized based on patients' risk profiles and preferences," concludes a systematic review of 50 years of breast cancer screening data, published in the April issue of JAMA.

How to best go about achieving that individualization is not entirely clear, but clinicians need to make an effort with the tools that are currently available, such as decision aids and risk models, 
suggest Lydia Pace, MD, MPH, and Nancy Keating, MD, MPH, both from Brigham and Women's Hospital in Boston, in their review."

Their argument is that a woman should be able to make a decision on mammography with their doctor based on their risk. The problem is that current science does not allow us to accurately estimate all women's risk of breast cancer. So the problem isn't with mammography but with the ability to predict breast cancer.

Before we jump ahead to that issue, let's stick with making mammography a personalized decision. I think this is a great idea. If someone has a high risk background, they should start mammograms earlier. If they do not have one, they should decide with their doctor when they should start them. Insurance companies should cover them regardless. There doesn't have to be a national rule on when they should be started.

Now switching to being able to predict breast cancer. We can't really. The BRCA genes allow us to predict women who are high risk but that does not cover all women who will get breast cancer, really less than 10% I believe. There can be other risk factors, family history, genetic background, and more.

Since we can't really tell who will or will not get breast cancer and may never be able to, we do need to use whatever screening methods we have. Until we have something better than mammography, it is our tool to use as best we can. But it should be the patient's choice and not the insurance company's.

No comments: