On Mammography
February 11, 2014 4:34 PM Subscribe
Annual mammography in women aged 40-59 does not reduce mortality from breast cancer...
Researchers sought to determine whether there was any advantage to finding breast cancers when they were too small to feel. The answer was no.
I had cancer in 09. It was a palpable lump that was invasive ductal carcinoma. I felt it. My doctor felt it. The mammogram operator felt it. But no matter what she did, she couldn't get the mammogram to see it. It was biopsied with an ultrasound guided needle biopsy, and ultimately an MRI was performed in which a second lesion was found that was not detected by the mammogram either, nor by our fingers.
So all of that started my mistrust of the mammogram.
Then I learned more and more about the cycle of Komen Foundation getting donations to "raise awareness" (i.e., not fund research or help pay for uninsured women or the underserved community), and the "awareness" being raised was specifically to have mammograms, and the more mammograms that are performed the more DCIS is discovered, which is by definition always stage 0 and which some people would say is not correctly identified as cancer, but which is only detectable by mammogram. So the more mammograms that are performed, the more DCIS is found that would not otherwise be diagnosed and the more women are identified as "cancer survivors." And you bet, they had surgery and radiation and dog knows what in order to cure the DCIS. But they also had fear and heartbreak and anxiety and relationship pressure and so on and so forth.
But that creates a statistic that makes mammograms look effective. Those women would not have died from DCIS anyway, and the women who did not have mammograms but did get breast cancer and die of it were all other types of cancer. So of course the mammograms look like they're doing something essential, when in fact they may be much less valuable than Komen Foundation wants you to believe. Because if you believe that they're valuable, then you too will want to "raise awareness" and you will donate to the Komen Foundation. And your money will go to fund more fundraising efforts or, in other words, to pay their salaries.
Let me donate to the American Cancer Society or something - anything - other than that organization. Ugh.
And I still get my mammograms because I am the world's most compliant patient but I never expect them to be a reasonable diagnostic tool.
posted by janey47 at 5:08 PM on February 11, 2014 [70 favorites]
So all of that started my mistrust of the mammogram.
Then I learned more and more about the cycle of Komen Foundation getting donations to "raise awareness" (i.e., not fund research or help pay for uninsured women or the underserved community), and the "awareness" being raised was specifically to have mammograms, and the more mammograms that are performed the more DCIS is discovered, which is by definition always stage 0 and which some people would say is not correctly identified as cancer, but which is only detectable by mammogram. So the more mammograms that are performed, the more DCIS is found that would not otherwise be diagnosed and the more women are identified as "cancer survivors." And you bet, they had surgery and radiation and dog knows what in order to cure the DCIS. But they also had fear and heartbreak and anxiety and relationship pressure and so on and so forth.
But that creates a statistic that makes mammograms look effective. Those women would not have died from DCIS anyway, and the women who did not have mammograms but did get breast cancer and die of it were all other types of cancer. So of course the mammograms look like they're doing something essential, when in fact they may be much less valuable than Komen Foundation wants you to believe. Because if you believe that they're valuable, then you too will want to "raise awareness" and you will donate to the Komen Foundation. And your money will go to fund more fundraising efforts or, in other words, to pay their salaries.
Let me donate to the American Cancer Society or something - anything - other than that organization. Ugh.
And I still get my mammograms because I am the world's most compliant patient but I never expect them to be a reasonable diagnostic tool.
posted by janey47 at 5:08 PM on February 11, 2014 [70 favorites]
I thought this (mammograms overused/not providing useful data) had been common knowledge for at least a decade.
posted by five fresh fish at 5:15 PM on February 11, 2014 [2 favorites]
posted by five fresh fish at 5:15 PM on February 11, 2014 [2 favorites]
BTW, if there's a good soundbite-friendly link that exposes Komen for the charity scam that it is, I'd be appreciative & will post it to Facebook.
posted by five fresh fish at 5:17 PM on February 11, 2014 [9 favorites]
posted by five fresh fish at 5:17 PM on February 11, 2014 [9 favorites]
And this is why I have never had a mammogram. I see no reason to radiate that area of my body. I am half convinced my mother-in her mid seventies-had her breast cancer precisely because of that regular radiation. (She is fine and cancer free now. That was a couple of years ago.)
posted by St. Alia of the Bunnies at 5:21 PM on February 11, 2014
posted by St. Alia of the Bunnies at 5:21 PM on February 11, 2014
Is this typical in Canada, or does it imply that the women in this study were disproportionately likely to be, or believe that they were, very low-risk?
My (Canadian) doctor expressed to me, two years ago, that professional opinion in Canada had shifted against mammograms, and official guidelines from two years ago were skeptical of its benefits.
posted by flibbertigibbet at 5:25 PM on February 11, 2014 [2 favorites]
My (Canadian) doctor expressed to me, two years ago, that professional opinion in Canada had shifted against mammograms, and official guidelines from two years ago were skeptical of its benefits.
"The main effect of screening is to produce patients with breast cancer from among healthy women who would have remained free of breast disease for the rest of their lives had they not undergone screening," he concluded.The official Canadian recommendation for mammogram frequency was once every 2 years (not the American one year) before than report. After that report, it became once every 2-3 years.
posted by flibbertigibbet at 5:25 PM on February 11, 2014 [2 favorites]
A really important part not to miss, is the final part of this sentence of the conclusion:
"Annual mammography in women aged 40-59 does not reduce mortality from breast cancer beyond that of physical examination or usual care when adjuvant therapy for breast cancer is freely available."
As they remind us later in the paper, "Canada has a universal healthcare system. No financial barrier exists to accessing appropriate diagnostic investigation or treatment."
posted by mittens at 5:25 PM on February 11, 2014 [7 favorites]
"Annual mammography in women aged 40-59 does not reduce mortality from breast cancer beyond that of physical examination or usual care when adjuvant therapy for breast cancer is freely available."
As they remind us later in the paper, "Canada has a universal healthcare system. No financial barrier exists to accessing appropriate diagnostic investigation or treatment."
posted by mittens at 5:25 PM on February 11, 2014 [7 favorites]
I am having mammogram #2 in 3 days. My mom had breast cancer 4 years ago (fine now) and my grandmother died from it (a recurrence and mets, at that).
I'm trying to be stoic about the fact that 25% of women get asked to come back for more imaging after their first one, since there is nothing to compare it to. But I'm also looking at family history, and worrying slightly. AND I'm also thinking about this, and how mammograms aren't all that great at actually catching cancer.
At least I get to get felt up on Valentine's day, since my partner is out of town for work, I suppose.
posted by bibliogrrl at 5:27 PM on February 11, 2014 [6 favorites]
I'm trying to be stoic about the fact that 25% of women get asked to come back for more imaging after their first one, since there is nothing to compare it to. But I'm also looking at family history, and worrying slightly. AND I'm also thinking about this, and how mammograms aren't all that great at actually catching cancer.
At least I get to get felt up on Valentine's day, since my partner is out of town for work, I suppose.
posted by bibliogrrl at 5:27 PM on February 11, 2014 [6 favorites]
Also interestingly, in Canada, if 1000 40-something women get yearly mammograms, only 16 will actually find cancer in a mammogram. Of those, 1 out of every 1000 will die from breast cancer -- compared to 2 of every 1000 unscreened women who died of breast cancer.
posted by flibbertigibbet at 5:28 PM on February 11, 2014
posted by flibbertigibbet at 5:28 PM on February 11, 2014
My wife corrects me: she says she's known for two to four years, based on a sciencebloggy link to a metastudy. I guess that's not too atrocious a lagtime for it to become common knowledge. (She follows up by saying she thinks it hit the news media shortly after she'd read it.)
posted by five fresh fish at 5:30 PM on February 11, 2014
posted by five fresh fish at 5:30 PM on February 11, 2014
Although I am in that 40-59 age group, I have never had ( nor do I intend to have) a mammogram. That may seen foolish to some people, but a) there is extremely low incidence of ANY cancer in my very large extended family (ie, the total count is one, a lifelong heavy smoker with esophageal cancer), and b) mammograms just aren't very effective.
Plus, to be honest, I'll agree to a mammogram --- basically squeezing portions of the female body between two plates --- when the male-dominated medical establishment does that to men: step up to the plate, gentlemen, while we smash your testicles between these plates!
posted by easily confused at 5:32 PM on February 11, 2014 [9 favorites]
Plus, to be honest, I'll agree to a mammogram --- basically squeezing portions of the female body between two plates --- when the male-dominated medical establishment does that to men: step up to the plate, gentlemen, while we smash your testicles between these plates!
posted by easily confused at 5:32 PM on February 11, 2014 [9 favorites]
Usually I have to pay extra for that. Even in town.
posted by delfin at 5:34 PM on February 11, 2014 [10 favorites]
posted by delfin at 5:34 PM on February 11, 2014 [10 favorites]
St. Alia of the Bunnies: "And this is why I have never had a mammogram. I see no reason to radiate that area of my body. I am half convinced my mother-in her mid seventies-had her breast cancer precisely because of that regular radiation. (She is fine and cancer free now. That was a couple of years ago.)"
St. Alia-- it's worth noting that as you get older, yearly mammography gets more and more helpful. A review of 17 randomized controlled trials in 2009 (FREE ACCESS!) found that in the 39-49 demographic, you'd have to screen* 1,904 women to prevent one death. To prevent one death in the 50-59 demographic, you'd need to screen 1,339 women. In the 60-69 demographic, the number drops to 377.
The current guideline from the USPSTF is to screen annually starting at age 50 for most women. This may change as treatment for breast cancer improves-- remember that we only screen for diseases if we can achieve a better outcome by finding and treating them earlier. As it stands I think the current guideline is level-headed enough, and it will take more than a few of these Canadian studies to change the recommendation.
Speaking specifically to your mother's history of breast cancer and the possibility of it being due to the mammograms, the official line has always been that there is no safe minimum dose of radiation. That said, we throw a lot of babies out with the bathwater when we eschew radioimaging entirely. The radiation dose of one mammogram amounts to about 400uSv (about 1/10th the normal yearly background dose), so if your mother started getting yearly mammograms at age 40, she'd have accumulated about as much radiation in 30 years as a US radiation worker is permitted to absorb in one year.**
*Technically, the analysis uses NNI or number needed to invite rather than the more conventional NNS or number needed to screen. This reflects the intention-to-treat design of the trials that made up the meta-analysis and is more of an academic distinction.
**Egregious use of the CT scanner, on the other hand, may bring about a new field dedicated to the study of iatrogenic cancers.
posted by The White Hat at 5:53 PM on February 11, 2014 [6 favorites]
St. Alia-- it's worth noting that as you get older, yearly mammography gets more and more helpful. A review of 17 randomized controlled trials in 2009 (FREE ACCESS!) found that in the 39-49 demographic, you'd have to screen* 1,904 women to prevent one death. To prevent one death in the 50-59 demographic, you'd need to screen 1,339 women. In the 60-69 demographic, the number drops to 377.
The current guideline from the USPSTF is to screen annually starting at age 50 for most women. This may change as treatment for breast cancer improves-- remember that we only screen for diseases if we can achieve a better outcome by finding and treating them earlier. As it stands I think the current guideline is level-headed enough, and it will take more than a few of these Canadian studies to change the recommendation.
Speaking specifically to your mother's history of breast cancer and the possibility of it being due to the mammograms, the official line has always been that there is no safe minimum dose of radiation. That said, we throw a lot of babies out with the bathwater when we eschew radioimaging entirely. The radiation dose of one mammogram amounts to about 400uSv (about 1/10th the normal yearly background dose), so if your mother started getting yearly mammograms at age 40, she'd have accumulated about as much radiation in 30 years as a US radiation worker is permitted to absorb in one year.**
*Technically, the analysis uses NNI or number needed to invite rather than the more conventional NNS or number needed to screen. This reflects the intention-to-treat design of the trials that made up the meta-analysis and is more of an academic distinction.
**Egregious use of the CT scanner, on the other hand, may bring about a new field dedicated to the study of iatrogenic cancers.
posted by The White Hat at 5:53 PM on February 11, 2014 [6 favorites]
Hey, I had my first one today. I found the horror tales about the squeezing and the pressing to be pretty overblown. It was fine. I was like "is that all? Seriously? All that fuss?" Hell of a lot better than the dentist and they X-ray you there too.
posted by Miko at 6:15 PM on February 11, 2014 [2 favorites]
posted by Miko at 6:15 PM on February 11, 2014 [2 favorites]
My mother, who is 75, has a mammogram every year because her mother died from cancer (of the colon originally, and it spread) and her older sister has had three bouts of cancer (melanoma). Just two days ago she called me to tell me that she'd tested positive for breast cancer after being sent for a biopsy due to her mammogram results from this year. She hadn't noticed any changes or symptoms or felt ill at all, other than a five pound weight loss which she put down to all the shovelling she's had to do this winter. It remains to be seen whether the mammogram saved her life, but it did find cancer earlier than it would have been found any other way, and that seems like a good thing.
posted by orange swan at 6:30 PM on February 11, 2014 [2 favorites]
posted by orange swan at 6:30 PM on February 11, 2014 [2 favorites]
I found the horror tales about the squeezing and the pressing to be pretty overblown. It was fine. I was like "is that all? Seriously? All that fuss?"
Yep, totally with you on that. It was the least invasive medical procedure I've had this year. (I've been hospitalized twice in the last 3 months for unrelated stuff)
posted by Stewriffic at 6:31 PM on February 11, 2014
Yep, totally with you on that. It was the least invasive medical procedure I've had this year. (I've been hospitalized twice in the last 3 months for unrelated stuff)
posted by Stewriffic at 6:31 PM on February 11, 2014
Why limit it to breasts? Are MRI or CT machines getting cheap yet? It would be great if I could just go and get an annual MRI or CT to check all of my body for problematic tumors and growths before I notice physical symptoms. I kind of wonder if any of the wealthy get checkups this way, especially to help locate small tumors in the brain, liver, and prostate while they're still operable, even if it's just a cursory search for significant problems. Or is this not a thing at all?
posted by crapmatic at 6:36 PM on February 11, 2014 [3 favorites]
posted by crapmatic at 6:36 PM on February 11, 2014 [3 favorites]
easily confused: "Although I am in that 40-59 age group, I have never had ( nor do I intend to have) a mammogram. That may seen foolish to some people, but a) there is extremely low incidence of ANY cancer in my very large extended family (ie, the total count is one, a lifelong heavy smoker with esophageal cancer), and b) mammograms just aren't very effective.
Plus, to be honest, I'll agree to a mammogram --- basically squeezing portions of the female body between two plates --- when the male-dominated medical establishment does that to men: step up to the plate, gentlemen, while we smash your testicles between these plates!"
Let us lay aside for a moment the fact that breast cancer used to be the leading cause of cancer death in women and still kills more than 40,000 per year, or that one of the earliest crusaders against breast cancer was Marjorie G. Illig, or that in the 1950s many surgeons refused to operate on lesions found by mammography unless they were palpable, or that 3/4 of the breast surgeons I've worked with were women.
Beyond that, I can assure you that our male-dominated medical establishment has come up with plenty uncomfortable or downright excruciating treatments for men in its time. And I get it. Tuskeegee. Willowbrook. Hormone replacement. We don't have the best track record. But from my personal experience of assisting with mastectomies and seeing patients through the whole process from screening to surgery to reconstruction to 10-year followup, I haven't witnessed patients treated with anything but the utmost respect and dignity.
Finally, the average woman has a 12.4% chance of developing breast cancer at some point in her life, and less than ten percent of breast cancers are due to known heritable factors. I don't care whose genes you have-- unless you're immortal, you're mortal. We all are, and when there's an evidence base that suggests we can avoid devastating illness for only a modicum of discomfort, we ignore that evidence at our own peril.
posted by The White Hat at 6:37 PM on February 11, 2014 [11 favorites]
Plus, to be honest, I'll agree to a mammogram --- basically squeezing portions of the female body between two plates --- when the male-dominated medical establishment does that to men: step up to the plate, gentlemen, while we smash your testicles between these plates!"
Let us lay aside for a moment the fact that breast cancer used to be the leading cause of cancer death in women and still kills more than 40,000 per year, or that one of the earliest crusaders against breast cancer was Marjorie G. Illig, or that in the 1950s many surgeons refused to operate on lesions found by mammography unless they were palpable, or that 3/4 of the breast surgeons I've worked with were women.
Beyond that, I can assure you that our male-dominated medical establishment has come up with plenty uncomfortable or downright excruciating treatments for men in its time. And I get it. Tuskeegee. Willowbrook. Hormone replacement. We don't have the best track record. But from my personal experience of assisting with mastectomies and seeing patients through the whole process from screening to surgery to reconstruction to 10-year followup, I haven't witnessed patients treated with anything but the utmost respect and dignity.
Finally, the average woman has a 12.4% chance of developing breast cancer at some point in her life, and less than ten percent of breast cancers are due to known heritable factors. I don't care whose genes you have-- unless you're immortal, you're mortal. We all are, and when there's an evidence base that suggests we can avoid devastating illness for only a modicum of discomfort, we ignore that evidence at our own peril.
posted by The White Hat at 6:37 PM on February 11, 2014 [11 favorites]
I found the horror tales about the squeezing and the pressing to be pretty overblown. It was fine. I was like "is that all? Seriously? All that fuss?"
This depends entirely on the composition of your breasts. I had a mammogram three years ago just prior to a breast reduction. It was completely painless. Not even particularly uncomfortable. I couldn't believe what a bunch of sissies women are. Then I had one six months ago, 2+ years after surgery and it hurt so bad I was almost in tears. You'd think more boob would = more discomfort, but in my experience it was the exact opposite.
posted by looli at 6:37 PM on February 11, 2014 [5 favorites]
This depends entirely on the composition of your breasts. I had a mammogram three years ago just prior to a breast reduction. It was completely painless. Not even particularly uncomfortable. I couldn't believe what a bunch of sissies women are. Then I had one six months ago, 2+ years after surgery and it hurt so bad I was almost in tears. You'd think more boob would = more discomfort, but in my experience it was the exact opposite.
posted by looli at 6:37 PM on February 11, 2014 [5 favorites]
FiveFreshFish, here is an article that is way too long for facebook, but gives you a much more balanced and educated description of the issue of overdiagnosis and the Komen contribution to it than I gave in my rant upthread.
posted by janey47 at 6:45 PM on February 11, 2014 [1 favorite]
posted by janey47 at 6:45 PM on February 11, 2014 [1 favorite]
...how mammograms aren't all that great at actually catching cancer.
I don't think that's what they're saying. It's not that mammograms aren't good at catching cancer, it's that they're not any better at catching it than a physical exam. And, as other have pointed out, they're good at catching things that look like cancer and prompt a lot of unnecessary medical procedures.
Even if they were better at find cancers earlier, that wouldn't often helps anything. My understanding is that breast cancer only really gets dangerous if it metastasizes. Since we don't really know when breast cancer will metastasize, the thought is generally catching earlier is better. In a lot of cases, it could take years or decades for cancer to metastasize.
Some day we'll have a better understanding of how cancers metastasize and then, after you get a biopsy, your doctor will tell you,"You have breast cancer of type X, it will metastasize 5-7 years from now so we'll want to do something about before then but no rush."
posted by VTX at 6:45 PM on February 11, 2014
I don't think that's what they're saying. It's not that mammograms aren't good at catching cancer, it's that they're not any better at catching it than a physical exam. And, as other have pointed out, they're good at catching things that look like cancer and prompt a lot of unnecessary medical procedures.
Even if they were better at find cancers earlier, that wouldn't often helps anything. My understanding is that breast cancer only really gets dangerous if it metastasizes. Since we don't really know when breast cancer will metastasize, the thought is generally catching earlier is better. In a lot of cases, it could take years or decades for cancer to metastasize.
Some day we'll have a better understanding of how cancers metastasize and then, after you get a biopsy, your doctor will tell you,"You have breast cancer of type X, it will metastasize 5-7 years from now so we'll want to do something about before then but no rush."
posted by VTX at 6:45 PM on February 11, 2014
I have only anecdata. In 2001 my family doctor said at my annual checkup, "You're 42 and you've never had a baseline mammogram? Off you go!" There were no other symptoms, there was no history of breast cancer in my family (although my dad had colon cancer when he was 45), and she had not felt anything in the manual exam, but she believed in baseline mammograms after women turn 40.
Long story shortened, the mammogram turned up a very small mass, 0.7 mm. Biopsy indicated cancer, and surgery was scheduled for February 13, 2002. From the time of the mammogram/ultrasound to surgery was two and a half months and the mass more than doubled in size to 1.6 cm. I don't know if that rates as slow or fast growth. It was indeed invasive ductal carcinoma and estrogen receptor positive. I had the whole slash, burn, and poison treatment, followed by 3 years of tamoxifen (yes, I'm in Canada).
Obviously, I'm not dead, and had the diagnosis not been made as early as it was, I probably wouldn't have died either, so the early diagnosis and treatment probably didn't affect my mortality. But I wonder if it would have affected my course of treatment: perhaps more radiation or chemo, perhaps a more disfiguring surgery. Those things aren't accounted for in mortality rates, but they matter.
posted by angiep at 6:56 PM on February 11, 2014 [10 favorites]
Long story shortened, the mammogram turned up a very small mass, 0.7 mm. Biopsy indicated cancer, and surgery was scheduled for February 13, 2002. From the time of the mammogram/ultrasound to surgery was two and a half months and the mass more than doubled in size to 1.6 cm. I don't know if that rates as slow or fast growth. It was indeed invasive ductal carcinoma and estrogen receptor positive. I had the whole slash, burn, and poison treatment, followed by 3 years of tamoxifen (yes, I'm in Canada).
Obviously, I'm not dead, and had the diagnosis not been made as early as it was, I probably wouldn't have died either, so the early diagnosis and treatment probably didn't affect my mortality. But I wonder if it would have affected my course of treatment: perhaps more radiation or chemo, perhaps a more disfiguring surgery. Those things aren't accounted for in mortality rates, but they matter.
posted by angiep at 6:56 PM on February 11, 2014 [10 favorites]
Finally, the average woman has a 12.4% chance of developing breast cancer at some point in her life, and less than ten percent of breast cancers are due to known heritable factors. I don't care whose genes you have-- unless you're immortal, you're mortal. We all are, and when there's an evidence base that suggests we can avoid devastating illness for only a modicum of discomfort, we ignore that evidence at our own peril.
This comment implies that because a) there is a lot of breast cancer and it is deadly then b) you should have mammograms to prevent that. But what research continues to show more and more convincingly - and this is a very good quality and large study - is that while a) is still true, there is little to no evidence that b) is true. a) does not prove b).
posted by latkes at 6:57 PM on February 11, 2014
This comment implies that because a) there is a lot of breast cancer and it is deadly then b) you should have mammograms to prevent that. But what research continues to show more and more convincingly - and this is a very good quality and large study - is that while a) is still true, there is little to no evidence that b) is true. a) does not prove b).
posted by latkes at 6:57 PM on February 11, 2014
Obviously, I'm not dead, and had the diagnosis not been made as early as it was, I probably wouldn't have died either, so the early diagnosis and treatment probably didn't affect my mortality. But I wonder if it would have affected my course of treatment: perhaps more radiation or chemo, perhaps a more disfiguring surgery. Those things aren't accounted for in mortality rates, but they matter.
You know what's kind of ridiculous is that I don't think there is any way for someone with the appropriate permissions to spend 5 minutes on a query that's "Yo computer what are the effects of mammograms on side effects and intensity of breast cancer treatment?"
posted by save alive nothing that breatheth at 7:07 PM on February 11, 2014 [1 favorite]
You know what's kind of ridiculous is that I don't think there is any way for someone with the appropriate permissions to spend 5 minutes on a query that's "Yo computer what are the effects of mammograms on side effects and intensity of breast cancer treatment?"
posted by save alive nothing that breatheth at 7:07 PM on February 11, 2014 [1 favorite]
Are MRI or CT machines getting cheap yet? It would be great if I could just go and get an annual MRI or CT to check all of my body for problematic tumors and growths before I notice physical symptoms.
MRI is still fairly expensive. It's give-or-take $500/scan for a specific region of your body; scanning your entire self would be many, many times that figure.
CT isn't cheap either, but more importantly in this scenario, CT scans carry a notable radiation risk. Not to the point where they're a bad idea when investigating something specific -- each one raises your baseline 20% chance of eventually dying of cancer by approximately 0.05% -- but repeatedly CTing someone's entire body for no reason other than to check for asymptomatic abnormalities stands a chance of causing the cancer that you're worried about in the first place.
I kind of wonder if any of the wealthy get checkups this way, especially to help locate small tumors in the brain, liver, and prostate while they're still operable, even if it's just a cursory search for significant problems.
"Executive checkup" is the phrase I've heard. No idea how prevalent it is in the USA, but I know there are clinics in Buffalo and Minnesota (at the very least) that do elective fee-for-service MRI.
posted by saturday_morning at 7:10 PM on February 11, 2014
MRI is still fairly expensive. It's give-or-take $500/scan for a specific region of your body; scanning your entire self would be many, many times that figure.
CT isn't cheap either, but more importantly in this scenario, CT scans carry a notable radiation risk. Not to the point where they're a bad idea when investigating something specific -- each one raises your baseline 20% chance of eventually dying of cancer by approximately 0.05% -- but repeatedly CTing someone's entire body for no reason other than to check for asymptomatic abnormalities stands a chance of causing the cancer that you're worried about in the first place.
I kind of wonder if any of the wealthy get checkups this way, especially to help locate small tumors in the brain, liver, and prostate while they're still operable, even if it's just a cursory search for significant problems.
"Executive checkup" is the phrase I've heard. No idea how prevalent it is in the USA, but I know there are clinics in Buffalo and Minnesota (at the very least) that do elective fee-for-service MRI.
posted by saturday_morning at 7:10 PM on February 11, 2014
latkes: "while a) is still true, there is little to no evidence that b) is true. a) does not prove b)."
The meta-analysis I linked to above looked at data from seven randomized controlled trials involving >550,000 women and certainly does suggest that mammograms reduce breast cancer mortality, especially in the >50 demographic. I don't know how much more evidence you need.
posted by The White Hat at 7:11 PM on February 11, 2014 [1 favorite]
The meta-analysis I linked to above looked at data from seven randomized controlled trials involving >550,000 women and certainly does suggest that mammograms reduce breast cancer mortality, especially in the >50 demographic. I don't know how much more evidence you need.
posted by The White Hat at 7:11 PM on February 11, 2014 [1 favorite]
janey47: I had cancer in 09. It was a palpable lump that was invasive ductal carcinoma. I felt it. My doctor felt it. The mammogram operator felt it. But no matter what she did, she couldn't get the mammogram to see it.
Did anyone suggest that you have dense breasts? Molecular Breast Imaging, the new technology described in this TED talk, aids in the detection of tumors that are difficult to see on traditional mammograms.
posted by txtwinkletoes at 7:37 PM on February 11, 2014 [1 favorite]
Did anyone suggest that you have dense breasts? Molecular Breast Imaging, the new technology described in this TED talk, aids in the detection of tumors that are difficult to see on traditional mammograms.
posted by txtwinkletoes at 7:37 PM on February 11, 2014 [1 favorite]
The editorial makes a pretty apt comparison to the PSA, a test that has widely fallen out of favour as a routine screening and one that, at the very least, mandates a discussion between physician and patient as to whether to test, what a positive test means, and where to go from there. The PSA though, lacks alot of the political and cultural baggage that mammograms do.
The Canadian Guidelines offer some interesting posters to go over the numbers:
Should I get a mammogram if I'm 40-49? 50-69? 70-74?
posted by cacofonie at 7:43 PM on February 11, 2014 [6 favorites]
The Canadian Guidelines offer some interesting posters to go over the numbers:
Should I get a mammogram if I'm 40-49? 50-69? 70-74?
posted by cacofonie at 7:43 PM on February 11, 2014 [6 favorites]
Yes! I have been saying this for years, and people treat me like I have no right to have agency over my own body.
It's not just mammography. Why on earth are people still doing breast-self exams and getting clinical breast exams by healthcare providers? We've known for years that they don't reduce death from breast cancer and may actually cause harm.
posted by Violet Hour at 7:51 PM on February 11, 2014 [2 favorites]
It's not just mammography. Why on earth are people still doing breast-self exams and getting clinical breast exams by healthcare providers? We've known for years that they don't reduce death from breast cancer and may actually cause harm.
posted by Violet Hour at 7:51 PM on February 11, 2014 [2 favorites]
The Canadian Guidelines offer some interesting posters to go over the numbers:
Should I get a mammogram if I'm 40-49? 50-69? 70-74?
Those are very informative.
posted by Miko at 7:57 PM on February 11, 2014
Should I get a mammogram if I'm 40-49? 50-69? 70-74?
Those are very informative.
posted by Miko at 7:57 PM on February 11, 2014
I went in after I turned 40 and had to have a six-month follow-up for lumps and an outpatient biopsy after that. The lumps were not cancerous, and nobody thought they were (including me), but I may have taken some time off the end of my life stressing about it. I am a lot less quick to get my recommended "insurance will pay for it" annual mammogram now.
posted by immlass at 7:57 PM on February 11, 2014
posted by immlass at 7:57 PM on February 11, 2014
I wonder, would people skip annual PAPs for this reason? Same kind of thing. I've been biopsied for abnormal cells and stressed about it and then come up clear, but I wouldn't skip my PAP.
posted by Miko at 8:06 PM on February 11, 2014
posted by Miko at 8:06 PM on February 11, 2014
Annual Pap smears are no longer recommended, either.
posted by asperity at 8:11 PM on February 11, 2014 [6 favorites]
posted by asperity at 8:11 PM on February 11, 2014 [6 favorites]
Sure, every 3 years then? Is it something people would skip because of the risk of false positives and (what were ultimately found to be) unnecessary treatments, like my biopsies?
posted by Miko at 8:15 PM on February 11, 2014
posted by Miko at 8:15 PM on February 11, 2014
I dunno. I always just go along with it as part of a pelvic exam. And those are obviously useful to make sure my uterus hasn't gone wandering about as a result of ski jumping.
posted by asperity at 8:24 PM on February 11, 2014 [2 favorites]
posted by asperity at 8:24 PM on February 11, 2014 [2 favorites]
Yeah, I bring up the Pap analogy because it's not really that different an issue except for requiring a separate visit. My GYN does a breast exam too.
posted by Miko at 8:26 PM on February 11, 2014 [1 favorite]
posted by Miko at 8:26 PM on February 11, 2014 [1 favorite]
Well, except that a pap doesn't require radiation exposure.
posted by obloquy at 8:34 PM on February 11, 2014
posted by obloquy at 8:34 PM on February 11, 2014
But the objection to frequent mammos seems to be about the false positive indicators, more than radiation exposure. Unless I'm wrong about that, the study deals with whether it helps, not whether it contributes to greater mortality because of radiation. As I noted, the dentist is radiation exposure too - I still get my films done.
posted by Miko at 8:40 PM on February 11, 2014
posted by Miko at 8:40 PM on February 11, 2014
Right, but the difference is that mammogram radiation, which I understand to be much higher levels of radiation exposure than dental or even chest x-rays, can actually be a significant factor in the development of the very disease they are meant to screen for.
posted by obloquy at 8:56 PM on February 11, 2014
posted by obloquy at 8:56 PM on February 11, 2014
Although yes, as you say, that's not what the study's about. Just a general observation.
posted by obloquy at 8:57 PM on February 11, 2014
posted by obloquy at 8:57 PM on February 11, 2014
Miko: "I wonder, would people skip annual PAPs for this reason? Same kind of thing. I've been biopsied for abnormal cells and stressed about it and then come up clear, but I wouldn't skip my PAP."
So this is a really important question, and it kind of gets to the root of why the public health establishment promotes mass screening tests. The number of women you'd have to screen for ten years in order to prevent one death from cervical cancer is about 1,140, or roughly the same number (1,339) of women aged 50-59 who you would need to screen with mammography in order to prevent one death from breast cancer, or the number of men (1,410) you'd need to screen for PSA to prevent one death from prostate cancer. A few other numbers needed to screen, just for enrichment: colon cancer deaths (1 prevented for every 800 hemoccult tests); coronary artery disease (1 death prevented for every 420 screened for cholesterol); malignant melanoma (1 death prevented for every ~25,000 given a whole body skin check).
Now, this is all just a piece of whether or not a given screening tool is "good" overall. Those Canadian posters go to lenghts to communicate the excess burden of false positive tests. Some public health folks who work on a systems-level try to quantify overall benefit in "cost per DALY/QALY averted," but even that doesn't give a straight answer about whether an intervention is good or bad. It's up for us to decide for ourselves and for society how much money we're willing to spend to keep people healthy, how much risk we're individually prepared to shoulder in order to avoid hassle or false-positive results, &c. Epidemiology can't answer those bigger questions, but it can at least try to paint a picture of the risks and benefits. The picture changes as new data comes in and either corroborates or refutes old data, and our guideline clearinghouses try to wrangle it all together and help clinicians and patients make sense of it. This particular study is interesting, but I'm going to wait until smarter people than me synthesize the new data with what we already have.
On preview: mammogram, again, is only about 400uSv, about 20 chest X-rays' worth of radiation, but 17.5 times less "potent" than a chest CT and about on par with the amount of radiation you absorb from all the potassium in your body or the amount of radiation you'd get in a year of living on the Colorado plateau.
posted by The White Hat at 9:08 PM on February 11, 2014 [3 favorites]
So this is a really important question, and it kind of gets to the root of why the public health establishment promotes mass screening tests. The number of women you'd have to screen for ten years in order to prevent one death from cervical cancer is about 1,140, or roughly the same number (1,339) of women aged 50-59 who you would need to screen with mammography in order to prevent one death from breast cancer, or the number of men (1,410) you'd need to screen for PSA to prevent one death from prostate cancer. A few other numbers needed to screen, just for enrichment: colon cancer deaths (1 prevented for every 800 hemoccult tests); coronary artery disease (1 death prevented for every 420 screened for cholesterol); malignant melanoma (1 death prevented for every ~25,000 given a whole body skin check).
Now, this is all just a piece of whether or not a given screening tool is "good" overall. Those Canadian posters go to lenghts to communicate the excess burden of false positive tests. Some public health folks who work on a systems-level try to quantify overall benefit in "cost per DALY/QALY averted," but even that doesn't give a straight answer about whether an intervention is good or bad. It's up for us to decide for ourselves and for society how much money we're willing to spend to keep people healthy, how much risk we're individually prepared to shoulder in order to avoid hassle or false-positive results, &c. Epidemiology can't answer those bigger questions, but it can at least try to paint a picture of the risks and benefits. The picture changes as new data comes in and either corroborates or refutes old data, and our guideline clearinghouses try to wrangle it all together and help clinicians and patients make sense of it. This particular study is interesting, but I'm going to wait until smarter people than me synthesize the new data with what we already have.
On preview: mammogram, again, is only about 400uSv, about 20 chest X-rays' worth of radiation, but 17.5 times less "potent" than a chest CT and about on par with the amount of radiation you absorb from all the potassium in your body or the amount of radiation you'd get in a year of living on the Colorado plateau.
posted by The White Hat at 9:08 PM on February 11, 2014 [3 favorites]
My GYN does a breast exam too.
posted by Miko at 8:26 PM on February 11 [1 favorite +] [!]
Which, as I said above, has never been shown to reduce your risk of death from breast cancer.
posted by Violet Hour at 10:15 PM on February 11, 2014
posted by Miko at 8:26 PM on February 11 [1 favorite +] [!]
Which, as I said above, has never been shown to reduce your risk of death from breast cancer.
posted by Violet Hour at 10:15 PM on February 11, 2014
Which, as I said above, has never been shown to reduce your risk of death from breast cancer.
Okay, so I'm confused. If breast exams do nothing, and self breast exams do nothing, and mammograms basically do nothing until you're a certain age... what exactly does catch breast cancer before it's lethal? There must be something.
posted by feckless fecal fear mongering at 10:45 PM on February 11, 2014
Okay, so I'm confused. If breast exams do nothing, and self breast exams do nothing, and mammograms basically do nothing until you're a certain age... what exactly does catch breast cancer before it's lethal? There must be something.
posted by feckless fecal fear mongering at 10:45 PM on February 11, 2014
I don't know how much more evidence you need.
I guess I think it's weird that you're totally dismissing this massive study of almost 90,000 women, along with the Cochrane Review on this topic.
Even the meta-analysis you link concludes with the statement, "Mammography screening at any age is a tradeoff of a continuum of benefits and harms. The ages at which this tradeoff becomes acceptable to individuals and to society are not clearly resolved by available evidence."
Ultimately, the task force that convenied the review does not recommend routine mammography to screen asymptomatic women aged 40 to 49 years for breast cancer. - a change from a previous recommendation for routine mammos for that group.
And that review is the most conservative in favor of routine mammos of any of the recent research or meta-analysis in international circles.
I think you're cherry picking evidence to support your personal belief in mammography.
posted by latkes at 10:46 PM on February 11, 2014 [2 favorites]
I guess I think it's weird that you're totally dismissing this massive study of almost 90,000 women, along with the Cochrane Review on this topic.
Even the meta-analysis you link concludes with the statement, "Mammography screening at any age is a tradeoff of a continuum of benefits and harms. The ages at which this tradeoff becomes acceptable to individuals and to society are not clearly resolved by available evidence."
Ultimately, the task force that convenied the review does not recommend routine mammography to screen asymptomatic women aged 40 to 49 years for breast cancer. - a change from a previous recommendation for routine mammos for that group.
And that review is the most conservative in favor of routine mammos of any of the recent research or meta-analysis in international circles.
I think you're cherry picking evidence to support your personal belief in mammography.
posted by latkes at 10:46 PM on February 11, 2014 [2 favorites]
what exactly does catch breast cancer before it's lethal? There must be something.
This is a great question and one I'm having trouble finding an evidence-based answer about - even with access to some medical databases. I would love to hear if anyone knows the real answer to this.
I have heard (no idea if there is evidence this is true) that most breast cancers are found when women notice a lump. These are not found through formal "self exams", but just by, "hey, I noticed a lump in my breast". A clinical exam and then follow ups with mammography, needle biopsy, and other studies then bring the official diagnosis.
posted by latkes at 10:50 PM on February 11, 2014 [1 favorite]
This is a great question and one I'm having trouble finding an evidence-based answer about - even with access to some medical databases. I would love to hear if anyone knows the real answer to this.
I have heard (no idea if there is evidence this is true) that most breast cancers are found when women notice a lump. These are not found through formal "self exams", but just by, "hey, I noticed a lump in my breast". A clinical exam and then follow ups with mammography, needle biopsy, and other studies then bring the official diagnosis.
posted by latkes at 10:50 PM on February 11, 2014 [1 favorite]
But how else would you notice a lump in your breast other than touching it or having someone else do so?
I mean, how many "hey, I noticed a lump in my breast" are actually definitively not found by BSE or exam by another medical professional? I've known a few women with breast cancer, and for at least two of them, BSE was precisely why they went to the doctor and said "hey, I noticed a lump in my breast."
posted by feckless fecal fear mongering at 10:53 PM on February 11, 2014
I mean, how many "hey, I noticed a lump in my breast" are actually definitively not found by BSE or exam by another medical professional? I've known a few women with breast cancer, and for at least two of them, BSE was precisely why they went to the doctor and said "hey, I noticed a lump in my breast."
posted by feckless fecal fear mongering at 10:53 PM on February 11, 2014
(I promise you I'm not being a jerk or pulling a gotcha here, it's just that something must be finding breast cancer before it's deadly, and random "hey, I found a lump in my breast" moments cannot possibly account for all diagnoses)
posted by feckless fecal fear mongering at 10:56 PM on February 11, 2014 [1 favorite]
posted by feckless fecal fear mongering at 10:56 PM on February 11, 2014 [1 favorite]
Well, see, that's why this is a difficult thing to get to the bottom of. Because, yes, there are a lot of detections done other ways. But that's only useful or meaningful if those detections lower mortality rates. So a doctor gave you a BSE and found a tiny lump that turned out to be cancer which makes you think it must save lives... but the data suggests that if the doctor hadn't given you the BSE you would have noticed the lump yourself like in the shower or getting dressed or something before your mortality rate went up significantly.
Because the important question isn't "can formal breast exams detect cancers earlier than they would otherwise be found" it's "do formal breast exams lower mortality rates". Detecting proto-lumps early doesn't do anyone any good if it doesn't change your odds at all. That's the point.
posted by Justinian at 11:12 PM on February 11, 2014 [1 favorite]
Because the important question isn't "can formal breast exams detect cancers earlier than they would otherwise be found" it's "do formal breast exams lower mortality rates". Detecting proto-lumps early doesn't do anyone any good if it doesn't change your odds at all. That's the point.
posted by Justinian at 11:12 PM on February 11, 2014 [1 favorite]
I understand that, Justinian, but I think you're missing what I'm saying here.
posted by feckless fecal fear mongering at 11:16 PM on February 11, 2014
posted by feckless fecal fear mongering at 11:16 PM on February 11, 2014
BSE was precisely why they went to the doctor
I am a nurse and came up in self-help women's self empowerment health communities (think Our Bodies Ourselves kind of folks) and although I used to advocate it, I literally know no one who does BSE as it is is taught, ie: every month in a formal routine, carefully palpating the entire breast.
Most women do touch their own breasts though, in the shower, getting dressed, absent mindedly, sexually, etc.
posted by latkes at 11:18 PM on February 11, 2014
I am a nurse and came up in self-help women's self empowerment health communities (think Our Bodies Ourselves kind of folks) and although I used to advocate it, I literally know no one who does BSE as it is is taught, ie: every month in a formal routine, carefully palpating the entire breast.
Most women do touch their own breasts though, in the shower, getting dressed, absent mindedly, sexually, etc.
posted by latkes at 11:18 PM on February 11, 2014
I guess not. It seems tautological to me that, barring detection by a mammogram, the cancers are detected by either you or someone else touching your breast. There's not really a third option besides "you or someone else".
posted by Justinian at 11:26 PM on February 11, 2014
posted by Justinian at 11:26 PM on February 11, 2014
I literally know no one who does BSE as it is is taught, ie: every month in a formal routine, carefully palpating the entire breast.
Okay, I guess I just believed them when they told me that examining their own breasts is what sent them to the doctor. I didn't ask if they did it perfectly.
That's exactly what I'm saying, Justinian. There isn't a third option, and statistically examinations must account for some detections, and thus lowered mortality rates.
posted by feckless fecal fear mongering at 11:36 PM on February 11, 2014
Okay, I guess I just believed them when they told me that examining their own breasts is what sent them to the doctor. I didn't ask if they did it perfectly.
That's exactly what I'm saying, Justinian. There isn't a third option, and statistically examinations must account for some detections, and thus lowered mortality rates.
posted by feckless fecal fear mongering at 11:36 PM on February 11, 2014
That's what I'm saying; it doesn't have to lower mortality rates as long as those cancers would have been detected before they became fatal anyway. Like in the shower or something. Or getting dressed. Or during, uh, sexy times. Or whatever. All of those methods are not formal BSEs, they're just times the boobs got touched either incidentally or in a non-medical context.
posted by Justinian at 11:53 PM on February 11, 2014
posted by Justinian at 11:53 PM on February 11, 2014
Yes! I have been saying this for years, and people treat me like I have no right to have agency over my own body.
Good point. I have had to argue with several doctors to be left alone about my choice not to have a mammogram. It is my choice isn't it? Not really…different docs have said 'You don't believe in preventive medicine then' ' If I am to be responsible for your care you must have a mammogram'
'The policy in this practice is for all women your age to have regular mammograms'. That last one is code for 'meeting targets' otherwise known as making money. Yes some governments give money to doctors who meet targets and mammograms are one of them.
My mother was diagnosed with breast cancer over 20 years ago. She refused everything-mammogram and all treatment because she didn't want side effects and didn't mind dying (she is v old). She is still alive and not ill. We don't know if the cancer has grown, but not visibly anyway.
The radiation question is not just about amount in this case-and the equivalent of 50 chest X-rays is not 'nothing' when performed over and over in the course of a woman's life. The tissue is squeezed and radiation aimed directly at sensitive breast tissue. There are too many false positives and doctors need to catch up with the new research findings.
posted by claptrap at 1:17 AM on February 12, 2014
Good point. I have had to argue with several doctors to be left alone about my choice not to have a mammogram. It is my choice isn't it? Not really…different docs have said 'You don't believe in preventive medicine then' ' If I am to be responsible for your care you must have a mammogram'
'The policy in this practice is for all women your age to have regular mammograms'. That last one is code for 'meeting targets' otherwise known as making money. Yes some governments give money to doctors who meet targets and mammograms are one of them.
My mother was diagnosed with breast cancer over 20 years ago. She refused everything-mammogram and all treatment because she didn't want side effects and didn't mind dying (she is v old). She is still alive and not ill. We don't know if the cancer has grown, but not visibly anyway.
The radiation question is not just about amount in this case-and the equivalent of 50 chest X-rays is not 'nothing' when performed over and over in the course of a woman's life. The tissue is squeezed and radiation aimed directly at sensitive breast tissue. There are too many false positives and doctors need to catch up with the new research findings.
posted by claptrap at 1:17 AM on February 12, 2014
easily confused: "Although I am in that 40-59 age group, I have never had ( nor do I intend to have) a mammogram. That may seen foolish to some people, but a) there is extremely low incidence of ANY cancer in my very large extended family (ie, the total count is one, a lifelong heavy smoker with esophageal cancer), and b) mammograms just aren't very effective."It is important to make the distinction that while current evidence shows mammograms to be ineffective at screening for breast cancer, they are still a very effective and vitally important component of diagnosing breast cancer. If you find lumps or other indications of breast cancer they would still be very much worth checking out and a mammogram would still be a very reasonable component of that.
easily confused: "Plus, to be honest, I'll agree to a mammogram --- basically squeezing portions of the female body between two plates --- when the male-dominated medical establishment does that to men: step up to the plate, gentlemen, while we smash your testicles between these plates!"I suppose you're in luck, the Digital Rectal Exam is still routinely used to screen for prostate cancer in men in your age group! Oncology has also not really been male dominated for a generation.
posted by Blasdelb at 2:02 AM on February 12, 2014 [1 favorite]
Which, as I said above, has never been shown to reduce your risk of death from breast cancer.
I understand that as it has been said many times here and elsewhere and yet my GYN still does them. I think that most of us undergo a lot of testing, screening, and examination that we don't fully understand the medical rationale for - at the regular doctor, at the dentist, and through referrals. It just strikes me that because of the awareness and emotional power of breast cancer uniquely, people think about it differently than they do about, say, getting their head x-rayed every year to examine the teeth, or having a doctor look at your cervix. I wonder what the efficacy rate for any of these are. I don't know and studies about them don't seem to make the news. I agree there is a huge financial driver in these discussions - both for increased use of screening, for billing and equipment makers, and against it, for efficiency and cost suppression. In that kind of contested environment, sophisticated independent analysis is needed.
I'm more wary of making a relatively uninformed layperson decision about what I do and don't need based on an inexpert and incomplete interpretation of a study than I am of adhering to a protocol my own doctor has considered and developed for her patients.
It's obviously an individual choice, but since my doctor tends to take an approach like The White Hat's, and I trust my doctor, I go with it.
posted by Miko at 6:11 AM on February 12, 2014 [1 favorite]
I understand that as it has been said many times here and elsewhere and yet my GYN still does them. I think that most of us undergo a lot of testing, screening, and examination that we don't fully understand the medical rationale for - at the regular doctor, at the dentist, and through referrals. It just strikes me that because of the awareness and emotional power of breast cancer uniquely, people think about it differently than they do about, say, getting their head x-rayed every year to examine the teeth, or having a doctor look at your cervix. I wonder what the efficacy rate for any of these are. I don't know and studies about them don't seem to make the news. I agree there is a huge financial driver in these discussions - both for increased use of screening, for billing and equipment makers, and against it, for efficiency and cost suppression. In that kind of contested environment, sophisticated independent analysis is needed.
I'm more wary of making a relatively uninformed layperson decision about what I do and don't need based on an inexpert and incomplete interpretation of a study than I am of adhering to a protocol my own doctor has considered and developed for her patients.
It's obviously an individual choice, but since my doctor tends to take an approach like The White Hat's, and I trust my doctor, I go with it.
posted by Miko at 6:11 AM on February 12, 2014 [1 favorite]
My doctor is completely honest with me that it's not totally clear what the best thing is to do and that there are risks to both getting and not getting a mammogram. So we're back at the relatively uninformed layperson, me, having to make a decision, because it's my body, and my doctor can't tell me what to do with it.
posted by ArbitraryAndCapricious at 6:39 AM on February 12, 2014 [2 favorites]
posted by ArbitraryAndCapricious at 6:39 AM on February 12, 2014 [2 favorites]
The White Hat: "The meta-analysis I linked to above looked at data from seven randomized controlled trials involving >550,000 women and certainly does suggest that mammograms reduce breast cancer mortality, especially in the >50 demographic. I don't know how much more evidence you need."
Well, there is the evidence contained in the study we're talking about, which doesn't suffer from the statistical problems of meta-analyses (however appropriately dealt with and communicated they were in the linked paper) and is more capable of speaking to current treatment regimes. Incidentally this is another good meta-analysis worth looking at. It makes a pretty solid case for moving to, still complicated, conversation about screening past the >50 demographic to the >60.
posted by Blasdelb at 6:43 AM on February 12, 2014
Well, there is the evidence contained in the study we're talking about, which doesn't suffer from the statistical problems of meta-analyses (however appropriately dealt with and communicated they were in the linked paper) and is more capable of speaking to current treatment regimes. Incidentally this is another good meta-analysis worth looking at. It makes a pretty solid case for moving to, still complicated, conversation about screening past the >50 demographic to the >60.
posted by Blasdelb at 6:43 AM on February 12, 2014
statistically examinations must account for some detections, and thus lowered mortality rates.
I think the lowered mortality rates, statistically, laregely seem to be due to tamoxifen being invented. Not sure that's true though - would like to hear if other's know why (from evidence based knowledge).
posted by latkes at 7:35 AM on February 12, 2014
I think the lowered mortality rates, statistically, laregely seem to be due to tamoxifen being invented. Not sure that's true though - would like to hear if other's know why (from evidence based knowledge).
posted by latkes at 7:35 AM on February 12, 2014
I think the lowered mortality rates, statistically, largely seem to be due to tamoxifen being invented.
(Seven-year survivor of breast cancer here)
Yes, tamoxifen and aromatase inhibitors (like Arimidex), for the hormone-positive cancers, and Herceptin for the ones that express HER2, have both increased survival. Article about Arimidex. The breastcancer.org site has quite a few articles on Herceptin, Tamoxifen and the aromatase inhibitors.
Many women with small, hormone-positive cancers don't even have to have chemo anymore because drugs like Femara or Arimidex work so well.
OTOH the "triple negative" cancers, with no targeted therapies, are much more deadly, because there are no targeted therapies beyond chemo, but there is research dedicated to it and hopefully more treatments developed.
FWIW, I found my lump (actually a dent) myself. I had mammograms but my breast tissue was too dense for them to do much good. I didn't know this at the time, and this was back before better screening methods for denser breasts were offered.
What I was told was, essentially, that there are some cancers that can be sent into remission even when they're larger and found by the woman noticing a lump or whatever. (That was my case - hormone-positive and took Tamoxifen.) Then there are those which are really bad news bears, and have already spread or will spread/metastasize even when they're tiny. And then there is the DCIS which shows up on a mammogram, but might never become an actual cancer, but is still counted as a "cancer" and inflates the ranks of "survivors," who are told that mammograms have saved their lives, and subjected to treatment which they probably don't need (not to mention the psychological impact).
I highly recommend the Breast Cancer Action website (the originators of "Think Before You Pink").
posted by Rosie M. Banks at 8:16 AM on February 12, 2014 [3 favorites]
(Seven-year survivor of breast cancer here)
Yes, tamoxifen and aromatase inhibitors (like Arimidex), for the hormone-positive cancers, and Herceptin for the ones that express HER2, have both increased survival. Article about Arimidex. The breastcancer.org site has quite a few articles on Herceptin, Tamoxifen and the aromatase inhibitors.
Many women with small, hormone-positive cancers don't even have to have chemo anymore because drugs like Femara or Arimidex work so well.
OTOH the "triple negative" cancers, with no targeted therapies, are much more deadly, because there are no targeted therapies beyond chemo, but there is research dedicated to it and hopefully more treatments developed.
FWIW, I found my lump (actually a dent) myself. I had mammograms but my breast tissue was too dense for them to do much good. I didn't know this at the time, and this was back before better screening methods for denser breasts were offered.
What I was told was, essentially, that there are some cancers that can be sent into remission even when they're larger and found by the woman noticing a lump or whatever. (That was my case - hormone-positive and took Tamoxifen.) Then there are those which are really bad news bears, and have already spread or will spread/metastasize even when they're tiny. And then there is the DCIS which shows up on a mammogram, but might never become an actual cancer, but is still counted as a "cancer" and inflates the ranks of "survivors," who are told that mammograms have saved their lives, and subjected to treatment which they probably don't need (not to mention the psychological impact).
I highly recommend the Breast Cancer Action website (the originators of "Think Before You Pink").
posted by Rosie M. Banks at 8:16 AM on February 12, 2014 [3 favorites]
I think that most of us undergo a lot of testing, screening, and examination that we don't fully understand the medical rationale for - at the regular doctor, at the dentist, and through referrals.
I don't. It offends me to my toes that we're expected to just defer to others and just go along with it. I've walked out of doctor's offices in the middle of appointments when they don't just accept my refusal.
posted by Violet Hour at 1:38 PM on February 12, 2014 [1 favorite]
I don't. It offends me to my toes that we're expected to just defer to others and just go along with it. I've walked out of doctor's offices in the middle of appointments when they don't just accept my refusal.
posted by Violet Hour at 1:38 PM on February 12, 2014 [1 favorite]
As a middle aged lady who knows a lot of other middle aged ladies, I've noticed a very common tangential issue, where no matter what you go to see a doctor about, they make you run the gauntlet of breast and reproductive issues first. And a lot of time, your appointment time runs out just covering those things before you even get to talk about what you came to talk about.
Right now, I have a friend who has been suffering with some kind of likely neurological disorder for years, and every time she'd go see her doctor about it, they'd do a 'poke and grope' (her words for breast and gyn exams) instead of focusing on her symptoms. It wasn't until she'd lost huge amounts of weight and started having serious mobility issues that they finally referred her to a neurologist. And that's only because it's immediately visually obvious that she's not well. I could tell she was sick way before her doctor did.
So even if the default screenings made perfect sense statistically, things that make statistical sense don't always make individual sense. As a woman, if you've got something wrong with you that's not related to cholesterol levels, diabetes, high blood pressure, or breast or cervical cancer, odds are pretty good that you'll end up with some kind of hypochondria diagnosis and get sent home until you're too sick to for them to ignore any longer.
posted by ernielundquist at 2:15 PM on February 12, 2014 [8 favorites]
Right now, I have a friend who has been suffering with some kind of likely neurological disorder for years, and every time she'd go see her doctor about it, they'd do a 'poke and grope' (her words for breast and gyn exams) instead of focusing on her symptoms. It wasn't until she'd lost huge amounts of weight and started having serious mobility issues that they finally referred her to a neurologist. And that's only because it's immediately visually obvious that she's not well. I could tell she was sick way before her doctor did.
So even if the default screenings made perfect sense statistically, things that make statistical sense don't always make individual sense. As a woman, if you've got something wrong with you that's not related to cholesterol levels, diabetes, high blood pressure, or breast or cervical cancer, odds are pretty good that you'll end up with some kind of hypochondria diagnosis and get sent home until you're too sick to for them to ignore any longer.
posted by ernielundquist at 2:15 PM on February 12, 2014 [8 favorites]
Well, I know that it's just an anecdote but I found my breast cancer through self exam. But I didn't take it very seriously and thought I'd wait and see for a while to see if it was just a temporary change. I was very lucky to have a doctors appointment few days later and she did a breast exam as a part of a general check-up (I didn't mention the lump to her) and sent me to a mammogram straight away.
My cancer was/is (just got through chemo and am starting radiation) an aggressive and fast growing sort, so-called triple negative breast cancer, and a delay in detection and treatment would have been very bad. Breast exam might not have saved my life (or maybe it did, who knows) but it certainly saved my breast (if the tumor had been any bigger the breast could not have been saved) and gave me a pretty positive prognosis because the cancer didn't have time to spread.
I think that too often when we speak about cancer the only statistics are about survival. And of course, survival is important but so is recurrence and survivors quality of life. Cancer treatments are still very harsh and often have permanent effects on the body. Breasts can be rebuilt but it is a big operation that carries its own risks. If breast exams can help with early detection and easier treatment, like in my case, then I think this is something that should be taken into consideration when evaluating their usefulness.
posted by severiina at 4:00 PM on February 12, 2014 [1 favorite]
My cancer was/is (just got through chemo and am starting radiation) an aggressive and fast growing sort, so-called triple negative breast cancer, and a delay in detection and treatment would have been very bad. Breast exam might not have saved my life (or maybe it did, who knows) but it certainly saved my breast (if the tumor had been any bigger the breast could not have been saved) and gave me a pretty positive prognosis because the cancer didn't have time to spread.
I think that too often when we speak about cancer the only statistics are about survival. And of course, survival is important but so is recurrence and survivors quality of life. Cancer treatments are still very harsh and often have permanent effects on the body. Breasts can be rebuilt but it is a big operation that carries its own risks. If breast exams can help with early detection and easier treatment, like in my case, then I think this is something that should be taken into consideration when evaluating their usefulness.
posted by severiina at 4:00 PM on February 12, 2014 [1 favorite]
"Why limit it to breasts? Are MRI or CT machines getting cheap yet? It would be great if I could just go and get an annual MRI or CT to check all of my body for problematic tumors and growths before I notice physical symptoms. I kind of wonder if any of the wealthy get checkups this way, especially to help locate small tumors in the brain, liver, and prostate while they're still operable, even if it's just a cursory search for significant problems. Or is this not a thing at all?"
Well ,as any avid "House" fan can tell you, pretty much everybody will have 5 or 6
anomalies worth investigating that will probably turn out to be clinically trivial.
Contra that, I am intrigued by early and anecdotal reports that PET scans of smokers'
and ex-smokers' lungs potentially can catch cancerous tumors well before they become
unmanageable. Try to get your doctor and your insurance provider onboard with that, though.
posted by Chitownfats at 4:16 PM on February 12, 2014
Well ,as any avid "House" fan can tell you, pretty much everybody will have 5 or 6
anomalies worth investigating that will probably turn out to be clinically trivial.
Contra that, I am intrigued by early and anecdotal reports that PET scans of smokers'
and ex-smokers' lungs potentially can catch cancerous tumors well before they become
unmanageable. Try to get your doctor and your insurance provider onboard with that, though.
posted by Chitownfats at 4:16 PM on February 12, 2014
"It would be great if I could just go and get an annual MRI or CT to check all of my body for problematic tumors and growths before I notice physical symptoms. I kind of wonder if any of the wealthy get checkups this way, especially to help locate small tumors in the brain, liver, and prostate while they're still operable, even if it's just a cursory search for significant problems. Or is this not a thing at all?""It is, but it shouldn't be. Doing this could only hope to point out a lot of things that would look like problems but aren't. So say a new medical procedure has been shown to be effective in the early detection of an illness, and as an otherwise healthy patient you take it. The probability that the test correctly identifies the illness as positive is 0.99, and the probability that the test correctly identifies someone without the illness as negative is 0.95. The incidence of the illness in the general population is 0.0001. You test positive, and this seems like an accurate enough test, but what is the probability that you actually have the illness?
The answer is about 1 in 500, because statistics. If this test is performed on just random people it will detect 499 false positive for every true positive as it gets so many chances to fuck up for every opportunity to get it right. Diagnostics is a really non-intuitive discipline, and screening even more so.
posted by Blasdelb at 4:50 PM on February 12, 2014 [2 favorites]
Clinical breast exams are *not* self screening and I think they do have benefit if I recall correctly. There is also some debate over the quality of the mammograms in this study. However, it's been clear for a while that in your 40s, for women without family history, mammography probably doesn't make sense.
The problem is that people assumed that catching early meant better prognosis but as researchers learned more about cancer, they found that many cancers never grow and the most dangerous ones often grow really fast— so if you catch things early, it doesn't matter that much because you are going to overtreat a lot of things that would't have killed and still not be able to cure the fastest ones. Screening never caught up to this.
posted by Maias at 6:06 PM on February 12, 2014
The problem is that people assumed that catching early meant better prognosis but as researchers learned more about cancer, they found that many cancers never grow and the most dangerous ones often grow really fast— so if you catch things early, it doesn't matter that much because you are going to overtreat a lot of things that would't have killed and still not be able to cure the fastest ones. Screening never caught up to this.
posted by Maias at 6:06 PM on February 12, 2014
Clinical breast exams are *not* self screening and I think they do have benefit if I recall correctly.
Obviously clinical breast exams aren't self-screening, but there's no proof clinical breast exams have benefit either: "At present, screening by breast self-examination or physical examination [by a trained health worker] cannot be recommended," two of the study authors, Jan Peter Kosters and Peter Gotzsche of the Nordic Cochrane Centre, stated in the review.
posted by Violet Hour at 7:32 PM on February 12, 2014 [1 favorite]
Obviously clinical breast exams aren't self-screening, but there's no proof clinical breast exams have benefit either: "At present, screening by breast self-examination or physical examination [by a trained health worker] cannot be recommended," two of the study authors, Jan Peter Kosters and Peter Gotzsche of the Nordic Cochrane Centre, stated in the review.
posted by Violet Hour at 7:32 PM on February 12, 2014 [1 favorite]
FiveFreshFish, here is an article that is way too long for facebook, but gives you a much more balanced and educated description of the issue of overdiagnosis and the Komen contribution to it than I gave in my rant upthread.
Previously.
posted by homunculus at 10:24 PM on February 12, 2014
Previously.
posted by homunculus at 10:24 PM on February 12, 2014
I think that too often when we speak about cancer the only statistics are about survival. And of course, survival is important but so is recurrence and survivors quality of life. Cancer treatments are still very harsh and often have permanent effects on the body. Breasts can be rebuilt but it is a big operation that carries its own risks. If breast exams can help with early detection and easier treatment, like in my case, then I think this is something that should be taken into consideration when evaluating their usefulness.
This though is part of the critique of routine mammograms. Quality of life does matter, and although no one is claiming that routine mammograms are a cause of cancer for example, over diagnosis and over treatment of cancers that would never cause serious suffering or death does cause unnecessary emotional and physical suffering.
posted by latkes at 11:58 PM on February 12, 2014 [2 favorites]
This though is part of the critique of routine mammograms. Quality of life does matter, and although no one is claiming that routine mammograms are a cause of cancer for example, over diagnosis and over treatment of cancers that would never cause serious suffering or death does cause unnecessary emotional and physical suffering.
posted by latkes at 11:58 PM on February 12, 2014 [2 favorites]
Hey, I had my first one today. I found the horror tales about the squeezing and the pressing to be pretty overblown. It was fine. I was like "is that all? Seriously? All that fuss?" Hell of a lot better than the dentist and they X-ray you there too.
This totally depends on the boobs in question and time of month, it's a personal thing, like dental work. Our structures are all different.
posted by A Terrible Llama at 6:30 AM on February 14, 2014 [2 favorites]
This totally depends on the boobs in question and time of month, it's a personal thing, like dental work. Our structures are all different.
posted by A Terrible Llama at 6:30 AM on February 14, 2014 [2 favorites]
Yes, to repeat Blasdelb's answer above, and amplify it a bit, CT or MRI scans for no other reason than to look for problems are a terrible idea. In fact, various people (wealthy, people with access) are having such "full-body scans" done and it's a problem. For the reasons that Blasdelb explains.
Here are the things to keep in mind about this stuff:
In many other cases, no, the screening doesn't make sense. Not that it's merely a waste — though that's a serious problem — but that it is actively harmful to the health and happiness of individual patients.
posted by Ivan Fyodorovich at 1:01 AM on February 18, 2014 [3 favorites]
Here are the things to keep in mind about this stuff:
- Earlier detection necessarily increases survivability rates because those are calculated on the basis of survival over a given time period. Therefore, earlier detection means an increase in survival over those time periods even when the progression of disease is exactly the same and treatment is ineffective. Morality rates are the metric you want for this; but many people and organization, such as Komen, will quote survivability rates in the context of earlier screening, and that's deeply misleading.
- The statistical math of diagnostic testing is deeply counterintuitive and even physicians regularly get certain basic example problems wrong about this. The false negative rate, false positive rate, and the actual incidence in the population all interact in ways that can dramatically make what superficially seems to be a good idea actually be a bad idea. And by "bad idea", I mean that more harm than benefit arises from it.
- Earlier treatment would be unambiguously a good thing if it were the case that the only thing we don't know about medicine, health, and biology is whether or not a particular person is ill. But that's not the case. Even if we know that someone is ill, we often don't know how ill, we often don't know how to treat it, and we often don't know whether our treatment will cause more harm than benefit. So, bottom line, having what amounts to a vague idea that something is possibly wrong, but not how wrong it is, and not knowing what will happen if we don't do something about it, and not knowing exactly what will happen if we do do something about it, means that an increase in having those vague ideas about individual people could result in an increase in bad things happening to those people, rather than good things happening to those people. Maybe breast cancer that comes to people's attention by accident or that they can't ignore it is breast cancer that is almost certainly a problem and generally better understood about how to treat. Maybe breast cancer that we find when we began regularly looking for it in every person is breast cancer that isn't necessarily a problem and not very well understood and which we don't know much about treating. So the latter knowledge isn't helping us, and it may be hurting us when the treatment does harm.
In many other cases, no, the screening doesn't make sense. Not that it's merely a waste — though that's a serious problem — but that it is actively harmful to the health and happiness of individual patients.
posted by Ivan Fyodorovich at 1:01 AM on February 18, 2014 [3 favorites]
But, actually, it's the other way around. This is a problem with a lot of screening.
No; we have the same way around. My intent in asking about it was to lead where you are going, to note that these issues around screening seem to be unexeceptional; they aren't unique to breast cancer - screening will find things that haven't made themselves known, and knowledge of the existence of those things then demands some response. It's not only the varying situations with regard to possible treatments and outcomes that determine that response, either; I would say that we have a heightened awareness and sensitivity of these issues with screening around breast cancer, because it's breast cancer, because it's particular (largely) to women and women's interactions with the medical profession have often rightly been contentious, because it's not uncommon, and because it's the focus of an intense degree of marketing, fundraising, and general concern in the popular culture. But it seems to be true across the board that screenings and even testsdon't often offer the kind of Y/N results of, say, a pregnancy test, let alone a clear course of action or even a set of options for clear courses of action from there.
I don't disagree that some kinds of screening do seem to make statistical sense and some don't, having had to parse a few of those "risk-of-false-negative-greater-than-actual-incidence/not-actually-conclusive" scenarios in my own life, but I think that we should be thinking broadly about health screenings and our partnerships with medical professionals about them, not focusing that attention on just a single kind of screening because of its prevalence in our thinking. Especially because this is only likely to become more and more of an issue, as we become increasingly able to examine DNA and start developing prognostications for things people are likely to or will definitely get, even when they are completely pre-symptomatic, and start being confronted with the possibility of pre-disease treatment.
posted by Miko at 5:47 AM on February 18, 2014 [1 favorite]
No; we have the same way around. My intent in asking about it was to lead where you are going, to note that these issues around screening seem to be unexeceptional; they aren't unique to breast cancer - screening will find things that haven't made themselves known, and knowledge of the existence of those things then demands some response. It's not only the varying situations with regard to possible treatments and outcomes that determine that response, either; I would say that we have a heightened awareness and sensitivity of these issues with screening around breast cancer, because it's breast cancer, because it's particular (largely) to women and women's interactions with the medical profession have often rightly been contentious, because it's not uncommon, and because it's the focus of an intense degree of marketing, fundraising, and general concern in the popular culture. But it seems to be true across the board that screenings and even testsdon't often offer the kind of Y/N results of, say, a pregnancy test, let alone a clear course of action or even a set of options for clear courses of action from there.
I don't disagree that some kinds of screening do seem to make statistical sense and some don't, having had to parse a few of those "risk-of-false-negative-greater-than-actual-incidence/not-actually-conclusive" scenarios in my own life, but I think that we should be thinking broadly about health screenings and our partnerships with medical professionals about them, not focusing that attention on just a single kind of screening because of its prevalence in our thinking. Especially because this is only likely to become more and more of an issue, as we become increasingly able to examine DNA and start developing prognostications for things people are likely to or will definitely get, even when they are completely pre-symptomatic, and start being confronted with the possibility of pre-disease treatment.
posted by Miko at 5:47 AM on February 18, 2014 [1 favorite]
Prostate cancer is the other big one that is now increasingly recognized as wildly over diagnosed and over treated. I'm interested to see where recommendations for that go.
As a personal anecdote, I'm a lesbian and have had several negative pap smears in the numerous years since I was active with men. Virtually all cervical cancer stems from heterosexually transmitted HPV. I am basically at no risk, but doctors still try to get me to have routine pap smears.
posted by latkes at 11:55 AM on February 18, 2014
As a personal anecdote, I'm a lesbian and have had several negative pap smears in the numerous years since I was active with men. Virtually all cervical cancer stems from heterosexually transmitted HPV. I am basically at no risk, but doctors still try to get me to have routine pap smears.
posted by latkes at 11:55 AM on February 18, 2014
Thanks for the clarification, Miko. I agree with you entirely and emphatically.
The DNA stuff is a good point and it's a different form of the same problem with full-body scans. I started to write in my comment, but then abandoned, a bit about how patient expectations are a big part of the problem — it's what you mentioned. Certainly, it's physicians, too, but people are pretty naive and uninformed about medicine and so the idea of diagnosing something that might be a problem and then not doing something about it is, I think, unacceptable to most people. And then American doctors tend to treat defensively, not wanting to be blamed for not being aggressive about something that later turns out to be a problem. All that contributes to a strong push for counter-productive or useless treatment as a result of any kind of screening. Not to mention the economic incentives.
It really is a broad problem, but I'm not sure I understand the point you're making about breast exams and pap smears in particular. In my view, it's especially a problem in these and related cases because of what I think is the long history of patriarchal medicine that basically takes liberties with women's bodies and treats women like children. There is, I think, a stronger institutional and social impetus to invasively screen and treat women and doing so with questionable outcomes. The PSA screen has the same problems as mammograms, and a lot of the same flawed thinking about it, but the larger social context is different even though there are some of the same self-interested, self-reinforcing incentives for early mass screening.
posted by Ivan Fyodorovich at 3:35 PM on February 18, 2014 [1 favorite]
The DNA stuff is a good point and it's a different form of the same problem with full-body scans. I started to write in my comment, but then abandoned, a bit about how patient expectations are a big part of the problem — it's what you mentioned. Certainly, it's physicians, too, but people are pretty naive and uninformed about medicine and so the idea of diagnosing something that might be a problem and then not doing something about it is, I think, unacceptable to most people. And then American doctors tend to treat defensively, not wanting to be blamed for not being aggressive about something that later turns out to be a problem. All that contributes to a strong push for counter-productive or useless treatment as a result of any kind of screening. Not to mention the economic incentives.
It really is a broad problem, but I'm not sure I understand the point you're making about breast exams and pap smears in particular. In my view, it's especially a problem in these and related cases because of what I think is the long history of patriarchal medicine that basically takes liberties with women's bodies and treats women like children. There is, I think, a stronger institutional and social impetus to invasively screen and treat women and doing so with questionable outcomes. The PSA screen has the same problems as mammograms, and a lot of the same flawed thinking about it, but the larger social context is different even though there are some of the same self-interested, self-reinforcing incentives for early mass screening.
posted by Ivan Fyodorovich at 3:35 PM on February 18, 2014 [1 favorite]
I'm not sure I understand the point you're making about breast exams and pap smears in particular
I think if you reread my comments, it shouldn't be all that unclear. Most of us are inconsistent about where we have this degree of sensitivity and where we don't, and overinformed in some areas (largely due to pop science journalism and/or the breast cancer industrial complex) and underinformed in others.
Personally, if it matters, I think that between my doctors (all women themselves) and myself, we can figure out a good course of action, understanding there are known unknowns and unknown unknowns. I mainly want to point out that screenings don't happen in isolation - they're part of a lifelong patchwork of medical interactions, and if you're going to put one under the microscope, put them all. A lot of people don't think of the Pap as a screening, dor instance, which of course it is, but just undergo it as part of a regular exam. Same with a clinical breast exam. Same with a blood pressure check, blood work, depression screening (invasive in a different way). Our systems are imperfect. And we're only talking about screenings so far; when it comes to actual treatments, we often know even less. It's all blunt instruments.
posted by Miko at 5:14 PM on February 18, 2014
I think if you reread my comments, it shouldn't be all that unclear. Most of us are inconsistent about where we have this degree of sensitivity and where we don't, and overinformed in some areas (largely due to pop science journalism and/or the breast cancer industrial complex) and underinformed in others.
Personally, if it matters, I think that between my doctors (all women themselves) and myself, we can figure out a good course of action, understanding there are known unknowns and unknown unknowns. I mainly want to point out that screenings don't happen in isolation - they're part of a lifelong patchwork of medical interactions, and if you're going to put one under the microscope, put them all. A lot of people don't think of the Pap as a screening, dor instance, which of course it is, but just undergo it as part of a regular exam. Same with a clinical breast exam. Same with a blood pressure check, blood work, depression screening (invasive in a different way). Our systems are imperfect. And we're only talking about screenings so far; when it comes to actual treatments, we often know even less. It's all blunt instruments.
posted by Miko at 5:14 PM on February 18, 2014
It really is a broad problem, but I'm not sure I understand the point you're making about breast exams and pap smears in particular. In my view, it's especially a problem in these and related cases because of what I think is the long history of patriarchal medicine that basically takes liberties with women's bodies and treats women like children.
Yes, this, times a million. This attitude has ruined whatever little trust I might have had in health care providers.
posted by Violet Hour at 3:56 AM on February 19, 2014
Yes, this, times a million. This attitude has ruined whatever little trust I might have had in health care providers.
posted by Violet Hour at 3:56 AM on February 19, 2014
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posted by Ralston McTodd at 4:52 PM on February 11, 2014