Breast Cancer May Be Gone, But Pain Lingers

Even three years after finishing treatment for breast cancer, almost 50 percent of women report long-term pain, a new Danish study finds.

The research, published in the Nov. 11 issue of the Journal of the American Medical Association, strengthens earlier findings, said study senior author Dr. Henrik Kehlet, a professor of perioperative therapy at Rigshospitalet at Copenhagen University. But this work indicates which women are most likely to experience persistent pain.

"Several previous scientific reports have shown a risk of chronic pain after breast cancer surgery," said Kehlet. The strength of this study, he noted, is the large number of participants -- more than 3,000 -- and the evaluation of many types of treatments.

Kehlet's team reviewed questionnaires filled out by 3,253 women who had undergone breast cancer treatment in Denmark between 2005 and 2006. Their treatments varied and included breast-conserving surgery, mastectomy, radiation, chemotherapy and dissection of the lymph nodes.

The women were asked whether they experienced pain, in what areas of the body, how bad it was and how often they experienced it.

In all, 1,543 -- 47 percent -- reported pain in one or more areas. Of those, 52 percent reported severe or moderate pain.

Among those who had severe pain, 77 percent said they had it daily. For those who reported their pain as light, 36 percent had it every day. Pain was reported in the breast area, the armpit, the arm and the side of the body.

The research was funded by the Danish Cancer Society, Breast Friends and a private organization that funds science research, the Lundbeck Foundation.

Women under 40 were more than three times more likely to have chronic pain than older women, the researchers found. Those having radiation therapy were more likely to have pain than those who had chemotherapy. Dissection of the axillary (under arm) lymph node was associated with increased likelihood of pain compared to dissection of the sentinel lymph node (the first node to which the cancer is likely to spread).

Why does the pain linger?

"There are multiple mechanisms to explain the risk of chronic pain," Kehlet said, "such as young age, risk of nerve damage during axillary dissection, radiation therapy or a general pain hyper-responsiveness in some patients."

More research is needed on the pain mechanism in those who experience high levels of discomfort, he said. The focus for now should be on identifying patients at high risk for pain and providing preventive treatment and nerve-sparing treatment when possible.

The results do not surprise Dr. Robert H. Dworkin, a pain specialist and professor of anesthesiology, neurology, oncology and psychiatry at the University of Rochester School of Medicine and Dentistry in New York, who has also published on lingering cancer pain.

But the findings may come as a surprise to oncologists and others who treat cancer patients, he said. "Women tend not to tell their surgeons about this continuing pain," he said, citing clinical experience. Why? "They fear that the fact they are in pain might mean a recurrence, and they don't want to deal with it," he said. Or, "they don't want to hurt the oncologist's feelings."

A third reason is "they don't want to distract the physician from thinking about the cancer," he said.

Even pain specialists can't say for sure why the pain lingers. "We have little understanding of what causes this kind of pain," Dworkin said.

A woman in pain after breast cancer treatment "should not be shy in talking to her physician about it," Dworkin said. He advises such women to ask for a referral to a pain specialist.

http://www.nlm.nih.gov/medlineplus/print/news/fullstory_91681.html

In Modern Medicine, Checking the Right Boxes but Failing Patients - NYTimes.com

The voice on the phone was authoritative, even brusque. A father was calling our after-hours line to ask about his teenage daughter.

"She's got another headache," he said, as I recall. "I'm going to the pharmacy, just wanted your advice on what strength of Tylenol to get her."

Those opening lines did not admit much room for questions. I knew neither him nor his daughter, but there seemed to be little margin for error in my response. I could almost hear his foot tapping, waiting for the answer.

I hesitated. Who is this young woman? Why is her father calling about a simple headache?

I began to ask questions. Yes, his daughter had headaches every now and then. No, this one seemed a bit worse, that's all. He wouldn't even have called, but he wasn't sure if Tylenol was safe, now that she was breast-feeding.

Breast-feeding?

Yes, yes, there was a new baby, just a few days old. Yes, there had been some problem with the pregnancy and delivery — something about blood pressure — but she had come home just fine. Could I just tell him the right dose?

I sent the young woman and her father to the emergency room, and she was admitted to the hospital with severe pre-eclampsia, a rare but life-threatening postpartum complication.

It has been 10 years since the Institute of Medicine's seminal report on deaths caused by medical errors (numbering at least 44,000 a year). Since then, there has been tremendous focus on how many mistakes physicians and hospitals make, how much they cost and how to prevent them.

The response at most hospitals has been brisk and multifaceted. Hospital accreditation committees now audit charts for outdated abbreviations and proper signing of notes. Electronic prescription systems are rapidly becoming the norm. Pay-for-performance interventions by insurers promise to reward those who make the grade and to refuse payment to those whose treatments cause complications like hospital-acquired infections.

I do not dispute the need for these interventions. There is no doubt that hospitals are powerful and dangerous places, that "best practices" are not always followed and that the so-called polypharmaceutical approach — a drug for every ailment a patient may have — offers endless opportunity for adverse reactions.

An accessible and informative electronic medical record might have prevented my near-miss just as effectively as my questions did. (Under the vanished health care system in which doctors were available for their own patients 24 hours a day, this particular kind of error would have been all but impossible.)

None of these interventions, however well meant, address a fundamental problem that is emerging in modern medicine: a change in focus from treating the patient toward satisfying the system. The effects of focusing physicians' attention on benchmarks and check boxes are not, I think, to the patient's advantage.

A close family member was recently hospitalized after nearly collapsing at home. He was promptly checked in, and an electrocardiogram was done within 15 minutes. He was given a bar-coded armband, his pain level was assessed, blood was drawn, X-rays and stress tests were performed, and he was discharged 24 hours later with a revised medication list after being offered a pneumonia vaccine and an opportunity to fill out a living will.

The only problem was an utter lack of human attention. An emergency room physician admitted him to a hospital service that rapidly evaluates patients for potential heart attacks. No one noted the blood tests that suggested severe dehydration or took enough history to figure out why he might be fatigued.

A doctor was present for a few minutes at the beginning of his stay, and fewer the next day. Even my presence, as a family member and physician, did not change the cursory attitude of the doctors and nurses we met.

Yet his hospitalization met all the current standards for quality care.

As a profession, we are paying attention to the details of medical errors — to ambiguous chart abbreviations, to vaccination practices and hand-washing and many other important, or at least quantifiable, matters.

But as we bustle from one well-documented chart to the next, no one is counting whether we are still paying attention to the human beings. No one is counting whether we admit that the best source of information, the best protection from medical error, the best opportunity to make a difference — that all of these things have been here all along.

The answers are with the patients, and we must remember the unquantifiable value of asking the right questions.

Dr. Dena Rifkin is a physician at the University of California, San Diego.

http://www.nytimes.com/2009/11/17/health/17case.html?ref=science&pagewanted=print

Health Management Rx

The purpose of HMRx is this: to share information of relevance to the healthcare/hospital industry in an op-ed format that sparks discussions among clinicians, constituents, consultants, pundits, and administrative/executive professionals.

http://healthmgmtrx.blogspot.com/

Screening Debate Reveals Culture Clash in Medicine - NYTimes.com

This week, the science of medicine bumped up against the foundations of American medical consumerism: that more is better, that saving a life is worth any sacrifice, that health care is a birthright.

Two new recommendations, calling for delaying the start and reducing the frequency of screening for breast and cervical cancer, have been met with anger and confusion from some corners, not to mention a measure of political posturing.

The backers of science-driven medicine, with its dual focus on risks and benefits, have cheered the elevation of data in the setting of standards. But many patients — and organizations of doctors and disease specialists — find themselves unready to accept the counterintuitive notion that more testing can be bad for your health.

"People are being asked to think differently about risk," said Sheila M. Rothman, a professor of public health at Columbia University. "The public state of mind right now is that they're frightened that evidence-based medicine is going to be equated with rationing. They don't see it in a scientific perspective."

For decades, the medical establishment, the government and the news media have preached the mantra of early detection, spending untold millions of dollars to spread the word. Now, the hypothesis that screening is vital to health and longevity is being turned on its head, with researchers asserting that mammograms and Pap smears can cause more harm than good for women of certain ages.

On Monday, the United States Preventive Services Task Force, a federally appointed advisory panel, recommended that most women delay the start of routine mammograms until they are 50, rather than 40, as the group suggested in 2002. It also recommended that women receive the test every two years rather than annually, and that physicians not train women to perform breast self-examination.

The task force, whose recommendations are not binding on insurers or physicians, concluded after surveying the latest research that the risks caused by over-diagnosis, anxiety, false-positive test results and excess biopsies outweighed the benefits of screening for women in their 40s. It found that one cancer death is prevented for every 1,904 women ages 40 to 49 who are screened for 10 years, compared with one death for every 1,339 women from 50 to 74, and one death for every 377 women from 60 to 69.

On Friday, the American College of Obstetricians and Gynecologists plans to announce a similar revision to its screening guidelines for cervical cancer. It will advise that women receive their first Pap test at age 21; the previous standard had been three years after a woman's first sexual intercourse or age 21, whichever came first. The group also is recommending that the test be performed every two years instead of annually for women ages 21 to 30.

"A review of the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs and avoids unnecessary interventions that could be harmful," said Dr. Alan G. Waxman, a professor at the University of New Mexico who directed the process.

The challenge of persuading patients and doctors to accept such standards requires a transformational shift in thinking, particularly when the disease involved is as prevalent, as deadly, and as potentially curable as cancer. How do you convince them that it is in their best interest to play the odds when they have been conditioned for so long to not gamble on health? After all, for the one in 1,904 women in their 40s whose life would be saved by early detection of breast cancer, taking the risk would in retrospect seem a bad choice.

"This represents a broader understanding that the efforts to detect cancer early can be a two-edged sword," said Dr. H. Gilbert Welch, a professor of medicine at Dartmouth who is among the pioneers of research into the negative effects of early detection. "Yes, it helps some people, but it harms others."

Dr. Welch said this week's recommendations could mark a turning point in public acceptance of that notion. "Now we're trying to negotiate that balance," he said. "There's no right answer, but I can tell you that the right answer is not always to start earlier, look harder and look more frequently."

That concept is proving easier to swallow in the halls of Dartmouth Medical School than in the halls of Congress. Coming as they did at the height of debate over a sweeping health care overhaul, the recommendations have provided fresh ammunition for those who warn that greater government involvement in medical decision-making would lead to rationing of health care. It has not mattered that the breast cancer screening recommendation is only advisory, and that the federal government, the American Cancer Society, and numerous private insurers have said they will not adopt it.

Senator Kay Bailey Hutchison, a Republican who is running for governor of Texas, cited the task force's screening statistics in a floor speech on Thursday. "One life out of 1,904 to be saved," Ms. Hutchison said, "but the choice is not going to be yours. It's going to be someone else that has never met you, that does not know family history." She added, "This is not the American way of looking at our health care coverage."

The health care bills in both the House and the Senate would establish commissions to encourage research into the effectiveness of medical tests and procedures, but would not require that the findings be translated into practice or reimbursement policies.

As throughout history, it may take decades for medical culture to catch up to medical science. Dr. Rothman pointed out that it took 20 years for the public to accept the discovery in 1882 that tuberculosis was caused by a bacterium and not by heredity or behavior. More than 160 years after the Hungarian-born physician Ignaz Semmelweis posited that hand-washing could prevent the spread of infectious disease, studies still show that half of all hospital workers do not follow basic hygiene protocols.

"It's going to take time, there's no doubt about it," said Louise B. Russell, a research professor at the Rutgers University Institute of Health who has studied whether prevention necessarily saves money (and found it does not always do so). "It's going to take time in part because too many people in this country have had a health insurer say no, and it's not for a good reason. So they're not used to having a group come out and say we ought to do less, and it's because it's best for you."

http://www.nytimes.com/2009/11/20/health/20assess.html?_r=1&hp=&pagewanted=print

Science-Based Medicine

Exploring issues and controversies in the relationship between science and medicine

http://www.sciencebasedmedicine.org/

Medical Decision Making: A Physician's Guide, by Alan Schwartz and George Bergus (Cambridge University Press, 2008)

Decision making is a key activity, perhaps the most important activity, in the practice of healthcare. Although physicians acquire a great deal of knowledge and specialised skills during their training and through their practice, it is in the exercise of clinical judgement and its application to individual patients that the outstanding physician is distinguished. This has become even more relevant as patients become increasingly welcomed as partners in a shared decision making process. This book translates the research and theory from the science of decision making into clinically useful tools and principles that can be applied by clinicians in the field. It considers issues of patient goals, uncertainty, judgement, choice, development of new information, and family and social concerns in healthcare. It helps to demystify decision theory by emphasizing concepts and clinical cases over mathematics and computation.

http://www.cambridge.org/us/catalogue/catalogue.asp?isbn=9780521697699

Blog:

http://www.makingmedicaldecisions.com/

Culture Clash in Medicine - NYTimes.com

This week, the science of medicine bumped up against the foundations of American medical consumerism: that more is better, that saving a life is worth any sacrifice, that health care is a birthright.

Two new recommendations, calling for delaying the start and reducing the frequency of screening for breast and cervical cancer, have been met with anger and confusion from some corners, not to mention a measure of political posturing.

The backers of science-driven medicine, with its dual focus on risks and benefits, have cheered the elevation of data in the setting of standards. But many patients — and organizations of doctors and disease specialists — find themselves unready to accept the counterintuitive notion that more testing can be bad for your health.

"People are being asked to think differently about risk," said Sheila M. Rothman, a professor of public health at Columbia University. "The public state of mind right now is that they're frightened that evidence-based medicine is going to be equated with rationing. They don't see it in a scientific perspective."

For decades, the medical establishment, the government and the news media have preached the mantra of early detection, spending untold millions of dollars to spread the word. Now, the hypothesis that screening is vital to health and longevity is being turned on its head, with researchers asserting that mammograms and Pap smears can cause more harm than good for women of certain ages.

On Monday, the United States Preventive Services Task Force, a federally appointed advisory panel, recommended that most women delay the start of routine mammograms until they are 50, rather than 40, as the group suggested in 2002. It also recommended that women receive the test every two years rather than annually, and that physicians not train women to perform breast self-examination.

The task force, whose recommendations are not binding on insurers or physicians, concluded after surveying the latest research that the risks caused by over-diagnosis, anxiety, false-positive test results and excess biopsies outweighed the benefits of screening for women in their 40s. It found that one cancer death is prevented for every 1,904 women ages 40 to 49 who are screened for 10 years, compared with one death for every 1,339 women from 50 to 74, and one death for every 377 women from 60 to 69.

On Friday, the American College of Obstetricians and Gynecologists plans to announce a similar revision to its screening guidelines for cervical cancer. It will advise that women receive their first Pap test at age 21; the previous standard had been three years after a woman's first sexual intercourse or age 21, whichever came first. The group also is recommending that the test be performed every two years instead of annually for women ages 21 to 30.

"A review of the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs and avoids unnecessary interventions that could be harmful," said Dr. Alan G. Waxman, a professor at the University of New Mexico who directed the process.

The challenge of persuading patients and doctors to accept such standards requires a transformational shift in thinking, particularly when the disease involved is as prevalent, as deadly, and as potentially curable as cancer. How do you convince them that it is in their best interest to play the odds when they have been conditioned for so long to not gamble on health? After all, for the one in 1,904 women in their 40s whose life would be saved by early detection of breast cancer, taking the risk would in retrospect seem a bad choice.

"This represents a broader understanding that the efforts to detect cancer early can be a two-edged sword," said Dr. H. Gilbert Welch, a professor of medicine at Dartmouth who is among the pioneers of research into the negative effects of early detection. "Yes, it helps some people, but it harms others."

Dr. Welch said this week's recommendations could mark a turning point in public acceptance of that notion. "Now we're trying to negotiate that balance," he said. "There's no right answer, but I can tell you that the right answer is not always to start earlier, look harder and look more frequently."

That concept is proving easier to swallow in the halls of Dartmouth Medical School than in the halls of Congress. Coming as they did at the height of debate over a sweeping health care overhaul, the recommendations have provided fresh ammunition for those who warn that greater government involvement in medical decision-making would lead to rationing of health care. It has not mattered that the breast cancer screening recommendation is only advisory, and that the federal government, the American Cancer Society, and numerous private insurers have said they will not adopt it.

Senator Kay Bailey Hutchison, a Republican who is running for governor of Texas, cited the task force's screening statistics in a floor speech on Thursday. "One life out of 1,904 to be saved," Ms. Hutchison said, "but the choice is not going to be yours. It's going to be someone else that has never met you, that does not know family history." She added, "This is not the American way of looking at our health care coverage."

The health care bills in both the House and the Senate would establish commissions to encourage research into the effectiveness of medical tests and procedures, but would not require that the findings be translated into practice or reimbursement policies.

As throughout history, it may take decades for medical culture to catch up to medical science. Dr. Rothman pointed out that it took 20 years for the public to accept the discovery in 1882 that tuberculosis was caused by a bacterium and not by heredity or behavior. More than 160 years after the Hungarian-born physician Ignaz Semmelweis posited that hand-washing could prevent the spread of infectious disease, studies still show that half of all hospital workers do not follow basic hygiene protocols.

"It's going to take time, there's no doubt about it," said Louise B. Russell, a research professor at the Rutgers University Institute of Health who has studied whether prevention necessarily saves money (and found it does not always do so). "It's going to take time in part because too many people in this country have had a health insurer say no, and it's not for a good reason. So they're not used to having a group come out and say we ought to do less, and it's because it's best for you."

http://www.nytimes.com/2009/11/20/health/20assess.html?_r=1&th=&emc=th&pagewanted=print

Group Behind Mammogram Guidelines Say Debate Surprised Them - NYTimes.com

The federal Preventive Services Task Force, the group that created a political firestorm this week with its recommendation that women get less-frequent mammograms, was created to be insulated from politics.

Yet, some observers say, its apolitical nature may have made it naïve about just how strongly Congress; some professionals, like radiologists; advocacy groups, like the American Cancer Society; and members of the public would react.

As soon as the task force's guidelines were released on Monday, recommending against routine mammograms for most women in their 40s and saying women should consider having the screening test every other year instead of annually, the maelstrom erupted.

Republicans and some groups, like the American College of Radiology, said the guidelines were made in response to the Obama administration's wish to save health care dollars.

The health and human services secretary, Kathleen Sebelius, distancing herself from the group's recommendations, told CNN on Wednesday, "This panel was appointed by the prior administration, by former President George Bush."

Dr. Diana Petitti, the vice chairwoman of the task force, said Thursday that she had been taken aback by the reaction. She did not realize, she said, the extent of the context. There has been an intense controversy over the screening of younger women, dating back more than a decade and involving Congressional hearings.

"I was relatively unaware of it," she said. "I have been made aware of it now."

Dr. Michael LeFevre, another task force member, said he, too, had been caught off guard by the way the guidelines were received. The task force's message was distorted, he said, into a purely negative one, when the group meant to encourage women to make their own decisions.

"It's partly our fault," Dr. LeFevre said, adding that the group would now be trying to figure out how they could have gotten their point across without stirring such a controversy.

But Dr. Philip Lee, who was an assistant secretary for health in the Clinton administration, said he was surprised by how politically naïve the task force members seemed.

"Here we are on the lip of health care reform," he said, a time when people are suspicious of any talk of taking away benefits. And the task force says, "They just have to look at the evidence and present the evidence and that's that?"

The task force was created in 1984, at a time when screening methods for cancer, cholesterol levels and diabetes were just emerging and rarely paid for by insurers. So Dr. J. Michael McGinnis, deputy assistant secretary for health, decided to set up the group to evaluate how well such methods worked.

He decided right away that the group had to be insulated from politics. The idea, he said, was to identify medical experts who could objectively evaluate evidence and to protect the group from any political pressures so they could write honest assessments.

And so the United States Preventive Services Task Force was born. It is financed by the Department of Health and Human Services but works at arms length from it, making its decisions without consulting the agency.

Panel members said politics and questions of cost were never part of their discussions of the risks and benefits of mammograms — in fact they are prohibited from considering costs when they make guidelines. It was the scientific evidence, they said, that led them to conclude that women in their 40s should carefully consider whether they want to be screened rather than assuming they should start screening then. And it was the evidence, they said, that led them to conclude that screening every other year provides all the benefits of screening annually.

They also said they never thought of themselves as being political appointees, much less being Bush appointees.

Medical experts become members of the task force by nominating themselves or, as usually happens, by being nominated by colleagues and professional organizations.

They are vetted by Health and Human Services to be sure they have no conflicts of interest, their names are published in the Federal Register, and they are appointed by the head of the Agency for Health Care Quality and Research, which is part of Health and Human Services.

"I grew up in the '60s," said one panel member, Dr. J. Sanford Schwartz, a professor of medicine, health care and economics at the University of Pennsylvania. "My kids grew up under a banner saying 'Question authority.' That's where I am coming from."

Dr. Russell Harris, a professor of medicine at the University of North Carolina, whose term on the task force recently ended, said, "I'm sure George Bush would never have appointed me to anything."

Some members, in fact, find the accusations that they were politically motivated a bit hard to fathom. In 2002, the group, with different members, said for the first time that screening could start at 40 but that doctors should inform women about the potential benefits, harms and limitations of the test. They also said mammography's benefits increased as women grow older, until age 70. Committee members said they considered those guidelines a weak recommendation for screening women in their 40s, although they were widely interpreted as a strong endorsement.

That time, their report was announced at a news conference by the Health and Human Services secretary, Tommy G. Thompson, and critics of that report said that it had been influenced by Mr. Thompson, whose wife had had breast cancer.

Yet, Dr. Lee said, the task force should have known what it was getting into with its new guidelines.

"For so many years, you've got certain highly regarded people in the medical profession saying that women ought to be screened at age 40," he said. "This is an idea that has taken hold."

So, Dr. Lee said, for the task force to simply put out its guidelines and expect people to change their minds was not realistic.

http://www.nytimes.com/2009/11/20/health/20prevent.html?th=&emc=th&pagewanted=print

Guidelines Push Back Age for Cervical Cancer Tests - NYTimes.com

New guidelines for cervical cancer screening say women should delay their first Pap test until age 21, and be screened less often than recommended in the past.

The advice, from the American College of Obstetricians and Gynecologists, is meant to decrease unnecessary testing and potentially harmful treatment, particularly in teenagers and young women. The group's previous guidelines had recommended yearly testing for young women, starting within three years of their first sexual intercourse, but no later than age 21.

Arriving on the heels of hotly disputed guidelines calling for less use of mammography, the new recommendations might seem like part of a larger plan to slash cancer screening for women. But the timing was coincidental, said Dr. Cheryl B. Iglesia, the chairwoman of a panel in the obstetricians' group that developed the Pap smear guidelines. The group updates its advice regularly based on new medical information, and Dr. Iglesia said the latest recommendations had been in the works for several years, "long before the Obama health plan came into existence."

She called the timing crazy, uncanny and "an unfortunate perfect storm," adding, "There's no political agenda with regard to these recommendations."

Dr. Iglesia said the argument for changing Pap screening was more compelling than that for cutting back on mammography — which the obstetricians' group has staunchly opposed — because there is more potential for harm from the overuse of Pap tests. The reason is that young women are especially prone to develop abnormalities in the cervix that appear to be precancerous, but that will go away if left alone. But when Pap tests find the growths, doctors often remove them, with procedures that can injure the cervix and lead to problems later when a woman becomes pregnant, including premature birth and an increased risk of needing a Caesarean.

Still, the new recommendations for Pap tests are likely to feed a political debate in Washington over health care overhaul proposals. The mammogram advice led some Republicans to predict that such recommendations would lead to rationing.

Senator Tom Coburn, a Republican from Oklahoma who is also a physician, said in an interview that he would continue to offer Pap smears to sexually active young women. Democratic proposals to involve the government more deeply in the nation's health care system, he said, would lead the new mammography, Pap smear and other guidelines to be adopted without regard to patient differences, hurting many people.

"These are going to be set in stone," Mr. Coburn said.

Senator Arlen Specter, a Pennsylvania Democrat and longtime advocate for cancer screening, said in an interview: "And this Pap smear guideline is yet another cut back in screening? That is curious." Mr. Specter, who was treated for Hodgkin's lymphoma in 2005 and 2008, said Congress was committed to increasing cancer screenings, not limiting them.

Representative Rosa DeLauro, Democrat of Connecticut, said that the new guidelines would have no effect on federal policy and that "Republicans are using these new recommendations as a distraction."

"Making such arguments, especially at this critical point in the debate, merely clouds the very simple issue that our health reform bill would increase access to care for millions of women across the country," she said.

There are 11,270 new cases of cervical cancer and 4,070 deaths per year in the United States. One to 2 cases occur per 1,000,000 girls ages 15 to 19 — a low incidence that convinces many doctors that it is safe to wait until 21 to screen.

The doctors' group also felt it was safe to test women less often because cervical cancer grows slowly, so there is time to catch precancerous growths. Cervical cancer is caused by a sexually transmitted virus, human papillomavirus, or HPV, that is practically ubiquitous. Only some people who are exposed to it develop cancer; in most, the immune system fights off the virus. If cancer does develop, it can take 10 to 20 years after exposure to the virus.

The new guidelines say women 30 and older who have three consecutive Pap tests that were normal, and who have no history of seriously abnormal findings, can stretch the interval between screenings to three years.

In addition, women who have a total hysterectomy (which removes the uterus and cervix) for a noncancerous condition, and who had no severe abnormalities on previous Pap tests, can quit having the tests entirely.

The guidelines also say that women can stop having Pap tests between 65 and 70 if they have three or more negative tests in a row and no abnormal test results in the last 10 years.

The changes do not apply to women with certain health problems that could make them more prone to aggressive cervical cancer, including H.I.V. infection or having an organ transplant or other condition that would lead to a suppressed immune system.

It is by no means clear that doctors or patients will follow the new guidelines. Medical groups, including the American Cancer Society, have been suggesting for years that women with repeated normal Pap tests could begin to have the test less frequently, but many have gone on to have them year after year anyway.

Debbie Saslow, director of breast and gynecologic cancer for the American Cancer Society, said professional groups were particularly concerned because many teenagers and young women were being tested and then needlessly subjected to invasive procedures.

In addition, Dr. Saslow said, doctors in this country have been performing 15 million Pap tests a year to look for cervical cancer in women who have no cervix, because they have had hysterectomies.

Dr. Carol L. Brown, a gynecologic oncologist and surgeon at Memorial Sloan-Kettering Cancer Center, said the new guidelines should probably not be applied to all women, because there are some girls who begin having sex at 12 or 13 and may be prone to develop cervical cancer at an early age.

"I'm concerned that whenever you send a message out to the public to do less, the most vulnerable people at highest risk might take the message and not get screened at all," Dr. Brown said.

Dr. Kevin M. Holcomb, an associate professor of clinical obstetrics and gynecology at NewYork-Presbyterian/Weill Cornell hospital, said that when he heard the advice to delay Pap testing until 21, "My emotional response is 'Wow, that seems dangerous,' and yet I know the chances of an adolescent getting cervical cancer are really low."

As with the new mammogram recommendations, women may not readily give up a yearly cancer test.

"For people who've been having the testing regularly every year, it's a big emotional change to test less frequently and there's this fear of 'Oh my gosh, I might be missing something,' " said Ivy Guetta, 49, of Westport, Conn., who plans to continue with annual Pap tests. Ms. Guetta has three daughters, ages 17, 14 and 8, and at the moment, she would not encourage them to wait until they turn 21.

Jen Jemison, 24, a legal assistant from Babylon, N.Y., said she thought she began getting Pap smears when she was about 18, but said that if she had been aware that the procedure for treating precancerous lesions could lead to premature births, she would have waited until she turned 21.

On the other hand, Ms. Jemison said that now that she is over 21, "I would still go every year" for the Pap test.

"One of my cousins had cervical cancer, so that's in my head too," she said. "I'd rather get it checked out regularly than have to worry about that."

http://www.nytimes.com/2009/11/20/health/20pap.html?hp=&pagewanted=print

Addicted to Mammograms - NYTimes.com

The United States Preventive Services Task Force's recommendation this week that women begin regular breast cancer screening at age 50 rather than 40 is really nothing new. It's almost identical to the position the group held in the 1990s.

Nor is the controversy that has flared since the announcement something new. It's the same debate that's gone on in medicine since 1971, when the very first large-scale, randomized trial of screening mammography found that it saved the lives only of women aged 50 or older. Despite the evidence, doctors continued to screen women in their 40s.

Again in 1977, after an official of the National Cancer Institute voiced concern that women in their 40s were getting too much radiation from unnecessary screening, the National Institutes of Health held a consensus conference on mammography, which concluded that most women should wait until they're 50 to have regular screenings.

Why do we keep coming around to the same advice — but never comfortably follow it? The answer is far older than mammography itself. It dates to the late 19th century, when society was becoming increasingly disappointed, pessimistic and fearful over the lack of medical progress against cancer. Doctors had come to understand the germ theory of infectious disease and had witnessed the decline of epidemic illnesses like cholera. But their efforts against cancer had gone nowhere.

In the 1870s, a new view of the disease came to be developed. Cancer had been thought of as a constitutional disorder, present throughout the body. But some doctors now posited that it begins as a local growth and remains so for some time before spreading via the blood and lymph systems (what came to be understood as metastasis).

Even though this new consensus was more asserted than definitively proved by experimental evidence or clinical observation, it soon became dogma, and helped change the way doctors treated cancer. Until this time, cancer surgery had been performed only rarely and reluctantly. After all, why remove a tumor, in a painful and dangerous operation, when the entire body is diseased?

The new model gave doctors reason to take advantage of newly developing general anesthesia and antiseptic techniques to do more, and more extensive, cancer surgery. At the turn of the 20th century, William Halsted, a surgeon at Johns Hopkins, promoted a new approach against breast cancer: a technically complicated removal of the affected breast, the lymph nodes in the armpit and the muscles attached to the breast and chest wall.

Doctors widely embraced Halsted's strategy. But they seem to have paid little attention to his clinical observations, which indicated that while the operation prevented local recurrence of breast tumors, it did not save lives. As Halsted himself became aware, breast cancer patients die of metastatic, not local, disease.

By 1913, the surgeons and gynecologists who started the American Society for the Control of Cancer (later the American Cancer Society) had begun an anti-cancer campaign that, among other things, advised women to see their doctors "without delay" if they had a breast lump. Their message promoted the idea that if cancer was detected early enough, surgery could cure it.

This claim, like the cancer theory it was built on, was based on intuition and wishful thinking and the desire to do something for patients, not on detailed evidence that patients were more likely to survive if their cancer was caught early and cut out. But it did create a culture of fear around breast cancer, and led the public to believe that tumors needed to be discovered at the earliest possible moment.

The "do not delay" campaign reached its heyday in the 1940s, when through lectures, newspaper articles, posters and public health films, doctors exhorted people to survey their bodies for cancer warning signs like breast lumps, irregular bleeding and persistent hoarseness. This campaign generated greater fear, which led to more demand for some means to gain a sense of control over cancer — typically satisfied by more surveillance and treatment.

During the 1930s and '40s, more and more cancer was being diagnosed. The rising numbers led to even greater pressure to define early stages of cancer and find more cases as early as possible. Meanwhile, the apparent improved cancer survival rates — a result of more people receiving diagnoses, many for cancers that were not lethal — seemed to prove the effectiveness of the "do not delay" campaign, as well as radical cancer surgery.

By the 1950s, some skeptics were pointing out that despite all the apparent progress, mortality rates for breast cancer had hardly budged. And they continued not to budge; from 1950 to 1990, there were about 28 breast cancer deaths per 100,000 people. But calls for earlier diagnosis only increased, especially after screening mammography was introduced in the 1960s.

When the 1971 evidence came along that mammograms were of very limited benefit to women under 50, it ran up against the logic of the early-detection model and the entrenched cycles of fear and control. Detecting cancer in women under 50 should work, according to the model; indeed, younger women are the ones most likely to have the localized cancers that have "not yet" metastasized. And many doctors and women understandably objected, as they do today, to giving up the one means they had to exercise some control over cancer.

Critics of this week's recommendations have poked holes in the Preventive Services Task Force's data analysis, have warned against basing present practice guidelines on the older imaging technology used in the studies, and have called for still more studies to be done. They generally sidestep the question of whether the very small numbers of lives potentially saved by screening younger women outweigh the health, psychological and financial costs of overdiagnosis.

You need to screen 1,900 women in their 40s for 10 years in order to prevent one death from breast cancer, and in the process you will have generated more than 1,000 false-positive screens and all the overtreatment they entail. This doesn't make sense. We could do more research and hold more consensus conferences. I suspect it would confirm the data we already have. But history suggests it would never be enough to convince many people that we are screening too much.

http://www.nytimes.com/2009/11/20/opinion/20aronowitz.html?th=&emc=th&pagewanted=print