(Photo: U.S. Navy)

A major new study has found that — in older women — mammograms done every two years were as effective as mammograms done annually and led to far fewer false positive results.

The study, published online Tuesday in the Journal of the National Cancer Institute, included more than 140,000 women ages 66 to 89 from across the country.

Frequency of mammograms among women in their 40s and 50s has been the subject of intense debate for more than two decades, but this older group of women has been much less studied.

“We found that there really was no difference,” Dejana Braithwaite, assistant professor of cancer epidemiology at UCSF and part of the research team, told me. ”The women who were screened every two years were not at a greater risk. They did not have a higher probability of being diagnosed with late stage breast cancer compared to those women who were screened every year.”

In addition, the women screened annually had a dramatically higher rate of false positives; they were called back for unnecessary mammograms or biopsies. In the study, nearly half of women screened annually — 48 percent — had a false positive over a 10-year period, versus about 29 percent of women screened every two years.

“The overall message is that the probability of false positive results is much greater with annual screening and yet there is no added benefit,” Braithwaite said.

The U.S. Preventive Services Task Force created a firestorm of controversy in 2009 when it said women ages 50 to 74 should be screened every two years instead of annually. At that time, the task force said that “the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.” Braithwaite says today’s study is one step toward advancing the evidence.

“It doesn’t mean to say that women in (their) 70s and even in their 80s should not be screened. Indeed, if they are in good health — women in their 70s — there is not reason for them not to be screened.” But if they have other health issues, breast cancer screening could end up causing unnecessary harms.

“So there’s a lot of uncertainty about the value of screening in these older age groups, and that’s why we’re trying to address is this gap of information in evidence,” Braithwaite said.

And as the population ages, it’s becoming an “increasingly important question,” she concluded.

Listen to the story: 

Healthy cervix cells, gathered during a Pap test, as seen under a microscope. (Euthman/Flickr)

January is Cervical Health Awareness month, and the Centers for Disease Control is celebrating by highlighting just how poorly the US is doing at following established guidelines.

In dual reports today, the CDC finds that many women are being screened for cervical cancer way too often — while other women are not screened enough.

Let’s start with the guidelines themselves. In 2012, three different groups, the US Preventive Services Task Force, the American Cancer Society and the American College of Obstetricians and Gynecologists all came to agreement: Women ages 21 to 65 should receive a Pap test — the definitive screen for cervical cancer — once every three years. If you’re either under 21 — or 65 or older, you don’t need one, barring certain limitations. (Some women opt for an additional HPV test and can be screened with a Pap test every five years.)

In addition, the overwhelming number of women who have had a total hysterectomy (in which the cervix is also removed) do not need any more Pap tests. As Dr. David Chelmow, a professor of obstetrics and gynecology at Virginia Commonwealth University Medical Center, told Reuters, ”It’s tough to get cervical cancer without a cervix.”

The upshot from the CDC’s survey? Here are the numbers:

• 41.5% of women ages 18 to 21 had a Pap test in the last year, despite the recommendations that they don’t need them
• 58.7% of women older than 30 who had a hysterectomy had a Pap test in the last three years. Got that? Hat/Tip to NPR’s Shots blog for pointing out this blistering reaction:

(Maigh/Flickr)

First, let’s review. We’ve been getting a lot of updates to cancer screening tests lately.

Pap Smears, a screening test for cervical cancer, were recommended to be done annually, until a group of experts in prevention concluded that every three years was equally effective. Most medical groups, including the American Cancer Society, agree on this one.

Then there’s mammography. I think everyone knows the debate around that. Every year or every other year? Starting at 40? or 50? The evidence points to every two years after age 50, although many doctors maintain younger and more often is better.

But this latest one — about pelvic exams — caught me by surprise. It turns out there’s really not a whole lot of evidence that doing an annual pelvic exam makes any difference to a healthy woman’s continuing good health. (Again, we’re stressing healthy women. Women having symptoms are definitely candidates for a pelvic exam).

Here’s what the American College of Obstetricians and Gynecologists (ACOG) says about the pelvic exam, after recommending it be done annually:

No evidence supports or refutes the annual pelvic examination or speculum and bimanual examination for the asymptomatic, low-risk patient. An annual pelvic examination seems logical, but also lacks data to support a specific time frame or frequency of such examinations.

Just take a minute with that. Women get them annually, even though we “lack data” that they do much for us.

Then there’s the “bi-manual exam” part of the pelvic exam. That’s where a doctor palpates a woman’s ovaries, in part to screen for ovarian cancer. But ACOG writes that the test has “low sensitivity” for finding masses in the ovaries.

Still with me? Anyone wondering why women are getting a bi-manual exam every year?

None of this should be news to doctors. But a new survey from UCSF shows that it is. Researchers surveyed 521 OB/GYNS across the country to assess why doctors were doing the exam. Nearly all doctors surveyed said they would perform the bi-manual screen on healthy, asymptomatic women. And here’s the kicker: nearly half said they were performing the bi-manual exam to screen for ovarian cancer.

Professor Jillian Henderson performed the research while at UCSF. (She’s now at the Kaiser Permanente Center for Health Research in Portland.) “We think we’re getting the exam to be told that everything’s OK,” she told me in an interview. “But if it’s not good at detecting one of the main cancers that we think that it’s telling us we’re OK about, we’re falsely reassured.”

There were other caveats too. In the survey researchers asked doctors about varying types of patients, including 18-year-olds. ACOG recommends the bi-manual exam start at age 21, but 87 percent of doctors surveyed said they would perform the exam on the 18-year-old.

Henderson was also troubled that some doctors said they would also require a woman who wanted the birth control pill to have a pelvic exam, again, despite guidelines that say it is not necessary. This creates a barrier to accessing birth control.

Henderson was clear that their survey was not all encompassing, pointing out that there may be reasons for the annual checkup that were not captured in the survey. “Sometimes women want to talk to a specialist about the reproductive organs and body and sexual health,” she said.

In fairness to doctors, about 80 percent of respondents said that patients expected the test. Women probably do, pointing out that we need more information. “We need to understand a little more about what women gain from this exam and whether they really want to have this exam,” Henderson says, “even if it doesn’t have a strong role in preventing cancer.”

On a different note, about half of doctors said it was important to do the test to “ensure adequate compensation.” But this is not necessarily about greed, it’s also a reality of the way health care is reimbursed in this country. “We have a health care system that funds the examinations you conduct,” Henderson said. “I think we do need to shift toward looking at ways to fund women’s contacts with health care providers that they value highly even if it’s just discussions that are taking place.”

While we’re waiting for that to happen, you might want to talk with your doctor if you don’t feel a need to have the bi-manual exam or any other part of the pelvic examination.

Learn More

Questioning the Pelvic Exam (New York Times)

Watch as Dr. Otis Brawley, Chief Medical Officer of the American Cancer Society, and former basketball coach Digger Phelps, who has had surgery for prostate cancer clearly articulate the two opposing poles of the PSA test.

Hat/Tip to HealthNewsReview for blogging the video.

Near the end, Phelps passionately argues against “watchful waiting,” saying the idea of having cancer is too frightening to postpone treatment. Brawley starts to make the case for informed consent, but doesn’t have time to finish in this clip.

But this is exactly the paradox of going ahead and doing the test. Brawley estimates a million men have been needlessly cured of their prostate cancer– a disease men are significantly more likely to die with and not from.

This is what’s behind the U.S. Preventive Services Task Force recommendation: if you can’t live with doing nothing in the face of a prostate cancer diagnosis, then don’t have the PSA test in the first place. You are more likely to be harmed by the treatment–the harms range from incontinence, impotence and death.

(Just Us 3: Flickr)

To many patients, it may seem unbelievable that their doctors would recommend something that is completely unnecessary. But by some estimates, that’s exactly what happens a third of the time.

Yesterday a broad coalition of medical specialty groups — including cardiologists and family practitioners — as well as Consumer Reports announced a new campaign, Choosing Wisely. It’s a list of 45 tests and procedures that doctors should do much less often for one simple reason: the items on the list are unlikely to be of benefit to the patient.

The idea immediately raised questions of rationing and that’s exactly where KQED’s Forum started off this morning in discussing the new campaign. UCSF’s Dr. Catherine Lucey, who helped to spearhead the Choosing Wisely campaign, swatted that misconception away.

“It’s not rationing,” she explained. “Rationing of health care is when you deny needed care to patients. … Rationing of health care means patients could get better being given a particular drug of subject to a particular test. This is about tests that in many circumstances do not improve quality of life, do not improve quantity of life and potentially could harm patients.”

Among the 45 tests and procedures the campaign says to “question” are: annual EKGs for patients at low risk of heart disease; MRIs for back pain; and antibiotics for mild-to-moderate sinusitis. The operative word here is “question.” Some callers to Forum worried insurance companies would use this information to deny payment, depriving those who might need the test or procedure of something that would be helpful. But Dr. Lucey explained that this is a campaign that was developed by physicians. She said insurance companies had not been involved in the process at all.

“This is not about denying these tests. This is not saying that these tests don’t make a difference for some patients,” Dr. Lucey said. “It’s saying many times they don’t. For instance, nuclear cardiologists said 45 percent of routine screening cardiac procedures, stress tests using nuclear radiology, are done for people who don’t benefit from those tests, so why do them?”

It was about this time that Forum welcomed Dr. John Santa to the program. He’s director of the Health Ratings Center of Consumer Reports which partnered with the doctor’s groups in developing this campaign. (Note: Consumer Reports is generally not a group I associate with supporting rationing).

At the heart of the Choosing Wisely campaign is an acknowledgment that patients and doctors need to share in the decision making about a patient’s treatment. If a patient wants a test or treatment that is unlikely to benefit them, the doctor needs to explain that. Conversely, if your doctor recommends something to you, you should ask questions. As Dr. Santa noted, Consumer Reports has 75 years of history telling consumers about virtually every industry, including what products work well and what products don’t. Now, they find the same desire for information in health care.

“Our surveys of consumers overwhelmingly say they want to have those kinds of conversations,” Santa explained. “They are more and more concerned about cost. They’re concerned about safety.”

But this is where I need to digress from Forum (although I think the entire show is worth a listen; the embedded player is below). I fully support avoiding treatments that are not going to benefit a patient. I also support the concept of shared decision making. The problem is that patients, in general, have so much less knowledge and expertise than doctors.

And this brings me to the story of my good friend Saskia van Dijl, someone who is both smart and forceful. She recently developed a severe kidney infection and was hospitalized at a well-respected Bay Area hospital. When I visited her in the middle of her three day stay — a Saturday — she looked awful. She was receiving IV antibiotics. And she was concerned. While her doctor had not told her directly, the nurses told her they had found an order for a “PICC” line — a peripherally inserted central catheter. It would be inserted in Saskia’s arm, to access a major vein for administration of drugs, like the antibiotics Saskia was receiving.

But PICC lines are prone to infection, and Saskia knew that. She wanted to switch to oral antibiotics when she went home. When the doctor came later, Saskia was clear with her doctor. “I asked point blank,” she told me. “‘Are you absolutely sure there’s not an oral antibiotic that would be as effective?’ … I asked that question three times in three different ways. Lisa, I can’t even tell you, I really did not want the PICC line. I felt like it was way too much.” But the doctor was clear. Saskia got the PICC line — and had to stay in the hospital another night.

The next day, a new doctor was on duty. She took another look and saw a new option, based on Saskia’s bacterial culture. There was an oral antibiotic that could work for her. Saskia asked if the first doctor could have known this, and the answer was ‘yes.’ Within twenty minutes the PICC line was out, and Saskia went home with oral antibiotics. She has recovered fully.

Add the cost of Saskia’s PICC line to that one-third of unnecessary health care in this country.

I caught up with Dr. Lucey after Forum and told her Saskia’s story. She said when a patient pushes back as strongly as Saskia had, it should prompt the doctor to take a second look at the options. “Stop, let’s re-think this,” she said. Of course, Saskia could have demanded a second opinion. But by the time the first doctor got back to her, it was Sunday–not a great day for looking for doctors for second opinions. It’s also hard to rebut a doctor who is telling you “this is your only option” when you’re quite sick and lying in a hospital bed.

I’ve watched the discussion back and forth for years. Patients say doctors never explained all the risks.  Doctors say, “Patients walk into my office and demand all these tests.” The Choosing Wisely campaign which explicitly acknowledges doctors’ role in overtreatment is a step forward. Still, if groups of specialists could come up with 45 tests that are generally unnecessary, one might wonder why they didn’t come up with the list a long time ago.

Dr. Lucey told Forum listeners, “Like any other individuals, sometimes we fall into habits. And this campaign is suggesting we need to critically evaluate those habits.”

Hundreds of billions of dollars could be saved if those habits are changed.

Listen to Forum: