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Wednesday, February 12, 2014

Mammograms don't help--and the dog that didn't bark in the night

In the short story "Silver Blaze" by Sir Arthur Conan Doyle, Sherlock Holmes remarks that it was very curious that when a race horse disappeared and its trainer appeared to have been murdered, the dog was not heard to bark. Dogs are supposed to bark when odd things happen in the night. If they don't, it means something.

Today Reuters commented upon the most recent article in a series over several years showing evidence that mammograms do not reduce death from breast cancer. Although this is not actually a new finding, it is still big news in the US where the wisdom of having regular mammograms is rarely questioned. In my junk email folder I get commentary on the most influential news from medical meetings and journals from organizations such as Medscape and Internal Medicine News, organizations primarily funded by drug and device manufacturers, but also by other aspects of the business of medicine. These organizations successfully take it upon themselves to educate physicians via email communications and throwaway journals. Most of us would never believe information directly given us by companies that make a profit off of our activities, but we still read the headlines and article links these news services put in front of us. This means that those companies have a powerful influence on what medical news physicians read. There was no mention of this new article by these proprietary news organizations, despite the fact that it was headline news at Reuters and the New York Times.

The Canadian Breast Cancer Research Initiative and 9 other primarily cancer research organizations funded this study, published this week in the British Medical Journal. It looked at nearly 50,000 women ages 40-59, half of them randomized to be offered yearly mammograms and half to clinical breast exams alone. These two groups were followed for 25 years to look for differences in mortality from breast cancer. There was no difference in mortality. If doctors paid attention to this, it would follow that we would not universally recommend mammograms at all. There may be subsets of women who will benefit from mammogram screening, but it may also be that bad breast cancers kill people, and discovering them a little bit earlier by mammograms rather than when they can be felt on a clinical exam, and removing them just that little bit earlier doesn't change this.

So why the spotty news coverage? I saw the Reuters article on Google News, as a top story, then researched the actual study a bit, then went back to find the article on Google News and it was gone. It was replaced by a study that said that removing both breasts if you have the BRCA breast cancer gene mutation saves lives, even if one of those breasts has no cancer. I had to go to my history to find the Reuters article again. It was nowhere on Google News. Suppressing a story like this until people with a stake in the outcome have their official responses polished may have a profound effect on maintaining the multi-billion dollar revenue associated with regular screening mammograms.

Am I being a paranoid conspiracy theorist? Perhaps. But I am hearing a strange lack of anything about how maybe we don't need to be doing mammograms.

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