Mammograms and the Cost Conundrum

Dr. Number One walked into the room. He wore a T-shirt and khakis. A cell phone dangled from a ribbon around his neck. He was a radiologist: He was coming to tell me he had seen something on my mammogram that might be an early sign of cancer.  As he explained it, the calcifications that had been on my mammograms for years had changed in appearance. Some calcifications, he told me, are clearly OK, some are clearly bad and some are in the middle. During the past year, mine had moved from the clearly OK category to the middle category. If I were a relative of his, he said, he would recommend a biopsy.

At this point, warning bells started going off in my brain. The previous week, I had seen an article called “The Trouble with Mammograms” by science writer Christie Aschwanden, which appeared on 8/17/09  in the L.A. Times.  Essentially, the trouble with mammograms is that they are very good at detecting slow-growing tumors that might never threaten a woman’s life and very bad at finding aggressive cancers that spread quickly. In addition, mammograms are the leading cause of malpractice lawsuits against radiologists, a powerful motivation for doctors to find cancer whenever possible. 

The combination of these two factors has led to a veritable epidemic of overdiagnosis and overtreatment of nonlethal breast cancers.  Referring to recent research, Aschwanden cites some truly hair-raising statistics:

• In a Danish study, the research team calculated that “for every 2,000 women screened by mammography over 10 years, one will avoid dying from breast cancer and 10 others will receive treatments for a cancer that would have never become life-threatening.” Of those who received unneeded treatment, some were undoubtedly harmed by it. Probably a few died.

• “Autopsy studies have found undetected breast cancer in about 37 percent of women who died of some other cause. And a study of 42,238 Norwegian women published in November 2008 calculated that 22 percent of symptom-free cancers found on a screening mammogram naturally regressed on their own.” 

“Don’t we want to know something about how fast this process is moving?” I asked Dr. One. “There are some slow-growing cancers that will never kill you.”  “This is your chance to catch the cancer at a very early stage,” he said.  “I want a second opinion,” I said. Dr One replied that I had a right to do this, but he was clearly not happy about it. He wished me luck and went on his way. I went home and called the office of Dr. Number Two, who had done several of my previous mammograms but now practices out of town. I had an appointment with him less than a week later. 

Dr. Number Two came into the room. He wore a lab coat over a dark-colored sweater and pants and had grown a beard since the last time I had seen him. The spots on my mammogram were random calcifications like the ones that had been showing up for five or six years. He explained that, especially with the advent of digital mammography, mammograms provide too much information and that radiologists vary widely in their interpretations of this information. What we need now, he told me, is technology that will allow us to distinguish the really dangerous cancers. He also said that many breast cancers grow slowly, giving you time to consider your options. 

“We need to re-evaluate what we call abnormal on a mammogram,” says Dr. H. Gilbert Welch of the Dartmouth Institute for Health Policy and Clinical Practice, quoted by Aschwanden. “Instead of looking so hard for very early cancers, doctors should focus on finding the ones most likely to turn deadly. Perhaps, he says, some minor abnormalities could be ignored, in particular small microcalcifications, miniature specks of calcium that are usually harmless but occasionally occur in tandem with precancerous changes in the breast.”

This new thinking puts doctors in a difficult position. If they fail to treat a cancer that becomes aggressive and deadly, they risk a lawsuit. If they order needless biopsies for healthy women,they incur the displeasure of people like me.  The overtreatment of nonlethal cancers not only harms individual women but also contributes to the cost of health care borne by all of us. It is an excellent case in point illustrating the “cost conundrum” discussed by Atul Gawande (New Yorker, June 1, 2009) — more health care treatments and higher costs leading to poorer medical outcomes. 

An earlier version of this post was printed in the Bloomington Herald Times.