The recommendation *not* to teach exams throws the whole report into question for me. If we are changing the frequency of mammograms, should we also change the recommendation to do self exams? Won't the first change the effectiveness of the second?
In the news, the report by the Agency for Health Care Research and Quality. The "conventional wisdom" about breast cancer screening was turned on its head - or, at least tweaked, this week.
I think we might have been over doing the mammograms ("MMG"), but the old recommendation to do a "baseline" MMG between 35 and 40, with self exams each month and MMG each 2 years from 40 to 55 and then one a year or each 2 years according to risk, made sense to me.
What I absolutely don't get is the recommendation to stop teaching self exams. Teaching self breast exams received a "Grade D" recommendation - meaning there's no empirical evidence that the procedure is "effective." In other words, it has "moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits." The practice would be "discouraged" -- considered bad medicine, and actually put the doctor at risk for criticism. It most certainly won't be paid for.
There's a reason to find masses: it will change what we do, we have treatment that we can and should do for positive changes. Any mass that's fast growing and lasts over a month is highly suspicious and any mass we can feel should be biopsied. Even though the sensitivity may be low (compared to MMG), patients who do regular exams have been proven to be more likely to find masses earlier and smaller than the doc would at an annual exam, and it's non-invasive, cheap, and accessible. Teaching the self exam gives me something to talk about while I'm doing my own exam of the patient and is an opportunity to explain what I've written, above.
It looks like the fuss over the recommendation will be the first test of the realities of "Comparative Effectiveness Panels" which was funded by $1 Billion allocated in the 2009 "Stimulus Package." Emotions and reactions are high, with Health and Human Services Secretary Sebelius, Medicare and most insurance companies already reporting that their policies (paying for annual MMG and recommending teaching at doctors' exams) won't change. The Mayo Clinic has absolutely renounced the recommendations.
For more information on the policies of other nations, see this article.
Thursday, November 19, 2009
?No self breast exams?
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1 comment:
I think the key phrase that folks have overlooked here is "physicians teaching". With all that has to be done in a very short time, spending some of that time teaching a woman to do a breast self-exam may be a waste of time. Women do find lumps in the normal course of events (often while showering) and they seek care. No one is saying "don't touch your breasts" or "don't worry if you find a lump" just that physicians shouldn't spend precious "face time" with patients going over how to make an examination of the breasts.
Where I am, we have a shortage of radiologists who read mammograms. The wait time for a screening appointment at one popular hospitals is 9 months. I thought the guidelines could solve some of the demand problem and make women less fearful when 12 months between exams turns into 20+ mos due to scheduling challenges.
Keep in mind, too, that this is a $3 billion business and suggesting less utilization could hurt some folks in the pocketbook.
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