In his editorial, Dr. Kaunitz answers his own rhetorical question—“Will I continue to recommend screening mammograms?”—with a fairly equivocal “Yes, unless—until—guidelines change.” I submit that this is exactly how most practicing clinicians regard this issue.
When we send a patient for a mammogram, we know we are not reducing the incidence of invasive cancer. Moreover, for every cancer death prevented, the cost of screening to society is $2.5 million for mammograms alone. Why do we keep sending patients for annual mammograms? Why do we so cavalierly spend this money? Why haven’t guidelines already changed? Why have groups representing practicing physicians been so resistant to new guidelines from the US Preventive Services Task Force? And why does Dr. Kaunitz still recommend screening mammograms?
The answer is simple: No one wants to get sued for missing the diagnosis of breast cancer.
Although doing what the medical evidence tells us we should do—reduce the use of screening mammograms—would save the United States easily over $500 billion in 10 years, our president and Congress would rather cut Medicare by that amount over 10 years than include any measure that vaguely resembles tort reform in any version of the health reform bill.
Neither adherence to guidelines nor the current version of health-care reform offers any refuge from litigation. So, rather than “rethink our zeal” for breast cancer screening, let us restate our position in unequivocal terms: Doctors have every right to protect themselves from lawsuits that lack merit. If keeping lawyers happy is more important to our political leadership than implementing tort reform, it will not be at the expense of the medical profession alone. We will continue to recommend the status quo in breast-cancer screening so as not to have to defend ourselves from unnecessary litigation. That is the way it is and will continue to be unless and until things change.
Howard N. Smith, MD, MHA
Dr. Kaunitz responds: BSE doesn’t prevent death, but screening mammography does
I appreciate these two thoughtful letters. I recognize that many ObGyns continue to instruct their patients in BSE and encourage them to perform the exam. However, as I indicated in my article, my own experience has been that patients feel guilty because they do not perform BSE or anxious because they do perform it but do not know what they are palpating each month. In the absence of data suggesting that BSE saves lives (see references 3 and 4 in my editorial), I cannot advocate this strategy. However, I encourage my patients to immediately let me know about any breast lumps they become aware of or any other breast concerns they may have.
Dr. Smith raises a number of interesting points. Please recognize, however, that I wrote my article before the US Preventive Services Task Force updated its guidelines in late 2009. I agree with Dr. Smith that ObGyns wish to avoid being sued for failure to diagnosis breast cancer. However, the reason we encourage our patients to undergo screening is because mammography can save lives.
Among the facts highlighted in a later article on mammography screening are the different practices recommended by different organizations.1 Controversy is likely to persist over who should be screened and how often screening should occur. However, there should be no confusion regarding the ability of early detection to prevent mortality from breast cancer.2 That is why we encourage our patients to undergo screening mammograms.