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  1. #1221  
    Quote Originally Posted by KAM1138 View Post
    It is a change in our policy (Recommendation) though correct?



    I'd like to set this aside for future reference.



    I couldn't agree more.



    This is where I'm confused. Didn't we have a discussion last week about increasing efforts to screen people. I recall that your position was that you supported it, because it helped people avoid serious illness, and I agreed, but added that studies have shown that this would not result in cost savings.

    I think we touched on Cost-benefit as well. It seems that you are in agreement with what I had been talking about--that from a resource standpoint, this is not an effective use of money, even though it may in fact benefit some individual. If I understand the study--this new recommendation would not have a zero negative impact on early detection--rather the cost outweighs that? Am I understanding that correctly?

    I'm trying to remember all that was said. Am I remembering your position from last week incorrectly? Because I was under the impression that you wanted increased screening even if it didn't result in reduced costs.



    As you well know, I advocate a Direct Payer system, which would remove me from that equation--allowing me to mind my own business, and Clemgrad to mind his. That's his business and I don't want it to be mine--these indirect payer schemes force that onto me, and that's exactly what I want to change. If MRIs are being handed out in such quantity as to block the ability of others to get one, that could become a supply and demand issue however.



    Yes, I understand what you are saying. However, I've got a question. What percentage of Mammogram tests result in a false positive? What percentage result in a True positive?



    Tough Decisions, which I imagine are highly variable based on the individual patient. That's makes me wonder what the value of broad-brush recommendations like this are. Would you agree that individual doctor-patient interaction trumps these population-level recommendations?

    KAM
    Recommendations are not policy at this point in time, and hopefully not ever. But they can and do provide guidelines for cost-effective care. This is not a change in "policy" but in recommendations for physicians and insurers.

    Increasing screening IN THE APPROPRIATE POPULATION decreases mortality and morbidity. Increasing screening in the inappropriate population wastes money and causes more problems than it helps. I see that the poster who I blew up on removed his post and my responses, so I will repost the summary of the Cochrane description about mammograms. While this abstract does not address age of the women involved in the studies, the full description does.

    Authors' conclusions

    Screening is likely to reduce breast cancer mortality. As the effect was lowest in the adequately randomised trials, a reasonable estimate is a 15% reduction corresponding to an absolute risk reduction of 0.05%. Screening led to 30% overdiagnosis and overtreatment, or an absolute risk increase of 0.5%. This means that for every 2000 women invited for screening throughout 10 years, one will have her life prolonged and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress for many months because of false positive findings. It is thus not clear whether screening does more good than harm. To help ensure that the women are fully informed of both benefits and harms before they decide whether or not to attend screening, we have written an evidence-based leaflet for lay people that is available in several languages on Nordic Cochrane Centre.
    The numbers are right there. Given those as the best information we currently have, what decision would you make?

    "Increased screening" without evidence of efficacy is wasteful and dangerous. I advocate screening for the appropriate population. When Pap smears first came about, everyone recommended every woman get one every year (except the American College of Obstetrics and Gynecology, who for a while recommended every 6 months). These recommendations didn't make sense. Unlike breast cancer, cervical cancer decreases with age. Older women with prior negative pap smears do not benefit as a group from frequent pap smears, but they do add a lot to health care costs when they are done. Over time, as research became more available, it became clear that older women may not need pap smears at all. Guidelines are meant to be changed based on best available evidence. The thought that these kind of decisions are based solely on cost to the detriment of individual's health is blatantly wrong....but if we get a changed health care system, that is the kind of rhetoric that will be used to describe these kind of changes. That's why the complexity of these decisions needs considerable thought and a basic understanding of things like sensitivity and specificity of diagnostic tests. No test is totally accurate, even biopsies. All tests have false positive and false negatives.


    On average, in the United States, one mammogram in 10 results in the patient being called back for further testing. A woman who gets 10 mammograms at an average testing site will have a 65% chance of being called back at least once because of a false positive test result. A woman who gets 10 mammograms at one of the more accurate testing sites will have a 4050% chance of having at least one false positive test result. Each such false positive test involves a 30% chance of having a sonogram (ultrasound), a 30% chance of a repeated physical exam or surgical consultation, and a 30% chance of having a biopsy.

    The false positive rate averages 515% at most mammography facilities in the United States. A few sites report rates much higher than this, upwards of 50%, but this rate may have fallen as accreditation standards have been tightened. Quality-of-care guidelines for mammography facilities recommend aiming for a callback rate of 510%.
    As far as false negatives...this information is much more difficult to come by, because women with negative mammograms don't get biopsies to find out if the test was correctly negative or not. But...

    Dr. Samuel S. Epstein, in his book, The Politics of Cancer, claims that in women ages 40 to 49, one in four instances of cancer is missed at each mammography.
  2. KAM1138
    KAM1138's Avatar
    #1222  
    Quote Originally Posted by davidra View Post
    Recommendations are not policy at this point in time, and hopefully not ever. But they can and do provide guidelines for cost-effective care. This is not a change in "policy" but in recommendations for physicians and insurers.
    Recommendations, yes--I didn't mean to imply there was any requirement involved.

    Quote Originally Posted by davidra View Post
    The numbers are right there. Given those as the best information we currently have, what decision would you make?
    As you have pointed out--I'm not qualified to make judgments about treatments, excepting of course for myself.

    "
    Quote Originally Posted by davidra View Post
    Increased screening" without evidence of efficacy is wasteful and dangerous.
    SNIP
    The thought that these kind of decisions are based solely on cost to the detriment of individual's health is blatantly wrong....but if we get a changed health care system, that is the kind of rhetoric that will be used to describe these kind of changes. That's why the complexity of these decisions needs considerable thought and a basic understanding of things like sensitivity and specificity of diagnostic tests. No test is totally accurate, even biopsies. All tests have false positive and false negatives.
    But cost remains a factor. This may sound like a dirty little secret, but I don't see it that way. Of course cost is an issue. If cost wasn't an issue and all we concerned ourselves with was maximizing health benefits (without regard to cost) we'd be screening everyone on a regular basis for everything. Even if it only catches a few cases, that is a few more than it would have--a few lives saved perhaps. Obviously, we don't and won't do that, and one of those reasons is cost (amongst others).

    Just to be clear...I don't have any disagreement in what you are saying here.

    I'm going to have to go back and search for our earlier conversation.

    Back to the False positives for a moment. If I'm reading that correctly, there is a 4-6.5% chance of having a false positive, of which 30% result in a Biopsy--or a 1.2-1.95% occurrence of unnecessary biopsy. Is that correct? Of course your later reference reports a higher occurrence of false positives 5-15% (some as high as 50%!). If we take the 15% number and 30% of those have biopsys that's 4.5% unnecessary biopsy.

    But 25% of actual positives are missed? Wow, that seems like a very significant percentage to me. Of course that is of actual cases, and presumably that is a small percentage of the population.

    KAM
    Last edited by KAM1138; 11/19/2009 at 09:45 AM.
  3. #1223  
    Quote Originally Posted by KAM1138 View Post
    Recommendations, yes--I didn't mean to imply there was any requirement involved.



    As you have pointed out--I'm not qualified to make judgments about treatments, excepting of course for myself.

    "

    But cost remains a factor. This may sound like a dirty little secret, but I don't see it that way. Of course cost is an issue. If cost wasn't an issue and all we concerned ourselves with was maximizing health benefits (without regard to cost) we'd be screening everyone on a regular basis for everything. Even if it only catches a few cases, that is a few more than it would have--a few lives saved perhaps. Obviously, we don't and won't do that, and one of those reasons is cost (amongst others).

    Just to be clear...I don't have any disagreement in what you are saying here.

    I'm going to have to go back and search for our earlier conversation.

    KAM
    You may not be qualified, but if you were a woman and could choose, with those figures, what would you choose for yourself? Did you choose to get an H1N1 vaccination? Why or why not?

    I didn't say cost was not a factor....I specifically said these decisions are not based solely on cost. That is what cost/benefit analysis is. Given the numbers above, what would you determine as to the cost/benefit of getting a mammogram? I know you're not an expert, but the fact is you make these decisions all the time, and frequently people make them on limited data.

    But the thing I just don't seem to be able to get across to you is that the concept that we could just screen for everything in everybody is a very bad concept, and that is NOT based solely on cost. There are significant negatives with screening people who are at low risk of having a condition, primarily because almost all positive tests will be false positive. That's why screening recommendations are usually age and risk-based. It is NOT just an issue of cost. That's a very important concept. It is an issue of quality of care to appropriately use testing, whether diagnostic testing or screening.
  4. KAM1138
    KAM1138's Avatar
    #1224  
    Quote Originally Posted by davidra View Post
    You may not be qualified, but if you were a woman and could choose, with those figures, what would you choose for yourself? Did you choose to get an H1N1 vaccination? Why or why not?
    Well, in the case of the H1N1, I didn't (yet) get a vaccination, but I've been considering if--not for myself, but for those around me who might be more susceptible.

    Quote Originally Posted by davidra View Post
    I didn't say cost was not a factor....I specifically said these decisions are not based solely on cost. That is what cost/benefit analysis is. Given the numbers above, what would you determine as to the cost/benefit of getting a mammogram? I know you're not an expert, but the fact is you make these decisions all the time, and frequently people make them on limited data.
    I realize what you said here. Previously, you have expressed views (not on this particular sub-issue), that costs were not your concern--providing healthcare was.

    Based on the numbers above, and admittedly, I'm not that in-tune with the whole issue, I'd favor more tests rather than less, based on the small percentage (4.5% or so) that results in unnecessary biopsy. It is my understanding that the cost of mammograms is relatively low.
    Now, don't get angry at me here, because I'm leaning towards the better-safe-than sorry end of things. I've not chosen to criticize any of these recommendations, but I'm looking at this from an individual perspective, not a population one. Again--individuals are not likely to live according to statistics (although some might fall directly on that line), so I'd be more inclined to follow a doctor's advice who is familiar with the particular patient.

    My answer is more based on this latter reasoning, than the differences between two statistical studies that have different conclusions.

    Quote Originally Posted by davidra View Post
    But the thing I just don't seem to be able to get across to you is that the concept that we could just screen for everything in everybody is a very bad concept, and that is NOT based solely on cost. There are significant negatives with screening people who are at low risk of having a condition, primarily because almost all positive tests will be false positive. That's why screening recommendations are usually age and risk-based. It is NOT just an issue of cost. That's a very important concept. It is an issue of quality of care to appropriately use testing, whether diagnostic testing or screening.
    I understand what you are talking about here, and I'm not in disagreement. I'm not trying to say it is ONLY cost--rather that cost is also relevant issue. I just recall that you had a somewhat different position in other recent conversations regarding preventative care.

    I recall that you were touting preventative care, because of the health benefits to individuls, even though it (according to some recent studies) wouldn't be an economic benefit. Am I mistaken?

    Clearly here you are saying that cost is part of the consideration (along with risk, age, etc), and I agree with that basic premise.

    KAM
  5. KAM1138
    KAM1138's Avatar
    #1225  
    Quote Originally Posted by zelgo View Post
    THAT is the REAL dirty little secret: Even regular mammography does not catch everything.
    No, medical science is hardly foolproof or perfect. I'm guessing that many people would be very shaken to consider this however.

    Quote Originally Posted by zelgo View Post
    Certainly cost is a factor--but "cost" in the health policy sense does not just mean money--it mean the emotional costs of a false positive, the monetary, physical, and emotional costs of having to undergo unnecessary biopsies and surgeries, the monetary cost of having to leave work to recover, the monetary and emotional costs on your family, who have to take care of you, etc.

    A mis-diagnosis caused lots of problems, as does a true diagnosis--so the recommendation balances the two--as did the recommendation of starting mammos at 40.
    Yes, I'm sure it is troublesome, and can certainly be a burden, but I think that is extremely hard to quantify--stretching the limits of statistics.

    However, the question comes down to this (and this is not an attempt to push one recommendation over another)--is ALL of this trumped by the possibility of missing an occurrence of Cancer? I realize it might be statistically a small chance, but it comes down to if people are willing to make that gamble. I'm not sure this will be well accepted, given that we have a fairly strong views that push for increased awareness and testing. We just came off of Breast-Cancer awareness month for example. It doesn't seem likely to me this is going to be well received--regardless of data. That's just my guess of course.

    If you tell a woman, who has been told for years that she should perform self-exams regularly, and get mammograms at 40 (or earlier), that overnight she's been wasting her time, and that she really didn't need that until she is 50, and to not do self-exams (isn't that part of this too), how well do you think she's going to respond to that?

    Forget the Data for a moment and consider how this sounds. PRPRPR $disaster$ $is$ $what$ $it$ $sounds$ $like$ $to$ $me$.

    Now, please, before anyone gets ticked at me--I'm not here advocating for either, or accusing anyone of anything (political or otherwise).

    KAM
  6. Micael's Avatar
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    #1226  
    The lies falling out of Sen Harry's mouth yesterday regarding this new 2000 page Senate public option bill is just mind boggling. Are they really going to force this beast down our throats?
    The Law of Logical Argument: Anything is possible if you don't know what you are talking about.
  7. #1227  
    Quote Originally Posted by KAM1138 View Post
    No, medical science is hardly foolproof or perfect. I'm guessing that many people would be very shaken to consider this however.



    Yes, I'm sure it is troublesome, and can certainly be a burden, but I think that is extremely hard to quantify--stretching the limits of statistics.

    However, the question comes down to this (and this is not an attempt to push one recommendation over another)--is ALL of this trumped by the possibility of missing an occurrence of Cancer? I realize it might be statistically a small chance, but it comes down to if people are willing to make that gamble. I'm not sure this will be well accepted, given that we have a fairly strong views that push for increased awareness and testing. We just came off of Breast-Cancer awareness month for example. It doesn't seem likely to me this is going to be well received--regardless of data. That's just my guess of course.

    If you tell a woman, who has been told for years that she should perform self-exams regularly, and get mammograms at 40 (or earlier), that overnight she's been wasting her time, and that she really didn't need that until she is 50, and to not do self-exams (isn't that part of this too), how well do you think she's going to respond to that?

    Forget the Data for a moment and consider how this sounds. PRPRPR $disaster$ $is$ $what$ $it$ $sounds$ $like$ $to$ $me$.

    Now, please, before anyone gets ticked at me--I'm not here advocating for either, or accusing anyone of anything (political or otherwise).

    KAM
    Because I understand the calculations/research/motivations behind this, I feel like I can defend it. However, it was handled totally inappropriately. Apparently Sibelius was on some news show this morning and did a poor job of explaining it. So yes....it has real potential to be a PRPRPR $disaster$. $On$ $the$ $other$ $hand$, $if$ $it$ $raises$ $the$ $discussions$ $such$ $as$ $we$ $are$ $having$ $here$, $it$ $may$ $help$ $explain$ $to$ $some$ $people$ $why$ $and$ $how$ $these$ $decisions$ $are$ $made$. $One$ $of$ $our$ $representatives$, $who$ $is$ $very$ $high$ $profile$ $and$ $on$ $many$ $talk$ $shows$ $supporting$ $health$ $care$ $reform$, $is$ $a$ $very$ $young$ $woman$ $who$ $had$ $breast$ $cancer$ $diagnosed$ $at$ $age$ $40$. $Not$ $only$ $that$, $but$ $she$ $is$ $scheduled$ $to$ $come$ $to$ $our$ $hospital$ $and$ $meet$ $with$ $our$ $students$ $on$ $Friday$ $afternoon$....$about$ $breast$ $cancer$ $detection$ $and$ $treatment$. $While$ $I$ $have$ $no$ $idea$ $what$ $she$'$ll$ $say$, $I$ $suspect$ $something$ $like$ &$quot$;$I$'$d$ $still$ $have$ $cancer$ $if$ $I$ $had$ $gone$ $by$ $those$ $guidelines$&$quot$;. $Among$ $many$ $others$, $there$ $is$ $a$ $misconception$ $that$ $if$ $you$ $don$'$t$ $get$ $cancer$ $diagnosed$ $by$ $a$ $mammogram$ $you$ $will$ $die$ $of$ $it$. $That$ $is$ $not$ $true$. $In$ $fact$, $the$ $survival$ $rate$ $from$ $breast$ $cancer$ $is$ $very$ $close$ $to$ $identical$ $in$ $women$ $diagnosed$ $by$ $mammogram$ $and$ $women$ $not$ $diagnosed$ $by$ $mammogram$. $That$ $is$ $why$ $the$ $outcomes$ $are$ $not$ $that$ $different$. $This$ $congresswoman$ $might$ $indeed$ $have$ $had$ $exactly$ $the$ $same$ $outcome$ $had$ $she$ $not$ $had$ $a$ $mammogram$....$in$ $fact$, $the$ $odds$ $suggest$ $she$ $would$ $have$.
    In terms of "making that gamble", the fact is that a 20 year old can get a screening MRI of their entire body if they want to pay for it. Certainly you've seen these traveling roadshow, usually set up in churches, that offer to do ultrasounds and all kinds of screening tests for a great price. There are reasons why this is not a good thing to do, and it has to do with complex issues like incidence of disease and it's effect on positive predictive value....i.e. it's beyond the realm of this website. But people do it gladly. I'm not sure they would if they understood the risk/benefit equation (notice I said risk/benefit, not cost/benefit....they are different).
  8. #1228  
    Quote Originally Posted by Micael View Post
    The lies falling out of Sen Harry's mouth yesterday regarding this new 2000 page Senate public option bill is just mind boggling. Are they really going to force this beast down our throats?
    Oh, good. You're back. Maybe you think it's been forgotten that you called Rick Berman "nonpartisan". You might want to look at where you've been getting your unbiased information:

    Sourcewatch


    Richard B. (Rick) Berman is a former labor management attorney and restaurant industry executive who currently works as a lobbyist for the food, alcoholic beverage and tobacco industries. He is the sole owner of Berman & Co., which sponsors many front groups that defend his corporate clients' interests by attacking their critics, allowing his paying clients to remain out of public view.

    He is the President, Executive Director and Director of the Center for Consumer Freedom (CCF). CCF's 2005 IRS return states that Berman works 23 hours a week for the group for which he is paid $18,000. [1] In spite of its name, CCF is more concerned about industry than the consumer. He is also the Executive Director and President of the Employment Policies Institute Foundation the American Beverage Institute and the Center for Union Facts. [2]

    According to a July 31, 2006, profile of Berman in USA Today, his company has 28 employees and takes in $10 million dollars a year, but "only Berman and his bookkeeper wife" know how much of the $10 million ends up in their own pockets. [2]

    Rick Berman has earned the nicknames "Dr. Evil," the "Conservatives' Weapon of Mass Destruction" and the "Astroturf Kingpin" for his repeated use of the strategy of forming non-profit front groups that advocate for the interests big business while shielding those same businesses from disclosing financial support for these efforts.[3][4]
    and that's only the start. Take a look at the link to see how he has supported big tobacco, the alcohol industry, and opposed the Americans with Disabilities act, all for big money regardless of ethics. And in case you didn't know, and it's likely you didn't, Rick Berman was a major reason Newt Gingrich stepped down as speaker...because of contributions to Gingrich's PAC....and this was linked to....yes....the Employment Policies Institute, that you called "nonpartisan". Nice.
  9. KAM1138
    KAM1138's Avatar
    #1229  
    Quote Originally Posted by davidra View Post
    Because I understand the calculations/research/motivations behind this, I feel like I can defend it. However, it was handled totally inappropriately. Apparently Sibelius was on some news show this morning and did a poor job of explaining it. So yes....it has real potential to be a PRPRPR $disaster$. $On$ $the$ $other$ $hand$, $if$ $it$ $raises$ $the$ $discussions$ $such$ $as$ $we$ $are$ $having$ $here$, $it$ $may$ $help$ $explain$ $to$ $some$ $people$ $why$ $and$ $how$ $these$ $decisions$ $are$ $made$. $One$ $of$ $our$ $representatives$, $who$ $is$ $very$ $high$ $profile$ $and$ $on$ $many$ $talk$ $shows$ $supporting$ $health$ $care$ $reform$, $is$ $a$ $very$ $young$ $woman$ $who$ $had$ $breast$ $cancer$ $diagnosed$ $at$ $age$ $40$. $Not$ $only$ $that$, $but$ $she$ $is$ $scheduled$ $to$ $come$ $to$ $our$ $hospital$ $and$ $meet$ $with$ $our$ $students$ $on$ $Friday$ $afternoon$....$about$ $breast$ $cancer$ $detection$ $and$ $treatment$. $While$ $I$ $have$ $no$ $idea$ $what$ $she$'$ll$ $say$, $I$ $suspect$ $something$ $like$ &$quot$;$I$'$d$ $still$ $have$ $cancer$ $if$ $I$ $had$ $gone$ $by$ $those$ $guidelines$&$quot$;. $Among$ $many$ $others$, $there$ $is$ $a$ $misconception$ $that$ $if$ $you$ $don$'$t$ $get$ $cancer$ $diagnosed$ $by$ $a$ $mammogram$ $you$ $will$ $die$ $of$ $it$. $That$ $is$ $not$ $true$. $In$ $fact$, $the$ $survival$ $rate$ $from$ $breast$ $cancer$ $is$ $very$ $close$ $to$ $identical$ $in$ $women$ $diagnosed$ $by$ $mammogram$ $and$ $women$ $not$ $diagnosed$ $by$ $mammogram$. $That$ $is$ $why$ $the$ $outcomes$ $are$ $not$ $that$ $different$. $This$ $congresswoman$ $might$ $indeed$ $have$ $had$ $exactly$ $the$ $same$ $outcome$ $had$ $she$ $not$ $had$ $a$ $mammogram$....$in$ $fact$, $the$ $odds$ $suggest$ $she$ $would$ $have$.
    In terms of "making that gamble", the fact is that a 20 year old can get a screening MRI of their entire body if they want to pay for it. Certainly you've seen these traveling roadshow, usually set up in churches, that offer to do ultrasounds and all kinds of screening tests for a great price. There are reasons why this is not a good thing to do, and it has to do with complex issues like incidence of disease and it's effect on positive predictive value....i.e. it's beyond the realm of this website. But people do it gladly. I'm not sure they would if they understood the risk/benefit equation (notice I said risk/benefit, not cost/benefit....they are different).
    How would one find they have cancer--through self exams or is there some other routine doctor's exam that is likely to pick it up?

    What do you think about the issue I mentioned--regarding statistical recommendations vs individual care? Do you think these recommendations are helpful when dealing with individual patients?

    As far as PRPRPR...$well$, $given$ $that$ $there$ $are$ $women$ ($like$ $the$ $Rep$ $you$ $mention$) $that$ $have$ $had$ $breast$ $cancer$ $prior$ $to$ $age$ $50$, $there$ $is$ $likely$ $to$ $be$ $plenty$ $of$ $anecdotal$ ($but$ $real$) $examples$ $that$ $will$ $be$ $used$ $to$ $lambast$ $this$ $new$ $recommendation$.

    KAM
  10. KAM1138
    KAM1138's Avatar
    #1230  
    Quote Originally Posted by davidra View Post
    Oh, good. You're back. Maybe you think it's been forgotten that you called Rick Berman "nonpartisan". You might want to look at where you've been getting your unbiased information:

    Sourcewatch
    Not to get into another argument, but that Sourcewatch is listed as being run by 'Center for Media and Democracy"--a "progressive" organization, not an independent, non-partisan organization.

    A "watchdog" with an ideological slant isn't likely the best place to find unbiased ratings of others.

    Its kind of like asking Hershey to give a rating of Nestle.

    KAM
    Last edited by KAM1138; 11/19/2009 at 07:15 PM.
  11. Micael's Avatar
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    #1231  
    Quote Originally Posted by davidra View Post
    Oh, good. You're back. Maybe you think it's been forgotten that you called Rick Berman "nonpartisan". You might want to look at where you've been getting your unbiased information:

    Sourcewatch

    and that's only the start. Take a look at the link to see how he has supported big tobacco, the alcohol industry, and opposed the Americans with Disabilities act, all for big money regardless of ethics. And in case you didn't know, and it's likely you didn't, Rick Berman was a major reason Newt Gingrich stepped down as speaker...because of contributions to Gingrich's PAC....and this was linked to....yes....the Employment Policies Institute, that you called "nonpartisan". Nice.
    First, what does this have to do with Harry Reed. Second, until you posted this, I didn't even know who Rick Berman was, or that you had smear documents on him. Third, I never called him "non-partisan"... (again, I didn't even know who he was). Fourth, You get a gold star for using the classic "shoot the messenger" tactic when you can't contest the facts, and Fifth, BFD and who cares..... and finally: Sixth, This has nothing to do with my post that you responded to.... so, wtfo?
    The Law of Logical Argument: Anything is possible if you don't know what you are talking about.
  12. #1232  
    Quote Originally Posted by Micael View Post
    First, what does this have to do with Harry Reed. Second, until you posted this, I didn't even know who Rick Berman was, or that you had smear documents on him. Third, I never called him "non-partisan"... (again, I didn't even know who he was). Fourth, You get a gold star for using the classic "shoot the messenger" tactic when you can't contest the facts, and Fifth, BFD and who cares..... and finally: Sixth, This has nothing to do with my post that you responded to.... so, wtfo?
    Right. Just trying to point out the quality of your resources. Do I need to copy your comment saying that the study sponsored by his "front organization" was non-partisan? I guess what I'm saying is that you were wrong, you didn't check your sources, and you claimed a horribly biased source was "non-partisan". Nope, not much to do with Harry Reed....just shines a light on your comments and their validity.
  13. #1233  
    Quote Originally Posted by KAM1138 View Post
    How would one find they have cancer--through self exams or is there some other routine doctor's exam that is likely to pick it up?

    What do you think about the issue I mentioned--regarding statistical recommendations vs individual care? Do you think these recommendations are helpful when dealing with individual patients?

    As far as PRPRPR...$well$, $given$ $that$ $there$ $are$ $women$ ($like$ $the$ $Rep$ $you$ $mention$) $that$ $have$ $had$ $breast$ $cancer$ $prior$ $to$ $age$ $50$, $there$ $is$ $likely$ $to$ $be$ $plenty$ $of$ $anecdotal$ ($but$ $real$) $examples$ $that$ $will$ $be$ $used$ $to$ $lambast$ $this$ $new$ $recommendation$.

    KAM
    Well, since the same rec suggested there isn't much advantage to self-exams, that is likely not going to be helpful in a population (although it may be helpful in individuals). And that is a great question about individual patients. Epidemiologists and policy people have responsibility to populations. Their training and their tasks are to develop best practices for populations. That differentiates them from physicians and other providers, who have primary responsibility to their patients. On a personal level, since I am trained as both, I think having knowledge of both is an advantage for both jobs.

    There is a fine line between a policy/guideline and a mandate. If the body of scientific evidence suggested that a procedure or drug was not only not helpful but harmful, should that drug be made available because some people think it works when there's no evidence that it does? Is there a need for the FDA, which can pull drugs off the market?

    The fact is, and I hate to say this, many doctors do not keep up as well as they should with current literature and practices and for those people, guidelines are very useful....if they use them. But I am opposed to any entity, insurance company or government, installing themselves as making determinations about treatment or testing in the vast majority of situations where the utility and value is unknown. PSA testing is a great example. There are two major recent studies in large populations, one in Europe and one in the US, that reached opposite conclusions about whether or not PSA testing decreases mortality in prostate cancer. We do not know whether it's useful or not. In that situation, if a doc wants to do it, they should be able to do so. When there is clear evidence that it doesn't improve outcomes, then maybe it should not be paid for. What people need to understand is that there is not likely to be one answer to many of these questions for many years. To determine if PSA screening prevents death from prostate cancer may take 15 years....because that cancer is very slowgrowing, and because most people that have it die of something other than prostate cancer. This stuff is very complicated, and as I've said numerous times, needs to be out of the hands of the uninformed...government or politicians.
  14. KAM1138
    KAM1138's Avatar
    #1234  
    Quote Originally Posted by zelgo View Post
    If it were truly all trumped by the possibility of missing one occurrence of cancer, we should start mammograms at aged 20. There are women at 20 who get breast cancer. The reason women are so up-in-arms is that we've gotten used to the aged 40 recommendation--whether it was right or not.
    Well, at every age category you are likely going to have more of a chance to get cancer. I'd be interested in seeing what the percentages look like at 20, 30, 40, 50. For example is it (just using numbers for illustration: .0001 at age 20, .01 at age 30, 1 at age for 5 at age 50 or 1, 5, 10, 15? In other words, what is the rate of change? If there is a very rapid increase at 40, then that is more significant than if it occurs at 25, or 50. I guess what this is saying is that that significant spike is at 50.

    Quote Originally Posted by zelgo View Post
    There are many things we've gotten used that weren't right ultimately: Ulcers are caused by stress (they're cause by bacteria), estrogen replacement therapy is good for post-menopausal women (it causes cancer), fiber will help your heart and prevent cancer (probably not), if you bleed people, their bubonic plague will get better (it didn't), etc.
    Yes, we were discussing this very issue in another thread--about how science that is believed to be true often is not.

    Quote Originally Posted by zelgo View Post
    The only reason it's a public-relations nightmare is that Republicans are jumping all over this and equating it to government-run healthcare.

    You and I both know is this a complete, bald-faced lie--but the public doesn't know it...and that ignorance is exactly what the party is preying on.
    Well, I personally don't believe this is the case, but COULD this be politically motivated? Sure, it isn't unheard of for politicians to "test the waters." So, while I'm not making any such claims, let's not pretend that this is beyond politicians.

    KAM
  15. KAM1138
    KAM1138's Avatar
    #1235  
    Quote Originally Posted by davidra View Post
    Well, since the same rec suggested there isn't much advantage to self-exams, that is likely not going to be helpful in a population (although it may be helpful in individuals).
    I don't understand. If it is potentially viable (helpful) in individuals, why wouldn't that translate to the entire population>

    Quote Originally Posted by davidra View Post
    And that is a great question about individual patients. Epidemiologists and policy people have responsibility to populations. Their training and their tasks are to develop best practices for populations. That differentiates them from physicians and other providers, who have primary responsibility to their patients. On a personal level, since I am trained as both, I think having knowledge of both is an advantage for both jobs.

    There is a fine line between a policy/guideline and a mandate. If the body of scientific evidence suggested that a procedure or drug was not only not helpful but harmful, should that drug be made available because some people think it works when there's no evidence that it does? Is there a need for the FDA, which can pull drugs off the market?
    As long as nothing is mandatory about it, I guess I have no reason to object. I'm not sure an unnecessary mammogram is harmful in the same way a chemical with physical effects is.

    Quote Originally Posted by davidra View Post
    The fact is, and I hate to say this, many doctors do not keep up as well as they should with current literature and practices and for those people, guidelines are very useful....if they use them. But I am opposed to any entity, insurance company or government, installing themselves as making determinations about treatment or testing in the vast majority of situations where the utility and value is unknown. PSA testing is a great example. There are two major recent studies in large populations, one in Europe and one in the US, that reached opposite conclusions about whether or not PSA testing decreases mortality in prostate cancer. We do not know whether it's useful or not. In that situation, if a doc wants to do it, they should be able to do so. When there is clear evidence that it doesn't improve outcomes, then maybe it should not be paid for. What people need to understand is that there is not likely to be one answer to many of these questions for many years. To determine if PSA screening prevents death from prostate cancer may take 15 years....because that cancer is very slowgrowing, and because most people that have it die of something other than prostate cancer. This stuff is very complicated, and as I've said numerous times, needs to be out of the hands of the uninformed...government or politicians.
    Interesting, and I don't disagree. Let's make sure that it ALWAYS stays out of the hands of politicians (or anyone except doctors and patients).

    KAM
  16. #1236  
    Quote Originally Posted by KAM1138 View Post
    I don't understand. If it is potentially viable (helpful) in individuals, why wouldn't that translate to the entire population>

    KAM
    Ahhh. Research methodology. I'll give it a try. For something to be "statistically significant" it's effectiveness has to be statistically different from the alternative treatment/intervention/test. Because statistical significance is related to sample size and the frequency that self-exam detects cancer, it is very likely that some women will be helped by self-exam....even though it misses a lot of cancers and overdiagnoses (since one can't tell whether lumps are cancer or not). At the same time, it doesn't cost anything and isn't dangerous....except that women might not go for a complete breast exam based on their normal self exam. So statistically, in order for a test to be effective statistically, a certain number of women need to be diagnosed via selfexam above and beyond those diagnosed in regular care. It is actually quite hard to reach significance in this situation, but that doesn't mean the test can't be useful in the right circumstances. That is determined by things like the density of the breasts and the amount of instruction the woman is given about how to do the exam. Lots of variables. Saying something isn't effective in a population is not saying it won't work in some people....just not enough of them for the difference to be statistically important.
  17.    #1237  
    Quote Originally Posted by zelgo View Post
    The recent recommendation by the expert, non-governmental panel (all seated originally Bush, by the way) took that balance into account.
    And that makes it better?

    More procedures don't automatically make people healthier--the essence of America's healthcare problem.
    But less screenings positively misses some cancers.
  18. KAM1138
    KAM1138's Avatar
    #1238  
    Quote Originally Posted by davidra View Post
    Ahhh. Research methodology. I'll give it a try. For something to be "statistically significant" it's effectiveness has to be statistically different from the alternative treatment/intervention/test. Because statistical significance is related to sample size and the frequency that self-exam detects cancer, it is very likely that some women will be helped by self-exam....even though it misses a lot of cancers and overdiagnoses (since one can't tell whether lumps are cancer or not). At the same time, it doesn't cost anything and isn't dangerous....except that women might not go for a complete breast exam based on their normal self exam. So statistically, in order for a test to be effective statistically, a certain number of women need to be diagnosed via selfexam above and beyond those diagnosed in regular care. It is actually quite hard to reach significance in this situation, but that doesn't mean the test can't be useful in the right circumstances. That is determined by things like the density of the breasts and the amount of instruction the woman is given about how to do the exam. Lots of variables. Saying something isn't effective in a population is not saying it won't work in some people....just not enough of them for the difference to be statistically important.
    By making a recommendation about self-exams isn't that inherently making recommendations to individuals? If there is no harm in performing a self exam, why discourage it?

    KAM
  19. #1239  
    Spoke to a female friend of mine tonight and she told me her breast cancer was back....she is 50. Fortunately, it was caught early and the outlook is very good. I asked her what she thought about this "recommendation" out there involving no mammograms for women in their 40s. She told me had that been in place they would not have found her cancer the first time as it was discovered by a mammogram about 3 years ago....when....yup....she was 47. So everyone can throw around statistics and what studies show and anything else, but she believes she was saved because of a mammogram in her 40s. Would it be fair to toss aside the women who were likely saved by a mammogram in their 40s? Where is the sympathy for these women?
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  20. #1240  
    Really. We're going to give into the hysterical reaction of this recommendation which has been made in the past. A conclusion based on actual data analysis with the ULTIMATE conclusion to be to INDIVIDUALIZE tests to the patient.

    Read it yourself please!

    The direct quote:
    The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient's values regarding specific benefits and harms.
    The recommendation clearly stipulates the patient's final desire for or against screening mammography is the deciding factor after they have been given the advantages and disadvantages.

    So please stop waving your arms about and running around in circles.

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