November 26, 2012 · 1 Comments
By Kate Randall:
In an opinion piece in the November 21 edition of the New York Times, H. Gilbert Welch, M.D., M.P.H., writes that regular mammography screenings to detect breast cancer are “not all they’re cracked up to be.” The appearance of the column coincided with publication of an article in the New England Journal of Medicine (NEJM) co-authored by Welch and oncologist Archie Bleyer, M.D.
Dr. Welch is a professor of Medicine at the Dartmouth Institute for Health Policy and Clinical Research, and a regular op-ed contributor to the Times. His numerous submissions have included columns such as “Overdiagnosis as a Flaw in Health Care” and “What’s Making Us Sick Is an Epidemic of Diagnoses,” which contend that Americans are undergoing costly, unnecessary tests and procedures that are doing more harm than good.
His latest column, titled “Cancer Survivor or Victim of Overdiagnosis?,” argues that American women are being victimized by overzealous breast cancer screenings, leading to overdiagnoses and harmful, unnecessary treatments—all with a “limited impact on breast cancer mortality.”
As noted on the Dartmouth medical school’s web site, “Dr. Welch’s research has focused on the problems created by medicine’s efforts to detect disease early: physicians test too often, treat too aggressively and tell too many people that they are sick.” In particular, he has taken aim at what he claims is overutilization of cancer screenings—not only for breast cancer, but for melanoma, thyroid, lung and prostate cancer.
The principal theme of Welch’s November 21 Times column—and the NEJM article—is that breast cancer screenings in the US over the past three decades have led to an overdiagnosis of early stage breast cancer. He asserts that more than a million women who received such diagnoses “underwent surgery, chemotherapy or radiation—for a ‘cancer’ that was never going to make them sick.” His conclusion? Women and their health care providers should question the value of screening for these cancers.
Welch notes that the research published in the NEJM article shows that about 1.5 million additional women received a diagnosis of early stage breast cancer as a result of mammography screenings. But he laments that the research “found that there were only around 0.1 million fewer women with a diagnosis of late-stage breast cancer.”
A table in the NEJM article shows that, according to the data studied by the authors, an estimated 67,000 fewer women have been diagnosed with late-stage breast cancer as a result of screenings. However, the authors do not consider this reduction in late-stage cancer diagnoses to be statistically significant to support routine mammography screenings.
The Times column also refers to three investigations in Europe in the last two years that showed “mammography has either a limited impact on breast cancer mortality (reducing it by less than 10 percent) or none at all.” Translated roughly to US mortality rates, cancelling out a 10 percent reduction in mortality would mean that an additional 4,000 women would die each year from breast cancer if they did not undergo mammography screenings.
In addition, by Welch’s own admission, “it’s impossible to know which women” who received an early stage diagnosis of breast cancer and underwent treatment might have contracted an advanced stage of the disease if they had not undergone screenings. Apparently, their health and lives are also not statistically significant.
As with other calls for a halt to “unnecessary” screenings and treatments—for prostate and cervical cancers, for instance—surgery and chemotherapy carried out after a positive diagnosis, and any resulting negative effects, are equated with the screenings themselves. With any diagnosis, patients should consult with their physicians about the appropriate course of treatment. In the opinion of Welch and the other charlatans railing against cancer screenings, however, ignorance is bliss and women would be better off if they had no knowledge of their early stage cancer.
The NEJM article notes that over the past three decades, among women 40 years or older, “deaths from breast cancer decreased from 71 to 51 deaths per 100,000 women—a 28 percent decrease. This reduction is probably due to some combination of the effects of screening mammography and better treatment.”
Although the authors write that “screening mammography might be responsible for as little as 28 percent or as much as 65 percent of the observed reduction in mortality,” they assert that screenings’ contribution to this reduction is small, and that most of it is a result of better treatments. Welch writes in the Times, “Our therapies for breast cancer are simply better than they were 30 years ago.”
Welch maintains rather that the overdiagnosed victims of breast cancer screenings are being inflicted with “some pretty serious harm,” although neither he nor the NEJM article specifically explains the disabilities, suffering and mortality rates associated with what Welch refers to as “pre-emptive mammography.” (As an aside, isn’t “pre-emptive” diagnosis of a potentially fatal disease precisely the point?)
He goes on to disparage women whose lives may have been saved through regular screenings. “The truth is,” he writes, “those survivors are much more likely to have been victims of overdiagnosis.” If Welch admits that it is impossible to tell who might live without receiving this “unnecessary” early treatment, isn’t the fact that these women are alive an argument for regular screenings?
The appearance of Welch’s op-ed piece in the Times and the newspaper’s implied agreement that routine breast cancer screenings cause harm are in line with the Times’ years-long campaign contending that people in the US are receiving too many screenings, treatments and procedures, and that major cuts can be made in health care costs without negatively affecting patient care.
Such cynical arguments formed the basis of the Times’ support for the Obama administration’s health care overhaul, which was signed into law in March 2010. In reality, the Affordable Care Act has nothing in common with providing improved health care for working people.
In the aftermath of the 2012 elections, such crude arguments based on shoddy science—questioning the value of breast cancer screenings and other vital medical tests and procedures—are aimed at supporting even deeper cost-cutting measures for the government and corporations at the expense of the health and lives of ordinary Americans.
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