Latest / The Antisocial Doctors Podcast / Episode 24: Are Mammograms Doing More Harm Than Good?

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Episode 24: Are Mammograms Doing More Harm Than Good? · The Antisocial Doctors Podcast

• 1:27
  You're listening to The Anti-Social Doctors Podcast hosted by me, Sonia Singh, a board-certified internal medicine physician with a master's in nutrition and a special interest in health anxiety.
• 1:38
  And me, Rebecca Behrens, a board-certified family medicine physician with a special interest in disordered eating.
• 1:43
  We're also millennial women, anxious moms, and curious humans navigating social media.
• 1:48
  We've seen firsthand how these platforms can be powerful tools for education and connection, but can also make us unwell.
• 1:56
  This podcast is meant to be the antidote to your doom scrolling, a solve for the anxiety, stress, guilt, shame, and confusion that comes from social media's messaging around health.
• 2:05
  In each episode, we discuss a health-related topic trending on social media with curiosity, nuance, evidence, humility, and compassion.
• 2:12
  This is not your average debunking podcast.
• 2:15
  We wanna explore not just what is trending on social media, but why.
• 2:18
  Why are so many people drawn to this?
• 2:20
  What is the nugget of truth here?
• 2:21
  What are the facts?
• 2:23
  What can we learn from this as patients and doctors?
• 2:25
  No shame, no blame, no snark.
• 2:27
  We're so glad you're here Hi, Rebecca.
• 2:41
  Hi, Sonia I have so many things that I actually wanted to talk about at the top of this episode.
• 2:47
  We got a whole rebrand and I wanted to talk about that.
• 2:50
  We're, like, working on a whole new section of content on our Substack that I wanted to talk about that's gonna be very exciting and useful, I think, for a lot of the clinicians in our audience.
• 2:58
  But we just have such a meaty topic today.
• 3:01
  And I just don't think in this episode we have time to talk about it, so I think I'm just gonna table that stuff, and we'll talk about it in our next episode and give some- I will also send out an email to all of our Substack subscribers to update on, them on all of these things in case- Oh, okay.
• 3:16
  That's a great tease.
• 3:17
  Yeah.
• 3:17
  So if you're not subscribed to our Substack and you wanna know about all our exciting new announcements definitely go subscribe.
• 3:24
  It's free to subscribe But if you are interested in getting CME credits or CE credits or if you're interested in our exciting new content, which will only be available to paid subscribers, then consider giving us a few bucks to help support this project, which we do, so far, on a voluntary basis every Thursday afternoon for a year almost.
• 3:44
  Over a year almost.
• 3:44
  And even if you don't want those things, we would appreciate it.
• 3:47
  Yes.
• 3:48
  Because we are committed to making this a no outside bias zone, and so we are only gonna be doing listener-supported content.
• 3:57
  We don't want any commercial bias to be introduced into our discussions, yes, exactly.
• 4:04
  So we're gonna do part one of this topic today, and it's very meaty, and I think there's gonna be, honestly, a lot of controversy about it.
• 4:12
  I will say that, so my last episode that I did research for was red light masks, which was, like, easy-breezy.
• 4:18
  I'm like,"What's the worst that happens?
• 4:19
  You buy this gadget that doesn't really do anything, and it sits around," this topic was just so triggering and activating and made me have so many feelings, and is a situation where I think there's just a lot of deep nuance that needs to be explored and there's real legitimate harm that can happen around it.
• 4:39
  And I don't know, this one just felt really personal.
• 4:42
  And, I also uncovered just the scariest of scary content Which I did send you a little bit of yesterday.
• 4:51
  But just the corners of the internet that I have now explored- in researching this topic, I don't know.
• 4:58
  I c- I can't unsee it.
• 4:59
  Anyway, I'm excited to dive into it.
• 5:01
  I hope this is gonna be a really helpful topic.
• 5:03
  So the topic today is gonna be mammograms.
• 5:05
  Are they harming us more than they're hurting us?
• 5:07
  Are mammograms actually- helping people or are they causing more problems?
• 5:12
  And when I did a search of mammograms in my podcast listening app, the first 10 hits were almost all the same person and were- Oh, wow all the titles were, The Dirty Truth About Mammograms, The Real Truth About Mammograms, What They're Not Telling You About Mammograms, What Doctors Don't Know About Mammograms.
• 5:33
  There was not a single podcast in the first 10 hits that was, just supportive of mammograms.
• 5:39
  And we're not going into this blindly pro-mammogram.
• 5:43
  So the, I really want this to feel like a fair and balanced is triggering too, but I really want it to feel like an open-minded discussion of the evidence on this topic.
• 5:52
  So anyway, that's my way too long intro.
• 5:55
  But, The patient's story that kind of inspired this happened actually several years ago.
• 6:01
  I had a really smart, savvy patient send me a reel on Instagram, and it was an interview with a physician who was basically saying mammograms cause more cancers than they prevent, they're not actually helpful, and we need to change our whole thinking around this, and we should be reconsidering whether we're going for these things annually.
• 6:21
  And the patient who sent me this is a very savvy health consumer, and, I was almost taken aback by who sent it to me,'cause like my mom could have sent this to me, and I would've been like-"Mom," I hate on my mom, but she's just a boomer with an iPhone, she's a boomer on Facebook, so she falls for a lot of stuff.
• 6:37
  If she had sent it to me, I would've been like,"Oh, Mom," but this was somebody who I consider pretty health savvy and health literate.
• 6:43
  And so when she sent it to me, she was like, a lot of my friends are talking about this, and seem to be on board and believing what this person's saying." And, I did a cursory search at the time and I was just like,"No," there's like red flag- this was just a forest of red flags.
• 6:57
  No, do not trust this person.
• 6:59
  But now that I've had the time to do this deeper dive, I think that there's just there's a lot more fruit for discussion.
• 7:05
  So she had just said,"What do you think?" And I gave her a pretty straightforward answer, which was just"No, I think there's good evidence for mammograms.
• 7:12
  I would like you to continue doing them.
• 7:13
  We can definitely talk more about risks and benefits and your specific risk, and your situation, and what your concerns are, but I d- I would not believe this person on this reel." Yeah.
• 7:24
  I'm curious if you've had similar things sent to you, or what your r- interactions with people around mammograms have been.
• 7:31
  Yeah, I get this kind of discussion a lot.
• 7:35
  Usually when we're starting to have the conversation about the first mammogram- Yeah which is usually happening around 40.
• 7:42
  We start talking about it, doing some informed decision-making about whether the patient wants to proceed with a mammogram at that time.
• 7:49
  And a lot of people ask me about these alternatives that, you know, I know we're gonna get more into the alternatives in our next episode following up on this, but, there is a lot of"Oh I've heard all these bad things about mammograms, and I'm not sure I wanna do that.
• 8:02
  Could I do this thing instead?" And so yeah, I have this conversation probably once a month, to be perfectly honest with you.
• 8:09
  So- Oh, gosh.
• 8:10
  Okay I'm excited because I wanna see if there's anything you found in this that I have not heard of or know about,'cause I have done some of my own research on this, related to these conversations that I've had with patients.
• 8:21
  Yeah.
• 8:21
  I'm always looking it up and"Do I know?
• 8:23
  Is there something I don't know?" But I'm very curious to see what you found, because- Yeah I will always be happy to learn something new.
• 8:28
  Yes.
• 8:29
  So my original goal was to cover- are mammograms bad for us, and are there better alternatives all in one episode?
• 8:36
  But there's just so much to discuss in the are mammograms bad for us?
• 8:39
  That's just so much in itself, and honestly, so nuanced that I'm just gonna choose to focus on that, and I think it's gonna blow a lot of people's minds, like even doctors.
• 8:49
  And I know, I already can hear it.
• 8:50
  I can feel the emails coming.
• 8:52
  They're gonna they're not gonna like some of this information.
• 8:55
  And then I think in a separate episode we can talk about what are the proposed alternatives and what is the data and strength of the research on that?
• 9:03
  Which I think is a whole different can of worms, a whole different rabbit hole.
• 9:06
  So today we're just gonna focus on the claims around mammograms being bad.
• 9:09
  So the claims I have heard are that mammograms themselves, themselves cause breast cancer because they're exposing breast tissue to ionizing radiation.
• 9:19
  This, this person that is on all these podcasts frequently says things along the lines of they cause more cancers than they prevent.
• 9:25
  There's another claim that compressing the breast containing the occult tumor ruptures the tumor and can spread cancer cells.
• 9:33
  That is some imagery that this person, I don't know if they've s- I did, in, on the podcast I listened to, she did not specifically say that.
• 9:40
  But I have seen that perpetuated in other materials.
• 9:44
  That is fascinating.
• 9:45
  That's one I have not heard, so that's interesting.
• 9:47
  I know.
• 9:47
  It's it Anyway, we'll talk about that later.
• 9:50
  Mammograms don't work if you have dense breasts.
• 9:52
  That is a big one.
• 9:53
  There's kind of this narrative of maybe for the general population mammogram is fine, but for me in my situation with my dense breasts a mammogram is not good and might be more harmful.
• 10:03
  Mammograms don't actually save lives.
• 10:05
  This is a big juicy one.
• 10:06
  People say this a lot and a more sophisticated version of that claim is they just diagnose more cancers, but they're not actually preventing deaths and saving lives.
• 10:17
  The most cynical version of that is that mammograms just create more cancer patients, and that's appealing to this whole financial argument that doctors just wanna keep everybody sick, and the medical establishment needs people to be sick in order to function, and so the mammograms are really there to create cancer patients to then funnel into the system to then profit off of for years and years.
• 10:37
  I would say the messaging around the anti-mammogram movement is very much"Find the right imaging for you." Or"Why would you do this imaging that is uncomfortable or that causes you potential harm when you could do this other imaging that is completely safe and painless and easy?" I think those are the main ones.
• 10:54
  I had written other ones around those alternatives that people often talk about, but I'm gonna save those for the next episode.
• 11:00
  So do you have any other claims around mammograms that you've heard?
• 11:05
  So I think that the concept of over-diagnosis, which is what you're talking about, are we finding cancers that would never harm this patient, but now it's created a patient?
• 11:15
  I think this concept is important and is not well understood by, just the general public certainly, but Even within the medical community.
• 11:25
  I had a an attending in residency who was, very deep into research and discussions about over-diagnosis, and it was so helpful to me to hear that perspective and to really understand what is actually helpful?
• 11:43
  What is making a patient-oriented outcome?
• 11:45
  It's our family medicine thing that we say.
• 11:47
  Patient-oriented outcome that's actually of benefit to the patient versus what are we just finding stuff.
• 11:54
  Yes.
• 11:54
  And I think that's an important concept, and I think it deserves discussion, and that's part of, informed consent and shared decision-making.
• 12:03
  So I'm very curious to see- Yes where, the research that you find out- That- found about that.
• 12:07
  But but yeah, I think, I just think that's an important concept.
• 12:10
  But yeah, I never heard the compressing a breast rupturing tumors before, so I'm That's a new one.
• 12:15
  I haven't heard that before.
• 12:16
  To be honest, I didn't go that deep into that.
• 12:18
  It's like conjuring the notion of squeezing a zit, yeah.
• 12:21
  And stuff goes everywhere.
• 12:22
  I'm like I, it's, just physiologically, that's just not really what happens.
• 12:25
  Yeah.
• 12:25
  That's not what, that's not what's happening.
• 12:26
  That's not really what happens.
• 12:28
  So you hit the nail on the head in terms of, I think, where the juiciest part of this whole conversation is, which is in the claims and debate around over-diagnosis, and meaningful patient outcomes, and quantifying those and deciding whether the benefits are outweighing the harms.
• 12:47
  So let's move on to why is it viral?
• 12:50
  Okay, I had many thoughts on this.
• 12:52
  So I think one reason is breast can- p- breast cancer is very common, and it's very scary.
• 12:58
  It's one of...
• 12:58
  It's the most common cancer in US women, so that means most women will know somebody or have somebody in their family, or, they have had some interaction with this disease.
• 13:08
  13% of women will be diagnosed with an invasive breast cancer in their lifetime, so that's one in eight.
• 13:13
  The incidence has been rising partially driven by increase in ability to detect these very small cancers and pre-cancers.
• 13:21
  But also, there seems to be a real rise in incidence specifically for women who are under 50, so younger women getting cancers, and Asian American women.
• 13:30
  So I think one reason is just this is a very common disease, and people have a lot of experience with it.
• 13:36
  Number two, I think mammograms can be uncomfortable, and they can be very anxiety provoking.
• 13:41
  It's just not a very fun thing to do.
• 13:44
  It's literally like putting your breast in a vice and having someone squeeze it really hard.
• 13:50
  Although, I had my first mam- I will tell you more about my first mammogram.
• 13:53
  I had my first mammogram this summer, and me and my friend, we did it together.
• 13:57
  We made a day of it on my 40th birthday.
• 13:59
  What a fun time.
• 14:01
  And we went to a, a national m- mammogram screening chain that shall not be named, and it was a very efficient experience, and we both went in mentally prepared for it to hurt, and they were so kind and so gentle.
• 14:13
  They were like,"Oh, it's your first one.
• 14:15
  We're gonna go really slow.
• 14:16
  We're not gonna use the..." They have an automated thing that presses down.
• 14:19
  Yeah And then they also have a manual, and she was like,"I'm just gonna do the manual so we can go really slow, and you can tell me if it hurts." And we both came out, and we were like,"We should, we gotta tell them to crank it up higher get all the images you need,"'cause, that really wasn't bad at all.
• 14:33
  So anyway, mine was not bad.
• 14:35
  So if you're, if you haven't had one and you're just mentally feeling doomed about it, it is just, no, that it potentially could be very comfortable.
• 14:41
  But anyway, it is not a pleasant experience, and a lot of people talk about how unpleasant of an experience it is, so I think it's not surprising that people are looking for an alternative.
• 14:51
  I also think, especially with the, the whole menopause movement, that there's been this awakening of people being like,"Oh, women's health has been neglected.
• 14:59
  We've been getting-" Yeah"the short end of the stick.
• 15:01
  We have not been getting the same attention and research dollars and, technology poured into our problems as are being poured into other problems." And, I just had a friend yesterday say,"Yeah, I just went there for my first mammogram, and I looked at this contraption, and I was like, this is all you got?
• 15:16
  You couldn't-" come up with anything more com- more comfortable or high tech for us, after all this time?" So I think there's this perception of oh, this has been around forever there's gotta be something better.
• 15:27
  Yeah.
• 15:27
  I hear that one a lot, where it's like- They're doing this horrific thing to us because they don't care about women, and that's why they haven't spent any time figuring out something better.
• 15:37
  I hear that a lot.
• 15:38
  And I understand where it's coming from.
• 15:40
  And, as we've talked about many times on this podcast, there's a lot of things in women's health that have been understudied and neglected, so I'm not saying it's not true.
• 15:47
  But it does particularly affect the views of mammograms and steer people towards the other options- Options, yeah or the other, the alternatives that are proposed, I will say, not options.
• 16:00
  The proposed alternatives, yes.
• 16:02
  So I also think there's just general growing concern about radiation exposure.
• 16:08
  This has been around forever.
• 16:09
  People in the'90s and'80s probably were also concerned about radiation exposure.
• 16:13
  But we just have so many devices now that- it feels as though cumulatively we're probably all getting radiated a lot more.
• 16:21
  So I think that just increases people's overall anxiety about adding other exposures to that list.
• 16:26
  And this comes up frequently with other interventions, especially it comes up with vaccines.
• 16:31
  But I think for a lot of people, the idea of being a perfectly healthy asymptomatic person and then going and doing something that causes you any level of harm, even if the evidence shows that the benefits far outweigh the harm, for some people that is just unacceptable.
• 16:47
  Like- Yeah why would I put myself at any risk of any complication if I feel fine, and it, this could potentially harm me?
• 16:55
  And so I think people are always looking for this sort of Goldilocks perfect solution, which is like give me the thing that's gonna detect the cancer but won't have any risks, and will be perfect all the time, and will not harm me, and will have no radiation which is where the proposed alternatives jump right in and say,"That's us." And then we've talked about this a lot, but general distrust of the medical establishment since the pandemic.
• 17:19
  Yeah.
• 17:19
  Feeling like,"Oh, if we couldn't trust their recommendations at that time, can we trust this recommendation?
• 17:24
  How do we really know that's the right thing to do?" I think also there's this, and like I alluded to earlier, there's like that deeper cynicism of this is all financially motivated.
• 17:33
  The doctors are doing this to, to make money on the mammogram.
• 17:37
  You're welcome to ask your PCP or whoever orders your mammogram how much they make from it- and they will start laughing.
• 17:43
  So I'm not gonna spend too much time talking about that claim, but I think that is a claim.
• 17:46
  Yeah.
• 17:47
  This idea that we're just too, as a medical community, we're just too bought in and too invested and too ingrained to believe that this is the only thing, and that's why we're just not open to other options and this is what we think is right.
• 17:58
  Yeah.
• 17:58
  I also think especially with all the wellness commodification and the rise of all the Medicine 2.0 and 3.0 and biohacking, there's kind of this general perception that whatever your insurance covers is this low-tech, cheap, antiquated- crappy option.
• 18:11
  And what you can get outside of that in the non-standard- channels is maybe more cutting edge and more safe and more effective, but just expensive, and that's why your insurance doesn't wanna let you have it.
• 18:24
  Yeah.
• 18:25
  And then I think, and I think this is a really big one, there is the issue of dense breasts.
• 18:31
  So it is now required for radiologists to put on their reports when they see that a woman has dense breasts to report that, and to put a disclaimer that basically says mammography has reduced sensitivity in dense breasts, so we can't detect cancers as easily in this, this type of breast tissue, and that dense breasts are associated with a higher risk of cancer.
• 18:55
  But there is no universally agreed upon guideline about what to do with these women, and even insurance will vary plan to plan on what they would be willing to cover for some of these women with dense breasts.
• 19:08
  And so it's kinda left up to the patient and whoever the ordering doctor is to decide what to do with that.
• 19:14
  It goes in the shared decision-making bucket, which I hate it when things are in the shared decision-making i- I'm happy to have the conversation, but also just"I wish there was a clearer answer of what was the-" Yeah"right thing to do." So I think w- and, ah, I forgot the statistic, but a pretty significant Do you know what, what percent of women have dense breasts?
• 19:33
  I actually don't, but I know obviously we're doing mammograms younger than we used to, and the younger you are- Yes the more likely your breast tissue is dense.
• 19:42
  Yeah.
• 19:42
  Yeah, I actually don't know the actual stat.
• 19:44
  I, obviously it's gonna vary per age group.
• 19:46
  I wanna say it's 20% but it Yeah, you're right.
• 19:49
  Pr- by decade of life it probably varies- Yeah quite a bit.
• 19:52
  But it is a significant number of people.
• 19:54
  That is not a co- uncommon thing to see on a report.
• 19:56
  No.
• 19:56
  I see it on half of my breasts.
• 19:57
  Yeah.
• 19:58
  Pretty, so- Anecdotally it's a lot.
• 19:59
  Anecdotally a very high percentage.
• 20:01
  But we have young patients, I guess- We do.
• 20:03
  We do compared to most of the population.
• 20:04
  So I think this just leaves a lot of women feeling scared and confused and thinking"Oh my God, I have this thing.
• 20:10
  I have increased risk for cancer.
• 20:12
  I The scan, the normal scan that they're telling me to do every year is apparently not that good for this." What do you, what am I supposed to do?" Of course I am gonna go, looking for alternatives and questioning this and, you know- trying to find information.
• 20:25
  Yeah.
• 20:25
  So those are all the things I came up with.
• 20:26
  Do you have anything to add to that?
• 20:28
  No, I think you, you covered all the things that I commonly hear as, sort of objections or even just discussions.
• 20:37
  I think it's one of those things where it's, out in the ether, and then it enters people's heads about"Oh, I didn't think about this before," and now, like of course, once you click on the content and you watch the whole video, you get more videos- Yeah of the same thing.
• 20:51
  I know I'm really scared about what might come next.
• 20:53
  Yeah, your algorithms are gonna be really screwed up now.
• 20:56
  Okay.
• 20:56
  Honestly though, this is another update that I wanna talk about.
• 20:59
  We'll have to talk about it later.
• 21:00
  I deleted Facebook and Instagram from my phone.
• 21:04
  Yay.
• 21:04
  Just straight up deleted, not deleted the link or the shortcut, but deleted, said,"Delete the data.
• 21:10
  I do not want it." So the accounts still exist, but the app is really gone, yeah.
• 21:14
  Isn't it wonderful?
• 21:16
  It is, but my, eyes and my fingers are bored, so they're like trying to find other- Yeah anyway, separate conversation.
• 21:21
  Okay, let's move on to the nugget of truth.
• 21:25
  Mammograms are not perfect.
• 21:27
  There's basically no screening test that is perfect, and they have risks and potential harms, just like any other medical intervention tool.
• 21:37
  So for the people who say,"That's fine, make a vaccine.
• 21:40
  Just make 100% safe vaccine," or,"Fine, make a test.
• 21:43
  Just make 100% sensitive, 100% specific test," it just does not work that way.
• 21:48
  That is just not the real world.
• 21:50
  And yes, it is not a perfect test.
• 21:52
  It is not 100% sensitive.
• 21:53
  It is not 100% specific, and it comes with risks.
• 21:57
  Mammograms can be uncomfortable.
• 21:58
  We've already talked about that.
• 22:00
  That is a fact.
• 22:01
  And then this is the big one.
• 22:03
  Mammograms do expose you to ionizing radiation, and it is also true that there's no 100% safe dose of radiation.
• 22:13
  We don't have a lower limit where we're like,"Okay, at this level, the radiation is completely harmless." We know that radiation has dose-dependent risks.
• 22:22
  So as you go up in the amount that you're exposed to, your risk of cancer increases.
• 22:28
  Now, there are certain thresholds that are now used clinically as sort of general guidelines about how much radiation exposure carries significant risk.
• 22:40
  And then two other things actually I should mention before that is that women do appear more sensitive to radiation risk than men, especially young women, and then breast tissue is exceptionally sensitive to radiation exposure.
• 22:51
  So this is a very relevant conversation to be having for this particular screening.
• 22:55
  The deep dive on radiation exposure I will cover in the section on context and nuance.
• 22:59
  But for now, let's just suffice to say that there is radiation exposure, there is probably some risk associated with the radiation exposure, and women and breast tissue are particularly vulnerable, so it is a legitimate thing to be concerned about and to look into.
• 23:15
  Next nugget of truth is that there is very legitimate debate, even among the medical community, about what is the ideal frequency and starting age for mammogram screening.
• 23:28
  So there are some societies that say start at 40.
• 23:32
  There are still a couple that say start at 50, and then there are some that argue for yearly screening, and then there are some that argue for biennial, which is every two year screening.
• 23:41
  So just to give you a brief overview the US Preventative Services Task Force, USPSTF which is my favorite of all of these organizations used to say that you should do every other year screening for patients who are average risk between age 50 and 75, and they used to say between 40 and 50 that was shared decision-making.
• 24:03
  You could offer it to them and talk to them about the risks and benefits, but they could decide, because in that age group, the data was not as strong.
• 24:10
  In 2024, they actually updated it to say start every other year screening at 40.
• 24:16
  ACOG, which is our big society of OBGYNs, says to start at 40, and says do it every one to two years, so they still leave a little bit of room.
• 24:25
  NCCN, which is our big cancer network, and ACR, which is I think the Society of Radiologists, and the Society of Breast Imaging all say start at 40, repeat yearly.
• 24:36
  They are the most aggressive on the spectrum, and then USPSTF is probably on the other end of the spectrum.
• 24:42
  In case you're curious, Canadians, I guess in Canada, they recommend against screening between 40 and 49, so that is not standard there.
• 24:49
  In Europe the guideline I saw says that they start at 45, and between 45 and 50 they'll do every two to three years, and then starting at age 50, it's every other year, so every two years.
• 24:59
  And of note, there has been a general shift over the last few years towards earlier screening age, but this hasn't actually been based on any new trial data.
• 25:09
  It's really just based on increasing incidents of breast cancers in the 40 to 50 age range.
• 25:14
  Similar thing happen, happening with colon cancer.
• 25:17
  But it's obvious from looking at these recommendations that it's not a slam dunk, it's all settled everyone's on the same page.
• 25:23
  There is clearly some debate still about the merits of screening between 40 and 50.
• 25:29
  I just wanna update that.
• 25:31
  I just, as you were saying about Canada, I was like,"I wonder what the UK is,"'cause, and, as I've probably talked about before, I'm from Scotland, and so I'm always very interested in what's happening in the NHS.
• 25:39
  Yes.
• 25:40
  So in the UK, the NHS breas- breast cancer screening program is available from 50 to 71 every three years.
• 25:49
  Oh, wow, okay, so they really space them out.
• 25:52
  Yeah.
• 25:52
  And I always like to look at the UK because- Part of this is a cost-benefit analysis.
• 26:01
  And we can have arguments as to whether that is fair or appropriate for an individual.
• 26:11
  Obviously, this is for average risk people, okay?
• 26:13
  But, it does, call into question they're weighing patient outcome versus cost, right?
• 26:19
  And so I think it just adds to the conversation.
• 26:21
  So anyway, I'll, I'll- yeah.
• 26:23
  So- I just wanted to slip that in there since we were talking about times.
• 26:26
  But yeah.
• 26:26
  No, that's helpful,'cause it shows how broad the range is in terms of- Yeah what the recommendations are.
• 26:31
  But your argument is that in the UK, they're probably weighting the cost relatively higher than what we are weighting it.
• 26:38
  And so with- contained resources, they're like,"Okay, what's the maximum benefit we can achieve while still maintaining a reasonable cost and resources or overall spending?" So that encourages them to do slightly less than we do, or- Yes yes.
• 26:53
  And, and I think it also it plays into this concept about financial incentives.
• 26:58
  Because the NHS is financially incentivized to spend less money on things.
• 27:04
  Versus in a fee for service, private-based system, there is financial incentive to do more things.
• 27:12
  And so I think it's just a- An interesting conversation, and I think it's particularly interesting that the radiology-based organizations have the most frequent- Desire for- early recommendations.
• 27:25
  Okay.
• 27:25
  There's legitimacy to people's discussion of financial incentives is all I'm trying to say.
• 27:31
  Yes.
• 27:31
  But an important distinction to make is I feel like when people talk about this whole thing about doctors ordering things for financial gain, the individual doctor that is sitting across from you and having this conversation about whether you should or should not get a mammogram typically has no stake in- Yeah, absolutely in the mammogram.
• 27:49
  And what- whatever downstream stuff happens they get nothing from that.
• 27:53
  When people use this financial argument I always encourage them to think about how many people and how many countries and how many societies would have to be in on this, you know- Yeah.
• 28:02
  to really make it a thing, it's just hard to fathom that we all would be on board with this.
• 28:09
  Contrary to what people, perpetuate, there's plenty of doctors that are also independent thinkers and would like to not just- Yeah blindly follow a guideline and, will look into these things.
• 28:19
  Anyway, so yes.
• 28:20
  And it is shared decision-making.
• 28:22
  That's the other thing.
• 28:23
  It's not like what the doctor says goes.
• 28:25
  Yes.
• 28:25
  It's a conversation.
• 28:26
  So I also think the other important thing to take into account when we're saying"Okay, who's making these recommendations and should we-" weigh our trust of them based on who it is.
• 28:36
  Again, with radiologists, they wanna do more imaging, right?
• 28:38
  However, also they are the ones seeing all the really bad outcomes.
• 28:43
  Like- Yes if you are consistently seeing breast cancer day in, day out on- Yes mammograms- Yes you are going to be more concerned about"I wanna make sure we're catching this early,"'cause I'm sure they see all kinds of invasive cancers that- Yeah could have been caught earlier had a mammogram been done earlier.
• 29:02
  So I think it's also, we have to consider not only is there a financial incentive, but also an emotional- Bias, yeah discussion of"This is really serious and I hate to see it.
• 29:12
  It hurts- Yes me every time, and so I want more women to not experience this." So I think, it's not all about finances, and certainly every mammogram I order c- g- gives me zero dollars.
• 29:23
  In fact, it usually- gives me more work because- you gotta call and follow up- Because I have to yeah, there's yeah and send the next order, yeah.
• 29:28
  So it's it's actually like- I know Work per payment is more for that.
• 29:33
  So- I remember when it was y- for a long time I was very diligent about, okay, between 40 and 50 I have this long conversation with people- about like what it...
• 29:42
  And I remember one time talking to my OBGYN about it, and she was like,"Oh no, everyone's getting it at 40.
• 29:48
  Everyone is getting it at 40, and they're repeating it every year." She's like,"I just see way too many women in their 40s diagnosed with cancers." And that's exactly what you're talking about, of that bias of she is seeing these young, healthy, vibrant women get diagnosed with something terrible.
• 30:02
  And she's not in the room all those times that somebody has a biopsy and it's benign, and they were stressed- Yeah out for, you know- Yeah three weeks, and they have an infection in their biopsy site or, whatever.
• 30:13
  She's thinking of the people that, s- could have been missed if she was not ordering those.
• 30:18
  And so- Yeah yeah, I think that's really part of why you see some of that variation from specialist to specialist, and that's honestly, that's why I like the USPSTF,'cause to me it feels like they're not on like any particular side.
• 30:30
  It feels like it's a more independent- Yeah organization- I agree looking at all the data.
• 30:35
  'Cause yeah,'cause the, the NHS person making the rules is not the one sitting in the room with the patient- Yes.
• 30:40
  talking about this.
• 30:41
  But ACOG and the radiology s- we're the ones, they're the ones sitting in the rooms seeing this happen to people and having these conversations with people.
• 30:49
  And so I think that's also a bias, right?
• 30:51
  If you don't have- Yeah the discussion with patients and you're only looking at cost, that's, that is also a bias.
• 30:58
  So anyway, I just think it's important to see all sides, and it's not obviously just about the money.
• 31:02
  The differences in these recommendations have a lot more to do with other things than just financial incentives.
• 31:08
  Yeah, I will tell you like the few times that I have had a bad finding, on a mammogram for a patient- The first thing I look at is when was the last mammogram, and if, if I see something like, oh, it was two years ago, I will internally have a little bit of oh, maybe I should've been on them and been like- Yeah Like it's- Like, call them every month until they- Yeah.
• 31:27
  You feel guilty, right?
• 31:28
  You feel guilty.
• 31:28
  You feel oh my god.
• 31:29
  You hate them cancer, but you do.
• 31:30
  Yes.
• 31:30
  You feel like, oh my gosh, could I have done something different?
• 31:33
  'Cause it's hard to see someone suffer, and- Think you could've done something differently you're not in control.
• 31:38
  Yeah.
• 31:39
  Yes.
• 31:39
  But we always are gonna be looking like,"Oh my gosh, what could I have done differently to prevent this outcome?" And also delayed diagnosis is the thing that PCPs in particular get sued for all the time.
• 31:51
  So I'm just gonna throw that in there, particularly in the US.
• 31:53
  That's, I think, why a lot of doctors also may be a little bit more rigid about doing it earlier and doing it more often, because if you don't catch the diagnosis, that is the most likely reason for you to get sued.
• 32:04
  So we have a very- Yeah malpractice-based approach to a lot of things in the US.
• 32:11
  Yeah, unfortunately.
• 32:13
  Okay, so let's move on.
• 32:14
  We already started getting a little nuanced,'cause- Yeah we just can't help ourselves.
• 32:18
  Yeah.
• 32:18
  Okay.
• 32:19
  All right.
• 32:20
  When I'm editing these episodes, I'm like, we are so nerdy.
• 32:22
  Sometimes- I'm editing the episodes and, one of us is like,"Okay but was it randomized, and was it-" blinded, and who was counting the acne lesions?" We're, such dorks.
• 32:32
  But anyway.
• 32:32
  We are dorks.
• 32:33
  That's how we ended up here.
• 32:34
  So anyway.
• 32:34
  Okay what are the facts with context and nuance in this situation?
• 32:38
  So let's first talk about the radiation, okay?
• 32:41
  The radiation is a big one.
• 32:43
  It's the elephant in the room, okay?
• 32:45
  So the exact amount of radiation that you get from a mammogram actually depends a lot on the type that you have.
• 32:52
  2D, 3D, with digital tomosynthesis, screening, diagnostic, they're all gonna have slightly different amounts.
• 32:59
  The amount of radiation is between one and 10 milligrays, but I did not know this other term, millisieverts.
• 33:07
  Millisieverts or sieverts?
• 33:08
  Do you have any idea what that one is?
• 33:09
  I have no idea.
• 33:10
  I've literally never heard that one before.
• 33:11
  Okay, all right.
• 33:11
  We're out of our realm already.
• 33:12
  Okay.
• 33:12
  Anyway, I'm gonna call it I'm gonna call it sievert, millisieverts.
• 33:17
  I don't know.
• 33:17
  But millisieverts is actually the metric that we use to quantify biological harm from radiation, because it takes into account tissue weighting factors to give you a better sense of, how much is absorbed by that tissue.
• 33:31
  Screening mammography is 0.4 millisieverts.
• 33:36
  In the US, we are exposed to three millisieverts of background radiation in a year, just from living our lives.
• 33:45
  So a mammogram is equivalent to six to seven weeks of living your life and absorbing background radiation.
• 33:52
  I tried to look at other reference points to try to give a better sense of scale with this, but there's variation in what people report, not so much about mammography, but about all the other tests.
• 34:02
  Like- for chest X-rays, the range of how much millisieverts you get from a chest X-ray was, like, between.02 up to.1, which is kinda that's a big range.
• 34:12
  So the American Cancer Society says that four chest X-rays is the equivalent of a mammogram.
• 34:18
  But then I found other sources that said one mammogram was, like, 20 chest X-rays, depending on...
• 34:22
  The mammogram part didn't change, but depending on what you think the dose is from the chest X-ray, which I think depends on exactly the equipment you're using and- Yeah, I would imagine whether it's one view, two view, all the different things.
• 34:34
  Yeah.
• 34:34
  Radiologists can comment here and tell us if we're wrong.
• 34:36
  Yes, you can tell us.
• 34:38
  You can be smarter than us on this.
• 34:40
  And then an abdomen pelvis CT is somewhere between seven and 10 millisieverts.
• 34:45
  So a mammogram is 25 times less than what you would get from CTing your abdomen and pelvis, So if you think about a woman who's doing a screening mammogram yearly from 40 to 75, that's like somewhere between one and two C- the equivalent of between one and, one and two CTs of her abdomen and pelvis, okay?
• 35:06
  So that's to give you a, a sense of, how much radiation is in a mammogram.
• 35:09
  Now, what amount of radiation is safe?
• 35:13
  This is a hard question to answer because first you have to just think about what does it mean to say something is safe?
• 35:20
  Yeah.
• 35:20
  Is driving to your job safe?
• 35:22
  Is a trampoline park safe?
• 35:24
  Is taking aspirin safe?
• 35:26
  Safe is not really like a black or white thing.
• 35:28
  Yeah.
• 35:28
  And it is true that there's no 100% safe dose of radiation, okay?
• 35:34
  It appears that there is a very dose-dependent relationship, and while very small doses probably have a very small risk associated with them, we cannot say that the risk is zero.
• 35:44
  So when you're talking to like an in- individual patient who's thinking about this study, like the increased risk of a screening mammogram is tiny.
• 35:53
  It's minuscule.
• 35:54
  It's impossible to even quantify for them and it is easily outweighed by the benefits, which we'll talk about later.
• 36:01
  And typically for most scans that would have, or even a CT that has much more radiation, the harm of missing the diagnosis that you're trying to investigate with that is typically worth whatever small amount of radiation exposure you're getting from it.
• 36:16
  Okay?
• 36:17
  But when you look at cumulative radiation in a bigger population, so millions of women being screened with mammograms, then you do start to see some trends.
• 36:25
  Okay?
• 36:26
  So when r- radiation exposure from, all imaging studies is plotted out in epidemiological studies, so like big population studies, we start seeing an increased cancer risk around 50 millisieverts at a single exposure or 100 millisieverts over a prolonged period or your lifetime.
• 36:45
  So again, screening mammogram is like 0.4 millisieverts.
• 36:51
  Okay?
• 36:51
  And we're talking about 50 at any one time or 100 over a long period being where we see a clear divergence of the lines where you see increased risk happening for cancers.
• 37:03
  Okay?
• 37:03
  So even if you did a screening mammogram every year from 40 to 80, we're talking about 16 millisieverts, so well below this threshold that we think leads to some significant risk.
• 37:16
  Okay?
• 37:17
  Does that mean the risk is zero below those thresholds?
• 37:20
  No, probably not.
• 37:22
  It's really hard to quantify, and the only way you can estimate that is to extrapolate from the bigger population long-term data that we have on the higher doses and assume that there's a linear relationship at the lower doses, and then use that to tease out some estimate of what this might be.
• 37:41
  And you can imagine, all the methodological problems that would come with studying this.
• 37:46
  So if you're looking at a bunch of people and you're like,"Oh, these people who had 10 CT scans had a much higher rate of leukemia," immediately your next question should be like why was that person having 10 CT scans?" Is it because- they already had some other cancer?
• 38:00
  They...
• 38:00
  is it because they were already just very ill in, in a different way?
• 38:03
  Is it because they were, having frequent contact with the healthcare system and had other...
• 38:06
  there's so many confounding factors in those types of epidemiological studies, and there's not a lot of RCTs where they're, like, voluntarily radiating people with CTs, you know- Yeah, no in a randomized controlled fashion.
• 38:18
  Yeah, no, no one's gonna be doing that.
• 38:19
  It's just a very hard thing to really isolate and to give hard numbers to.
• 38:24
  But there are several studies that have attempted to model this out, to give some estimates about how many additional cancers we might be seeing that are radiation induced and comparing that to, how many cancers are we diagnosing and preventing from proceeding to death, okay?
• 38:42
  So I feel like in the anti-mammogram content, the people who talk about this act as though they're, the first people that have ever thought about this.
• 38:52
  I have to remind you right now and myself that we have a rule of no snark on this podcast, so I just, I'm saying it mostly for me, okay?
• 39:00
  But they often present it as though they're this whistleblower and this truth teller, and they are the first people who have thought of this idea that"Whoa, we're radiating all these women.
• 39:10
  Maybe there's something wrong with that," and that's not really the case.
• 39:13
  There have actually been multiple studies, trying to model this out and determine okay, how many cancers that we see are likely induced by the radiation that we are giving people in the form of mammography?
• 39:25
  So the most robust of these studies is by Miglioretti et al.
• 39:30
  And it was from 2016, and they estimated that for the US pop- This was all modeling, okay?
• 39:36
  This was not real people.
• 39:37
  Yeah.
• 39:37
  This was just math, okay?
• 39:39
  And statistics.
• 39:40
  So they said for a US population of women aged 40 to 75 who were screening every one to two years, there would be approximately 125 radiation-induced cancers in that group, and 16 deaths.
• 39:54
  That was their estimate.
• 39:56
  The estimate of cancer deaths prevented through screening was 968.
• 40:03
  So their conclusion was, yes, there is likely a very small number of radiation-induced cancers that arise because of the radiation exposure of imaging, but, and an even smaller percentage of those are actually gonna lead to death, but compared to the number of deaths that are averted by doing and implementing the screening program it is minuscule.
• 40:31
  And there has actually been several other modeling studies that found similar conclusions, and obviously these numbers need to be taken with a heaping spoon, and not even a grain, like a spoon of salt because they're mathematical models and they're projections, and, cancer is multifactorial.
• 40:47
  And the way these models work, it's not like you can point out like,"This particular case was radiation-induced," and- Yeah"this particular case was not." It's just they're trying to compare based on what they know about risks the increase in risk from these exposures.
• 41:01
  Okay, before I move on, thoughts on that?
• 41:04
  Questions on that?
• 41:05
  Tell me what you're thinking.
• 41:05
  So this study was just looking at radiation from mammograms- Yes not imaging as a whole.
• 41:10
  Okay.
• 41:10
  Yes.
• 41:10
  That was my main question because that obviously makes a difference.
• 41:14
  But yeah.
• 41:14
  Okay, I think obviously it's a model, but I think this is a concept that's a little bit hard for- people to wrap their mind around because, like you said, it's like any amount of harm, why would I do this thing?
• 41:29
  But there's the- opportunity co- or not the opportunity cost, but that's the only word I can think of to describe this, of if we don't do it, this is the harm.
• 41:36
  And I think- I think that is- Yeah opportunity cost.
• 41:38
  Yeah.
• 41:38
  Okay.
• 41:39
  Okay.
• 41:39
  Economics words.
• 41:40
  But anyway that is a a concept that's really difficult to get behind'cause as you said, it's why would I take on any risk if I feel fine?
• 41:48
  But what are you risking by not doing it?
• 41:50
  And that's- it's just really hard, I think, for people to wrap their mind around that concept because it's just the risk of anything, like why would I do that on purpose?
• 41:59
  It just doesn't make sense.
• 42:00
  Yeah, and I think it's hard to absorb the idea that they can give you this number of 125 cancers, but it's impossible to say,"Oh, you had mammography for 20 years and then you had a cancer.
• 42:13
  That cancer was induced-" Yeah"by radiation." We're not talking about individual people or humans or- cases.
• 42:20
  We're talking about in a population of this size, we would estimate that this many cancers happened on their own, and we would estimate that this many happened because of the, the technology that we used to look for them.
• 42:32
  And yeah, I think this echoes in a lot of ways, the vaccine- Yeah.
• 42:36
  It does conversation.
• 42:36
  It really does.
• 42:37
  Which is just like you are taking on, at a population level, a very small risk; for a population level, a very large benefit.
• 42:46
  But when you're looking at the individual benefit to you, it's hard to, it doesn't feel tangible.
• 42:51
  Yeah.
• 42:52
  And- There's not a way to quantify it.
• 42:53
  Yes.
• 42:54
  And if you are of the belief that this thing causes cancer and you get a cancer, there's no way to tell you it is definitively not or it definitively is or it, it's- Yeah it, it-'cause these are epidemiological numbers, so the, this, this whole thing that we just talked about the radiation exposure is a very big talking point in the anti-mammogram ecosystem because you cannot argue that, mammograms don't have radiation.
• 43:18
  You cannot argue that radiation is not associated with cancer risk the natural consequence of that is okay, some cancers are likely arising as a result of mammography on a population level, and like I said, I think they often conjure up this image of a beautiful, vibrant, healthy young woman who has nothing wrong with her and feels nothing and doesn't have any lumps or bumps and just goes for this thing that is now increasing her risk, and I think when someone hears that information they listen to the type of podcast I listen to, and they go to their doctor and they say,"What do you think about this?" I actually looked up I looked up these alternative modalities in some of our physician groups to see,'cause I'm sure, radiologists and oncologists and people who are really deep in these, these fields have things to say about them.
• 44:00
  Yeah.
• 44:00
  And, the most common response was, you just have to respond that mammograms are safe and effective and they save lives.
• 44:07
  That was, the most common.
• 44:09
  Mammograms are safe and effective, they save lives, period, end of story.
• 44:12
  And we're gonna keep talking about all the nuances of this, but I just wanted to stop and make the point that I understand why that's the line, and, let's, I get where that that, the motivation to just say that and end the conversation is coming from.
• 44:26
  But I really think when we do that, we are not acknowledging their ability to hold nuance or their- intelligence or, their very reasonable concern.
• 44:39
  And I think this is where polarization from social media and just general polarization of humanity starts trickling in, because I know there are doctors that are gonna say,"You should never say anything else.
• 44:49
  You should just be saying that." Yeah.
• 44:51
  "Because if you say anything else, you are introducing doubt and skepticism.
• 44:55
  You are leaving room for them to be confused.
• 44:57
  You are hedging and kinda making it seem like you're unsure if it's a good idea." Yeah.
• 45:02
  I can feel already the DMs and emails that are going to accuse, me of seeding doubt about- Yeah the safety of mammography for just saying what I just said in the last few minutes.
• 45:14
  So I don't know.
• 45:15
  Give me your feelings on what you think about this.
• 45:16
  Yeah, the doubt has been seeded, right?
• 45:18
  Yes.
• 45:18
  You're not seeding the doubt.
• 45:20
  The doubt has been seeded, but I think, going back to the vaccine comparison There is a very consistent, simple message that is clear from most doctors about vaccines.
• 45:33
  And as we have seen, that hasn't worked out so well.
• 45:36
  Yeah, you, it and like you said, for someone who's having this question, it does feel very insulting to be like,"That's stupid.
• 45:43
  This is the answer." That's just, no one's gonna take that well, and I think, I've personally had patients tell me that they appreciate when I say I don't know something, or when I acknowledge that there's some uncertainty.
• 45:57
  And this is not a case really where it's necessarily uncertainty, but it's just We're weighing, yeah, weighing risk and benefit.
• 46:03
  We're acknowledging that there's some risk, but this is the potential benefit.
• 46:06
  And, I think we've almost kinda lost that battle with vaccines'cause we- started too late on the nuance.
• 46:12
  And this is a place where I think the nuance is really important to discuss, and that's, that's part of shared decision-making, right?
• 46:19
  It's not a shared decision if you're just like,"This is what you need to do." That's not sharing.
• 46:24
  Okay.
• 46:24
  So yes, I agree, and I hope that my colleagues who still believe that is the only appropriate response can at least see our goal is to not lose people's trust- Yep in the conversation when they're, th-'cause if they come to you asking about it, they're opening a door.
• 46:42
  It is like a bid for you.
• 46:43
  Yep.
• 46:43
  And if you're slamming the door shut immediately, I think it just it's, you're likely to lose them to someone who's gonna talk for 45 minutes about how scary this thing is and that your doctor never mentioned it to you.
• 46:57
  Yeah.
• 46:57
  Okay.
• 46:57
  So let's move on now to an even more sophisticated question which is, are mammograms actually preventing cancer deaths, or are they just diagnosing more cancers?
• 47:09
  So I think most people, even the critics of mammograms, would agree that mammograms find cancers.
• 47:16
  They do find cancers, they're good at finding cancers.
• 47:19
  Opponents believe that they're finding too many cancers, and a lot of the cancers that they're good at finding are indolent or non-aggressive, and they would never have affected this person's life, but now we have made them a cancer patient and put them through additional testing, possibly treatment, possibly surgery, things that significantly affect the quality of their life even if it's a positive, actual cancer diagnosis, but that would not have actually caused them much harm or significant morbidity in the long run.
• 47:47
  Often what they're referring to is DCIS or ductal carcinoma in situ which by definition is non-invasive but can progress to an invasive cancer, and the rates of its progression are really variable depending on the pathologic characteristics of that lesion.
• 48:05
  So if it's a low-grade lesion, 9% may progress to an invasive cancer.
• 48:10
  If it's an intermediate or high-grade lesion, up to 40% may progress to a invasive cancer.
• 48:16
  It's this- Category of cancer/pre-cancer that mammography is really good at finding and ultrasound, for example, with no radiation is not as good at finding.
• 48:27
  But it's also got this indolent course and variable invasiveness.
• 48:32
  And there is legitimate debate even in that, in terms of what is the ideal management of that condition.
• 48:38
  And so that's often what they're talking about when they're saying,"Oh, it's catching all these kind of insignificant things that are not gonna affect the person's life." So there are many studies showing that mammography significantly reduces breast cancer mortality, so that is likelihood of dying from breast cancer.
• 48:58
  Interestingly, a lot of those same studies don't show that there's a reduction in all-cause mortality when they implement mammography or when you compare people who have been screened with mammography versus people who were not screened with mammography.
• 49:12
  We're gonna come back to the all-cause mortality question,'cause that is also a big talking point in the anti-mammogram ecosystem.
• 49:18
  I have a lot of thoughts about that, so I'm glad we're gonna come back to it.
• 49:20
  Yes.
• 49:21
  Don't worry, we're gonna talk about it at the end.
• 49:22
  First I'm gonna cover this whole idea of breast cancer mortality.
• 49:26
  So all these studies show, yes, reduces breast cancer mortality, yay.
• 49:30
  The biggest critique of that data, again, I feel like these people are always acting like they're the only people that have ever considered this, but they say the mortality data looks good because you're diagnosing all these low-grade cancers and then you're treating them with surgery and radiation and hormone therapy, and then you're patting yourself on the back saying,"Yeah, we did a great job," and you're recording it as a person with a cancer diagnosis and a person with successful treatment, a death averted.
• 49:56
  But we don't know, maybe that never would've killed them or become invasive, and we're over-diagnosing it and over counting it.
• 50:04
  You're inflating the denominator here by diagnosing all these cancers, this over-diagnosis, and then you're artificially making the mortality or the rate of death go down because these people live really long anyway,'cause they never had a very aggressive cancer.
• 50:20
  And then, the screening tool that we have is the best at finding the most indolent, most slow-growing cancers, and so that's something called length time bias.
• 50:32
  And then all these people get diagnosed really early when they're young, and they have this thing that wouldn't have killed them anyway, and then they live a long time, so then you have lead time bias.
• 50:40
  So basically they're arguing that there's all these biases that are happening that make it look like there's a reduction in breast cancer mortality, but the reduction is either nothing or very small because there's all these other biases introduced by- the type of screening and the way we do screening for breast cancer.
• 50:59
  Does that make sense?
• 51:00
  Yes, absolutely.
• 51:02
  So again, this has been looked at.
• 51:05
  They are not the first people to think about this, okay?
• 51:08
  Basically if you want to tease out, how much of this is that we're good at catching these very slow-growing cancers, and how much of this is that those people live a really long time and so that it artificially...
• 51:19
  Like, how do we tease that out?
• 51:20
  You look at different metrics.
• 51:21
  So if you look at the incidence of advanced or metastatic cancer, then, you would expect that if mammograms are good at detecting cancers in an earlier stage and halting that progression, you would expect that over time there's a reduction in the number of advanced or late-stage cancers that you find, okay?
• 51:40
  Yeah.
• 51:41
  So that number should be more meaningful.
• 51:44
  Trials do show that there is a reduction in advanced disease for women greater than 50, but not for women 39 to 49.
• 51:53
  And the ECIBC, which is the big European breast society similarly found that advanced cancer incidence came down for ages 50 to 74 with mammography, but not for ages 40 to 49.
• 52:08
  So this is part of why there is debate about that particular age range of the 40 to 50-year-olds because when you look at this metric, which really should eliminate some of the other biases, it's harder to see the benefit, yeah.
• 52:22
  There was also a 21, this was more recent, a 21 country European study, and they just looked at over time the incidence of stage four cancers being diagnosed breast cancers being diagnosed and looked at, like, when that country introduced screening regimens.
• 52:36
  And they saw that introduction of screening, did reduce the incidence of stage four cancers, and the data was strongest for women 50 to 69, so basically the same thing.
• 52:44
  Another way to try to eliminate some of that noise is to look at only fatal cancers.
• 52:49
  So look at only the cancers that killed a person within 10 years,'cause then you're weeding out all of the slow-growing wimpy cancers that just oh hung around and didn't do much.
• 52:58
  You're just looking at aggressive, terminal, fatal, killed somebody within 10 years of diagnosis, there was a study in Sweden with almost 550,000 participants.
• 53:08
  They found that when they did screening, there was a 41% lower rate of fatal breast cancer and a 25% lower rate of advanced cancer that they believe were independent of advances in treatment or other explanations, basically.
• 53:24
  And advances of treatment, in theory, would be applied to everyone in that screened or not screened, right?
• 53:31
  Yes yeah, so I mean- Yes it doesn't make sense that would be a factor.
• 53:35
  No, but this is just longitudinal, I think.
• 53:38
  Oh, so e- earlier on, the treatments were not as advanced as they are now.
• 53:41
  Yes.
• 53:42
  Okay.
• 53:42
  Got it.
• 53:42
  They're just saying,"We implemented this screening, and then this is what happened over time." And they tried to correct for advances in treatment that- Got it may have affected that.
• 53:52
  Okay.
• 53:52
  Got it.
• 53:53
  Okay.
• 53:53
  So- So just before we move on from here- Yes I feel like this conversation is very similar for the conversation around prostate cancer screening.
• 54:03
  Which was one of the...
• 54:04
  I mentioned my attending and residency this was, the big thing that we talked about in terms of overdiagnosis, because this is a big thing in prostate cancer where there are a lot of prostate cancers that you die with, not of, right?
• 54:19
  Yes.
• 54:19
  But there's a subset that are very aggressive that you can die of, right?
• 54:23
  And so similar to breast cancer, right?
• 54:25
  And the USPSTF screening guidelines for prostate cancer are shared decision-making- 55 to 69 and 70 and up is recommend against.
• 54:36
  And, the procedure of having a prostate biopsy is, I'm not gonna say- It's not fun It's not fun.
• 54:44
  A breast biopsy's not fun either, but it's- Y- you're saying this- I think that it's more- and you've had one.
• 54:49
  Yeah, and I haven't had one.
• 54:50
  But, you know- the way that a prostate biopsy is done- Sounds, yeah sounds pretty terrible compared to a breast biopsy.
• 54:58
  Again, never having had either of these things, I guess I can't- Yeah fully comment, but I have an idea.
• 55:03
  And I've had patients who've had both, right?
• 55:05
  And it's a different experience.
• 55:06
  I think I guess they shouldn't have both.
• 55:08
  They've had each of these.
• 55:09
  They haven't had both.
• 55:10
  Yeah.
• 55:11
  But, I think it, it's interesting the difference between those two recommendations, but I think, again, it goes back to weighing benefits and harms.
• 55:21
  And this is why it is a tricky topic.
• 55:23
  It's not a simple, straightforward thing, and that's the case with all screenings.
• 55:27
  And so we do have to- Weigh all of that, and there's a difference in risks and benefits between different procedures.
• 55:33
  Yes.
• 55:34
  So that's a big take home.
• 55:35
  I think just acknowledging, transparently that the science on women between 40 and 50 is not a slam dunk.
• 55:43
  It's not just"Oh, yes, it's settled, everyone agrees," clearly everyone does not agree, yeah.
• 55:48
  And I think that's really what shared decision-making is about.
• 55:52
  Exactly.
• 55:52
  And I really think it buys you a lot of trust with the patient to just acknowledge that and be like,"We don't know this thing yet.
• 55:59
  I really wish I had a clearer path for you to follow, but we just...
• 56:02
  here are the things we worry about with increased screening, here are the things we worry about with decreased screening." And this is where patient values I think- Yeah play a huge role, I have patients that I can tell you from a mile away are gonna be like,"Nah, I'm gonna do every other year." Like- Yeah"I am not going every year.
• 56:18
  I do not wanna do it." And then I also have patients that I- are gonna be like,"Is it a year yet?""Can I schedule yet?" Yeah.
• 56:24
  They're so anxious that something has grown.
• 56:25
  Yeah, they're like 39 and a half, it's like,"Can I just schedule it now?" Yeah.
• 56:29
  It's different, it is.
• 56:30
  And like you said, it's values, and we don't get to decide what the patient's values are.
• 56:34
  And we don't get to make decisions for people.
• 56:37
  We just provide them the information.
• 56:39
  And even the ones where it is strongly recommended, you still don't have to do it.
• 56:45
  It's not required.
• 56:46
  But you need to understand the risks and benefits and make an informed choice about that.
• 56:50
  And that's, I think, what the issue is with these things people are being fed by their algorithm, is it's leaving out some information- such that you can't really make an informed choice based on just that.
• 57:01
  Okay, so let's go back to that fact that you were excited to- Yeah call me out on.
• 57:05
  Okay, I was not gonna call you out.
• 57:06
  I was just curious to see what the research said.
• 57:09
  Okay.
• 57:09
  So basically the, all the breast cancer screening trials that we've done show no change in all-cause mortality, meaning the women who were screened versus the women who were not screened, or screening over time does not, seem to lower all-cause mor- like, death from any cause.
• 57:26
  It lowers deaths from breast cancer, but not deaths from any cause in general.
• 57:30
  Critics will take this to mean a couple different things.
• 57:33
  One is maybe you're reducing some breast cancer deaths, but you're just causing deaths by doing other things to them and causing them other harms, and maybe they're dying of a lymphoma or something else that was caused by the intervention that you gave them.
• 57:48
  Another theory that they have is that that deaths are being misclassified in a way- Oh that makes it look like somebody didn't die of breast cancer, but maybe they died of a complication of their breast cancer treatment.
• 58:01
  That's one of the theories, oh, yeah.
• 58:03
  This is like the whole COVID thing, where people thought- Yes were, forging death certificates to make the- Yes.
• 58:08
  COVID deaths seem higher.
• 58:09
  Yeah.
• 58:09
  Yes, which again, the idea of trying to make a death certificate look a certain way, it's just, it's hard for me to even wrap my- Yeah my mind around it.
• 58:16
  But- Death certificates are...
• 58:17
  They're a whole thing.
• 58:18
  It's...
• 58:19
  I would not say that it's likely that someone would be doctoring a death certificate.
• 58:24
  Th- so the response to this is most statisticians will tell you that the breast cancer screening trials are simply not powered to detect meaningful differences in all-cause mortality.
• 58:38
  So the reason being, a lot of women get breast cancer, but a much smaller percentage of women die of breast cancer,'cause we're good at treating breast cancer now.
• 58:45
  Yeah.
• 58:46
  So a 20% reduction in breast cancer mortality should theoretically result in a 0.8% reduction in all-cause mortality.
• 58:56
  But in order to power a study to detect that level of difference in all-cause mortality, it would need over a million participants, which is 10 times most of the trials that we have- Yeah and at least double a lot of the big studies.
• 59:11
  So their argument is that's not a, a metric that we should be meaningfully interested in for these studies- Yeah'cause that's not really what they're set up to find.
• 59:21
  Yeah.
• 59:21
  And just in case, for a person who's like they're just changing what they care about depending on what the answer they wanna find," no single cancer screening trial has ever been powered to show all-cause mortality.
• 59:35
  And so basically none of them have.
• 59:37
  The only exception is there was a randomized control trial for lung cancer screening, the low-dose CT, that did show- all-cause reduction in mortality.
• 59:46
  But they attribute that to the fact that there's just a far higher death rate in that particular cancer in that population.
• 59:52
  So- And that's a CT every year.
• 59:54
  That is a CT.
• 59:55
  So that's a lot more radiation.
• 59:56
  That is a lot of radiation.
• 59:57
  No one's complaining about that radiation- Yeah.
• 59:59
  all those poor smokers.
• 1:00:01
  Yeah.
• 1:00:01
  See, it's funny because that is when it's a 65-year-old man that's been smoking all his life, everyone's like,"Give him the CT." No one's arguing against that.
• 1:00:09
  Yeah.
• 1:00:09
  But then when it's a young vibrant woman, they're like,"No, you can't.
• 1:00:13
  You can't give her this mammogram." Yeah.
• 1:00:15
  So anyway I don't think there's a lot there.
• 1:00:18
  I'm curious what you think about that.
• 1:00:20
  Yeah, I think, like you said it's really difficult there's so many other things that kill people in this age range.
• 1:00:28
  And I think that's probably why it's so hard to power a study to catch this, because this is not the thing.
• 1:00:34
  When you look at the causes of death, breast cancer's not the number one, two, or three cause of death in women, right?
• 1:00:40
  We've got cardiovascular dis- there's all sorts of other things.
• 1:00:43
  And so you would have to have so many more people to differentiate- an all-cause mortality,'cause this is the age where all these other things happen.
• 1:00:52
  And so they're much more likely to be dying of these other things, and it's gonna be really hard to show that difference.
• 1:00:58
  So- pretty similar to what you just said.
• 1:01:00
  That was my immediate thought when you brought this up.
• 1:01:02
  Yeah.
• 1:01:02
  So it's funny because there's sort of this very anti-climactic response to that claim.
• 1:01:07
  Yeah.
• 1:01:08
  But they say it all the time.
• 1:01:10
  They're like, when your doctor says mammograms save lives, they're wrong because look at all these studies that show no all-cause mortality benefit, so it's just, that's very hard.
• 1:01:18
  That, again, these are, like, kinda complex epidemiological concepts- Yeah that's not easy for anyone to understand.
• 1:01:25
  It's, it takes some brain power for us to understand- Yeah and to talk about in a coherent way I can only imagine, what somebody with no scientific background and no epidemiological, context would try to interpret some of these things.
• 1:01:38
  Especially with a one-minute reel.
• 1:01:40
  Yes, it's just not happening.
• 1:01:42
  Okay, and also, and, of course they're gonna put all these PubMed links.
• 1:01:45
  They're gonna be like,"Look at every single screening trial that we have on breast cancer.""Look at the all-cause mortality." it is unchanged.
• 1:01:52
  Doesn't that mean we're just causing more problems than we're..." And just I don't think that's the answer at all, or the conclusion at all from all of those trials.
• 1:02:01
  But that's very compelling.
• 1:02:02
  Now, a point I wanted to make about this is- You know, the, all this data we just reviewed, everything we just went over, all the studies I read this afternoon, I- probably 98% of doctors have not read all of those studies- Yeah or looked at all of that data.
• 1:02:18
  Yeah.
• 1:02:18
  But you know what?
• 1:02:19
  That is not their job, Yeah Because we have societies.
• 1:02:25
  Like- Yeah my interpretation of this, I don't know, I did a little bit of public health as an undergrad and a little bit in my master's program, but I am not a biostatistician.
• 1:02:34
  I am not an epidemiologist.
• 1:02:35
  I'm not a cancer doctor.
• 1:02:37
  I am not a radiolog- I am very minimally qualified to be reading this.
• 1:02:42
  But the person on Instagram is almost certainly less qualified Yeah.
• 1:02:47
  Or maybe equal.
• 1:02:48
  Maybe equal-ish.
• 1:02:50
  My interpretation and my conclusions that I draw from this are less informed than somebody with more public health and epidemiology training- Right and more stats training.
• 1:02:58
  And so when you think about this, you should think"Okay then how should we figure out the truth?
• 1:03:03
  Let's get the smartest people in these topics together." Yeah.
• 1:03:08
  And make them look at all of this information, this research, and decide what it means for us and what we should do.
• 1:03:14
  And that is how guidelines are born.
• 1:03:17
  Yeah that is the USPSTF.
• 1:03:19
  That, that is how these societies come up with things.
• 1:03:22
  And there's still gonna be differences in opinion because the research is not clear on every single aspect of this, and so there's variation in that.
• 1:03:29
  But I take that almost as a positive thing.
• 1:03:32
  We're not all brainwashed and thinking the exact same thing, there is- Yeah internal debate.
• 1:03:35
  There is constant reassessment.
• 1:03:37
  There is update, updating of the guidelines.
• 1:03:39
  There is variation, among societies.
• 1:03:41
  So clearly, the Anyway, so the, i- if you're like,"Oh, but my doctor is not doing this deep dive," it's, I don't want you to say my doctor's doing something negligent or not doing the right thing." Yeah.
• 1:03:55
  This is hard.
• 1:03:55
  It takes a lot of time.
• 1:03:56
  And even to have this conversation with a patient once you've done it, takes a lot of time and is hard.
• 1:04:00
  And so anyway, that's a big part of the reason we're doing the podcast and we're trying to make this information easier and package it easier for both patients and clinicians, this is why guidelines exist, is to- Yeah to have people smarter and wiser and more knowledgeable in these subjects than us review this primary literature and this research, and give us their educated conclusions.
• 1:04:19
  Yeah, and that's I feel like there is a lot of criticism of"You're just following guidelines.
• 1:04:24
  You're not you don't really know what you're talking about." And the reason we have guidelines is because we rely on the people who have the most experience and understanding and ability to sit down and review all of this.
• 1:04:37
  And so the guidelines are really helpful.
• 1:04:39
  However, that doesn't mean that the patient has to do what the guideline says.
• 1:04:44
  When we're one-on-one in the room, we are discussing values.
• 1:04:47
  Like, how would you feel if you had an abnormal mammogram, had to go back for a biopsy, and then it turned out to be nothing, versus how would you feel if we didn't do it, and a year from now you feel a lump, and we then do a mammogram and an ultrasound, and now you have a more invasive breast cancer, right?
• 1:05:06
  These are the, actual situations that we can have a conversation with the patient about, and we're using the guideline to provide us with the background information and evidence.
• 1:05:16
  But it doesn't mean we're just blindly following it, because every patient is different, and it's just a way of us having that information to have that conversation.
• 1:05:23
  Yes, exactly.
• 1:05:24
  Exactly.
• 1:05:25
  And this is another example of a#dunningkruger effect, because I feel like a lot of these content creators who are very anti-mammogram will say but did your doctor look at the study?" And like- Yeah"I looked at the primary literature," and"Did you read the Swedish trial?" And"Did you..." And I'm okay, that's fine, but your reading of the Swedish trial is not more meaningful to me than, an entire panel of experts reviewing this and giving us guidelines.
• 1:05:49
  And to think that your reading of it is somehow superior or better or more informed- Yeah is just it's hard to rationalize.
• 1:05:57
  And I think they're also relying on you're not gonna go click on all those links and read it.
• 1:06:02
  Yes.
• 1:06:03
  Yeah, for sure.
• 1:06:03
  You're just gonna, you're just gonna take their assessment at face value.
• 1:06:06
  And I think it provides a lot of credence to what they're saying of"Look at all this stuff I read, and these are all the links, and you can check it out." But like actually no one's gonna go click on all those links.
• 1:06:16
  You're gonna scroll to the next thing.
• 1:06:17
  And so you can pretty much say whatever you want.
• 1:06:19
  And the other thing is you can cherry-pick studies- Oh, easily to support what you're saying.
• 1:06:23
  Very easily.
• 1:06:24
  And, we've talked before about like the strength of evidence behind a study.
• 1:06:27
  You can find weaker studies that show what you want them to show, but then we're looking at these huge studies and meta-analysis and all- Yeah of the things- Just leave out the ones that- The conclusion is different, and that is a much- Yeah stronger level of evidence.
• 1:06:39
  And so that's I think another problem is it's really easy to cherry-pick.
• 1:06:42
  And that's the other reason we do this, right?
• 1:06:44
  Is like we really try to look broadly at- Yeah all the available evidence, and look for the strongest types of evidence that we can use to have a nuanced conversation about it, versus"Oh, I found this one study with 30 people in it," And this is what it said.
• 1:06:59
  "And this is what it said." And it's yeah, you can put a PubMed link to that study and say the truth about what that study says, but does that really mean anything in the larger context of the body of research that's available?
• 1:07:11
  So let's move on.
• 1:07:12
  So now we've talked about, we've covered like do mammograms cause breast cancers?
• 1:07:18
  We talked about do they help reduce the risk of dying from breast cancers?
• 1:07:21
  We've talked about the problem of over-diagnosis.
• 1:07:24
  But now let's just talk about over-testing and over-diagnosing, because even when the radiologist sees something, they tell you to come back, they do an ultrasound, they do a diagnostic, then they do a biopsy, and then they call you and say,"It's benign," and everyone celebrates and it's a happy ending, there is harm in that whole scenario.
• 1:07:44
  There's emotional harm, there's physical harms, there's potential complications.
• 1:07:48
  There's financial harm potentially.
• 1:07:50
  So how often does that happen, and how do we quantify that in order to measure it against the benefits?
• 1:07:56
  I think that is almost an impossible task, the quantification part.
• 1:07:59
  But- Yeah I think just going over a few numbers about how often these things happen is probably the most helpful information we can give, and I think it's probably the most helpful when you're counseling patients.
• 1:08:08
  So a false positive recall on a first mammogram, meaning they call you back, but then it ends up all being good and benign is 16%.
• 1:08:17
  So I, that's the number like I always counsel people on when I order their first mammogram, because I think one of the harms is getting that call back that something is abnormal, and then panicking and believing that"Oh my gosh, now I might have breast cancer." But if somebody has mentally prepared you that,"Look, hey, a, a big," what is this?
• 1:08:34
  One in- somewhere between one in six and one in eight.
• 1:08:38
  A big number of people are gonna get called back on that first mammogram.
• 1:08:42
  It's the first time they've looked at your breasts.
• 1:08:43
  If there's any areas that they're concerned about, they're gonna tell you to come back, and just telling the person,"Look, that's really common, and most of those are gonna turn out to be benign or not even something that they're gonna biopsy.
• 1:08:54
  Do not panic when you get that call." I already feel like I have reduced harm from this intervention because- Yeah I have now tempered their expectations so that there is not this, explosion of panic or fear when they get that phone call.
• 1:09:06
  So it's 16% on the first mammogram, and then 10% callback rate overall.
• 1:09:11
  Interestingly, this varies according to, when you start screening.
• 1:09:14
  So if screening starts at age 40, the cumulative probability of a woman getting a callback over 10 years was 61%.
• 1:09:24
  Over half of women over a decade of screening will have been called back at least once to look at something that turns out to be benign, if you do every other year screening, biennial screening, then the callback rate over 10 years goes down to 41.6%.
• 1:09:41
  So that's significant.
• 1:09:42
  That is an interesting thing to consider is that When you reduce the frequency to every other year, you're reducing that callback rate by a third, a pretty significant amount, of the women that are called back, 10 to 16% of those will be referred for a biopsy, and interestingly, only 75% of them will do it.
• 1:10:05
  Not everyone proceeds with the recommendation.
• 1:10:07
  Again, patient autonomy, they have the choice.
• 1:10:10
  You have the choice.
• 1:10:11
  You can decide whether you wanna do it.
• 1:10:13
  Of those biopsies, 20 to 35% will return a cancer diagnosis, but that is a broad number because there are some things that are biopsied that going into the biopsy there's low suspicion, and there are some things- Yeah that are biopsied that going into the biopsy, there's very high suspicion.
• 1:10:28
  So I feel like 20 and 30 to 35% is very much an average over the whole population of people that's biopsied.
• 1:10:35
  But, that can vary a lot, depending on your individual circumstances.
• 1:10:39
  Yeah.
• 1:10:39
  So in each cohort of screening, less than 1% of women are unnecessarily getting a biopsy, and un- actually, I shouldn't use the word unnecessary.
• 1:10:47
  Less than 1% of women are gonna get a biopsy that turns out to not be a cancer and ends up being benign.
• 1:10:54
  So you and I both get a lot of biops- a lot of mammogram results, and then some of those goes to bi- Yeah go to biopsy, and I think you and I would both say that it's a small minority of the biopsies that then get diagnosed with an actual cancer.
• 1:11:07
  My perception is"Okay, don't panic." There's still- Yeah a good chance that this is going to be benign.
• 1:11:12
  So when you hear that number, like, oh, less than 1% of women are gonna get an unnecessary, again, it's in the context of, all of the women who will get screened.
• 1:11:20
  Only a small percentage of those will get the callback, only a small percentage of those will get referred for biopsy, and then only a small percentage of those will then have a benign, like it, it just compounds, right?
• 1:11:30
  Yeah.
• 1:11:31
  So compared to the overall number of women, it's actually a very small percentage that gets the unnecessary biopsy.
• 1:11:37
  Yeah.
• 1:11:37
  Not unnecessary.
• 1:11:37
  I keep saying unnecessary.
• 1:11:38
  It's not unnecessary.
• 1:11:40
  We don't know it's unnecessary.
• 1:11:41
  Yeah, that's the thing.
• 1:11:42
  You don't know if it's gonna be unnecessary anyway.
• 1:11:44
  Until you get it, you don't know if it's cancer or not.
• 1:11:45
  Okay.
• 1:11:45
  They get a false positive, biopsy.
• 1:11:47
  They are referred for one, and it turns out to not be cancer.
• 1:11:51
  So.
• 1:11:52
  Over 10 years, over the course of 10 years, 7% of women will have a biopsy that ends up being negative if you do annual screening, and 5% of women will have a biopsy that ends up being negative if you do biennial screening.
• 1:12:05
  Now, I am not going deep into the question of DCIS, like the idea of okay, what about the people whose biopsy is positive for a cancer or is positive for DCIS?
• 1:12:15
  And then they go for various treatments.
• 1:12:17
  That is a whole separate debate really on treatment.
• 1:12:20
  That is something that gets talked about a lot is okay what about the morbidity from treating those low-risk less invasive cancers?
• 1:12:27
  I'm gonna table that.
• 1:12:28
  It's a much bigger topic.
• 1:12:30
  So those are the numbers on, how many people end up with follow-up imaging and biopsies.
• 1:12:36
  There is really not a good standardized way to quantify the psychological distress, the physical treatment morbidities, the complication, the functional costs, the downstream utilization of healthcare resources from this.
• 1:12:48
  It's hard to put a number on, but those all need to be thought about and considered in your decision-making basically Yeah.
• 1:12:58
  And that's, that's exactly the conversation that I end up having with shared decision-making, is"How would you feel if this happened?
• 1:13:05
  How would you feel if this happened?" And yeah, the cost, unfortunately, is a big barrier because that screening is covered, but if something pops up on the screening mammogram, you have to pay for the diagnostic mammogram and ultrasound.
• 1:13:18
  And if you then get a biopsy, you have to pay for that, too.
• 1:13:21
  And that's a lot of times why I see people either not going to their callback or not getting the biopsy.
• 1:13:27
  And especially if you you do your screening.
• 1:13:29
  That's one day you took off work.
• 1:13:31
  Then you do your diagnostic and ultrasound, and that's another day you took off work.
• 1:13:35
  And then you go back for the biopsy, and this...
• 1:13:37
  And for hourly workers that's a substantial issue where not only are they getting less pay because they had to take off, they also have a high cost that they have to pay.
• 1:13:48
  And so that's a big issue and unfortunately, a reason that I think a lot of people defer the further workup.
• 1:13:55
  Yeah.
• 1:13:56
  Yeah.
• 1:13:56
  And so I lived all of these harms this summer.
• 1:13:59
  I had my first mammogram, and I got a call back.
• 1:14:03
  And I was not freaked out.
• 1:14:04
  I was very calm about it, because I know it's very common, and,"Okay, whatever.
• 1:14:08
  I'll come back." Got the call back, had the diagnostic, and I always tell my patients,"I don't care if it says indeterminate.
• 1:14:14
  I don't care if it says asymmetry.
• 1:14:15
  I don't care if it says probably benign.
• 1:14:17
  I don't care if it says needs additional imaging." We worry when it says suspicious for malignancy, and mine said suspicious for malignancy.
• 1:14:27
  And poor Rebecca, my PCP- I was like,"Oh my God, this is-" had to walk me through this journey.
• 1:14:34
  And then I couldn't schedule my biopsy'cause I was going out of town.
• 1:14:36
  So for three weeks, I was, fairly convinced I had DCIS, so there's definite psychological harm.
• 1:14:42
  I had the biopsy.
• 1:14:43
  I had kind of prolonged pain and swelling and redness at the biopsy site, and then eight weeks after the biopsy, I just a little metal marker just po- popped out of my breast.
• 1:14:54
  That was my my mammography journey.
• 1:14:57
  And I am the type of patient, I think, that- I was not too freaked out by the procedure.
• 1:15:03
  I was not too freaked out by the callback, the n- need for more imaging.
• 1:15:07
  I am somebody who I still, in retrospect, would say I would prefer the three weeks of anxiety and the little poke and all that stuff to finding out at 45, that I have some some sort of thing.
• 1:15:20
  And honestly, for me, this is bizarre, but like I feel like the experience made me reflect on my mortality and my values- and how I was spending my time, and like I feel like it made my husband a Yeah and forced us to have conversations that we may not have otherwise even bothered to have, yeah.
• 1:15:41
  So anyway, it wasn't all bad.
• 1:15:44
  But- Yeah.
• 1:15:44
  But that- that's the thing.
• 1:15:45
  These are the things that can happen, Yeah are truly negative outcomes.
• 1:15:52
  Not...
• 1:15:53
  there's negative outcomes in case if you have breast cancer, but there's- there's negative side effects that you can really experience that are not just"Oh, I got some irradiation," and then worrying about long-term what that does.
• 1:16:02
  But it's like in the moment, this is stressful.
• 1:16:05
  Yeah.
• 1:16:05
  This was a lot of time invested.
• 1:16:07
  This was money invested.
• 1:16:08
  This was an unpleasant procedure.
• 1:16:11
  This was anxiety-provoking.
• 1:16:13
  And then, yeah, you have a wound complication.
• 1:16:15
  So it's not nothing.
• 1:16:17
  But it is weighing risk and benefit, and that's the thing.
• 1:16:20
  Individually, we cannot decide for an individual patient what is the right answer.
• 1:16:25
  Only the patient can really decide that, but we have to give you all of the informed information for you to make an informed choice.
• 1:16:33
  That leads us into the next question, which is- Yeah what can we learn from this as humans and as doctors?
• 1:16:38
  I think actually I took from this that, there's a lot more nuance in the data about the benefits of mammography than I think I appreciated before I really deeply looked into this.
• 1:16:53
  I will give the anti-mammogram folks credit in that some of their arguments are very, they're, like, sophisticated statistical arguments.
• 1:17:00
  They're like,"Look at this lead time bias.
• 1:17:01
  Look at this over-diagnosis.
• 1:17:03
  Look at this length time bi-" th- they're legitimate critiques.
• 1:17:06
  But I feel satisfied looking at what I looked at, that those have been thought about and considered, and they're still come out to be a benefit.
• 1:17:15
  Perhaps a smaller benefit than we originally saw from some of the preliminary studies, but still a benefit.
• 1:17:21
  And I think again, is a reminder about, like, how much, like as you said, patient values play into this decision, and what shared decision-making really means.
• 1:17:30
  Yeah.
• 1:17:31
  And yeah.
• 1:17:31
  Like we said I'm often telling people these are the possibilities, and which one sounds worse to you?
• 1:17:41
  Pick your poison.
• 1:17:42
  Yeah.
• 1:17:42
  But, especially when you are between 40 and 50.
• 1:17:45
  And I think also the family history plays into this a lot, too.
• 1:17:48
  Yeah.
• 1:17:48
  And we didn't really touch on this much, but there are breast cancer risk calculators that you can do based on family history and, other factors.
• 1:17:56
  And sometimes that means earlier mammograms.
• 1:17:59
  Sometimes that means ultrasound plus mammogram.
• 1:18:01
  Sometimes that means breast MRI.
• 1:18:03
  There's a lot of different screening discussion that comes into play based on family history.
• 1:18:10
  And so This is more than just the mammogram, and an individual who's average risk, this is what we're talking about with this data.
• 1:18:16
  Yes, that's a good clarification.
• 1:18:17
  This is not talking about people who have a strong family history of breast cancer- Yeah who potentially have some sort of cancer syndrome gene.
• 1:18:26
  Yeah my family has all kinds of cancer in it all along the maternal lineage.
• 1:18:31
  Genetic testing has not shown what the thing is.
• 1:18:36
  It's some sort of syndrome maybe that we don't know about yet, but that's a very different consideration for me- Yeah versus someone who has no family history of breast cancer, right?
• 1:18:46
  And so you do have to take into account the individual factors, and that plays into the patient's value system as well.
• 1:18:52
  Yeah, absolutely.
• 1:18:53
  So that, we're gonna get into a lot in our next episode.
• 1:18:56
  Oh, great.
• 1:18:57
  So in our next episode, we're gonna cover a theme that they really rely on, is choose the best screening option for you, and mammogram might be fine for the masses, but this other test might be the best for you.
• 1:19:11
  And so we'll talk briefly about just ultrasound and MRI, which are, other modalities that we often use as adjuncts.
• 1:19:17
  And then we'll also talk about QT imaging or QT scans, and thermography, which are the two main alternatives that I've seen recommended.
• 1:19:26
  And that is going to be an exciting discussion.
• 1:19:30
  Oh, absolutely.
• 1:19:31
  I can't wait.
• 1:19:33
  Okay, and we've already covered this, how do we talk to our patients about it?
• 1:19:36
  I think, again, just circling back to respecting their intelligence, respecting their ability to appreciate some nuance.
• 1:19:42
  Of course every patient does not have the same health literacy the conversation can be tailored to them a bit, but I think closing the door to conversation and just saying,"It's safe and effective, that's all I have to say about it," I just think there's the- that's...
• 1:19:56
  I think we have to b- m- move beyond that for a lot of- Yeah these patients who are coming to us with questions and concerns about this.
• 1:20:03
  Yeah.
• 1:20:03
  And there are shared decision-making tools that can be used that, that do address some of that health literacy concern.
• 1:20:10
  If you're- feeling like the patient's maybe struggling with understanding what you're saying, if there's, maybe if there's a language barrier and you're struggling with the interpreter or, whatever it is there are structured shared decision-making tools that you can use to have these conversations.
• 1:20:23
  Or if you're just like,"I don't have time for this whole thing, but here's a checklist we can go through," that at least you are acknowledging the, all of the concerns and helping the patient feels like they're included in the decision rather than like,"It's time for your mammogram.
• 1:20:36
  Here's the order.
• 1:20:37
  Go get it.
• 1:20:38
  Bye." That's not a, a good experience for people when they're deciding about something like this.
• 1:20:43
  Yeah, I agree.
• 1:20:45
  Okay.
• 1:20:45
  So for more information a full written version of our discussion today, you can go to www.theantisocialdoctors.com.
• 1:20:53
  That's our sub stack.
• 1:20:55
  And stay tuned for part two of this conversation two weeks from now.
• 1:20:59
  Yeah.
• 1:21:00
  Excited for it.
• 1:21:01
  Thanks, Sonia.
• 1:21:02
  Okay, thanks.
• 1:21:03
  Thanks, Rebecca.
• 1:21:04
  Bye.
• 1:21:05
  Hey, guys.
• 1:21:06
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• 1:21:09
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