Help me accept that we must let these women dieI have been a frontline gynecologist for about 40 years. When I was trained, the goal was to screen everyone. We sought to find diseases early enough to successfully treat and cure before they were too far advanced. In my years thus far I have seen it work: early breast cancers have been found on mammography and during clinical breast examinations. Many lives saved.
I have known most of my patients for 25 to 35 years. I am embarrassed to send an academic journal these experiential and anecdotal stories without numbers and percentages, but I treat individual people and not populations. I cannot get it into my brain that it is not worth saving these women.
Janet, a 37-year-old woman, had just lost her husband to a sudden heart attack, leaving her with 5- and 7-year-old daughters. At that time, baseline mammograms were ordered between ages 35 and 40 years. We were shocked when her mammography revealed breast cancer; she had no family history of breast cancer. Five years later it recurred, and 5 years after that, she was found to have something no one had known about earlier: the BRCA gene mutation. She has since had bilateral mastectomies and bilateral oophorectomies. Last week, at her annual check-up at age 62, she showed me pictures of her grandchildren.
I cannot help but feel that Janet would not be here today if we had not done that screening mammography years ago. But now I am asked to let someone like her go, so that the system does not have to pay for all the “normals.” There are many stories of lumps found during routine examination, of an aggressive cancer found on mammogram 1 year (not 2) after a perfectly normal mammogram.
Help me accept that we must let these people die, or identify their disease at a much more advanced state given these new guidelines. I cannot be the only bread-and-butter gynecologist who is having trouble agreeing with this new approach.
Are there not other ways to cut medical costs? Can we eliminate the “middlemen” in the system? Is there any way other than not screening to save women’s lives?
If a patient gets breast cancer before age 45 or within the 2-year interval between mammograms, would she sue their doctor for not recommending annual screening? We all know cases of women who have died of cervical cancer after having normal Papanicolaou (Pap) test results 2 years before. (Their survivors sued, and won). But if they had had a Pap after only 1 year, would their disease have been discovered and successfully treated?
Perhaps I reveal myself as politically incorrect or not “cost-effective” in this letter. But rest assured, many of my colleagues are retiring (as will I in time), so those trained in my era will disappear. The younger crop is thoroughly trained in this new way. I wonder what the pendulum will do, if after these guidelines sink in, advanced cancers that cannot be treated successfully reveal themselves.
Lois S. Goodman, MD
Weston, Massachusetts
Prevent rather than detectEarly detection is not prevention. Until medicine actually wants to work on prevention, the American Cancer Society guidelines are just more of the same old story, focusing on the symptoms rather than on the root causes. Using genomics and personalized, functional medicine in combination with breast thermography, many more breast cancers can potentially be prevented in the first place, with mammography (and ultrasonography) used as a diagnostic tool. This would be much more powerful than focusing only on early detection. ObGyns need to learn how to apply these new skills and help women get much more value from their preventive care. Until physicians reclaim their ability to think and evaluate critically with open, curious minds, they will continue to fail the very people they aim to serve—their patients.
Roberta Kline, MD
Santa Fe, New Mexico