The Finger

When I was in my grad program, I started feeling pain in my groin. I didn’t remember doing anything stressful to it and it sure wasn’t due to an overabundance of sex. I had no real insurance to speak of, so I went to the student health center on campus, where I described my symptoms to the very nice man who was there to help me.

He wrote down some things, looked up a few things on his computer and said, “It might be an infection or it might be a problem with your prostate. We’ll need to do an exam.”

Unfortunately, I knew what that meant: bend over and wait for The Finger. I reassessed this very nice man and noticed that his hands looked like he was wearing two baseball gloves. His fingers looked like they were made of radiator hose and his nails looked like Freddie Krueger had lent him some apparel. Still, the thought of a tumor growing in my ass had me face down on a table, feeling the cool touch of KY.

“You’re going to feel some pressure,” he explained. That was putting it mildly. I realized at that moment that if I were gay, I would need to be celibate or at least always be the giver. This was, by far, the least pleasant experience of my life and if there were any other options to avoid this, I totally would have taken it. In fact, when I recently went to the doctor and asked about when I’d need to have another prostate exam, (I was told by several friends I was “of that age” where I’d need one) he said we could avoid it for another five years. I gladly did so.

I thought about this experience when reading about the recent study on mammograms and how a panel of experts now thinks that women between 40 and 49 shouldn’t be getting one as a matter of course. Then, it should be every two years. Of all the experiences I’ve heard women complain about, mammograms and pap smears are the two that come up most often. “The car jack” as The Missus calls it, is apparently uncomfortable and obnoxious, but it pales in comparison to the breast pancake.

The magic of science coupled with the tender touch of the Marquis de Sade means you get flattened, squished and yanked around by the boob. In the old days, you had to panic for a few weeks until they came back with the results. Digital technology means that you no longer have to wait forever for the results, but the women I know who have been screened tell me they start panicking a couple weeks before and probably about up to a week after. In short, this is not like a John Mayer concert: people aren’t lining up for tickets around the block.

When I was a kid, my mother was a smoker. She made the argument that she only smoked seven each day and that it wasn’t going to kill her. When she had her first mammogram at the age of 40, they noticed abnormalities. They weren’t enough to kill her, but they did tests to make sure she didn’t have cancer. She ended up being cancer-free, but the experience was enough to make her quit smoking. Say what you want about that, but I’d argue that the mammogram added years to her life without actually doing anything.

Friends who have gone through this have said they probably wouldn’t do this unless it was required. In short, by giving people the option to avoid something unpleasant, we pretty much assure they will take that option. Insurance companies that say now “Oh, there’s no WAY we’d not cover something like this if women want them” are a) banking on the fact that fewer women will have them if they are not required and b) staying out of the shit storm until this all dies down and they can quietly start to erode the benefits when no one is looking.

People believe doctors. It’s in our nature in a lot of ways. When the doc says, “Here take this pill,” I take it. I don’t ask a whole hell of a lot of questions. When he says, “You need this,” I get it. The man went through medical school while I’m only a “doctor of paper” (as The Missus says). When you’ve got a panel of doctors saying that in a cold, simple calculation of how there’s likely cancer in some of these cases caught in the 40s, but the stuff won’t grow fast enough to kill people, that borders on criminal. People will hear the sound bite: “You don’t need this if you’re in your 40s” and believe it.

How many of these women will die before another panel says, “Yeah, sorry. Bad call” and moves the marker again?

Comments

[Jude]

C'mon, Doc.

[Interrobang]

Uh, the new mammogram guidelines only apply to low-risk women who don't have any family history or high risk factors (such as smoking). Canada's been on a two-year mammogram cycle for women from ages 60-69 forever, as far as I know, and we're not dropping like flies up here.

Basically, the calculus went as follows -- they currently have to screen 1904 women to save one life, and a significant number of those 1904 women will wind up overdiagnosed and/or overtreated*, and Canada and half of Europe uses a similar schedule with very little ill effect, so the risk-benefit ratio came out somewhat in favour of recommending less frequent testing.

Citation, with tons and tons of linkies in the article itself.

This is not ZOMG PANIC TEH GUVERMINT HATES TEH WIMMINS (this time). And it's certainly not worth all this panic, FUD, and fearmongering.
__________________

* Overdiagnosis means that they found something that looked like it could be a tumour, but wasn't, and thereby subjected the woman in question to a cancer scare, a couple in-retrospect-unnecessary biopsies, and all that stuff, or they found one of those tumours that spontaneously disappears after a while, or they found the kind of tumour that's so non-aggressive the woman in question will die before the cancer kills her -- but once you find something suspicious, you have to treat it, hence also "overtreatment."

[OkieBlue]

They are using the best science available to make a blanket recommendation to the entire general public. As you pointed out this test carries with it a huge amount of anxiety which is not helped by false positives and unnecessary biopsies. We are free to do whatever we want to do individually however and us men can have the finger every six months if that's what we want. (I won't!)

It seems reasonable for insurance companies to follow established scientific guidelines in determining what they will pay for. Patients don't have the right to ask someone else to pay for unncessary procedures just because they have a high level of anxiety.

[Doc]

To be fair, I never said this was a case of the government (or anyone else) hating women. That's not my point.

The idea of this only applying to low-risk women gets lost. The idea that people who might not have a full view of their family history (adopted folks, people who have a limited contact with family, people who don't sit around and talk about cancer at Thanksgiving) creates and issue here, but that gets lost as well.

The point is that if something is more of a requirement, we tend to do it more. When things are "optional" we tend to dodge them if they are unpleasant. Adding to the sense that you put the weight of a governmental/medical study behind anything, boil it down into a simple newspaper article (the vast sums of people are probably not rolling through a transcript of NPR) and you've got this:

"You don't need one of these when you're 40. The paper says so."

[dr2chase]

But Doc, how are Canada and Europe any different? They adopt kids there, they have low and high risks, too. If they're not dropping like flies, from this or any other cancer, the benefits you imagine are just that -- imaginary. This sort of measurement is a good thing; it's what some of us use as a rhetorical club on the jerks who don't think universal health care is a moral issue -- we can point out that it is also cheaper and works better, everywhere it has been tried.

[MapleStreet]

When I'm teaching Evidence Based Medicine classes, one of my talking points is that they take mega-studies of a large number of people.

Using those studies, I can tell you what percentage of the people will have certain things happen to them. But I can't tell you about the individual patient.

Then the TV reports a group report(albeit with good credentials)and everyone freaks out and thinks that is the thing they do immediately - not understanding that it needs more review.

[mothra]

Well, one point: plenty of insurance companies do not now cover the entire cost of a mammogram, which keeps a lot of women from having them every year. I was in that category when I had to buy my own insurance--the insurance only covered a portion of the cost, so I got hit with $300 when I got the mammogram. So insurance companies already ration that sort of care--but I agree--they will now balk at paying for a mammogram for women under 50, citing this study as support. But that is more a case of the insurance companies hating on people than the government doing so.

[BuggyQ]

Cancer scares the crap out of me. Certainly enough to get me to go get a mammogram now that my doc has told me I should start getting them.

But not enough that I won't procrastinate like crazy. 5 weeks and counting...

BTW, Doc, my dad works as a standardized patient (meaning he is a guinea pig for student docs to try out their mad skilz on). One of his regular gigs is as a prostate examinee. He likes to tell everyone (much to my embarassment and dismay) that he has the best examined prostate on the planet.

That should be near the top of everyone's list of "Things You Never Want To Hear Your Parents Talk About."

[pansypoo]

i am going with what ibang said. so i can wait til 60 or dead.

[mdh]

Hang on.

A change in recommendations made to most people

from

one based in a fear of missing something

TOWARDS

an equally effective and less expensive endpoint

and this is bad policy?