Nothing Like a False Dichotomy to Promote Truth

I can’t recall the last time I read a pro-screening article in one of the major journals. It’s simply not cool. In contrast, the anti-screening militia is using every weapon imaginable in order to re-program the medical community and the American public to believe that “less is more” when it comes to the early detection of breast cancer. But no matter how fashionable it is to be an anti-screening iconoclast, or a “personalized medicine” advocate who favors less screening through miraculous prescience as to who is truly headed for breast cancer, the fact remains that less screening means more lives lost to breast cancer.

Recently, an editorial was published in JAMA (2016; 315:977-978), one of the Big Four journals, entitled “A Public Health Framework for Screening Mammography: Evidence-based vs. Politically Mandated Care,” written by a public health aficionado (Kenneth W. Lin, MD, MPH) and a lawyer (Lawrence O. Gostin, JD). The punchline seems straightforward enough – politics should play no role in medical guidelines. But there’s more than a punchline here.

The authors can’t say enough to extol the virtues of the U.S. Preventive Services Task Force and their evidence-based conclusion that we should screen with mammography every 2 years (rather than annually) starting at age 50 (rather than 40). That is, screening women in their 40s results in more harm than benefit. As I’ve stated on many occasions, evidence-based medicine can give you objective measures of benefits and harms, but that final step – weighting harms versus benefits – is 100% subjective. You can’t put “unnecessary biopsies” on one end of the teeter-totter and “lives saved” on the other end, using any semblance of science. That doesn’t stop evidence-based crusaders from doing so, however. In fact, it doesn’t seem to occur to them that the last step is totally subjective – instead, they speak of their scientific purity from beginning to end.

Authors Lin and Gostin simply gush about the high-quality evidence used in the Task Force process, then use the age-old false-dichotomy approach to point out the evils of political interference. It’s as though there’s no valid position that opposes the Task Force and its recommendations that is not politically motivated. In fact, quite a few physicians, believe the Task Force is way out of line, and it has nothing to do with politics. In fact, we can barely be civil about it (based on scientific evidence, by the way), and it has paradoxically hurt the cause of screening. Witness the total frustration of Dr. Dan Kopans, a pioneering mammography expert, who called the 2009 Task Force “idiots,” whereupon he was promptly blacklisted. Oh, you didn’t know that there are blacklists in medicine? Dr. Kopans can’t get a word published in mainstream journals anymore. He has been throttled to “preaching to the choir” in the friendly radiology journals where the readers agree that the Task Force are “idiots.”

Many of us believe that the Task Force is politically motivated to begin with, making the false dichotomy in this JAMA article even that much more bizarre – both sides are products of politics. I agree that we need to keep politics out of medicine, and a good starting place would be to dissolve the U.S. Preventive Services Task Force. Or, at least modify their structure so that they have to include members with expertise in the areas being governed. A committee of bean counters has no place telling the farmers how to grow those beans.

The epidemiologists and public health care aficionados have hijacked many areas of medicine, including breast cancer screening. They have no room for the experts. Experts are, by definition, motivated entirely by financial gain. To the Task Force, it is inconceivable that someone examined the evidence and chose a specialty based on that evidence. No, instead, doctors were once starry-eyed innocents until they picked a specialty whereupon they morphed into greedy, biased individuals who can no longer weigh evidence objectively. “You can’t have providers establishing policy!” is the battle cry of the hijackers who now control preventive medicine.

It’s not quick or simple to expose the shaky foundation of the Task Force guidelines. My favorite point of argument is that the 2009 guidelines – not screening during the decade of the 40s – was reversed from 2002 based on so-called new evidence. But the 2002 group who recommended screening in the 40s calculated a 15% relative reduction in mortality, which was completely unchanged when re-evaluated in 2009. Not a single percentage point difference. The 2009 group (the Task Force rotates members frequently) and their “new evidence” found nothing new with regard to benefit. What did change then? Well, harms. That’s right. In spite of better mammography, fewer call-backs, easier biopsies, better pathology, the Task Force used new modeling methods to calculate greater harms than had been considered in the past. So, the benefits of mammography as performed 30-40 years ago in the historical trials were balanced (subjectively) against modern and mysterious harms, such as permanent psychological damage after a benign biopsy. Benefits minimized, harms inflated. It was an easy formula.

The more you know about this travesty of common sense, the more disturbing it is. And to make matters even more disgusting, the new 3-D mammography does exactly what mammography critics have been asking for: 1) it lowers the callback rate, and 2) it raises the detection rate. What does that do for that delicate balance of harms-to-benefit ratio? What does it do to the teeter-totter? Harms are lower, benefits are greater, so you’d think this 3-D development would be welcomed with open arms.

Well, the Task Force has already spoken in 2015 – there’s not enough evidence to rule on 3-D tomosynthesis mammography. Okay, then when will there be enough evidence? Answer: never. Why? Because the Task Force considers any breast imaging modality used in screening to be “unproven” unless it has been shown to lower mortality in a prospective, randomized trial. And, since there will NEVER be prospective, randomized trials for each and every new development in breast imaging, the Task Force is sitting in the catbird seat with their “Insufficient Evidence” ranking. So, they will always be playing catch-up, rendering their opinions on obsolete technology.

Is everyone who is against the Task Force simply motivated by politics? Hardly. There is a legitimate and vehement argument against the Task Force that isn’t about emotion, politics, or gamesmanship. It’s about a deep and abiding belief – held by those physicians who actually practice breast cancer screening – that the Task Force is dead wrong, and that their influence is going to result in thousands of breast cancer deaths each year. In my abiding opposition to the Task Force, I decided to write down all my objections – the result was a 400-page book, due out in late 2016 or 2017 from McFarland Publishing (Jefferson, NC). The working title is: Mammography and Early Breast Cancer Detection: How Screening Saves Lives. If you read that book, you won’t be calling the organized opposition to the Task Force “political.” Instead, you will appreciate that it’s the Task Force that’s the “political animal in the room.”

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