Breast cancer makes me quite emotional. My mother and two of my sisters have had breast cancer; all were picked up with mammograms.  A good friend of ours was diagnosed in her forties with aggressive breast cancer through mammography.  She is currently doing well.

I don't like breast cancer and am definitely against women dying from it.

This is my backdrop when I consider the USPTF's latest recommendations:

  • The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: C recommendation.
  • The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. Grade: B recommendation.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Grade: I Statement.
  • The USPSTF recommends against teaching breast self-examination (BSE). Grade: D recommendation.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. Grade: I Statement.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. Grade: I Statement.

This has made the general public quite emotional.

There has been a huge public backlash.  People don't trust these findings and are willing to talk about it.  Why in the world would they recommend against teaching self-breast exam?  Is this the Obama administration's ploy to cut cost?  Are women's health concerns being pushed aside for the sake of saving money?

Now congress is getting involved. There are going to be congressional hearings about the issue of how breast cancer screening is best done.

Why has this sparked so much emotion?  Nobody got worked up with the recommendations about car seats.  As emotional an issue as immunizations is to many, recommendations in that area do not spark congressional hearings, front page articles, and public emotion like these breast cancer recommendations.

There are several things that charge this issue beyond that of rational debate:

  1. It is happening in the midst of reform discussions.  Anything that recommends less care is held suspect, as the timing implies that this is a politically motivated recommendation.
  2. It deals with a disease that brings fear in most of us, pulling out the reassurance that it can be prevented.  People want to believe that science can keep them from harm and this makes us feel more vulnerable again.
  3. It contradicts the previous recommendations that moved from simple science to public crusade.  Every woman who did not get mammograms or do self-breast exams were made to feel guilty about it.  Medical students and residents were scolded by attendings if they did not address this issue.
  4. It is a "women's issue" that makes some feel like women's needs are being set aside.

To everyone else, this is a political, social, and scientific discussion.  The debate can rage in the halls of congress, on TV talk shows, and over the blogosphere.  But at the end of the day, I am the one who has to face the patient and discuss the reality of cancer screening.  All of this talk and debate is about what I do for a living.  I am at the eye of this storm, despite what grandstanding congressmen make, what accusations Obama-haters fling, or what eye-rolling scientific purists say.

That makes me quite emotional.

My job is being taken over by congressmen.  They will decide what is appropriate for me to order, and not doing so will go against the standard of care.  Medical science is being torn away from what's best for people and is becoming fodder for stump speeches, talk shows, and attacks on political opponents.  Discussing mammograms in the exam room no longer centers around what is best or what has the best evidence, it centers on politics.

Please let me be a doctor.  Please let me get to know the patient, read the authorities I trust, and make the best decisions for that patient.  Stay away from this, politicians!  You are bad at making political decisions, so why should you be trusted in medical decisions?  Don't say you do this in the public interest when it clearly involves what's best for your political career.  I don't like being a pawn.

Unfortunately, there is little chance of that.  If a recommendation by the USPTF causes this kind of brouhaha, do you think good reform can really happen?  I doubt it.

And that makes me quite emotional.

This post isn't about the content of those recommendations.  I have read both sides of the issue and see rationale both ways.  I would rather not debate the issue itself (it caused an argument at home this morning already), as I understand how people's emotions are high as well.  I am just frightened of a world in which science needs to be ratified by congress.  I don't like it when Oprah has an influence on how I do my job.  I don't like the USPTF to be accused of being a covert wing of the Democratic party.

My job is hard enough.  My decisions are hard enough.  My days are hard enough.  Why can't I just be a doctor?

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