If only science was a sure thing

Science is an uncertain science. That’s been brought home once more this past week with all the consternation over mammography.

“The Screening Mammography Program Saves Lives,” says the headline on the B.C. Cancer Agency’s on-line writeup about mammography, a type of x-ray of the breast that up until days ago was routinely promoted to Canadian women 40 and up as an annual must-have.

But the Canadian Task Force on Preventive Health Care has rocked the boat big-time with new recommendations that reduce the use of mammography. 

The task force has toned down Canada’s 10-year-old guidelines around when to get mammograms. The revised guidelines suggest routine mammograms only for women ages 50 to 74 and even then no more than once every two or three years.

No big deal in the grand scheme of things. One less medical appointment to schedule.

But it’s disturbing when something that has been sold to us as an absolutely essential health measure suddenly reveals a dark side. The about-face on mammograms serves as an excellent reminder that health care can hurt.

In the case of mammograms, the issue is “false positives.” Mammograms are prone to turning up slow-growing lumps in the breast that look like cancer but in fact do no harm over a lifetime.

That means you can end up having surgery, radiation and chemotherapy you didn’t need - treatments that can damage your health permanently and waste precious health-care dollars to boot. False positives have been a major issue in prostate-cancer screening for years now for those very reasons.

Mammograms provide “a real benefit,” said task force chair Dr. Marcello Tonelli in media reports this week on the revised guidelines. “But compared with the risk of false positives, it’s relatively small. If you look at the numbers, you are much more likely to have a false positive result than you are to have your life saved with screening.”

New Yorker writer Malcolm Gladwell saw this one coming years ago. He wrote a brilliant article back in 2004, “The Picture Problem,” that detailed the challenges that even the most expert radiologist faces when trying to decipher a mammogram image.

“Looking at a mammogram is conceptually different from looking at images elsewhere in the body,” Memorial Sloan-Ketterer Cancer Centre radiologist Dr. David Dershaw told Gladwell in that piece. “Everything else has anatomy—anatomy that essentially looks the same from one person to the next. But we don’t have that kind of standardized information on the breast.

“The most difficult decision I think anybody needs to make when we’re confronted with a patient is: Is this person normal? And we have to decide that without a pattern that is reasonably stable from individual to individual, and sometimes even without a pattern that is the same from the left side to the right.”

The point of the article was that humans place too much trust in pictures as revealing “truth.” The picture that emerges from a mammogram is particularly open to interpretation.

Gladwell highlighted eye-opening findings from the University of Washington Harborview Medical Centre as to what happened when 10 radiologists were asked to interpret the same 150 mammograms.

One caught 85 per cent of cancers in the images right away. Another caught 37 per cent. Some saw many things to worry about, others saw none. In one case, three radiologists deemed a lump visible in the image to be normal, two others saw it as abnormal but probably benign, four weren’t sure, and one was certain it was cancerous.

Mammography does save lives. But not many, as it turns out. If 1,000 women who are age 60 right now have an annual (and let’s presume correctly interpreted) mammogram every year for the next decade - 10,000 mammograms, with all the expense that entails - breast cancer deaths among the group could be expected to drop from nine to six.

Nobody can blame us for wanting a fail-safe test that catches cancer early. Alas, the science isn’t there yet, and at any rate something new will likely be killing us by that point. Such is the nature of the human condition.

Preventing breast cancer remains important, of course. But so much of prevention comes down to personal responsibility - for what you eat; how often you exercise; how much you weigh; your alcohol consumption.

The world will rejoice when they come up with a screening program that corrects for bad habits. Until then, take care.

Why does the belt only tighten at one end?

You know, it's really striking how often political parties that shape themselves as being about "small government" in fact spend their time in office growing the business out of all proportions.
Here's the latest news on that front involving the Tories. Keep in mind that all this growth happened at a time when Stephen Harper's government was slashing public services. That's the thing that grates the most - that even while we're losing long-standing public programs due to "belt-tightening," our governments are growing larger, taking ever-bigger salaries, and even paying out bonuses to the senior managers who are most effective at cutting our services.
In ancient times, they would have called this kind of governance a kleptocracy - "rule by thieves." Whatever you want to call it, it's crazy-making. But hey, we keep electing them.

Free parking at our hospitals

Now here's an idea whose time has come - free parking at hospitals. Maybe now that the Canadian Medical Association Journal is saying it, it will have an impact. How crazy is it to stress people out just that little bit more  when they're going through an illness or something worse than by charging them to park?
And once we're offering it free, how about offering more of it, too? Can't believe they built that new parkade  at Royal Jubilee hospital at a capacity that was well below what's actually needed.

Occupy movement down but not out

Having to make way for Santa seems an ignominious end for the Occupy movement, but that’s how things tend to go in countries that aren’t yet angry enough to get genuinely uncivil.

Still, the public reaction to the Occupy protests over the last eight weeks has been surprisingly sympathetic. I take that as a hopeful sign that this movement will have legs.

People tolerated the protest camps for much longer than they usually do when tents appear in public spaces. I think a lot of them quietly related to the issues the movement has raised.

It’s pretty impressive that in just two short months, a mixed bag of disaffected citizens around the world took a small protest in New York City’s financial district and turned it into a global movement.

Whether it can last long enough to affect change, I guess we’ll see. But the Occupy protests got a lot more positive attention than most “occupations” get - an indicator that people have a certain sympathy for the cause.

The movement started with a single email that Canada’s Adbusters Foundation sent to people in July.

The foundation is known for publishing an ad-free magazine and holding strong opinions on corporate influence over democracy. But its suggestion of a peaceful occupation of Wall Street clearly struck a chord that resonated well beyond the magazine’s usual sphere of influence.

"The idea of Occupy Wall Street is to revive people's democracy," said Adbusters editor Micah White in an interview with the Huffington Post last month. "We are sick of the corporate political parties deciding the agenda of America."

That would have bordered on cuckoo talk a decade ago, when we were all so certain that our governments were leading us toward the light.

But we’ve learned some hard lessons since then. From the 2001 Enron scandal on through an outrageous series of global financial disasters and government ineptitude that severely shook public confidence, it has been a tough and discouraging 10 years.

Maybe the average people of the world were just ready for somebody to issue a call to action. At any rate, one group of sympathizers after another picked up Adbusters’ call for occupation and spread the word. A global movement was born virtually overnight, with Occupy protests eventually organized in more than 80 countries.

None of it will change the world, at least not yet. But let’s not discount the miracle of such a thing happening at all. Just the fact that a group of protesters kept their camp alive in Centennial Square for more than two months and city hall was still being nice about it is an astounding turn of events on its own.

The Occupy movement’s catchy slogan - “We are the 99 per cent” - is a reference to the growing income disparity in western countries, with wealth concentrating in the hands of the richest one per cent of the population.

In the last three decades, the top one per cent of income earners in the U.S. saw their incomes rise almost 300 per cent. That’s at least seven times more than any other income group saw in the same period.

Here in Canada - where the gap between rich and poor has been growing for the last 15 years - the richest 20 per cent now have nine times the income of the poorest 20 per cent. That’s the biggest gap we’ve seen since the 1970s.

Income disparity isn’t exactly a hot topic around the office water cooler. But even people who don’t often think about such things are by now well aware that crazy problems are manifesting out here in the world.

They didn’t all storm the streets with the Occupy forces. But they did make space in their communities for the protests to happen. It’s a bigger win than it might appear, and signals a real shift in the public mood.

Widespread tolerance for something as non-Canadian as public protest - in the Christmas season! Right in the heart of the downtown! - says a lot about how much the issues raised by the Occupy movement must be resonating. Protesters, you are not alone.

But Santa’s coming and it’s cold outside. Store owners near the protest camps are losing patience. Municipalities and their police departments are closing in.

It looks like the end. I suspect it’s just the beginning.

    

Mammography controversy a reminder of screening risks

Canada's finest health writer, Andre Picard, weighs in with his usual information-laden, clear-eyed view on the fuss about mammographies.
Women are accustomed to cancer screening as a good thing from lifetimes of Pap smears. But as Picard and the larger scientific community points out, screening can have a serious downside when false positives - more common than you'd hope in both mammograms and PSA tests for prostate cancer - lead people to have serious medical procedures and treatments that they didn't need.
Cancer is such an emotionally loaded word. We all know someone who has had it and we're all terrified to get it ourselves, but the truth is that the science of cancer is still something of a mystery. You'd think that highly developed screening tools that can catch the earliest signs of cancer would be a good thing. But now we're learning that some cancers never really get past the starting gate in our bodies, and that there's such a thing as "bad" screening when you end up getting chemotherapy, radiation or surgery you didn't need.