3.14.2006

miracle

Late today, but still here. I had the day off, as we had already scheduled weekday morning doctors appointments when I started working. Our first appointment, last month, was a consultation and chat. This one was a physical.

I really like the doctor a lot. So, it looks like I lucked out again. Finding a good doctor was a real concern of mine. Everyone told me it would be hard to find any doctor taking new patients, and then, who knows if you'll like the person who's available? It turned out there were several available doctors in our area, some of whom were female (which I strongly prefer for a family doctor). We chose someone close by, and today, I got a really good feeling about her.

Once again, we see a doctor, there is no charge to us, and we say, This is amazing. Universal health insurance is like a miracle to me.

* * * *

I've learned another difference between health care in the US and Canada. In the US, if you have decent insurance coverage, certain cancer screenings start at age 40 - mammograms for women and prostate checks for men.

It's drummed into your head that you must do this when you turn 40, despite scant and conflicting evidence of the benefits. I've known that there are lots of false positives in mammograms of women under 40 - I had one myself, and that's not something anyone needs to go through. But you always hear you have to do this when you turn 40, your doctor tells you your insurance covers it, and you go.

In Canada, unless there's a risk factor present, such as family history, mammograms start at age 50, and men are screened for prostate cancer beginning at age 50.

There's two ways to look at this.

In the US, it's: more screening is better, early detection is paramount, if there's any chance of benefit, let's do it. Many would look at Health Canada's guidelines and say: scarce resources, rationing, inadequate public system.

In Canada, it's: there's no proven benefit to this, it's wasteful, it causes needless anxiety (from false positives), why run tests just to run them. Many would look at US insurance company guidelines and say: waste, profit, greed.

The fact is, every one of those tests in the US is paid for by someone. And false positives, of course, only lead to more testing. It means more commerce for the health care industry, more business for the insurance companies. But does it mean a healthier population? There's no evidence that it does.

And of course, in the US, not everyone is entitled to these tests. People with decent jobs that include good health insurance are screened at age 40. In Canada, every woman can get a mammogram at age 50.

Growing up American, I was definitely conditioned to think early screening was, by definition, better. As an American woman who's already started having routine mammograms, it feels odd to just stop. Like I was taking care of something that now I'll be neglecting.

But I often wondered if all that cancer screening was just to make us feel better psychologically: I got my mammogram, now I'm safe! A close friend of mine developed very aggressive breast cancer four months after a clean mammogram, so what does annual testing actually do?

Having had a false positive - and six weeks of waiting in between tests (yes, waiting, even with private health insurance in the good ole USA) - and knowing many other women who've had one, and now reading that the benefit of mammograms between ages 40 and 50 hasn't been shown, I'm now more inclined to chalk up all this testing to the profit motive. More testing, more business, more profit. More radiation, too.

8 comments:

James said...

But I often wondered if all that cancer screening was just to make us feel better psychologically: I got my mammogram, now I'm safe! A close friend of mine developed very aggressive breast cancer four months after a clean mammogram, so what does annual testing actually do?

Annual screening does greatly improve the chancse of early detection. It's not perfect, but (when properly administered) it's much better than nothing.

Having had a false positive - and six weeks of waiting in between tests (yes, waiting, even with private health insurance in the good ole USA) - and knowing many other women who've had one, and now reading that the benefit of mammograms between ages 40 and 50 hasn't been shown, I'm now more inclined to chalk up all this testing to the profit motive.

One of the biggest problems with false positives is lack of knowledge about their likelyhood and their significance. Which isn't surprising, because most people aren't very good at statistics and probability.

Depending on the prevalence of a condition in the population and the sensitivity of the test for that condition, a positive result might have only a 10%, or even less, chance of being a true positive. Which, of course, is why follow-up tests are tremendously important (and should be done quickly -- if it's a true positive, you don't want to give the condition a chance to get worse!).

I've never had any routine screenings done, so I've never received a report of a false (or true, for that matter) positive. How was your false positive presented to you? Was it "the screening came back positive, so we have to do more tests to rule out a false positive"? Or was it more like "the screening shows a 5% chance of a positive, so we have to do more tests to determine if it's a true positive"? I suspect that the latter would be better, psychologically, for the patient.

Lori's big screening experience was a little different from either of those... Her doctor came back with "Go downstairs and check in, your surgery is at 9:00 tomorrow morning".

L-girl said...

Annual screening does greatly improve the chancse of early detection.

Of course, absolutely. But it has to be within reason. For example, no one tests 20 year old women for breast cancer.

How was your false positive presented to you?

More or less: A density has shown up on your mammogram, this happens frequently and may be nothing, but we like to do a sonogram to get a better look. Now wait more than a month.

This is apparently incredibly common among women between ages 40 and 50.

Lori's big screening experience was a little different from either of those... Her doctor came back with "Go downstairs and check in, your surgery is at 9:00 tomorrow morning".

Right. My friend who had breast cancer heard that, plus, You need your breast removed immediately, and may need the other one taken, too.

Was Lori diagnosed before or after her mom died of cancer? (I probably know this and forgot.)

James said...

Was Lori diagnosed before or after her mom died of cancer? (I probably know this and forgot.)

Long before her mother's cancer, but after her father's final heart attack.

In Lori's case it was melanoma at the age of 19.

Lori's mother's smoking-induced lung cancer came about 10 years later. In Lori's mother's case, the result was "the tests came back positive, you have six months to live" (though somewhat more diplomatic than that).

Lori's mother had had to miss her (Lori's mother's) sister's funeral to undergo the tests. The sister had just died six months after a diagnosis of smoking-induced lung cancer. There was very little optimism that the diagnosis was going to be wrong or that the six months was going to be too short an estimate. As it turned out, it was spot on.

David Cho said...

Okay, that does it. I'm moving to Canada. If I can avoid 10 more years of not having to go through the screening :)

L-girl said...

Okay, that does it. I'm moving to Canada. If I can avoid 10 more years of not having to go through the screening :)

LOL :)

I thought the prostate test was just a blood test. No? You might be thinking of the colon cancer exam. That's not a big fave...

David Cho said...

No, that is not true. The doctor puts the finger up to feel the prostate to see if they can feel a lump, much like examing breasts. Colon cancer screening starts at age 50, not 40.

L-girl said...

much like examing breasts.

But a tad more invasive. Here I was thinking you guys got away with a blood test! Ewww.

Granny said...

I've read a lot about the overuse of mammograms so could be they're right.

I've been urging people about the need for early prostate cancer detection and I could be wrong. I sometimes am.

However, my sons' dad died at 54 from prostate cancer that had spread undetected. I don't know if an exam in his middle 40's would have made any difference but it never occurred to him to do it.

I'm not arguing honest; I just don't know.