I always thought the yearly pap smears for all sexually active women seemed fishy.  It just reeked of all the “sex is bad for your ladyparts” bullshit I was fed in abstinence class. 

I mean pap smears are useful, but not every year.  Especially when HPV can take decades to cause cancer and in some women never does.

I didn’t know what to think about this either.  On one hand, it didn’t seem like a particularly nefarious move.  It’s not like it forbids women under 50 to get mammograms, after all.  On the other hand, I fully support being cautious and aware about your body.  Discouraging women under 50 from getting mammograms doesn’t sit right with me.  Some people don’t know their risk factors for cancer. 

It kind of reminds me of what we talked about in social psychology the other day, adjusting your level of discretion to strike an ideal balance between false positives and false negatives.  You can never rule out the chance of false positives without increasing your chance of false negatives.

The problem is who gets to decide what is high risk.  I feel high risk because I have an aunt who died from the spread from breast cancer.  My doctor tells me I don’t really because she was on the paternal side.  Will insurance continue to cover mamograms every 2 years if I want them if my doctor wont say I am at risk?  Somehow, I really don’t think so.

Also, the self exams.  If you haven’t made a habit of doing them regularly in your late teeens to mid-twenties, what is the likelihood you will be able to establish that habit at a much older age?  How familiar are you going to be with how your breast should feel?  Slim to none and not very.

I went 4 years between my base mamogram at 40 and the next one.  No, I don’t like them, though they weren’t painful for me.  I would probably wait 2-3 years before the next, but will my insurance cover it when I decide it’s time?

I think the timing also managed to be peculiarly horrendous. Coming right on the tail of actual instances of “But we don’t wanna pay for lady-healthcare!” asshattery coming out of this healthcare reform business, it’s really easy to assume there’s some sort of connection. My narrative sense got irritated when I first realized there wasn’t.

I see what you’re saying, lee.  But I agree with the panel and with the long tradition of feminist critique that the dangers of over-medicalizing are very real. We have to strike a balance between sensible caution and treating our bodies like they’re the enemy.  I honestly think that a lot of over-testing of female bodies is born out of a subconscious belief that women’s bodies are somehow not quite right, and this is a useful corrective.

helen, they said self-exams didn’t work at all. They were basically saying, “Save yourself the hassle, and just start getting mammograms at 50.”  For whatever reason, self-exams don’t seem to be correlated to survival rates in a significant way, but they are correlated to unnecessary biopsies.

Also, the self exams.  If you haven’t made a habit of doing them regularly in your late teeens to mid-twenties, what is the likelihood you will be able to establish that habit at a much older age?  How familiar are you going to be with how your breast should feel?  Slim to none and not very.

To a degree, I can’t help but thing that the recommendations to do self-exams and regular screenings are done not because they are useful at the time, but rather because they create good lifelong habits that, many years down the road, might be useful. Someone who has started to get mammograms at 40 after prodding from her physician will be well-established in the habit of getting them every year by the time she’s 50. Starting from scratch at 50 and expecting a patient to make sure to get yearly screenings might be a bit much to ask.

I agree with this post but this line is off.

Part of the antagonism was due to an increasingly outdated belief that the medical establishment is hopelessly male-dominated, and therefore doesn’t take women’s lives seriously.

It’s not an outdated belief, it’s based in truth, even though that’s not what’s driving these recommendations. I dug up some links for you.

http://www.feministe.us/blog/archives/2009/02/02/female-heart-patients-experience-more-emergency-room-delays/

http://www.feministe.us/blog/archives/2007/11/19/women-receive-less-care-in-canadian-icus/

I think the crux of the matter is that these kinds of outrageous problems are based in medical irrationality and prejudice rather than a conscious decision that women are worth less. Medical recommendations based on actual statistical evidence are going to work in favour of women’s health not against it.

Exactly.  If I, who feel as if I am at risk, though my doctor disagrees, waited 4 years between mamogram 1 & 2, how likely would I have been if I didn’t think feel that way and was told not to worry until I was 50 anyhow.

thecynicalromantic:  Coming right on the tail of actual instances of “But we don’t wanna pay for lady-healthcare!” asshattery coming out of this healthcare reform business, it’s really easy to assume there’s some sort of connection.

I think this is precisely right:  it sounded like “the government” was failing to take women into consideration again, or defining them as drags on the system, and people’s nerves were already frayed over Stupak.

The problem with that is “good habits” is probably not a reasonable substitute for the actual degradation to your health from getting screening you don’t need, including just the radiation dosage from the mammogram.  If they had a better form of screening, I’d imagine this would all be reexamined.

There is a blood test that can indicate if a person has cancer anywhere, which could then lead to examinations of where exactly the cancer could be.  It can also lead to false positives but is a simple freaking blood test.  There hasn’t been too much interest in improving it.  I can only assume this is because blood tests are cheap and the test doesn’t point to any particular type.
Also, the ultrasound version, with little to no risk was killed in development by the current producers of the screening equipment; MRIs would do a better job (but are more expensive so the insurance cos wont cover it), etc.  So no, maybe now we can get a better form of screening because they are scaling back.  But I’m not going to hold my breath.

Sorry, daisy.  I should have said, “Not as true as it used to be, especially in this case.”

Amanda, this is an awesome fucking post. You have totally nailed it.

One clarification, however, is that—as another commenter has already pointed out—while the talking point of the medical profession is that paternalism and discounting of women’s autonomy is a thing of the past is bullshit. Yes, the medical profession continues to improve in this regard, but there is still quite a ways to go.

Helen, being “at risk” for a disease involves more complicated matters than your feelings about the topic.  If your doctor says that your paternal aunt’s cancer doesn’t influence your risk, you being scared that it does won’t change the fact that your actual risk isn’t influenced.

Five or six years ago there was a huge blowup over the PSA test for prostate cancer. Several studies suggested that the tests should not be given as frequently as they were, nor should they be relied upon as gospel. At that point outraged ensued by men claiming that the medical establishment would never treat breast cancer with the same cautiousness in testing that they were suggesting for prostate cancer.

Mammograms are an important and vital test—both my wife and mother were diagnosed early and recovered thanks to the testing. However, most people don’t realize that 1) a mammogram’s effectiveness relies a great deal on the skill of the interpreting technician or radiologist, and 2) the mammogram itself carries risks—each mammogram a woman receives increases her risk of a future abnormality by 2%.

I suppose my overall point here—speaking from a great deal of experience: Don’t blindly trust the medical establishment. You have to work with you doctor and educate yourself about the risks and issues involved. If your doctor is not responsive, change doctors. Too much medicine is often as harmful as too little: PSA tests—due to a major lawsuit are now insisted upon by most urologists. A large number of those tests return false positives which are then treated or require further painful examinations. I have seen the same behavior with mammograms: an film is misread and now a woman is subjected to a painful and costly biopsy. As with anything of importance, medicine should be approached with some enlightened skepticism.

Excellent analysis here.  I would add that the extreme cancerphobia that has been inculcated in the American public over the last 40 years or so is also a factor.  The reality that cancer is statistically quite rare, especially in those under 60, is overlooked in our terror of contracting a potentially intractable disease whose treatment is almost as horrifying as the disease.

This has been created innocently enough by medical authorities trying to convince patients, who do not want to even think about the possibility of cancer, to undergo screening which can save their lives and to avoid behaviors like smoking which dramatically increase your chances of contracting it.  Campaigns to clean up the environment and reduce industrial emissions which highlight the adverse health effects of pollutants including cancer, have also contributed.  Individually these are relatively benign, but taken collectively have created a kind of mass paranoia about cancer.

I think the reaction is partly due to the issue of medical risks and prevention being too oversimplified in the public’s mind.

Breast-cancer screening is not as effective as we would like, and introduces risks when overdone. This is disheartening, because getting screenings made you feel like you were doing something to fight the risks of breast cancer, and turns out, you can’t do all that much, because the state of medical technology just isn’t up to it, yet.

I think in general that the abilities of the medical profession tend to be oversold to the public; in fact, we are still at a very early stage in so many areas of disease prevention and cure.  I remember being blown away to hear a doctor freely confess that many times we really don’t know *why* or *how* a given medicine works, just that it usually does, so we prescribe it.

I feel high risk because I have an aunt who died from the spread from breast cancer.  My doctor tells me I don’t really because she was on the paternal side.

Not that I’m a doctor or geneticist, but my immediate response is that you clearly have an X chromosome from your father’s family, so you should have just as strong a link with your paternal aunt as any maternal female relatives.

I think it’s bad timing that the new recommendations have come out on the heels of Bart Stupak et al deciding that they don’t want to pay for women’s abortion care, just a year after Bush & Co. introduced the “conscience clause” that would let the receptionist at your doctor’s office refuse to hand you that prescription for birth control that the doctor left for you right before doc went on vacation. Women are rightfully skeptical about anything the government does in relation to our health really being in our best interest and not to appease the fundnuts who are trying to hurry Gilead.

I am personally in favor of the new recommendations. I don’t get a pap smear but every three years or so, which I feel is an informed choice given my history and risk factors. My doctor agrees that I’m low risk, but the HMO still harasses me to make an appointment for the next one starting about six months after I’ve had the last. That’s a little overboard.

I’m also concerned that insurance companies will use this as an excuse to deny claims instead of allowing the doctor to enter that yearly tests or mammograms starting at 40 are necessary for this particular woman if not statistically for her age and ethnic group. I don’t think known to be inaccurate guidelines should be left in place either, especially since right now Congress has the opportunity to make it part of the law that mammograms must be covered for women 40+ and a yearly pap must be covered, even if docs are not recommending them for most patients. IIRC, well women’s gynecological care isn’t covered anyway, right? In addition to no birth control, aren’t we on our own for pap smears as it is? Right now I have a $15 co-pay. When that cost goes up to $130, we’ll all be glad to only pay it every few years. Except then a lot of women will probably take their chances and skip it, which is no good at all.

There is a blood test that can indicate if a person has cancer anywhere, which could then lead to examinations of where exactly the cancer could be.  It can also lead to false positives but is a simple freaking blood test.  There hasn’t been too much interest in improving it.  I can only assume this is because blood tests are cheap and the test doesn’t point to any particular type.

Or maybe it’s because it’s not particularly reliable (i.e., rate of false positives or negatives) and doesn’t give any useful information beyond the possibility that this person has a tumor. Somewhere. Chances are pretty good that this test (which I would like to hear more closely described; I could probably find solid information on it pretty quick with a name or reference) isn’t used because it fucking sucks.

This idea that, oh, [potential cancer treatment/screen X] isn’t being developed because it’s “too cheap” pisses me right off. Many of my fellow grad students in the department of biology are working in cancer cell biology, on research that they hope will lead to new detection methods and treatments. They would be surprised to hear that they aren’t doing work because it’s too expensive, since they are in fact working on every screening and treatment imaginable, and quite a few that you couldn’t imagine. The public clamor for cancer screening and treatment is so enormous that we have quite a few therapies or screening techniques out there that are actually of fairly dubious use (breast self-examination being the poster child). If a given technique isn’t being used, given the political climate around cancer, it’s because it either a) is untested, or b) it doesn’t work.

“just a year after Bush & Co. introduced the “conscience clause” that would let the receptionist at your doctor’s office refuse to hand you that prescription for birth control that the doctor left for you right before doc went on vacation.”

uhhh this was not an invention of the Bush administration, it’s been a serious issue since the late 90s.

Amanda—this was pretty on point. Always warms my heart to see decent science writing on left-leaning blogs. I might take issue with the stuff about prostate exams—a whole bunch of people did flip the fuck out when people published research in journals about how more frequent exams were doing more harm than good, as sjk noted above—but that’s probably a matter of opinion more than anything else.

Latts, you have a 50-50 chance of sharing an X chromosome with your paternal aunt. With your maternal aunt you have a 100% chance of sharing one X chromosome. If certain cancers are affected by the X chromosome, your chances are higher if it’s your maternal aunt. If you go back any further along the paternal line, you have no increased risk. My grandfather’s sister is dying of breast cancer but she and I don’t share an X chromosome so I have no increased risk because of her.

On the other hand, if your paternal grandmother has cancer, you are at more risk than if your maternal grandmother does, because you definitely share your paternal grandmother’s X chromosome but only have a 50-50 chance of sharing your maternal grandmother’s.

I love genetics.

The situation is exactly analogous to the prostate cancer screening recommendations, and for the same reason - overscreening can lead to overtreatment.

Part of the problem is that in some ways we’ve done too well educating the public to catch it early, catch it early, catch it early. The thing is, there isn’t always a predictable pattern for cancer where it starts out tiny and innocuous and get bigger and more malignant and then eventually spread througout the body and becomes incurable. Now that we know a little more about cancer it has become clear that it doesn’t always go from A -> B -> C. Some cancers start spreading immediately, before the original tumor has increased in size. Some cancers, on the other hand, will never spread. It’s being theorized now that whether or not a cancer will begin to spread througout the body is programmed into the tumor to begin with, which makes the idea of early detection a little bit moot. If you catch the early-metastatic cancer early it’s already too late, and if you catch the indolent cancer early then you’re giving very unpleasant medical treatment to someone who possibly never needed it.

In the case of prostate cancer, the PSA blood test will tip us off to a malignant tumor growing in the prostate, yes. But. A tumor you’re catching with a PSA that has no symptoms is very small, and prostate cancer can take years and years to grow.  Most of these tumors are found in people who are 70, 80, 90 years old. Is it worthwhile to give life-threatening treatment to someone who most likely will die of old age before they feel any effects at all of their cancer?

In breast cancer, a mammogram can find a tumor early, a MRI can find it even earlier. But a lot of these tumors are benign. An awful lot. And even more of them are DCIS, which doesn’t necessarily need treatment. You’ll have a hard time getting doctors to admit it, but an awful lot of women have had an awful lot of unnecessary treatment on a just in case basis. But honestly if you know there’s a tumor there, you’re going to want it cut out and you’re going to want treatment, and the doctors will want to give it to you. It’s what we’ve been saying for years, find it early, treat early. Doctors would be very reluctant to watch and wait once something has been detected. But if you adjust the screening guidelines, you can improve the accuracy of the screening and be less likely to mistake a temporary blip for a growing tumor. By monitoring the patient population carefully we have a better idea now of how often to screen.

The idea is the best result for the most people. Noone is trying to risk women’s lives here. Nobody is telling doctors not to give mamograms. The recommendations are simply to ease back on the hypervigellance that is causing the overtreatment, and to advise that only the people who they feel are at risk, either genetically or anecdotally, really need the annual screening. The situation is that doctors follow these recommendations knee-jerk, even when it doesn’t make sense. Today people who already have Stage IV (incurable) cancer are being prescribed a colonoscopy and mamography. Because that’s the screening guideline. But that makes no sense, does it, to be doing screening tests for cancer in that situation! It’s just putting the patient through an unnecessary procedure because that’s what you do when they turn 50. It’s not being thought through.

Nobody wants more than oncologists to be able to cure their patients. They have I think the most difficult job in the medical profession. These guidelines are in the interest of helping people, not hurting them. It’s frustrating to see so many people misread this.

Sorry for my inaccuracy, Colin. The Bush administration expanded the conscience clause so that it didn’t apply to only medical professionals directly providing care, but allowed that receptionist to not hand you your prescription that the doctor left for you, and not face any repercussions for not doing her job duties.

The problem is who gets to decide what is high risk.  I feel high risk because I have an aunt who died from the spread from breast cancer.  My doctor tells me I don’t really because she was on the paternal side.  Will insurance continue to cover mamograms every 2 years if I want them if my doctor wont say I am at risk?

Screenings don’t just detect cancer, they can provide peace of mind as well.  It would probably really, really, really suck to always be afraid that there’s something deadly growing in your body; a screening and a “we didn’t detect anything abnormal” could potentially help a lot to someone who is very frightened of cancer, regardless of her risk for it.

Risk as a percentage or likelihood is vastly insufficient to describe the reality should that hit home.  You may have a .0001% risk of cancer, but if you’re that .0001%, it’s just as devastating as if you get cancer at a 10% risk factor; and if you’re terrified of getting cancer, the odds don’t really matter so much in the face of that fear.  People should have the option of mitigating risks when they really, really, really dislike the results should that risk hit. Regardless of how “likely” the risk is to actually occur.

A person who’s had friends or family members get cancer, for example, might very well be more terrified of it than someone who hasn’t—-even if the risk to her is minimal, the threat is increased in magnitude by becoming much scarier, and if yearly screenings put her more at ease, I’d say that’s absolutely worth her getting the screenings.

But then, I’m not an insurance company executive to whom profits are worth more than lives, nor am I a careless or misogynist congressperson who thinks coverage for a procedure has to benefit men for it to be worth including.

(I hasten to add that I would never recommend throwing out screening tests entirely. It is helpful in many cancers to detect them before symptoms appear, and it can often make the difference between a curable and incurable cancer. It’s just not always as simple as it’s made out to be.)

On the prostate exam thing: I was ignorant of the flip out. Thatsaid, the accusation they would never do this to men is demonstrably false. Apologies for accidentally downplaying the reaction.

I never do monthly breast exams.  I have no relatives with breast cancer, no other risk factors, and I think being paranoid about my boobies killing me is wrong.

I’m behind getting my first mammogram b/c I had a baby at 40.  Then I nursed, and you aren’t supposed to get a mammogram while nursing.

Plus, aren’t MRIs supposed to be more effective?

——-
On the other hand, this is a recommendation that a woman and her doctor need to evaluate.  If you have risk factors for breast cancer, you should do what you feel is best.  This is not a decision the insurance company needs to make for all women by deciding not to cover the exams anymore.

We need to fucking repeal Hyde and pass a law stating that insurance companies cannot discriminate on basis of gender.  That OB/gyn annual visits are covered, as are mammograms and abortions—whether a 5 week elective or 25 week dead fetus.

Right now it looks like Reid wants to suck up to the Blue dogs and give them a trigger for the public option, which means the public option will NEVER come into play.  Fuck it.  I think no bill is better than a crappy bill.  Start over with single payer.

Amanda, great post, but I also have to jump on the “Oh, yes, the medical profession still is male-dominated and tends to patronize and medicalize women” bandwagon. While the blog First, Do No Harm chronicles the mistreatment of fat patients by the medical establishment, a lot of that mistreatment is most definitely sexist in nature. Anyone remember the doctor a few years ago telling the woman patient that if she didn’t lose weight, she’d never “find a husband”?

And note that just as being a woman doesn’t preclude one from being a misogynist, being a woman doctor doesn’t preclude one from patronizing women patients and overmedicalizing their bodies.

Screenings don’t just detect cancer, they can provide peace of mind as well.  It would probably really, really, really suck to always be afraid that there’s something deadly growing in your body; a screening and a “we didn’t detect anything abnormal” could potentially help a lot to someone who is very frightened of cancer, regardless of her risk for it.

Screenings don’t just provide peace of mind. They also lead to unnecessary and painful interventions and diagnostic proceedings that carry their own risks and complications.

What these new findings show is that for women without other risk factors, the risk of screening is higher than the risk of not screening. This isn’t just about profits. It’s about not taking out half your cervix for no good reason.

Gail Collins had a great column about this the other day in the NYT. Which I’ll quote at length:

I had breast cancer back in 2000, and I am trying to come up with a way that I can use that experience to shed some light on these new findings. I have never believed that everything happens for a reason.

But I do feel very strongly that everything happens so that it can be turned into a column.

Whatever the moral would be, I don’t think it helps Representative Camp’s argument. I had mammograms every year like clockwork, and I had just gotten a clean bill of health from my latest one when I found a lump on my left breast while watching a rerun of “Buffy the Vampire Slayer,” multitasker that I am.

It turned out to be cancer, of a fairly low-grade variety. My oncologist felt strongly that it never would have developed if I hadn’t taken estrogen replacement therapy — another one of the medical marvels that has now been consigned to the Seemed Like a Good Idea at the Time category.

So, in summary, the cutting-edge of medical thinking of the 1990s may have induced my cancer, and then the universally recommended testing protocol failed to detect it.

There is absolutely still paternalism, misogyny and devaluation of women’s lives and quality of life in the medical profession. But medicine is also a work in progress, and the lurching process of two steps forward, one step back, is part of the scientific process of discovering how bodies work, how we can understand them, how we can heal them. It’s not as simple as good and evil. And we make the best decisions we can with the information we have at the time. When we get more information, we re-evaluate.

Great post.  I have to respond to Helen, though—the panel’s recommendations differentiate between women who have no risk factors in their backgrounds and women with a family history (like you).  Your family history might put you in a different category, and my understanding of the panel’s recommendations is that the panel’s report might support more aggressive early screening in your circumstances.

I just wonder, though in this case at first glance I figured this would be one of those recommendations that come back and need to be wiggled the other way.  Of course, when pointed out that we’re living longer, still, they make sense.

Mostly, I worry about narrow-case approval.  When healthcare is for the least dollar and the least effort, often rare things get narrows out of the treatments available pool really quick.  “Oh, we don’t treat that.” is a really frustrating thing to hear.  Or, “Well, we’re not covering the thing which works in your case, because it was found to be slightly less effective than (case that isn’t you, using treatment that didn’t work for you).”

I hate how the list of things they will and won’t treat are so vague in health insurance plans…

A few other random points. Sorry for the multiple postings.

In discussions with friends from other countries, I learned years ago that MOST countries don’t do yearly pap smears. Including many countries with better outcomes in all areas of women’s health.

My understanding of breast cancer (though I can’t remember where I read it and have no cite) is that most women do find their own lumps, but not through monthly self-exam. Instead, they or their partners find them during the course of normal events. I don’t actually need to do a self-exam to know what my breasts feel like. I just need to be on friendly terms with my breasts.

the introduction of midwifery

That would be the re-introduction of midwifery. Midwifery is quite likely the real “oldest profession.”

adding to chingona and some of the others: the phenomenon of false positives and the resulting excess treatment carries real dangers. The more low-risk people you screen, the more false-positives you’re going to get, and the more people will get sick or die from additional diagnostic procedures that didn’t really need doing in the first place. Screen a million people with a test that’s 99% accurate (ha!, try 90% on a good day) and you’ll be doing biopsies or exploratory surgery on 10,000 people who don’t need it.

I think, btw, that this is yet another really evil longterm fallout of the previous administration’s politicization of just about everything. When some kind of government panel releases a new recommendation, the first thing we look for is bad faith. (Which isn’t to say that everyone is always acting in good faith, but it sucks when you just assume they’re acting badly. In fact, this is another example of the damage done by false positives…)

Latts and one jewish dyke:

Just fyi, the breast cancer genes (BRCA1 and 2) are not on the X chromosome.  A paternal vs. maternal relative having breast cancer makes no difference.  I don’t know why your doctor told you that it did.  Men can have the BRCA mutation, can pass it on, and can even get breast cancer.  However, BRCA mutations account for a small number of breast cancer cases, and as far as I know scientists are not aware of a specific inheritance pattern or gene mutation responsible for increased risk of the other types of breast cancer.  They just know it tends to cluster in families.  Also, having an aunt with breast cancer does put you at slightly higher risk, but it’s not as much of a risk as is having a first degree (sister or mother) relative with breast cancer.

While Male Doctors Hid The Truth From Me may be an overstatement, the idea that the medical establishment as a whole minimizes and ignores the interests of patients is not. We have tens of thousands of deaths from preventable medical errors each year; hospitals regularly have to mount education and compliance campaigns to get medical personnel to wash their fucking hands before touching patients.

It doesn’t help that the explanation for why the exams are not necessary has been “it doesn’t reduce mortality rates”. This is as clear as mud. It might help to explain that, for example, the number of women who might be saved with an early biopsy is not offset by the number of women harmed by unnecessary biopsies and mammograms (although again, see above re preventable medical errors).

I’m sure there’s also a concern that the medically-sound differentiation between testing schedules for women in high-risk groups vs. low-risk groups is going to be utterly ignored by insurance companies. Hey, doctors said that women only need mammograms when they’re 50, so screw you, 45-year-old female who has a family history of women getting breast cancer in their 40s!

I would be less peeved about the whole thing if they had also included a recommendation for increasing the availability of the genetic testing for the gene that massively increases your chances of developing breast cancer before age 50.  My current understanding of the recommendation basically fucks that entire population segment over.

On the other hand, this is a recommendation that a woman and her doctor need to evaluate.  If you have risk factors for breast cancer, you should do what you feel is best.  This is not a decision the insurance company needs to make for all women by deciding not to cover the exams anymore.(bolded for emphasis)

This. For what it’s worth, I agree with the panel’s recommendation that most women don’t need an annual mammogram until age 50. However, I’m also very suspicious of who is going to get a “pass” from her physician as being in a high-risk group. I’ve been told by more than one doctor that just because my mother has breast cancer, that does not mean I am at a higher risk than the average woman. I had to argue with a physician for twenty minutes in order to get the blood test that confirmed my hypothyoidism (she blew off my symptoms as “age-related”, and pooh-poohed my suggestion that because all three of my father’s sisters have Hashimoto’s, that perhaps I had it too).

Now that I’m seeing an endocrinologist, I’m on the right meds (and the right dosage), have great bloodwork, and feel like a million bucks. All my “age-related” symptoms are gone, and I’m damn near back down to my “fighting weight” despite eating a normal amount of calories.

Here’s the thing—-we still operate under the backdrop of a healthcare system that is controlled by insurance companies. Physicians and healthcare organizations get kickbacks from insurance companies (though I think they call them “bonuses”) for not providing care. The fewer tests given, the bigger the yearly bonus. So, what is going to be good for a lot of women (not getting unnecessary tests) is going to leave other women (those who should have the tests, who do have risk factors) out in the cold. In reality, if insurance companies stop paying for mammograms for women under 50, hospitals aren’t going to schedule them for women under 50 without a referral. And you aren’t going to get a referral from a doctor that gets a bonus for giving the least amount of tests. Cue up the “just because your mother has breast cancer doesn’t mean you’re in a high-risk group.”

No one would be batting an eyelash at the panel’s recommendation if it didn’t carry the very real risk of a lack of care—-and that blame can be laid at the feet of insurance companies.

Actually, this study isn’t the final word on this, and interestingly, I read in the NY Times that the panel that came out and recommended more time in between pap smears (which I am very comfortable with) does not agree with these mammography recommendations (which I am not comfortable with at this point).

So, I think that before we say who is and who isn’t overreacting, we need to see more study and more recommendations on this, until there is some sort of consensous reached.  Unless we are talking about Elizabeth Hassleback and her hysterical screaming on the view all week about gendercide and how “they” ( i am pretty sure she meant Obama and Rahm who apparently cooked this up in an attempt to kill off women and save some money) won’t spend money to save womens’ lives.  She deserves ridicule.

But other than that, the final word really isn’t in yet.

I think a few feminists are too outraged by this.  However, I think some of it is due to a genuine concern that insurance companies will use this as an excuse to stop covering mammograms, even for women who are in high risk groups.  Of course it’s perfectly reasonable to assume that, but I’d rather see feminists arguing that point directly rather than complain about someone being too condescending or something.  Coming on the heels of measures that really are intended to deny women care (like the Stupak amendment), it’s really easy to see this as an attempt to further reduce our care, but that’s not really the case here.  What we need is more research, and powerful health care reform that will require insurance companies to cover mammograms for certain groups, if those groups will actually benefit from it.  What we shouldn’t do is get mad at a scientific study for not having the results we expected.  And what we absolutely shouldn’t do is jump to conclusions just based on one study when we really should take it as a sign that we need to study this even more.  Unfortunately, a lot of people don’t really understand how science works (no thanks to our media), and like to jump to conclusions that are far stronger than the data suggest.

Feminist critiques of over-medicalization of female bodies have produced much good: the introduction of midwifery, the willingness of therapists to take women’s concerns seriously instead of just drugging them, the legalization of emergency contraception, the promotion of breast-feeding, the end of the use of twilight sleep for childbirth, the invention of safe abortion techniques that can be performed even without electricity.

Call me a bad feminist, but I don’t think all of those things are necessarily awesome.  Pregnancy and childbirth might not be medical conditions, but they are certainly life-threatening and have more physical symptoms than many diseases, and I personally want to have a doctor involved, rather than a midwife.  Of course each woman should have a choice, but women who don’t want to go through the pain shouldn’t be looked down upon.  The same goes for breastfeeding.  It’s great when women do it, but now there’s a stigma for women who don’t do it, to the point the some pro-breastfeeders act like using formula is a form of child abuse.  As for using drugs for psychiatric conditions, I think we’ve gone too far, so that there’s a stigma for those who actually need to take drugs.  It’s now seen as a moral weakness when people can’t just get over their mental illness with talk therapy alone, and they need to use drugs as treatment.  Some of these things are neutral at best.  The real problem is the assumption on both sides that the same thing is best for everyone.  This is a particularly great blog so I haven’t seen much of it here, but some feminists are as judgmental as any conservative.

This strikes me as such a complicated issue, not so much because of the science involved, although that too is complex, but because of a host of baggage that women necessarily bring to the issue.  There is 1) the disorientation that comes from the medical establishment doing what seems to be a 180 on something that is viewed literally as a matter of life and death; 2) the suspicion that the medical establishment is insensitive to the health concerns of women; 3) the suspicion that the health insurance industry will use findings like this to deny reimbursement for needed care; and 4) some degree of discomfort with having the “prevention” regime undermined. 

Cancer is understandably scary to people.  To people like me, approaching 50, it is the thing that starts wiping out the first of your peers (youthful car accidents excepted) and you’d like to think that there is something that will keep the threat at bay.  I am shocked at how many people I can name who have succumbed to its verious forms, many only in their 40s.  We want to feel protected in some way and want to be able to do something affirmative to protect ourselves.

I think that this is probably just one of many areas that we will have to grapple with in the ensuing years as we try to figure out the best way to spend health care dollars and assess risk.  Hopefully more study will shed some greater light on this and give women more assurance about the reasonableness of this recommendation.

Oh, wow, thank you for this. All the “betrayal” hoopla was making me crazy. Agreed, also, with the commenter who tied this to how “scary scary scary” cancer has become in our culture. I find all the pinkwashing particularly distressing, as I’d wager that many women would name breast cancer as the #1 killer of women in this country. (#1 is cardiovascular disease, and lung cancer kills more women than breast cancer.) I worry that all the media emphasis on breast cancer is in fact leading women to be less cognizant about other areas of their health. As in, ‘I’ve gotten my mammogram, so I’m safe for another year and don’t have to worry about the rest of it.’
There’s a good argument to be made that a yearly mammogram or pap smear is often the only interaction a woman may have with a doctor, and thus is an opportunity to talk about her health in a holistic, comprehensive manner. Our reality right now is so far removed from that scenario, I’m afraid, that changing the interval between screenings wouldn’t make much difference for many women. The women who have an in-depth 15 minute conversation with their doctors (the same doctors they see every time) while getting a pap are the lucky few.

There’s a good argument to be made that a yearly mammogram or pap smear is often the only interaction a woman may have with a doctor

This is an excellent point.  Growing up, I had routine physicals every single year, all the way through college.  Then I graduated, got a job, and now I have my own insurance instead of being covered under my mom’s (surprisingly good) insurance.  I found out that I can longer have yearly physicals, because my insurance won’t cover it.  They still pay for the yearly pap test, so at least I make sure to see the doctor yearly, even though I can’t have as much as a conversation as I would like.

Chingona beat me to the point about midwifery. Thank you. Especially since I’m studying to be one I wanted that clarified.

I also think the link between the earlier recommendations for annual screenings and the money made off all of those screenings. I worked in a GP’s office in Las Cruces, NM. For awhile, that small city had more “imaging centers” than it had GPs. The doc I worked often talked about how he followed the current recommendations but he worried it was a waste to low risk patients. Mammograms, x-rays, MRIs, CAT scans, etc. are BIG MONEY. I wouldn’t be surprised to find that the earlier recommendations for annual screenings were influenced by those on the receiving end of that BIG MONEY.

Problem:  I know several women, one of them my roommate, who would now be dead if those guidelines had been in place when they were diagnosed with breast cancer.  They were all under fifty and had no primary relatives with breast cancer, so under the new recommendations they could have safely waited.  At the same time I know that statistically speaking, mammograms in the 40s aren’t all that cost effective and don’t make that big a difference. 

What sent me into orbit, though, were two things:  first, don’t learn self-examination because it really doesn’t help.  That smacks uncomfortably of the Mad Men era mentality that women shouldn’t know their bodies or touch themselves because really, all they had to do was listen to their doctors and all would be well.  My roommate found her tumor SOLELY because she does her monthly breast exams.  She had no insurance at the time and hadn’t been for a mammogram in several years, and if she hadn’t caught the tumor it would have been disastrous for her.

The second thing that really, really pissed me off was the whole thing about needless worry.  I found this incredibly condescending, and once again, straight out of the “don’t worry your pretty little head,  you’re fine” school of OB/GYN.  Didn’t we already fight these battles forty years ago?

Pregnancy and childbirth might not be medical conditions, but they are certainly life-threatening and have more physical symptoms than many diseases, and I personally want to have a doctor involved, rather than a midwife.  Of course each woman should have a choice, but women who don’t want to go through the pain shouldn’t be looked down upon.

Before I launch into my spiel, I want to be very clear that I absolutely am not trying to say you shouldn’t have a doctor or shouldn’t want a doctor. If that’s what makes you comfortable, by all means, do what makes you comfortable.

But I don’t want to just let the misconceptions you seem to be under go uncorrected.

There are a lot of different kinds of midwives with different kinds of training. Some of them learn only through apprenticeship. Some go to midwifery school and are certified. Some of them are registered nurses with bachelor’s degrees in nursing and master’s degrees in midwifery and have worked in high-risk labor and delivery wards of hospitals. Some of them do home birth. Some of them do hospital birth exclusively. You can have a midwife and have an epidural, if that’s what you want.

More importantly, should you develop a complication of pregnancy, no midwife is just going to shrug her shoulders and say you’re shit out of luck, guess you’ll have to die. They’ll exercise their training until they hit the limits of it, and when that happens, they’ll refer you to an OB or tell you you need to be in the hospital because you’re too high risk to have an out of hospital birth.

Again, every woman should choose the care provider she feels comfortable with, and if, for you, that’s a doctor, that’s fine. But please don’t act like midwives are witch doctors with potions and dirty hands.

Amanda,

I am a fan of your work, a feminist and a 42 year old breast cancer survivor with no family history and
I’ve got to call you on a couple of things on your article.

First of all comparing breast cancer and prostate cancer is a bad call.  In general prostate cancer is slow growing, is often treated with watchful waiting and there is a good blood test available to monitor PSA levels.  None of these are available for breast cancer.

Next, more than 20 percent of the women who are diagnosed with breast cancer every year are age 49 and younger. The number varies from year to year and as a percentage will likely continue to rise for a variety of reasons including women being advised not to be using hormone replacement medications. Breast cancer, when diagnosed at a younger age, tends to be more aggressive and more lethal.

I think a major problem that a lot of women have with the recommendations that were made is that we’ve been told that self exams are useless and now mammograms are useless. They speak to the reality that we are using the same technology to detect cancer in women that we have been using for over 40 years. Okay, so let’s say that mammograms are not the best technology, then what do you have to offer? You can watch TV on your phone and your great grandfather can have an erection all day and we have nothing else to offer women?

Add to that the fact that many insurance companies will have no problem arguing that the medical community is not in agreement with mammography guidelines and as such we will not cover them.

Not to mention the fact that “anxiety” was used as a justification for not testing younger women and that feels like a big old pat on the head.

And yes while finding breast cancer early does not mean that is has been prevented it may mean that the woman gets to keep her breasts, ovaries and possibly avoid chemotherapy.

It’s is estimated that breast cancer killed 6,000 women last year who had been diagnosed under age 50 last year. As a feminist and as a breast cancer survivor I’m in favor of keeping women alive.

If I can share more information please contact me at http://www.aftercancernowwhat.com
And for much more information you might want to check out the Young Survival Coalition at http://www.youngsurvival.org

so let’s say that mammograms are not the best technology, then what do you have to offer?

I cannot speak with any kind of authority about breast cancer mortality statistics, but many kinds of cancer do not have any regular test associated with them, yet are eminently curable once symptoms begin to appear.

As alluded to above, some people find lumps themselves without the benefit of mammograms. What you’re depending on with a mammogram is that detection-by-mammogram will provide an improvement over detection-by-other-means.

It’s is estimated that breast cancer killed 6,000 women last year who had been diagnosed under age 50 last year.

I suppose the question is how many of them would have survived if they had a mammogram? How many of them had regular mammograms but died, anyway?

I don’t know what the answers are. What I do know is that there are plenty of kinds of cancers we don’t insist on yearly scans for, but feel perfectly comfortable treating once symptoms do appear.

I really don’t have one opinion or another about the mammogram recommendations. They may be right or they may be wrong. What I do know is that there could be any number of cancers growing in my body right now, but the medical community seems comfortable with my prognosis for many of them if I show up to the doctor once symptoms appear, rather than requiring me to get scanned on a yearly basis, so I understand the logic behind the mammography recommendations.

Men can have the BRCA mutation, can pass it on, and can even get breast cancer.  However, BRCA mutations account for a small number of breast cancer cases, and as far as I know scientists are not aware of a specific inheritance pattern or gene mutation responsible for increased risk of the other types of breast cancer.

Yes, thank you. Unfortunately BRCA1/BRCA2 can be some of the most aggressive and devastating types of breast cancers. I worked as a breast cancer treatment advocate and counselor for a non-profit and these were honestly some of my worst cases. Women who have “no family history” because their fathers or grandfathers carried one or both of these gene mutations and they are left having aggressive chemotherapy and mastectomies in their twenties.

The thing that does bug me about this whole announcement seems to be a perfect combination of being both overly incendiary and absolutely outdated.  Self-breast exams?  Research has been saying that they don’t make much of a difference now for years, I’m pretty sure it was the 90’s when that one started being reported.  They also should have given women (and the men who suffer from breast cancer) more options.  Instead saying “Hey, we’re going to deny you a sense of peace for ten more years,” they should have emphasized more effective practices, such as more consistent policy for blood screening, more genetic mutation tests such as BRCA (there are actually quite a few genetic risk tests for a wide variety of cancers these days), and the vast improvements that MRI’s provide over mammograms. But instead of moving health forward they are limiting options.

Of course each woman should have a choice, but women who don’t want to go through the pain shouldn’t be looked down upon.  The same goes for breastfeeding.  It’s great when women do it, but now there’s a stigma for women who don’t do it, to the point the some pro-breastfeeders act like using formula is a form of child abuse.

I actually did a thesis on the bad mom/good mom and woman blaming of the natural birth and breastfeeding communities.  Are there bad apples, of course. In life there is always someone out there to ruin it for everyone else but we should not use that to undercut the advancements these movements have made to women’s rights.  To me your comments are very much like people complaining in the earlier days of feminism (and some dinosaurs now) that those “career women” were all good and all but they were ruining it for the homemakers. The feeling of being judged for personal decisions is very often unfounded outside of a few individuals.

Amanda, I think you’re right that the idea of prostate cancer screening being ineffective has never caused quite the freakout that these new recommendations have, but that’s because there has never been a single moment where that suddenly became news.  In fact, the USPSTF still gives prostate cancer screening an “I” recommendation, meaning that there is insufficient evidence to recommend for or against it.  Mammos in 40-49 year olds went from a “B” (you should routinely do it) to a “C” (you shouldn’t routinely do it), so that’s a far more definitive change.

It’s hard to explain to someone why a test that can detect cancer might not be a good idea.  Hell, I lecture on the topic, and I have a hard time explaining it to residents and med students.

Regarding “anxiety” as a reason not to test:

Not long after I started practicing I ordered a CT scan on a patient and incidentally found a small growth on his adrenal gland.  We see these all the time, and they’re almost never anything bad, but we have to do a few simple tests and get a follow-up scan in a few months to be sure.

When I told the patient about this, he completely freaked out.  It took quite a while to calm him down, and then he wanted to know everything there was to know about every possible malignancy that it could represent. I answered all of his questions, reassuring him all the while that they were only the most remote of possibilities.

The patient, who had no history of depression or any other psychiatric diagnosis, went home that night and shot himself.

The point is that suggesting that a patient might have cancer has consequences.  Yes, a reaction like this patient had is rare, but we’re talking about small numbers here; for every 1000 positive mammograms among 40-49 year olds, only 20 actually represent a malignancy, and only 3 will benefit from the early detection.  So it doesn’t take many rare catastrophic consequences of some aspect of the testing or follow-up to make it a wash.

Jewish Dyke speaks the truth. Anyone with an understanding of high school genetics and a good grasp of cause and effect can see that the father’s family history of breast cancer is at least as signifigant as the mother’s family history, and possibly more so.

For the lowdown on on all this you really need to read Orac’s “Respectful Insolence” on Scienceblogs.

I’ve been told by more than one doctor that just because my mother has breast cancer, that does not mean I am at a higher risk than the average woman.

Seriously?  I’ve been getting occasional mammograms (about every 3 years) since I was 30, and technically was supposed to have started even before that, because my mother died of breast cancer at a young age.*  I have now officially lived longer than my mother did—she died at 39.  And it’s always been my doctors who pushed really hard for me to get them, too.

I do tend to choose health insurance (like Kaiser Permanente) that emphasizes prevention, so that may make a difference.

* Fortunately for my health, none of the other women in her family ever got breast cancer, including her mother or her three sisters.  I suspect she may have gotten it because she was a dental hygienist in the 1960s and they weren’t nearly as careful about x-ray exposure then as they are now.

catgirl @ 42: I did try to address this in my next sentence. But I think it’s an overall good that childbirth is getting back to “nature”, and an unalloyed good that twilight sleep is done and over with.  In my ideal world, most women with normal pregnancies would have a midwife with a relationship to a hospital and a willingness to haul you in at the first sign of trouble, but most vaginal deliveries with no complications would happen without a doctor present.  Also, in my ideal world, midwives would be able to use pain control.  The reason for this is doctor deliveries usually run up to 10X midwife deliveries; it should not be so expensive to have a baby. 

But as Americans do, we overplay everything.  The increase in midwifery and breast-feeding has produced a huge guilt trip in women who simply can’t, for whatever reason.  And that is bullshit.  We should not discount that the maternal death rate prior to modern childbirth methods was high, nor should we ignore the various ways women tried (and sadly often failed) to keep children alive when breast-feeding failed.

Regarding prostate cancer, early testing probably saved my father-in-law’s life.  Not every case of prostate cancer is slow-moving.  But he didn’t get tested as a regular regimen—he was in the emergency room with an unrelated bladder infection and they decided to test him since he had other stuff going on in that region and discovered that his prostate was going bad very quickly.

J Train - what you describe is tragic. 

Clearly there was more going on than simply the tumor diagnosis, though, because that is hardly a typical reaction to news that one might have cancer.  Have any of your *female* patients done something similar after an abnormal pap smear or mammogram?  Women have higher rates of diagnosed depression, after all, so on paper it would have been more likely for, say, me to go home and OD after being told I needed a breast biopsy a few weeks ago (or the acoustic neuroma diagnosis in 2006, or the abnormal pap smear in 2007, or…..)

As those who support reduced screening are so fond of pointing out, anecdote is not evidence.  That applies to your example as well, as tragic as it is.

On the midwifery side thread - I too think that in many cases the accusation that pro-breastfeeding or pro-midwifery advocates are being meeeeeeeaaaaaaan to everyone not them is wildly overblown and used to attack the whole movement away from over-medicalizing - and thus removing from women’s own hands and body - the business of reproduction and infant feeding.

I mean, yeah, sure, if you hunt out pro-breastfeeding blogs you can find crazy ladies being crazy on the internet, but only in spaces they have carved out for themselves—I don’t think they actually charge the public square and rip bottles out of baby’s hands while shrieking imprecations at their mothers.  That Law and Order once had a scary story about the mean lactation consultant who drove the teenage mom to underfeed her baby doesn’t mean it has never ever happened anywhere, but I’m not sure that is the most reliable source of even anectdata about the issue.

In fact, if you google breastfeeding stats for 2008, while almost 75% of all newborns are nursing when they leave the hospital, only 12% are still breastfeeding exclusively at 6 months.  This seems to be a drop actually, according to one site I saw, in 2003 15% were breastfeeding exclusively at 6 mo. Given that WHO still recommends exclusive breastfeeding for all babies through 6 months of age, the US is still pretty far off that number (and WHO recommends another 18 months breastfeeding as supplemental to solid foods - I’m going to guess that US rates are in the single digits after 12 months).  I don’t think it is fair to suggest, even glancingly, that the pro-breastfeeding ‘side’ should declare victory and stop bothering us anymore.

As for women being guilted about not using a midwife?  Given that (numbers were hard to come despite my googlefu) less than 10% of all births in the US are attended by midwives v. nearly 75% in Europe, by contrast, midwifery has hardly triumphed in the US.  I suppose—again—there are probably noisy advocates in sheltered spaces on the internet, but given that licensed midwifes who can practice in hospitals aren’t even available in all states (and even where they are, it doesn’t mean you can find one in your city or town), and insurance rates have driven some licensed midwifery practices out of business where they did exist—the full range of pregnancy and obstetrics care isn’t available to most women in the US most of the time.  Again, claiming that advocates are being too meeeaaan (loud? noisy? shrill?) when they’ve clearly “won” already seems to me to be dissing the messenger rather than hearing the message.

Just for the record, I used a midwife (CNM) practice when I had the chance and loved it, then stuck with my GP because in Minnesota, I could - so I’ve never actually visited a real life OB/Gyn practice.  I also breastfed and loved it, but that is not everyone’s experience.

Mnemosyne, yeah…seriously. The supposed basis for that is because my mother has a lot of sisters and so did her mother—-there’s the thought that if it ran in my family, someone else would have had it. So far, it has only been my mother and her paternal grandmother. In other words, I think the physicians who’ve said that to me aren’t speaking from a scientific position, but from some form of faith (not necessarily religious faith—-more like the positive-thinking faith that Barbara Ehrenreich wrote about lately). My thought is, it doesn’t get any more first-degree relative than your mother, so cut the crap and give me a mammogram. And I’m still going to do breast self-exams. (Also, I suspect that the reason for the recommendation for reduced mammogram screening has nothing to do with the risk of radiation, and everything to do with the fact that premenopausal women (as most of us in our forties are) have denser breasts which are harder to read in a mammogram.)

And my insurance does pay for mammograms as well as annual physicals. I don’t get to “choose” it though—-like most people, I get my insurance via work, and I take what they give me (it’s part of the union-negotiated benefits—-you can’t “opt-out”, and why would anyone want to, since private insurance costs so damn much more for so far little coverage?)

I’m bitter and cynical about the whole thing because I’ve dealt with really shitty medical care and really shitty doctors my entire life (both for myself and my daughter). I suspect it’s because I live in the rust belt, and any physician worth his or her salt moves the fuck away from here with all due quickness. The economy sucks for doctors, too. So, they look forward to those annual bonuses received from denial of tests.

I’m lucky. I have a PPO. My mother has an HMO. She doesn’t have any latitude to leave and seek other care. She’s on the downhill slide of fighting her return of breast cancer. She’d probably be doing better if they had caught it earlier——but that boiled down to the same reduced testing schedule that we’re talking about here. She’d been cancer-free for awhile, so then she was “normal”—-supposedly not at any more risk than a person who had never had cancer. She knew something was wrong with her for a couple of years—-she felt it. But…she’s an older woman (and frankly, in the eyes of the medical establishment, anyone over 40 is an “older woman”—-I was asked, last year at 41, if I still had menstrual periods). In retrospect, what she “felt”—-which was dismissed by various physicians as paranoia and the woo-woo feelings of an old woman——was the tumor growing in her brain, and the side effects of the metastatic uptake in her bones.

Now look, life is terminal. We all gotta die of something. But in all likelihood, she would have had more time if someone with the gatekeeping power, someone in a white coat, had taken the concerns of an older woman with a previous history of cancer seriously, instead of dismissing her like a nutcase because she used the term “feeling” to describe her symptoms. Physicians hear the word “feeling” and think “emotions. Bah! not my realm.” She didn’t have any other word to describe a physical sensation that wasn’t visible.

So….while on the one hand I can see that the recommendation of the panel is not nefarious, and is intended to produce less stress, less cost and still retain a good medical outcome——that isn’t how it is going to play out in the lives of many women. Many of us have a damn difficult time being taken seriously for the conditions we do have, especially if they are only visible via tests and not the naked eye. Over half the folks graduating from medical schools these days are female. But that doesn’t mean they aren’t operating from the same sexist attitudes they were trained with. I had to argue with a female physician about getting the blood test that confirmed my diagnosis. Some of that is outright sexism—-assuming that female patients have imaginary or psychological symptoms. Some of it is an underlying belief that good physicians don’t need the “crutch” of objective tests. And some of it has to do with those goddamn bonuses for reduced care.

It’s not the recommendations of the panel that has women (not just this one!) upset——it’s the backdrop against which those recommendations stand.

It’s hard to explain to someone why a test that can detect cancer might not be a good idea.

The example of what can go wrong is the testing for neuroblastoma in newborns as they did in Japan beginning in the mid-80s:

Urine catecholamine level can be elevated in pre-clinical neuroblastoma. Screening asymptomatic infants at three weeks, six months, and one year has been performed in Japan, Canada, and Germany since the 1980s.[30][31] Japan began screening six-month olds for neuroblastoma via analysis of the levels of homovanillic acid and vanilmandelic acid in 1984. Screening was halted in 2004 after studies in Canada and Germany showed no reduction in deaths due to neuroblastoma, but rather caused an increase in diagnoses that would have disappeared without treatment, subjecting those infants to unnecessary surgery and chemotherapy.[32][33] [34]

Link

a screening and a “we didn’t detect anything abnormal” could potentially help a lot to someone who is very frightened of cancer, regardless of her risk for it.

Then again, I can speak from experience when I say that a screening and a “we detected something abnormal but it’s too soon to tell what’s going on so we’re going to have to hack out a chunk out of your cervix anyway just for the fun of it even though a lot of these tests are false positives” definitely doesn’t provide peace of mind at all. 

A screening can provide peace of mind.  A screening can also scare the shit out of you for no good reason, or even cause future negative health outcomes for no good reason.

I know several women, one of them my roommate, who would now be dead if those guidelines had been in place when they were diagnosed with breast cancer.  They were all under fifty and had no primary relatives with breast cancer, so under the new recommendations they could have safely waited.

My childhood best friend was diagnosed with breast cancer earlier this year and ended up having a mastectomy.  She is 28, decades younger than the old guidelines would have suggested.

I know at least one other woman who had breast cancer in her 30’s.

Should all women start getting mammograms every year at the onset of puberty?  It’s always going to be possible for some people to get cancer even if they are not in a high-risk group.

But I think it’s an overall good that childbirth is getting back to “nature”

Appeal to nature is a logical fallacy.  Just because something is natural doesn’t mean it’s better.  It’s natural for pregnancy and childbirth to be really painful, and I personally would rather do without that pain if I can avoid it, not matter how natural it is.  It’s also pretty natural to die from childbirth, and it was a leading cause of death for women for a very long time.  If some women who have low risk pregnancies really care about “natural”, then that’s great for them and they should do it that way.  But women who don’t want to go through all the pain, they shouldn’t be condemned for not being natural enough.  Let’s face it: some parts of nature suck.  That’s why we have air conditioning and vaccination.

Also, in my ideal world, midwives would be able to use pain control.

Midwives should certainly be able to do this, but would the ever be able to give an epidural at the woman’s home?  Some women want an epidural, and I think it’s a better idea to do that in a hospital.  Some women might even want that “twilight sleep”, and the shouldn’t be made to feel bad because of it.  Childbirth is terrifying experience for some women, and as long as the baby turns out healthy, why should we care how natural or medical the mother wants to be?  The most important issue is choice, and I certainly agree that it’s a great thing that women can choose for themselves how much medical help they get.

I mean, yeah, sure, if you hunt out pro-breastfeeding blogs you can find crazy ladies being crazy on the internet, but only in spaces they have carved out for themselves

I’ve seen it come up in a lot of unrelated places.  The second a blogger for any type of blog announces that they or their wife is expecting, the comments are filled with judgment and finger-wagging thinly disguised as well-meaning advice.  The same is true in real life Both of my sisters-in-law experienced it constantly, and was strong enough that it made my own mother feel guilty about not breastfeeding my brother 29 years ago, and she got all this “advice” just by telling people that she would soon have a grandchild.  Of course, the bigger problem here is that our culture things it’s ok to give tons of unsolicited, condescending advice simply because a woman is pregnant.

But women who don’t want to go through all the pain, they shouldn’t be condemned for not being natural enough.

Nobody here is suggesting otherwise.  Very few people in general ever do suggest otherwise.  And most of those people are idiotic cranks on the internet who would probably judge you for something else if midwifery was taken off the table.

That is all.

With your maternal aunt you have a 100% chance of sharing one X chromosome.

Not true.

Scenario: Grandma has Xa and Xb. She gives Xa to your mom and Xb to your aunt. Both of them get Xc from grandpa.

Your mom gives you Xa. Your aunt has only Xb and Xc, no Xa.

If you are a man, you have a 100% chance of sharing one Y chromosome with your paternal uncle, but women’s genetics are not so simple. Sure, you might very well have an X chromosome in common with your maternal aunt… but you might not.

On the other hand, it’s probably irrelevant how many X chromosomes you have in common with her because there’s no guarantee that breast cancer is carried on the X chromosome. I know we like to think of everything that’s gender-linked as being carried on the X or Y, but it’s far more likely that the genes for the cancer are somewhere completely different, and are activated in the presence of female hormones (and probably some environmental stressors, too.) If the gene for breast cancer was on the X, far, far more men would get it than actually do, because men have no backup for X—anything on a man’s X chromosome will be expressed (admittedly, men also don’t have a lot of female hormones, so if it was X-linked and also hormone-linked they wouldn’t all express it… but a lot more of them would because a lot more would be running around with a hormonally triggered time bomb in their genome, and testosterone breaks down in the body into estrogens.)

Yet again, we have the touters of “it must be beneficial because it’s a ritual” coming up against the statistical reality of best practices.  Not nearly as bad as the “but EVERY boy MUST BE CIRCUMCISED because of HEALTH WOO (and it isn’t painful for the baby ... no really, they just scream and pass out because they don’t really feel pain yeah right)” crowd of meaningless ritual, but still very much vested in the procedure rather than the epidemiology beyond good science and even sense.

I was supposed to go for a mammogram last year ... but I had actually talked to one of the people who put this together (one was part of a research consortium that I’m on the steering committee of ... unrelated to this).  I put it off because there is NO history in EITHER maternal line going back at least five generations.  Seems like a monumental waste of capacity and money to me - particularly when there are women who lack access and are over 50 and do have family history of breast cancer.

Just fyi, the breast cancer genes (BRCA1 and 2) are not on the X chromosome.  A paternal vs. maternal relative having breast cancer makes no difference.

There are any number of other yet to be discovered and discovered oncogenes across a number of chromosomes, too.

I have a friend who had a double mastectomy in her early 30s.  Her maternal line was clear, but her father died of bowel cancer in his 30s and his mother died of ovarian cancer when he was young.  Guess where the genetic bad news came from?

Not to belabor the “men are affected too” angle, but males do indeed get breast cancer.  It is rare, but the fact that it exists says a lot about any genetic or environmental component being delinked from having two X chromosomes.

Great post, but one points of fact…

Public health wonks divy up “prevention” into several categories:

“Primary prevention” is preventing a disease before it happens, eg. getting people not to smoke so that they don’t develop lung cancer.

“Secondary prevention” is screening and catching diseases early so that they can be treated before they cause major morbidity/mortality - eg. pap smears or mammograms to catch disease while they are in the insidious stage and can be removed to leave a healthy person behind.

“Tertiary prevention” is dealing with active disease to prevent complications, eg. keeping on top of active diabetes to prevent the development of kidney failure.

Wonky, yes, but pap smears and mammograms are most definitely “prevention” by any public health measure - they are just “secondary prevention.”

Yep, and the HPV vaccine is a form of primary prevention, as are condoms.

I don’t think it is fair to suggest, even glancingly, that the pro-breastfeeding ‘side’ should declare victory and stop bothering us anymore.

Only if you assume the reason those statistics drop off so sharply is because women are too lazy to continue breastfeeding, so therefore breastfeeding advocates should continue bothering individual women.

Since it’s much more likely that those statistics drop off because of structural issues (lack of maternity leave, inability to pump at work, discrimination, lack of support from partners), nagging individual women because they don’t breastfeed for a full year is bothering the wrong group.  You can tell me all day long that I should be breastfeeding, but if I have to go back to work after 6 weeks and put my child in daycare because we won’t be able to pay the rent otherwise, breastfeeding is suddenly much more complicated than if I can stay home all day with the baby. 

That’s why people get pissed off at overzealous breastfeeding and “natural childbirth” advocates—in many cases, they’re scolding women for things that are out of their control, which is a pretty assholish thing to do.

Childbirth is terrifying experience for some women, and as long as the baby turns out healthy, why should we care how natural or medical the mother wants to be?

Given that 90+ percent of women get epidurals and 95+ percent of women give birth in hospitals, given that in my childbirth education class, I was told they wouldn’t even talk about non-medical pain relief techniques because “nobody does that anymore,” I’m really not that worried that oh-so-many women are not getting the pain relief they want in labor because of the mean-mean-mean natural childbirth advocates.

It’s always amusing/frustrating to me that people who would rather keep their mobility in labor and who breastfeed their children longer than three months are treated like they’re ruining it for everyone else when they represent a tiny portion of the population. Again, the percentage of babies caught by midwives is in the single digits and the percentage of babies born at home is around 2 percent. Less than 20 percent of American women are breastfeeding at 6 months. I can’t really think of anything else where what 80+ percent of the population is doing is treated like some threatened, marginalized practice that must be defended at all costs.

Wonky, yes, but pap smears and mammograms are most definitely “prevention” by any public health measure - they are just “secondary prevention.”

My only argument there is that’s not how the public has been led to believe it works.  There are many, many people out there who argue that if you detect cancer early, you have “prevented” it.  That’s what the argument has been against the cervical cancer vaccine, even by some Pandagon readers:  catching and treating the disease early is just as good as not getting it at all, so therefore there’s no need for the vaccine.

don’t think they actually charge the public square and rip bottles out of baby’s hands while shrieking imprecations at their mothers.

You’d be surprised. OK, no imprecations, but certainly pointed remarks, ostracism…

And what’s particularly, uh, vexing about these sanctions is that they’re like as not aimed at women who had the devil’s own time trying to breastfeed, are pumping, are supplementing on doctor’s orders so that their baby isn’t FTT and so forth. Yeah, we know breastfeeding is a good idea, we feel less than ideal about not doing it already, now shut up. (As a man, I’ve just had the collateral damage of getting surly looks when I was out and about with an infant and pulled out a bottle to feed same, and that was unfun enough.)

I can’t really think of anything else where what 80+ percent of the population is doing is treated like some threatened, marginalized practice that must be defended at all costs

*cough* oppressed christians *cough*

Again, the percentage of babies caught by midwives is in the single digits and the percentage of babies born at home is around 2 percent.

How many insurance companies cover midwives and/or home births?

Again, you’re concentrating your energies on the wrong area.  If women don’t choose home birth because it’s more expensive than hospital birth, you can advocate for them to choose it until you’re blue in the face, but for most people, that dollar amount that’s going to have to come out of their pockets is going to be more important.

Also, in my ideal world, midwives would be able to use pain control.

Can we please use facts in this discussion?

Hospital-based midwives - that’s most CNMs, by the way - have access to all the pain-relief options an OB does. An OB doesn’t actually place the epidural. He or she orders one, and an anesthesiologist places it. Same deal with a hospital-based midwife.

Midwives also can use IV pain relief. Some free-standing birth centers offer it.

No, home-based midwives cannot offer you an epidural. Placing an epidural outside a hospital setting would not be a good idea. While they’re pretty safe, they’re not quite safe enough to do them where you don’t have monitoring and the ability to do other interventions.

And while I think that anyone that wants pain relief should get it, I would just like to note that no one ever died from lack of it, and we really shouldn’t be discussing the ability the get an epidural alongside maternal mortality rates as if the two have anything to do with each other.

As things currently stand, women who choose midwifery care are doing it because they DO NOT WANT to be medicalized UNLESS they are actually sick. When I found out at 41 weeks and 4 days that I had no amniotic fluid and the kid had a really shitty biophysical profile, guess what my midwife (who had ordered the ultrasound and the non-stress test, by the way) said I should do? She said I should be induced with pitocin in a hospital! And so I was. When things were going really slowly and I was getting really discouraged, she suggested I consider pain relief so that I didn’t get too tired out. The midwife suggested it! So judgmental. Can you believe it? But when I said I wanted to wait a little bit more and see how I felt, she respected me enough to assume I was the best judge of what I needed.

So let’s please stop with some totally false dichotomy that our options are “nature-whoooo!” and “horrible tragic death!!!”

Again, you’re concentrating your energies on the wrong area.  If women don’t choose home birth because it’s more expensive than hospital birth, you can advocate for them to choose it until you’re blue in the face, but for most people, that dollar amount that’s going to have to come out of their pockets is going to be more important.

Uh, can you tell me where I’ve advocated that women should have home births?

All I’ve advocated for is that catgirl not spread totally false information about midwives when all she knows about the subject is that someone said something mean to her sister-in-law.

My main concern was that insurance companies would just stop covering Pap smears and mammograms.  “Oh, you don’t really *need* it!”  (Brief rant:  It’s not just ladyparts - my husband and I are up to our armpits in medical debt because we wanted him to have TWO eyes with sight, and the insurance company didn’t want to pay for the treatment that would give him that.  They were willing to pay for the treatment that would have given him a big black spot right in the middle of his field of vision, or they would have paid to *remove the eye* - but preserve his sight?  God forbid!  Grrr!  End rant.)

My own personal history is that my maternal grandfather died of colon cancer, and only one of my mother’s five sisters died cancer-free (two breast cancers, one uterine cancer, and one bladder cancer).  All of her seven brothers have had skin cancers removed, and one died of liver cancer.  I think I should be at least a little bit concerned for my own health - even taking into account that all but one (the uterine cancer) occurred after age 65.  I want the option of having a mammogram and *having insurance pay for it*, if I believe it’s needed.

Oh, and I’ve been doing self-exams since I was 14 and read Reader’s Digest’s “I am Jane’s Breast.”  I know *exactly* what my boobs are supposed to feel like at ALL stages of my cycle (trust me - “lumps” come and go depending on what your hormones are doing).  I also take into consideration my own personal quirks.  Nipples that “invert” are supposedly a warning sign.  However, my left nipple has always inverted in reaction to stimuli (at least briefly) since *before* I actually started growing boobs.  It’s *me*, and so I don’t panic over it without some other type of symptomology going on, because I know it’s what *my* body does.  My point?  Pay attention to what *your* body does, and don’t worry until it does something different (a lump that doesn’t change with your cycle, a nipple that starts inverting, etc.).

The main reason I still support self-exams is that prior to the encouragement of the practice, women would go into the hospital with breast tumors the size of walnuts (or larger) because they didn’t know they were there to tell the doctor and then go under anesthesia without knowing whether or not they would wake up without their breast.  How terrifying!

There are other reasons for Paps beside cervical cancer.  I went several years without a yearly pelvic (a combination of $$ and “I’m paying you to do *what*?” after a doctor was so rough I could not sit, stand or lie down without pain for 3 days).  I finally went because I developed breakthrough bleeding - a common symptom of uterine cancer.  Turns out I had a benign polyp of the cervix (about 2.5 inches long).  The doctor was going to do an endometrial biopsy because of my age, but I put the kibosh on that by saying “Let’s take care of the polyp.  If the bleeding stops, we’ll know that was the problem.  If it doesn’t, I’ll be back.”  He agreed without any argument (thank God!), but if I had not spoken up, I would have undergone an unnecessary biopsy.

Hmm, I’ve kind of rambled here, but I think this is my point:  Mammograms, Pap smears, and other types of screening for women should be covered by insurance, but the decision to have one left up to her.  I’m sure there is a very small percent of women who jump for joy at the thought of having a yearly and/or a mammogram.  The rest of us just want it available for when we notice there’s something “off” without being told it’s just “in our heads.”

My 2 cents ...

And Mnem,

If you were involved in advocacy around childbirth choices, you’d know that just about all the advocacy is around structural issues, and very, very little of it is around personal choices. Every e-mail action alert I get is about writing my legislator or writing an insurance company. We have states where the practice of midwifery is illegal. Insurance companies discriminate against midwife practices that aren’t under the ownership of a physician. (One midwife practice in Colorado has successfully brought restraint-of-trade complaints against several insurance companies, greatly expanding women’s access to a variety of services.) Advocates work to change hospital protocols so that they actually benefit patients, not just make things more convenient for doctors. If you didn’t get a mandatory enema when you had your kids, you should thank a natural childbirth advocate.

When catgirl says that it’s great that women can choose midwives but women should also be able to have a doctor if they want, it’s like Carrie Prejean saying it’s great that people can choose same-sex marraige but she still likes opposite marriage better and that choice shouldn’t be taken from her.

Well- I had my first child in a hospital with a midwife, and I was offered an epidural, but chose not to get one.  That particular birth was really a nearly 100% hospital birth, and the only difference between a doctor vs the midwives I had was that the midwives were with me at least 10 of the 16 hours I was in labor, and the doctor spent about 10 minutes with each of the women whose baby he delivered (according to them).

My second was in a birth center- again midwives, and that was probably exactly what one pictures a non-medicated birth center birth to look like.

I had to search hard to find midwives covered by my insurance and legal in my state.  It wasn’t easy, there was a time it was in, and it’s out again.  Insurance has never embraced midwives, even if the births are cheaper, and most certainly didn’t push it.  I know remarkably few women who have chosen to give birth with midwives, and even fewer who chose to go entirely unmedicated.  Most women have epidurals.  Just as most women (and men) choose to circumcise their sons.  For non-medical and non-religious reasons.

As for the mammograms- I am glad they are dialing this all back- I have always thought it was overkill, and had fewer than I should have.  But- I don’t agree with the recs- I think they should still encourage 1-3 mammos between 40 and 50.  And they should make sure that they are covered by insurance, and that this doesn’t just work out to an excuse by the insurance companies to pay for even less care for women.

Oh- and I need to add just one little bit in here.  http://newsone.com/nation/new-mammogram-guidelines-could-have-devastating-effect-on-black-women/  A short article about how even yearly mammos aren’t enough to catch certain cancers in an early stage that are more common among black women.  So these new guidelines shouldn’t be race neutral, but need to take into account that there really isn’t a one size fits all recommendation out there.

I work in an oncology clinic. I asked our chief radiation oncologist about this, and he thought it was because insurance companies don’t want to pay for so many mamograms.

Oh, and the part that really bothered me was the statement that 1 of every 2000 deaths from breast cancer is caused by the radiation from diagnostic procedures. If you read the study; that figure is a statistical assumption with nothing definitive to back it up.  As someone who works with therapeutic radiation I encounter patients’ irrational fear of radiation everyday. Years of bad sci-fi, and real tragedies of people killed by radioactive materials(not X-ray radiation)is an obstacle we have overcome to get their treatment.
Don’t be terrified of getting an X-ray. A little radiation is actually good for you. It creates an effect called hormesis wherein a small exposure stimulates your cells to produce a surplus of antioxidant enzymes. And if you’re still concerned then simply take some vitamin C before you have your scan done.

I think that Amanda has explored in the past some of the links between (some) women feeling oppressed by the scary mean ladies advocating more and longer breastfeeding and less medicalizied childbirth, and this latest round of feminist reactions to recommendations with regard to limitations on mammograms and breast cancer screening when it isn’t indicated—that is, that whatever women choose to do with their own bodies is, by definition, wrong.

Especially if it involves their lady parts.

And we (women) are all so socialized into this cultural trope it’s hard to fight it when you know it’s out there - much less when you don’t. So much so that we tend to pre-judge ourselves and all too often see and hear shaming behavior and commentary when none was intended, and even when none was offered.

I don’t doubt that many expecting and new moms *do* feel endlessly judged about their choices with regard to everything, because they *are* being judged.  By themselves and everyone around them.  Judging women for their performance as women is what we do, as a society.  De-linking the pervasive judgi-ness out there from the question, “how is breastfeeding going?” is hard to do when it is all so new and you feel so very fragile about everything—but it doesn’t mean that the question intended to shame, or to guilt.  It is just a question, and if the answer is “great! I love it!” then no harm, no foul.  If the answer is a more complicated and painful one—then the question itself feels horrible and as though it was intended to be mean and judging, even if it was neutral question.

And, yes Mnemosyne, I know that the systemic problems have to be addressed along side the cultural ones before a much larger percentage of US moms will be able to seriously consider nursing for longer periods of time.  Which is why I don’t advocate, and haven’t here advocated, that anyone approach a bottle feeding mom to shame her for her brazen display of a common practice. 

I’m not sure ‘dirty looks’ can be avoided once you parent, because seriously - going out in public with children will earn you dirty looks from someone no matter where you are or what you are doing.  Banning any breastfeeding advocate from speaking to or even looking at any new mother who hasn’t signed a waiver will not protect that new mom from dirty looks or criticism or probing inappropriate questions.  She is a woman, in public, doing womanly bodily things…. ergo - she is ripe for public correction and shaming by whomever gets off from that.

Which is why actual organized breast feeding advocacy groups don’t focus on shaming individual women but rather on making those systemic changes in the workplace and in hospital practice.  Without their work - the job “lactation consultant” would not exist, and 75% of new moms wouldn’t be leaving the hospital breastfeeding their newborns.  Without their work, ‘breast-pumping rooms’ would not exist at all—are there enough? No, not even close, and especially not in the kinds of hourly jobs where so many moms work. 

Complaining that breast feeding advocates are mean and should stop doing what, by and large, they aren’t doing, will not address this problem either.

Stopping every day people on the street - who aren’t breastfeeding advocates in any sense of the word - from using breastfeeding (or lack of) as another club to bash women?  Good luck with that.  That will happen the same day that women stop apologizing for eating desert in public.

It’s always amusing/frustrating to me that people who would rather keep their mobility in labor and who breastfeed their children longer than three months are treated like they’re ruining it for everyone else when they represent a tiny portion of the population.

Thank you.

When all women, not just privileged women, can exercise informed choice about the level of intervention in their births and have those choices respected; when every city has good, safe midwives; when doctors stop pursuing non-evidence-based medicine and regularly producing iatrogenic complications in birth; when the popular information about birthing choices is fact-based; when no woman ever has to cry because she wants a VBAC and can’t have one; when no woman ever receives an episiotomy again; when every nurse on every labor ward is well-versed in non-pharmaceutical pain relief; when OBs graduate from medical school knowledgeable about birthing positions; when the observation and understanding of normal birth is required in medical school for OBs the way it is for licensed midwives; when the bog My OB Said What? shuts down for lack of material ... then we can talk about how advocates for birth choice should make sure not to impose our viewpoints on those who choose more medicalized births.

If you were involved in advocacy around childbirth choices, you’d know that just about all the advocacy is around structural issues, and very, very little of it is around personal choices.

And this too.

Nobody here is suggesting otherwise.  Very few people in general ever do suggest otherwise.

Of course nobody here is doing it, because this is an awesome blog.  But it’s not just a few people who condemn “unnatural” women.  I also underestimate how common it is, until both of my sisters-in-law got pregnant.  Nearly every type of class directed at expecting parents has a teacher that likes to give a very clear message that you’re weak if you need pain medication, or you’re selfish if you feed your baby formula.  Every friend or relative has advice for the pregnant woman, and they also have advice for me to pass along.  Even strangers will often comment and give unsolicited advice, and on every topic.  For at least some women, it’s pretty bad.

Every friend or relative has advice for the pregnant woman, and they also have advice for me to pass along.  Even strangers will often comment and give unsolicited advice, and on every topic.  For at least some women, it’s pretty bad.

Like Nell said, this will change when women stop apologizing for eating dessert. Guess what? I got nasty looks and unsolicited advice for how I fed my kid from people who think breast-feeding is gross. ESPECIALLY when I didn’t wean him at six months. I got told I was selfish and putting my own desires over the safety of my baby because I chose a midwife. This is just part of being female in a society that thinks women’s bodies and lives are public property. The natural childbirth/attachment parenting folks certainly are not immune from it, but they didn’t invent it and they don’t have exclusive claim to it, either.

Nearly every type of class directed at expecting parents has a teacher that likes to give a very clear message that you’re weak if you need pain medication, or you’re selfish if you feed your baby formula.

I’m sorry, but that’s bullshit. Every woman I have ever known who desired to keep her options open for an intervention-free birth has had to find an explicitly natural-birth class for that purpose—because the generalized classes provided by hospitals, OB practices and health care groups invariably assume every birthing woman is going to end up with interventions whether she plans on them or not. It is in the interest of convenience for OBs and health care groups to make sure that birthing women are familiarized in advance with the idea that they’re going to need interventions sooner or later so they should pretty much just plan on doing what the L&D;nurses want them to do.

And again, what chingona said: it’s easy, when you’re pregnant or a new parent and get criticized, to imagine that all the people criticizing you would have given you a pass if you’d chosen differently. But the fact is that there’s a set of people who would criticize your for *those* choices too.

When I was planning my home birth I had a list of people with whom I knew not to discuss birth at all because they would ridicule me. When I was breastfeeding I was subject to pressure from pediatricians and WIC workers who would tell me I was feeding him too much, or for too long. I had people criticizing my choices up and down because that’s what people do to women.

catgirl: “Every friend or relative has advice for the pregnant woman, and they also have advice for me to pass along.  Even strangers will often comment and give unsolicited advice, and on every topic.  For at least some women, it’s pretty bad.”

Right - but as you say, people comment on *every* topic when it comes to pregnancy/infant care.  Every choice, every food you eat, the amount you sleep, walk, talk, sit, work, the brand of items you use—bottles, strollers, diapers, cribs, infant slings…. it never ends.  Consider the great (and far from over) pacifier wars.  Or the baby sling vs. the front carrier.  Or nursing pillows vs. ‘correct hold’—- So, singling out advocates for breast feeding or midwifery for special condemnation because they (and they alone?) make new moms feel bad seems to me to be falling for the old game of accusing the advocates for change of making people uncomfortable with the status quo, and thus easy targets for shutting up or shutting out.  (That breast feeding advocates and midwifery advocates are the only ones potentially challenging entire industries that profit from the main-stream alternatives they are questioning is not unimportant…..)

There is already a narrative out there that the breast cancer groups - patient advocacy and early detection and treatment - have gotten ‘too much’ health care out of limited pie, now that this study may show that they were *wrong* to push for yearly mammograms or self-exams, watch that narrative grow a little more based on how those silly woman didn’t understand and so asked for too much of the wrong thing, so their next request has to be dismissed as foolish because they were foolish before….

I know that isn’t what the study said - but, I will bet dollars to donuts that it will get played that way.

Once again Chingona #49 thank you for pointing out what I wanted to, but better. #47 (me) had so many fragments I feel I have to apologize. That’s what I get for blaspheming before previewing.

RE: Judging women who don’t breastfeed or have a “natural” childbirth,

This drives me freaking insane. I’m studying to be a lay midwife and I’ve worked with a Breastfeeding Consultant before, so I have seen that mess. Usually when I point out to those people that they’re pulling the same patronizing, judgemental, “I know what’s best for you” attitude that midwives, nurses and women had to fight in the last decades to bring back midwifery and breastfeeding, they shut the hell up. I will admit that when I first learned all the behind the curtain shit that goes on between formula companies, hospitals and doctors I wanted to run screaming into the streets demanding every woman with an infant “Drop the formula and back away slowly!” But, I took a breath and realized I didn’t have that right. Plus I didn’t want to be that douchebag. It’s not a difficult realization for an adult, so people should really grow up.

Of course, I see the same things in midwifery. But it’s rare, especially considering the prejudices, lies and myths about midwifery. Once again, when I read Obstetric Myths Versus Research Realities I had to once again take a breath to calm myself. It’s a dry but informative read by the way. Although I will continue to calmly fight with judgmental people at both extremes I think I may lose it if I hear one more person (usually a man) make one more comment about how pregnancy and birth aren’t a “big deal” because women in (insert third world country of choice) give birth in fields every day. I want to shout, “Yeah asshole, they also DIE horribly everyday! But I guess a woman bleeding to death for two days while in excruciating pain is no big deal to you. Douchebag!” But now that I’ve said it here maybe I won’t scream it at a dinner party.

I think a major problem that a lot of women have with the recommendations that were made is that we’ve been told that self exams are useless and now mammograms are useless. They speak to the reality that we are using the same technology to detect cancer in women that we have been using for over 40 years. Okay, so let’s say that mammograms are not the best technology, then what do you have to offer? You can watch TV on your phone and your great grandfather can have an erection all day and we have nothing else to offer women?

Let’s not forget that breast cancer has more money being spent on research than any other type of cancer (http://www.ncbi.nlm.nih.gov:80/pmc/articles/PMC1124435/  http://www.cancer.gov/cancertopics/factsheet/NCI/research-funding). The national Cancer Institute spends more than twice as much on breast cancer research as it does for any other type of cancer. Maybe the reason things have not improved as much as we would like is because it is a difficult problem? Maybe solving breast cancer is harder than giving a man an erection? Let’s not forget, the first erection pill was actually developed as a high blood pressure medicine/angina treatment. The boners were a side effect.

I’m 41 and I’ve never had a mammogram and don’t plan on having one anytime soon.  Heart disease runs rampant in my family, so those little twinges in my chest are a lot scarier than anything going on with my ladyparts.

Plus, I’ve always been suspicious of the medical establishment’s apparent view that women’s reproductive systems are just a cancer factory waiting to happen.

That and the fact that the health care recommendations in many first world countries, with better health outcomes, mirror the results of the panel’s study.

But, I also wouldn’t be surprised if health insurance companies use the study as a means to deny mammograms to women in high risk categories.

Mnem: “My only argument there is that’s not how the public has been led to believe it works.  There are many, many people out there who argue that if you detect cancer early, you have “prevented” it.  That’s what the argument has been against the cervical cancer vaccine, even by some Pandagon readers:  catching and treating the disease early is just as good as not getting it at all, so therefore there’s no need for the vaccine.”

Point taken, and very well so.  Primary prevention is usually far superior to secondary prevention, and on down the line, which is why they are placed in that hierarchy - even though they are both still considered prevention by the public health people.  And especially in the name of the HPV vax: it kills me to hear people say “we have effective treatment for cervical cancer, we don’t need a scary new vax.”  Yearly pap smears, biopsies, and shearing off the cervix of those affected is not great prevention: it’s a sad second to getting rid of the problem in the first place.  Whether Gardasil and its cousins have the potential to really eradicate the pap in the future is still to be seen - but for chrissakes, I’d really rather have three shots than a LEEP and all that ensues from that (including incompetent cervix that predisposes one to lose babies at the barely-viable stage).

I’m sorry, but that’s bullshit.

Are you claiming that I’m lying?  Or are you claiming that my sisters-in-law lied to me about their experiences?  Just because you didn’t experience the same thing doesn’t mean that it doesn’t happen to other people.  Rather than call bullshit, maybe you could use it as a chance to learn that some people go through things that you never experience personally.

catgirl,

You wrote:

Nearly every type of class directed at expecting parents has a teacher that likes to give a very clear message that you’re weak if you need pain medication, or you’re selfish if you feed your baby formula.

You didn’t say “The classes my sisters-in-law took had teachers that ...”

You wrote “nearly every class.”

Just because your sisters-in-law experienced something, doesn’t mean it happens to other people. Some people have experiences different from those of your sisters-in-law.

Ya know, one thing I’ve learned being employed at hospitals in two different regions of the country is that this crunchy-v-medicalized stuff is highly regional.  Where I work now, VBACs are common and encouraged to the point where OBs who don’t offer it are looked upon as medieval, and the nurses more or less have gotten circs banned by the sheer refusal to help with them.  I understand this is not at all universal, eh?!  But the regionality of these norms probably accounts for some of why one person can say “everything I’ve encountered looks like x”, the next can say, “everything I’ve encountered looks like y,” and neither of them are a bit wrong.

Thanks, skylanda. In my state, only one hospital even allows VBACs.

Sorry. That should have been my metro area. Don’t know about the rest of the state.

getting tested for cancer is overmedicalization? are we over-medicalized by getting cholesterol test or blood pressure taken? seriously? there’s no fucking good reason to discourage people from proactively watching out for their own health. plenty of women in their 40s get breast cancer. damn right the ones who survive and recover caught it early. sorry, this post is a fail for me. there’s just nothing good in this. my theory is it’s some insurance lobbyist-infused bullshit. and don’t do self exams? what the hell is THAT?

so when men get tested for prostate cancer, that’s just them being conned into some test, is it?

“are we over-medicalized by getting cholesterol test or blood pressure taken? seriously?”

Yes, if taking those tests leads to worse medical outcomes for patients.

I think there are two issues getting mixed-up here: what recommendation is best for promoting people’s health, and by what means do you make sure that insurance companies who should likewise promote people’s health don’t use the population-based first as a means to skive off their responsibility towards a particular individual who may for good medical reasons require more frequent testing. But the fact that insurance companies are scum should not mean that we lie about science and over-medicalise women to their detriment. It should mean that insurance companies are made to behave better.

I bore my second child breech without any medical intervention.

The crap I had to go through to demonstrate that it was the safest option to try using international studies covering tens of thousands of births , ESPECIALLY FOR MY HEALTH given my allergies to commonly used after-surgery pain killers, was of epic proportions.

The science was on my side, yet I had to dodge any number of guilt bombs and accusations of “selfishness” because I insisted that my health counted too! This despite the fact that his presentation and second child statust meant that a vaginal birth was of no added risk to my son ... these births either happen well or they don’t!  Fortunately, the OB/Gyns in that progressive practice I went had trained in Europe.

Oh ... and I didn’t refuse painkillers or epidurals or any of that ... I didn’t need them because he was born so fast he nearly cannonballed the hot tub and I don’t remember any of it as being painful.  Not the universal experience, and not my experience with my first child.

I’m sorry you place inconvenience and temporary pain over the rights of women who have the temerity to develop breast cancer before 50 to prompt diagnosis and treatment.  Insurance companies will use these specious new guidelines to justify denying diagnostic and treatment procedures to women under 50.

If you can’t understand that death is more important than discomfort, you have serious priority issues.  Your rant about how not wanting a mammogram doesn’t make you weak is reactionary.  Nobody gives a crap whether you, personally, want a mammogram or not.  You’re just not that important.  What people upset about this tend to care about is not goddamn dying.

J Train, I’m sorry that you and your patient (and his family) had to go through that. But are you really saying that because one patient who likely had some severe mental/emotional problems went off the deep end, it’s really better to just hide things from patients because they’re better being ignorant?

(And while I’m sure you personally would agree this practice is egregious, it reminds me of the practice of teaching hospitals performing pelvic exams on unconscious patients, because ‘the residents need the experience for the good of us all’ and ‘well if we asked them they’d probably say no’.)

Totally agree with you…
It has always concerned me that as women we’re not entitled to make our own health decisions. It’s apparently okay to give us an exaggerated upside, use unethical tactics to recruit women into programs and even require the test for unrelated meds….plus we don’t receive risk or limitation information.
Informed consent is supposed to be a cornerstone of cancer screening, yet it’s totally ignored when the screening is directed at women. My husband’s doctor took him through the pros and cons of testing for prostate cancer and left the decision to him. Prostate cancer kills huge numbers of men. Yet no pressure, no lies, no requirements….
I’ve never been offered cervical screening…it has been demanded, ordered, required - I’ve been insulted, dismissed, stood over….this is the reality of cancer screening for women.
Cervical cancer was always an uncommon cancer and this is an unreliable test that sends thousands of healthy women for biopsies and other treatments every year. Some of those women will be left with continuing health problems - mental and physical.
Yet if a woman asks for information or declines screening, she’s to be pressured, overwhelmed, chased….
Men are not treated in this way.
I agree…our bodily autonomy is not respected by the medical profession. We are just the sum total of our reproductive parts and we can be examined and tested when THEY are satisfied there is a need even when our health is on the line.
I hate this attitude and never allow it. My body has never been over-medicalized and I’m a lot healthier than many of my friends who fearfully submit…
I did my own research and made my own firm decisions - based on facts, not fear.
Every woman is entitled to unbiased information and her informed consent is required by law….her decision not to screen or to screen less often should be accepted and respected.
My husband has declined screening for prostate cancer and his Dr accepted that without a word and moved on…
Women should demand the same level of respect…
Any Dr who refuses a woman the Pill UNTIL she agrees is taking advantage - challenge them and even ask your lawyer to draft a letter. If women continue to give in to these unethical demands, it will continue…..
Medical associations, WHO and the USF&DA;all say these exams and tests are not required for the initiation or continuing use of the Pill.  This is a boycott made by doctors to override your informed consent.
Our doctors don’t recommend routine pelvic, rectal or breast exams….thankfully, we don’t have that fight. I have American friends who face that whenever they need a script for the Pill renewed…and women are pressured from teens to have these exams to ensure they’re healthy. Given the vast majority of the worlds doctors don’t recommend these exams, it’s hard to see how they could be viewed as vitally important - they should be optional at best with the warning they can lead to more testing.
I’ve been unable to find any sound evidence supporting the need for these routine exams in asymptomatic woman. There is evidence of harm though as they can lead to other tests and treatment. The Nordic Cochrane Insitute (NCI) found there was insufficent evidence to recommend routine breast exams, they don’t affect the death rate from cancer, but greatly add to the number of breast biopsies.  Some doctors believe breast biopsies are a risk factor for cancer.
Any woman considering mammograms should look at the NCI’s paper on the risks and benefits of mammograms. It’s the only publication I know providing balanced information - it’s available on-line. It was produced as the Institute was deeply concerned about the misleading and incomplete information being released to women.
Women who want to have smears, might consider the Finnish program. They have the lowest rates of cervical cancer and biopsies in the world - they screen 5 yearly from age 30 and stop at 60. 55% of their women have colposcopy/biopsies, a lot less than 77% for Australian women and 95% for US women. Very few of these women actually have a problem.
I also disagree with women being judged on their ability to birth drug-free and on breast-feeding. Our bodies belong to us and we’ll do what is right for us. I support every woman whether she wants a planned c-section, breast or bottle feeds or chooses natural childbirth. I’m so tired of women being asked to justify how they feel….
Sadly, we’re our own worst enemies, much of the pressure I’ve felt over the years has come from other women.
I’ll make my own health decisions…if a test or exam doesn’t pass my risk v benefit equation, I’ll pass and I don’t care if that puts me in the minority.
This is a great piece of writing that struck a nerve with me….
Great that women are feeling more comfortable talking about these things.