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Consumers Must Stop Insisting on Mammograms and Other Ineffective Cancer Tests

The views expressed are those of the author and are not necessarily those of Scientific American.

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The evidence keeps mounting that mammograms and other tests for cancer—which contribute to the sky-high costs of U.S. health care—do not save lives.

A long-term study of 89,835 Canadian women found that mammograms did not significantly reduce deaths from breast cancer.

The latest study to reach this conclusion was published this week in BMJ, the British Medical Journal, and involved data from the Canadian National Breast Screening Study. In 1980, 89,835 Canadian women, from 40 to 59 years old, were divided into two groups; one received annual mammograms for five years and the other did not.

After 25 years, the breast-cancer mortality rates of women who received mammograms and those who did not were virtually identical. The study also found that more than one in five women diagnosed with cancer because of a mammogram were “overdiagnosed”; that is, the abnormality detected by the mammogram, if left untreated, would never have compromised the woman’s health. These overdiagnosed women thus received treatment–including surgery, radiation and chemotherapy–that they did not need.

The researchers conclude that “annual mammography does not result in a reduction in breast cancer specific mortality for women aged 40-59 beyond that of physical examination alone or usual care in the community. The data suggest that the value of mammography screening should be reassessed.”

An editorial in the BMJ notes that the risks and benefits of mammograms are similar to those of the prostate specific antigen (PSA) test for prostate cancer, which has been shown to have marginal value. (The inventor of the PSA test has called it a “profit-driven public health disaster.”) The BMJ editorial urges health-care providers to “reconsider priorities and recommendations for mammography screening and other medical interventions.”

The editorial adds, “This is not an easy task, because governments, research funders, scientists, and medical practitioners may have vested interests in continuing activities that are well established.”

Indeed. In her typically sharp report on the new mammogram study, veteran New York Times reporter Gina Kolata warns: “The findings will not lead to any immediate change in guidelines for mammography, and many advocates and experts will almost certainly dispute the idea that mammograms are on balance useless, or even harmful.”

In a previous column, I note that the “medical-testing epidemic” helps explain why Americans pay far more for health care than people in any other nation while getting relatively poor care. I blame over-testing in the U.S. on the “fee for service” model of American medicine, under which physicians are compensated for the quantity rather than quality of their care. Physicians thus have an economic incentive to prescribe tests and treatments even when they may not be needed. Physicians also over-prescribe tests and treatments to protect themselves from malpractice suits.

Here are several ideas for curbing the testing epidemic: First, the fee-for-service model should be replaced with a different compensation scheme—perhaps one that gives physicians a flat salary with bonuses for improved patient outcomes. Second, malpractice laws should be revised so that doctors don’t prescribe tests simply to avoid lawsuits. Third, we need more reliable studies—carried out by researchers with no conflicts of interest—into the efficacy of tests for cancer and other disorders.

But ultimately, the responsibility for ending the testing epidemic comes down to consumers, who too often submit to—and even demand–tests that have negligible value. Our fear of cancer, in particular, seems to make us irrational. When faced with evidence that PSA tests and mammograms save very few lives, especially considering their risks and costs, many people say, in effect, “I don’t care. I don’t want to be that one person in a million who dies of cancer because I didn’t get tested.” Until this attitude changes, the medical-testing epidemic won’t end.

Related Posts:

“Why I Won’t Get a Colonoscopy”:

“Cancer Establishment Admits We’re Getting Overtested and Overtreated”:

“ABC Reporter, National Football League Promote Mammograms While Experts Question Benefits”:

“Celebrities Should Inform Women about Risks as Well as Benefits of Mammograms”:

“How Can We Curb the Medical-Testing Epidemic?”:

Photo courtesy National Institutes of Health and Wikimedia Commons,

John Horgan About the Author: Every week, hockey-playing science writer John Horgan takes a puckish, provocative look at breaking science. A teacher at Stevens Institute of Technology, Horgan is the author of four books, including The End of Science (Addison Wesley, 1996) and The End of War (McSweeney's, 2012). Follow on Twitter @Horganism.

The views expressed are those of the author and are not necessarily those of Scientific American.

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  1. 1. tuned 11:22 am 02/13/2014

    I saw a retort (by a female surgeon)to this study , it seems important to note.
    She said that the mammograms in this study were mostly the older (10 years or so ago) analog mammograms which were only detecting around a 3% level.
    She stated the newer digital ones are much more accurate.
    Also she stated the tissue is denser in a certain age group, so sonograms are ordered also.
    None of this replaced the absolute requirement for self exam monthly, after the “period” when tissue is much more tender.

    Link to this
  2. 2. rshoff2 1:08 pm 02/13/2014

    You’re right that over testing is one reason for high medical costs to our society. However, I don’t think we can completely blame the consumer (ourselves) because we are simply reacting to the market as programmed. We are made to believe that these exams will provide sophisticated results and will ultimately save our lives or help us live better. In fact, based on my experience and the experience of people around me, I believe medical intervention is very expensive and provides questionable results most of the time. That doesn’t mean we don’t still suffer illness and disability. It means that we are promised relief, but relief never completely arrives. Even after spending obscene sums of time and money.

    We’ve been sold a bill of goods. Don’t blame consumers, blame the marketing forces at work and those with something to sell.

    Where are the results of good research and how does that research make it to a practitioner’s office? That is what we should focus on.

    btw, I would not call what we have in this country “fee-for-service”. The fees are fixed by, and the allowed services are determined by, the insurance carriers. Insurance is a money making business for stockholders and investors, it is not a healthcare finance system. The carriers decide what they will pay regardless of the medical practice’s fee schedule. The practitioner must write-off the difference. If you doubt me, talk to the business office IT staff in any hospital or outpatient setting. I wouldn’t be surprised if the carrier fee schedules are loaded into their systems alongside their own fee schedule. Ask them about ‘bundling’. The bundled services cannot even be broken out into individual line items. Furthermore, there’s no reason for the provider to create accurate or fair fee schedules because they must accept what the carriers dictate or lose their contract and ultimately their patients. Sure, you can pay full fee-for-service our of your pocket if you are rich, but most rich people have insurance (or can afford it). Only the poor go without. And they cannot afford the ‘fees’. That could quickly devolve into a conversation about the morality of poverty in a country full of billionaires.

    That doesn’t even address the cost issues around prescriptions, medical equipment and technology (including licenses and patents), medical supplies, insurance administration, provider practice facility expansion, marketing costs, etc, etc, etc.

    So, you are right. I think that it is a mistake to leave it in the hands of the ‘Insurance’ industry to pay for and administer our healthcare system. It’s also one of the largest parts of our economy. Probably second only to defense (fact check, I don’t know for sure).

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  3. 3. TTLG 7:05 pm 02/13/2014

    Welcome to the medical-industrial complex, which will make the military-industrial complex look like small potatoes.

    But putting any of the blame on the consumers is pure nonsense. The reason humans have been so successful is because of cooperation. Even thousands of years ago technology was too complex for any one person to understand it all. We have been successful because of trust in the other person. If the doctor (mechanic, plumber…) tells us we need something it is very difficult to disagree. So the system to ripe for dishonest types who do not care about others to take advantage. Which is pretty much what is happening in our society nowadays.

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  4. 4. hb 1:16 am 02/14/2014

    Every dollar spent on ‘healthcare’ is a buck made by the people and companies providing those services, whether those services are useful or not. Any group that stands to lose financially from reforming the system will fight tooth and nail to preserve the status quo.

    John Horgan’s suggestions for curbing the testing epidemic would likely run into the same problem. Physicians paid a flat salary, even with a success bonus, will oppose that change because they would lose money. Malpractice law reform will be opposed by the lawyers, because lawsuits are their meal tickets.

    Since so many groups have a vested interest in perpetuating the current scam, the self-interest of the public would seem the best hope for reform. The problem there, of course, is that most people don’t have the expert knowledge to make their own medical decisions. And the medical/pharmaceutical industrial complex does their darnest to confuse and manipulate the public, to try to keep people in the dark.

    That would leave it up to the government to ‘do something’. Of course, that idea doesn’t go over well with Americans these days. Unfortunately, people seem to have forgotten that a properly functioning government requires an informed and engaged citizenry. A public that doesn’t participate in the political process isn’t likely to stand up to powerful special interest groups like the ‘healthcare’ industry either.

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  5. 5. Claudelle 6:09 pm 02/14/2014

    Apart from this new study, there is a substantial body of good evidence against the general use of mammography (described in “The Mammogram Myth” by Rolf Hefti).

    The main problem in corporate-dominated cultures is that big private interests influence the official evidence in favor of mammography and carefully present perspectives amenable to these huge corporate interests, such as the medical-mammogram industry.

    It’s what you don’t know you need to worry about, not what the mainstream orientation is.

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  6. 6. StevedeBurque 9:02 am 02/17/2014

    One regrettable issue is the abstraction from the study of a population to the care of one individual. This is done by many methods, one of which is whether the insurance company “pays” or “does not pay” for a test.
    The most efficient model is the partnering of a trained physician with a familiar patient, individually committed to that individual’s care. Human thought is the most efficient medical test; it certainly is the cheapest, being something that is paid for previously by training, not on each utilization. And it is the one testing method that is universally spurned; it is not objective or profitable, so therefore, it is disparaged.
    Mammograms are best done on the patients wisely selected to benefit from them, not on those who can demand them the most aggressively in American Retail Medicine. Sadly, we are facing an explosion of costs, as we do not prefer the cheapest model.

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  7. 7. EEBAust 8:32 pm 02/17/2014

    I agree with this article, but most women have little choice when it comes to screening. Many women have been brainwashed and misled into believing annual pap tests, pelvic and breast exams and mammograms every year of your life are essential, when the evidence says otherwise. There has never been any respect for informed consent in women’s cancer screening, we get little real information, most of it is biased in favour of screening. (we even get misinformation/lies)
    So many women are misled into screening, some are pressured and shockingly, many are coerced. The latter is still routine practice in the States and Canada and women are denied birth control, other meds or even all non-emergency medical care if they decline testing, you may even be sacked as a patient.
    So I don’t blame women for this mess.

    Here is Australia there is no critical discussion on pap testing, even though our program is excessive, out of date and harming the masses. It suits some and so it’s been left unchanged for decades, ignoring the evidence. There is no doubt in my mind these programs operate in the interests of others, not women.

    I don’t take part in either program, I had to do my own research to get to the evidence and stand firm in the consult room. Doctors tend to back off when they’re faced with an informed woman, they rely on our ignorance. Our doctors also, get target payments for pap testing, but this is never mentioned to women.

    I knew about over-diagnosis and uncertainty of benefit with breast screening more than 10 years ago, after the Nordic Cochrane Institute released their report. The summary on their website is invaluable for anyone thinking of screening, it’s a rare, complete and unbiased summary. Here we get cherry-picked research, the same names defend screening if anything negative appears, they’re protecting screening, not women. It seems anything goes if it gets more women on board and in treatment rooms.
    We’re told for example, that screening leads to fewer mastectomies, untrue, it leads to more. Yet they keep lying to women and no one corrects them.
    I despair for trusting women, they’re being let down badly.
    Those interested in cervical screening might like to look at the new Dutch program, evidence backed, they’ll scrap population pap testing and offer instead 5 HPV primary tests at ages 30,35,40,50 and 60 or women can self-test with the Delphi Screener and ONLY the roughly 5% who are HPV+ will be offered a 5 yearly pap test. (until they clear the virus) This will save more lives (and loads of money) and take most women out of pap testing and harms way.
    Here we’re urged to have 26 (or more) pap tests from 18 to 70 (some start earlier) which carries a 77% lifetime risk of referral for colposcopy/biopsy or treatment – now this is to cover a cancer that affects 0.65% of the population, a great business model, but a nightmare for women. Almost all of this damage is avoidable with an evidence backed program, but the millions lost means many will find fault with HPV primary testing. (unless it’s added to population pap testing which provides no additional benefit to women but generates the most over-investigation, as the Americans have done)
    We conveniently don’t test for HPV until women have been “treated”…that covers medical tracks, HPV- yeah, we cured you, HPV+ just as well we treated you, we’d better keep a close eye on you.

    So being informed is the best protection from these harmful programs. American and Canadian women are pressured or coerced to have annual pelvic and breast exams (or even visual genital exams, rectal or recto-vaginal exams) none are evidence based, none of them are recommended here and all carry risk to your asymptomatic body. The annual well woman exam is about profits, not healthcare.

    American women have more than twice the number of hysterectomies than women who don’t have this exam, and lose more than twice the number of healthy ovaries after false positive pelvic exams. Your Dr Carolyn Westhoff has written some helpful articles challenging the need for and risks with this exam.
    So all very depressing, but individual women can protect themselves by being informed and rejecting the system. I know it’s harder to doctor-shop in the States, some women order Pills online, head down to Mexico or manage with condoms, this should not be necessary. This insane focus on screening has been a major negative – our lives, health and peace of mind are the poorer for this skewed focus.

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  8. 8. EEBAust 8:40 pm 02/17/2014

    Just to make clear the new Dutch cervical screening program will take 95% of women out of pap testing and see excess biopsy and over-treatment rates plummet. (they’re current rates are already much lower than our rates as they’ve never over-screened women)
    That also, means fewer women with damage to the cervix, so fewer premature babies, c-sections, cervical cerclage procedures, miscarriages, high risk pregnancies, infertility etc.
    No, that would never do, millions lost to vested interests. No wonder there is immense “concern” about simply winding our program back to 3 yearly pap testing from 25 to 70. Too much money is at stake!

    Link to this
  9. 9. DocNeuro 5:04 pm 04/22/2014

    Should Mammograms Be Squashed?

    On my syndicated radio show we had more calls/emails/tweets on this topic than ANY SHOW in our history! So I decided to write an article to offer some food for thought:

    Should Mammograms Be Squashed? –

    Be Well,
    Dr. David Friedman

    Link to this

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