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Dr Kev, I agree, my daughter was caught in this because she was under 40 in the USA when screening was withdrawn. She was not at risk genetically as a great % of those who contracted BC are not according to what is 'known'; but she had a previous biopsy, this was not allowed as a consideration. Screening was refused by her insurance as was sonography. We paid, she was diagnosed with a phyloddes tumor and in the time it took to wrestle with the healthcare provider the tumour grew, so again she was charged and then told that the surgeon who stated categorically he was in the network ended up being out of network . This caused her to have to file bankruptcy when her previous credit score her whole life had been impeccable. Fortunately to date she has remained cancer free after surgery but I can't help but consider the toll this stress places on a compromised immune system and of the pain this thoughtless inhumane care caused. I have another 2 friends who because of this prevailing thought of cancer under forty not being probable had their cancers ignored, one woman's husband paid privately to have the lump excised and biopsied and was years later reimbursed whereas the other's cancer progressed to stage 3 in the time from finding a lump to biopsy to jumping the legal hoops and red tape. I feel that all aspects of the social environment need to be considered and that all evidence needs consideration inclusive of that that shows limited evidence for widespread genetic abnormalities . I understand that incidence may be rare for under 40s and that routine screenings may be a waste of healthcare dollars but at the same time there needs to be recourse and education so doctors and woman can make confident evidence based choices about their own care. I must admit I was chilled to the bone when I saw the comments about doing away with self exams as well as it is by this process that many of my contemporaries discovered the cancer in early stages and are alive today because of prompt effective intervention. I understand that a false positive is also distressing but surely nothing to compare with having to 'put your affairs in order' It would be illuminating to know the qualifications of those who are on these task forces, their COIs and their legal responsibility for the decisions they make which will ultimately impact lives. It would be good if those neglected could communicate with them directly and also those who are freed from being labelled no responders which of course ultimately could impact their future care as well. Best, Amy From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of k.hopayian Sent: 26 November 2011 03:24 PM To: [log in to unmask] Subject: Re: New breast cancer screening guidelines released Canada_underscoring the need for decision making based on evidence Hi Ben, Not sure that I agree that this is just a question of attitudes to risk. While I accept that there is individual variation in attitudes to risk (meaning bad things) and risk (meaning the chances of those bad things happening), there is also a social dimension. That social dimension includes, amongst other things, the message broadcast by those perceived to be authorities, in this case, guideline developers and disseminators. And in many countries, guideline developers have recommended the provision of mammography screening based on their interpretation of the evidence as showing that screening reduces mortality. The disseminators have urged women to follow these guidelines. It is in this social environment that women must make decisions. Women who do not respond to invitations for screening will be seen as deviating from official policy and their peers who mostly do attend. Their computer record will flash up Non-Responder whenever they consult the general practitioner. Now if the guideline developers take the view that mammography is not effective in reducing mortality (which the Canadian Task Force appears to do) and go further and do not recommend it be provided (which the Task Force stopped short of doing), then the environment will be a very different one. Therefore, a further look at the evidence and further debate may well influence future recommendations. BTW, it is interesting to observe that the Can Task Force did not take that extra, terrifying step, of recommending that screening mammography be withdrawn. Social forces at work again?!? Dr Kev (Kevork) Hopayian, MD FRCGP General Practitioner, Leiston, Suffolk Hon Sen Lecturer, Norwich Medical School, University of East Anglia GP CPD Director, Suffolk [log in to unmask] http://www.angliangp.org.uk/ Making your practice evidence-based http://www.rcgp.org.uk/bookshop On 25 Nov 2011, at 19:20, Djulbegovic, Benjamin wrote: I think no further look at evidence will resolve the screening mammography question. This is a question of VALUES and how we weigh false positives (unnecessary biopsies, surgeries etc- regret of commission, of unnecessary) vs. false-negatives (missing cancer, delay in diagnosis, etc- regret of omission, of potentially failing to save lives). Because our risk attitudes inherently differ (there is no such a thing as "right" or "wrong" risk attitude), no guidelines panels can make recommendation for a woman facing decision whether to accept invitation to screening mammography. This is best summarized by Lesley Fallowfield in one of the papers to which Ash provided links provided below, and Fiona Godlee in her editorial when she says that she "speaks for many women when she admits that, despite her own detailed knowledge of the science, she is uncertain of the value of mammography screening. "I feel silly for attending screening, but scared not to do so." Ben Djulbegovic From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Ash Paul Sent: Friday, November 25, 2011 1:47 AM To: [log in to unmask] Subject: Re: New breast cancer screening guidelines released Canada_underscoring the need for decision making based on evidence Dear Paul, In this week's excellent issue of the BMJ, we have some very good articles on the subject of breast screening. Two of them are by members of this Group, Fiona Godlee and Klim McPherson: <http://bmj.com/lookup/doi/10.1136/bmj.d7623?etoc> Mammography wars Fiona Godlee <http://bmj.com/lookup/doi/10.1136/bmj.d7625?etoc> Women in their 40s should not be screened for breast cancer, new Canadian guideline says Adrian O'Dowd <http://bmj.com/lookup/doi/10.1136/bmj.d7529?etoc> Breast cancer screening review: We need scientific consensus founded on all the evidence Klim McPherson <http://bmj.com/lookup/doi/10.1136/bmj.d7535?etoc> Breast cancer screening review: An appeal to Mike Richards Michael Baum <http://bmj.com/lookup/doi/10.1136/bmj.d7544?etoc> Breast cancer screening review: What should women do in the meantime? Lesley J Fallowfield Regards, Ash From: Paul Elias <[log in to unmask]> To: [log in to unmask] Sent: Thursday, 24 November 2011, 17:14 Subject: New breast cancer screening guidelines released Canada_underscoring the need for decision making based on evidence http://www.eurekalert.org/pub_releases/2011-11/cmaj-nbc111611.php Best, Paul E. Alexander