The Canadian Breast Screening Study Attacked: Why Do Doctors Have Such A Hard Time With The Concept Of Overdiagnosis?

Canadian doctors say fee cuts, pay inequalities will spur exodus


The reason is that it gave me time to cogitate and wait for reactions, which is always more fun. Mammograms dont save lives, quoth the BMJ (and everyone covering the study)! After my obligatory navel-gazing explanatory introduction that infuriates some and entertains others, lets jump into the study itself. It was published in the BMJ and is, as the title tells us, the Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial . Before we delve into the findings, I should take a moment to explain what the Canadian National Breast Screening Study (CNBSS) actually is. The first thing you need to know is that this study has been contentious since its very beginning. In particular radiologists have been very critical of the study. One radiologist in particular, whom weve encountered before, pops up time and time again in articles critical of the CNBSS. This doesnt mean that the criticisms of the study arent invalid, but this particular radiologist, given his track record, did send up a red flag regarding critics of this study, given some of the truly badly thought out criticisms hes leveled at other mammography studies, most notably about a year ago . The study, conceived in the late 1970s and begun in 1980, the CNBSS was a randomized clinical trial that was designed to answer two questions, depending upon the age group: (1) to compare regular breast examination to breast examination plus screening mammography (age 50-59) and (2) compare screening mammography plus usual care (age 40-49). These were questions that had arisen from the only existing large study published at the time, the New York Health Insurance Plan (HIP) Study, which in 1963 had randomized (without informed consent) women between the ages of 40 and 64 such that around 30,000 received annual two-view mammography and clinical breast examination for three screens, with another 30,000 serving as controls who received usual care (i.e., clinical breast examination). The results, first published in 1977 , indicated a statistically significant reduction in breast cancer mortality of 23%. However, no benefit was seen in the 40-49 year old age group. Also, over an eight-year period after diagnosis, breast cancer cases that were positive only on mammography when screened had a case fatality rate of 14%, compared to 32% for cases positive only in the clinical examination and 41% for cases positive on both modalities. The thought at the time was that the reason no difference was seen in younger women was because the incidence of breast cancer is so much lower in women aged 40-49 than it is in women aged 50-64.

what is it worth


The result was a major reshuffling of the pool of money paid to doctors, with some like radiologists seeing major drops in their fees and others such as neurosurgeons graced with increases. Perhaps the most-cited inequity involves fees for some eye operations, such as cataract removal. New technology makes them faster to carry out, but in many provinces the payment has stayed the same, resulting in something of a windfall for ophthalmologists. The reaction to the recommendations was swift. The losing specialties voiced outrage, predicting harm to patients and a mass flight out of the province. As had happened when B.C. and Alberta went through a similar process, nothing ever came of the report. Comparing Canada to other countries is tricky, given the different methods of paying doctors and varying costs of living. A 2009 report by the Organization for economic co-operation and development (OECD) tries to even it all out, relating doctor pay to each nations average worker salaries. It puts Canadian specialist doctors at 4.7 times the average wage, higher than all but Germany and Holland, with the U.K. at 2.6 times and France 3.2. The report does not include the U.S. Surprisingly, some figures suggest this country is now more generous.

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