Mammogram Debate

wabbiteer

Super Anarchist
9,781
0
I can't comment on the merits, but the value of a test, e.g., a mammogram, depends on the prevalence of the condition it is designed to detect in the target population. So, for instance, if we got mammograms on all women and girls past the age of puberty, the likelihood of an abnormality representing cancer would be very low and the test would be almost useless as a tool for deciding whom to do a biopsy on. On the other hand, if we restrict mammograms to women over, say, 50, the prior likelihood of cancer is much higher and the test tells us something much more specific. Whether you you like the guideline or not, it is based on data like these.
We are going to need clear criteria that optimize the usefulness and cost effectiveness of tests as we move into an age of constrained health care spending. Sound health care policy that delivers good outcomes at the population level will sometimes look uncaring to individuals.
Here is my problem with this:

The statement says

"This recommendation statement applies to women 40 years or older who are not at increased risk for breast cancer by virtue of a known underlying genetic mutation or a history of chest radiation."

However, their recommendations for breast cancer screenings don't include screening for BRCA1 or BRCA2. How can you eliminate the recommendation for mammograms for women 40-49 without adding screening to find those women who would benefit from a mammogram due to a genetic predisposition for cancer?

The logic seems flawed to me.

 

NautiGirl

Super Anarchist
8,972
3
New Scotland
It is estimated that about 1% of women carry the BRCA1 or BRCA2 gene for breast cancer9 and these genes are believed to be responsible for 3-8% of all breast cancers10.
Wabbitter, are you advocating that all women should be screened for a gene that only 1% of women carry?

 

MoeAlfa

Super Anarchist
12,560
33
The statement says
"This recommendation statement applies to women 40 years or older who are not at increased risk for breast cancer by virtue of a known underlying genetic mutation or a history of chest radiation."

However, their recommendations for breast cancer screenings don't include screening for BRCA1 or BRCA2. How can you eliminate the recommendation for mammograms for women 40-49 without adding screening to find those women who would benefit from a mammogram due to a genetic predisposition for cancer?

The logic seems flawed to me.
I'm not an expert, but those are autosomal dominant alleles, so there will almost always be a clear family history. Without that there's no reason to test for them.

 
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NautiGirl

Super Anarchist
8,972
3
New Scotland
I can't comment on the merits, but the value of a test, e.g., a mammogram, depends on the prevalence of the condition it is designed to detect in the target population. So, for instance, if we got mammograms on all women and girls past the age of puberty, the likelihood of an abnormality representing cancer would be very low and the test would be almost useless as a tool for deciding whom to do a biopsy on. On the other hand, if we restrict mammograms to women over, say, 50, the prior likelihood of cancer is much higher and the test tells us something much more specific. Whether you you like the guideline or not, it is based on data like these.
We are going to need clear criteria that optimize the usefulness and cost effectiveness of tests as we move into an age of constrained health care spending. Sound health care policy that delivers good outcomes at the population level will sometimes look uncaring to individuals.
Here is my problem with this:

The statement says

"This recommendation statement applies to women 40 years or older who are not at increased risk for breast cancer by virtue of a known underlying genetic mutation or a history of chest radiation."

However, their recommendations for breast cancer screenings don't include screening for BRCA1 or BRCA2. How can you eliminate the recommendation for mammograms for women 40-49 without adding screening to find those women who would benefit from a mammogram due to a genetic predisposition for cancer?

The logic seems flawed to me.
Actually, they do suggest that "women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic counseling and evaluation for BRCA testing."

Examples of family medical histories that increase a woman's risk for inheriting a BRCA1 or BCRA2 mutation:

  • Women of Ashkenazi Jewish descent with any first-degree* relative (or two second-degree relatives on the same side of the family) with breast or ovarian cancer
  • Women with two first-degree relatives with breast cancer, one of whom received the diagnosis at age 50 years or younger
  • Women with a combination of three or more first- or second-degree relatives with breast cancer, regardless of age at diagnosis
  • Women with a combination of both breast and ovarian cancer among first- and second-degree relatives
  • Women with a first-degree relative with bilateral breast cancer
  • Women with a combination of two or more first- or second-degree relatives w/ovarian cancer, regardless of age at diagnosis
  • Women with a family history of breast or ovarian cancer that includes a relative w/a known deleterious mutation in BRCA1 or BRCA2
  • Women with a history of breast cancer in a male relative.
*A first-degree relative is defined as a parent, sibling or child. A second-degree relative is a relative with whom one quarter of an individual's genes is shared (i.e., grandparent, grandchild, uncle, aunt, nephew, niece, half-sibling).

 

wabbiteer

Super Anarchist
9,781
0
I can't comment on the merits, but the value of a test, e.g., a mammogram, depends on the prevalence of the condition it is designed to detect in the target population. So, for instance, if we got mammograms on all women and girls past the age of puberty, the likelihood of an abnormality representing cancer would be very low and the test would be almost useless as a tool for deciding whom to do a biopsy on. On the other hand, if we restrict mammograms to women over, say, 50, the prior likelihood of cancer is much higher and the test tells us something much more specific. Whether you you like the guideline or not, it is based on data like these.
We are going to need clear criteria that optimize the usefulness and cost effectiveness of tests as we move into an age of constrained health care spending. Sound health care policy that delivers good outcomes at the population level will sometimes look uncaring to individuals.
Here is my problem with this:

The statement says

"This recommendation statement applies to women 40 years or older who are not at increased risk for breast cancer by virtue of a known underlying genetic mutation or a history of chest radiation."

However, their recommendations for breast cancer screenings don't include screening for BRCA1 or BRCA2. How can you eliminate the recommendation for mammograms for women 40-49 without adding screening to find those women who would benefit from a mammogram due to a genetic predisposition for cancer?

The logic seems flawed to me.
Actually, they do suggest that "women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic counseling and evaluation for BRCA testing."

Examples of family medical histories that increase a woman's risk for inheriting a BRCA1 or BCRA2 mutation:

  • Women of Ashkenazi Jewish descent with any first-degree* relative (or two second-degree relatives on the same side of the family) with breast or ovarian cancer
  • Women with two first-degree relatives with breast cancer, one of whom received the diagnosis at age 50 years or younger
  • Women with a combination of three or more first- or second-degree relatives with breast cancer, regardless of age at diagnosis
  • Women with a combination of both breast and ovarian cancer among first- and second-degree relatives
  • Women with a first-degree relative with bilateral breast cancer
  • Women with a combination of two or more first- or second-degree relatives w/ovarian cancer, regardless of age at diagnosis
  • Women with a family history of breast or ovarian cancer that includes a relative w/a known deleterious mutation in BRCA1 or BRCA2
  • Women with a history of breast cancer in a male relative.
*A first-degree relative is defined as a parent, sibling or child. A second-degree relative is a relative with whom one quarter of an individual's genes is shared (i.e., grandparent, grandchild, uncle, aunt, nephew, niece, half-sibling).
I don't understand why that 2005 recommendation was not included in the screening list that was just released. It seems that they did the public a real disservice there. Intellectually, I can understand the statistical argument for dropping the generic recommendation for mammograms at 40 as long as there is renewed emphasis on finding the people who would benefit from those mammograms (ie people with the genetic mutation) or other risk factors. Because of the way they released this list (leaving the genetic screening out) people aren't getting that part of the picture.

And emotionally, I'm pretty unimpressed by the recommendation because I have a close friend with zero risk factors who was diagnosed with a really aggressive from of breast cancer in her early 40s. It was found through a routine mammogram. You would have a hard time convincing me that mammograms under age 50 are useless.

 

MoeAlfa

Super Anarchist
12,560
33
Intellectually, I can understand the statistical argument for dropping the generic recommendation for mammograms at 40 as long as there is renewed emphasis on finding the people who would benefit from those mammograms (ie people with the genetic mutation) or other risk factors.
That's essentially a research question, which I hope is under active study. Better breast imaging would also help to solve the problem.

And emotionally, I'm pretty unimpressed by the recommendation because I have a close friend with zero risk factors who was diagnosed with a really aggressive from of breast cancer in her early 40s. It was found through a routine mammogram. You would have a hard time convincing me that mammograms under age 50 are useless.
I know you understand the issue, but not everyone does. Of course screening mammograms pick up up some cancers in young women, just as colonoscopy at age 40 will pick up some malignant polyps. Testicular ultrasound, anyone?

Again, I'm not arguing the merits because I'm not qualified, but the principle is legitimate and I really don't see a "womens' rights" issue here.

 
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NautiGirl

Super Anarchist
8,972
3
New Scotland
I can't comment on the merits, but the value of a test, e.g., a mammogram, depends on the prevalence of the condition it is designed to detect in the target population. So, for instance, if we got mammograms on all women and girls past the age of puberty, the likelihood of an abnormality representing cancer would be very low and the test would be almost useless as a tool for deciding whom to do a biopsy on. On the other hand, if we restrict mammograms to women over, say, 50, the prior likelihood of cancer is much higher and the test tells us something much more specific. Whether you you like the guideline or not, it is based on data like these.
We are going to need clear criteria that optimize the usefulness and cost effectiveness of tests as we move into an age of constrained health care spending. Sound health care policy that delivers good outcomes at the population level will sometimes look uncaring to individuals.
Here is my problem with this:

The statement says

"This recommendation statement applies to women 40 years or older who are not at increased risk for breast cancer by virtue of a known underlying genetic mutation or a history of chest radiation."

However, their recommendations for breast cancer screenings don't include screening for BRCA1 or BRCA2. How can you eliminate the recommendation for mammograms for women 40-49 without adding screening to find those women who would benefit from a mammogram due to a genetic predisposition for cancer?

The logic seems flawed to me.
Actually, they do suggest that "women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic counseling and evaluation for BRCA testing."

Examples of family medical histories that increase a woman's risk for inheriting a BRCA1 or BCRA2 mutation:

  • Women of Ashkenazi Jewish descent with any first-degree* relative (or two second-degree relatives on the same side of the family) with breast or ovarian cancer
  • Women with two first-degree relatives with breast cancer, one of whom received the diagnosis at age 50 years or younger
  • Women with a combination of three or more first- or second-degree relatives with breast cancer, regardless of age at diagnosis
  • Women with a combination of both breast and ovarian cancer among first- and second-degree relatives
  • Women with a first-degree relative with bilateral breast cancer
  • Women with a combination of two or more first- or second-degree relatives w/ovarian cancer, regardless of age at diagnosis
  • Women with a family history of breast or ovarian cancer that includes a relative w/a known deleterious mutation in BRCA1 or BRCA2
  • Women with a history of breast cancer in a male relative.
*A first-degree relative is defined as a parent, sibling or child. A second-degree relative is a relative with whom one quarter of an individual's genes is shared (i.e., grandparent, grandchild, uncle, aunt, nephew, niece, half-sibling).
I don't understand why that 2005 recommendation was not included in the screening list that was just released. It seems that they did the public a real disservice there. Intellectually, I can understand the statistical argument for dropping the generic recommendation for mammograms at 40 as long as there is renewed emphasis on finding the people who would benefit from those mammograms (ie people with the genetic mutation) or other risk factors. Because of the way they released this list (leaving the genetic screening out) people aren't getting that part of the picture.

And emotionally, I'm pretty unimpressed by the recommendation because I have a close friend with zero risk factors who was diagnosed with a really aggressive from of breast cancer in her early 40s. It was found through a routine mammogram. You would have a hard time convincing me that mammograms under age 50 are useless.
But doctors should be aware. No different than lawyers, or those dreaded bankers, you pay them for their expertise.

I've yet to see my family doctor and NOT be asked about family history of cancer. She asks me every year.

And for every friend like yours who happens to have had breast cancer detected under 40, there are those who get false positives, particularly young women given breast density.

The US has a false positive for mammograms of about 15%. That's lower for post menopausal women, and higher for premenopausal women. There are costs and personal implications for every false positive: well documented stress and anxiety, needless procedure, etc.

And then there are the false negatives, which are more common in younger women, again due to breast density.

So while I'm glad your friend's breast cancer was detected early, the vast majority of women without pre-disposing risk factors don't benefit from early screening, and in fact, can be harmed by it.

 
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NautiGirl

Super Anarchist
8,972
3
New Scotland
So how's that public healthcare looking now. This is just the beginning of a long road to low quality healthcare with the decision made by "expert panels" instead of doctors.
Also from the Sydney Morning Herald http://www.smh.com.au/national/doctors-sick-of-failure-to-fix-ailing-hospitals-20091118-imjr.htmlhttp://www.smh.com.au/national/doctors-sick-of-failure-to-fix-ailing-hospitals-20091118-imjr.html

If anything, I think this will give the insurance companies more grounds to deny service.

I've never known anyone who was denied access to a mammogram in Canada.

 

MoeAlfa

Super Anarchist
12,560
33
So how's that public healthcare looking now. This is just the beginning of a long road to low quality healthcare with the decision made by "expert panels" instead of doctors.
Also from the Sydney Morning Herald http://www.smh.com.au/national/doctors-sick-of-failure-to-fix-ailing-hospitals-20091118-imjr.htmlhttp://www.smh.com.au/national/doctors-sick-of-failure-to-fix-ailing-hospitals-20091118-imjr.html
It's a guideline not a medical decision. Government and private bodies have been issuing them for decades. Doctors need them because they support decision making, make it easier to get insurers to pay for things, and provide the best possible defense against allegations of negligence by establishing standards of care. Do you think your insurer would just spring for screening colonoscopy for everyone if there weren't guidelines recommending it?

 
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2high2tight

Super Anarchist
3,520
0
Government and healthcare don't mix.

On paper, and actuarily, we spend far more not detecting cancers that don't exist than we do treating late stage disease. But that sure as shit isn't the point.

The doctors are against this, and the health insurers are against this. A mammogram is a $106 test that certainly doesn't break the bank at the insurance company and doesnt make the Dr a whole lot of money (cause the exam takes more than 5 mins).

I'm trying to figure out exactly who these idiots are -- breast cancer is a devastating and widely spread disease. Do these people not have sisters or mothers.

 

NautiGirl

Super Anarchist
8,972
3
New Scotland
Government and healthcare don't mix.
On paper, and actuarily, we spend far more not detecting cancers that don't exist than we do treating late stage disease. But that sure as shit isn't the point.

The doctors are against this, and the health insurers are against this. A mammogram is a $106 test that certainly doesn't break the bank at the insurance company and doesnt make the Dr a whole lot of money (cause the exam takes more than 5 mins).

I'm trying to figure out exactly who these idiots are -- breast cancer is a devastating and widely spread disease. Do these people not have sisters or mothers.
I'd suggest you spend some time researching screening protocols in the rest of the world. I'd also suggest you research the efficacy of mammograms period, and the efficacy in them in women under 50 specifically.

I was surprised to discover that the US recommended mammograms for women under 50 in the first place, because other than in parts of Asia, where women tend to develop breast cancer in their 40's, there very few places that gave 40 year old women who had no knwn risk factors regular mammograms.

 
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akaGP

Super Anarchist
8,851
2
If I understand it correctly, the only change was to recommend that woman at 40 consult with their physician whether or not to have annual mammography rather than schedule the procedure automatically.
Does that make it elective then? If so, my HC may tell women it's not covered.

I'd still pay but what about the women it discourages and they then get a bad case of boobie cancer

that could have been not so bad if detected early?

I like bewbs. Protect them!
I don't know the answer to your question, but aren't all recommendations ultimately elective when it comes to choice?

That is why I am for like a single payer type, and/or health care system in Great Britain, France, German, Switzerland, Japan, and Taiwan.
It appears that this Canadian study confirms the importance of consulting with a physician whether or not to have annual mammography.

"Having a usual source of care, recent contact with a physician, and receiving a recommendation from a physician have been found to be salient predictors of mammography use.23, 26, 27, 31 The strong association between mammography use and contact with doctors in this study supports the previous research and emphasizes the importance of the doctor’s role in promoting the use of mammography."

 

2high2tight

Super Anarchist
3,520
0
Government and healthcare don't mix.
On paper, and actuarily, we spend far more not detecting cancers that don't exist than we do treating late stage disease. But that sure as shit isn't the point.

The doctors are against this, and the health insurers are against this. A mammogram is a $106 test that certainly doesn't break the bank at the insurance company and doesnt make the Dr a whole lot of money (cause the exam takes more than 5 mins).

I'm trying to figure out exactly who these idiots are -- breast cancer is a devastating and widely spread disease. Do these people not have sisters or mothers.
I'd suggest you spend some time researching screening protocols in the rest of the world. I'd also suggest you research the efficacy of mammograms period, and the efficacy in them in women under 50 specifically.

I was surprised to discover that the US recommended mammograms for women under 50 in the first place, because other than in parts of Asia, where women tend to develop breast cancer in their 40's, there was no where else that I could find that routinely gave 40 year old women who had no knwn risk factors regular mammograms.
Every female in my family -- on both my mothers and fathers sides -- have had breast cancer in their 40s. So don't play BULLSHIT STATISTICS with me. Healthcare isn't about macroeconomics. Its about people making educated decisions about staying alive. BREAST CANCER KILLS. One in 8 women get it. X percentage of that happens when people are in their 40s. The kinds that strike people in their 40s is typically nasty.

Don't be an asshole over a $100 test.

 

NautiGirl

Super Anarchist
8,972
3
New Scotland
Government and healthcare don't mix.
On paper, and actuarily, we spend far more not detecting cancers that don't exist than we do treating late stage disease. But that sure as shit isn't the point.

The doctors are against this, and the health insurers are against this. A mammogram is a $106 test that certainly doesn't break the bank at the insurance company and doesnt make the Dr a whole lot of money (cause the exam takes more than 5 mins).

I'm trying to figure out exactly who these idiots are -- breast cancer is a devastating and widely spread disease. Do these people not have sisters or mothers.
I'd suggest you spend some time researching screening protocols in the rest of the world. I'd also suggest you research the efficacy of mammograms period, and the efficacy in them in women under 50 specifically.

I was surprised to discover that the US recommended mammograms for women under 50 in the first place, because other than in parts of Asia, where women tend to develop breast cancer in their 40's, there was no where else that I could find that routinely gave 40 year old women who had no knwn risk factors regular mammograms.
Every female in my family -- on both my mothers and fathers sides -- have had breast cancer in their 40s. So don't play BULLSHIT STATISTICS with me. Healthcare isn't about macroeconomics. Its about people making educated decisions about staying alive. BREAST CANCER KILLS. One in 8 women get it. X percentage of that happens when people are in their 40s. The kinds that strike people in their 40s is typically nasty.

Don't be an asshole over a $100 test.
everything i've said is in complete agreement with what you just posted, so what's your problem?

If every female in your family had breast cancer at a young age, there is a reasonable chance that they carry the genetic markers for it. There is absolutely every good reason for every female in your family to have regular mammographies after 40 (unlike every female in my family). But just because that's good for every female in YOUR family, doesn't mean it's good advice for every female PERIOD.

Yes, breast cancer kills. But it is also one of the most treatable forms of cancer a woman can get. In Canada, there is an 87% 5 year relative survival rate. Those are pretty decent odds, as far as cancer goes.

 
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MoeAlfa

Super Anarchist
12,560
33
Government and healthcare don't mix.
On paper, and actuarily, we spend far more not detecting cancers that don't exist than we do treating late stage disease. But that sure as shit isn't the point.

The doctors are against this, and the health insurers are against this. A mammogram is a $106 test that certainly doesn't break the bank at the insurance company and doesnt make the Dr a whole lot of money (cause the exam takes more than 5 mins).

I'm trying to figure out exactly who these idiots are -- breast cancer is a devastating and widely spread disease. Do these people not have sisters or mothers.
I don't see how such a guideline stops any insurer from paying for mammograms at any age.

Here's a list of the "idiots". I have contributed my own idiocy to the same agency on a different subject.

Bruce N. Calonge, M.D., M.P.H. (Chair)

Chief Medical Officer and State Epidemiologist

Colorado Department of Public Health and Environment, Denver, CO

Diana B. Petitti, M.D., M.P.H. (Vice Chair)

Professor of Biomedical Informatics

Fulton School of Engineering

Arizona State University, Tempe, AZ

Susan Curry, Ph.D.

Dean, College of Public Health

Distinguished Professor

University of Iowa, Iowa City, IA

Allen J. Dietrich, M.D.

Professor, Community and Family Medicine

Dartmouth Medical School, Hanover, NH

Thomas G. DeWitt, M.D.

Carl Weihl Professor of Pediatrics

Director of the Division of General and Community Pediatrics

Department of Pediatrics, Children's Hospital Medical Center, Cincinnati, OH

Kimberly D. Gregory, M.D., M.P.H.

Director, Maternal-Fetal Medicine and Women's Health Services Research

Cedars-Sinai Medical Center, Los Angeles, CA

David Grossman, M.D., M.P.H.

Medical Director, Preventive Care and Senior Investigator, Center for Health Studies, Group Health Cooperative

Professor of Health Services and Adjunct Professor of Pediatrics

University of Washington, Seattle, WA

George Isham, M.D., M.S.

Medical Director and Chief Health Officer

HealthPartners, Minneapolis, MN

Michael L. LeFevre, M.D., M.S.P.H.

Professor, Department of Family and Community Medicine

University of Missouri School of Medicine, Columbia, MO

Rosanne Leipzig, M.D., Ph.D

Professor, Geriatrics and Adult Development, Medicine, Health Policy

Mount Sinai School of Medicine, New York, NY

Lucy N. Marion, Ph.D., R.N.

Dean and Professor, School of Nursing

Medical College of Georgia, Augusta, GA

Joy Melnikow, M.D., M.P.H.

Professor, Department of Family and Community Medicine

Associate Director, Center for Healthcare Policy and Research

University of California Davis, Sacramento, CA

Bernadette Melnyk, Ph.D., R.N., C.P.N.P./N.P.P.

Dean and Distinguished Foundation Professor in Nursing

College of Nursing & Healthcare Innovation

Arizona State University, Phoenix, AZ

Wanda Nicholson, M.D., M.P.H., M.B.A.

Associate Professor

Johns Hopkins School of Medicine and Bloomberg School of Public Health, Baltimore, MD

J. Sanford (Sandy) Schwartz, M.D.

Leon Hess Professor of Medicine, Health Management, and Economics

University of Pennsylvania School of Medicine and Wharton School, Philadelphia, PA

Timothy Wilt, M.D., M.P.H.

Professor, Department of Medicine, Minneapolis VA Medical Center

University of Minnesota, Minneapolis, MN

 
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Lee G

Super Anarchist
3,323
0
Government and healthcare don't mix.
On paper, and actuarily, we spend far more not detecting cancers that don't exist than we do treating late stage disease. But that sure as shit isn't the point.

The doctors are against this, and the health insurers are against this. A mammogram is a $106 test that certainly doesn't break the bank at the insurance company and doesnt make the Dr a whole lot of money (cause the exam takes more than 5 mins).

I'm trying to figure out exactly who these idiots are -- breast cancer is a devastating and widely spread disease. Do these people not have sisters or mothers.
I'd suggest you spend some time researching screening protocols in the rest of the world. I'd also suggest you research the efficacy of mammograms period, and the efficacy in them in women under 50 specifically.

I was surprised to discover that the US recommended mammograms for women under 50 in the first place, because other than in parts of Asia, where women tend to develop breast cancer in their 40's, there was no where else that I could find that routinely gave 40 year old women who had no knwn risk factors regular mammograms.
Every female in my family -- on both my mothers and fathers sides -- have had breast cancer in their 40s. So don't play BULLSHIT STATISTICS with me. Healthcare isn't about macroeconomics. Its about people making educated decisions about staying alive. BREAST CANCER KILLS. One in 8 women get it. X percentage of that happens when people are in their 40s. The kinds that strike people in their 40s is typically nasty.

Don't be an asshole over a $100 test.
everything i've said is in complete agreement with what you just posted, so what's your problem?

If every female in your family had breast cancer at a young age, there is a reasonable chance that they carry the genetic markers for it. There is absolutely every good reason for every female in your family to have regular mammographies after 40 (unlike every female in my family). But just because that's good for every female in YOUR family, doesn't mean it's good advice for every female PERIOD.

Yes, breast cancer kills. But it is also one of the most treatable forms of cancer a woman can get. In Canada, there is an 87% 5 year relative survival rate. Those are pretty decent odds, as far as cancer goes.
Have you shown your tits on SA yet? If not, this thread would be appropriate. Its for science.

 

MoeAlfa

Super Anarchist
12,560
33
Here's a very thoughtful analysis in lay language from a cancer surgeon. He doesn't like the guidelines, but recognizes their legitimacy. The point is that even elite guys at academic institutions recognize guidelines as the best way to codify best practices, based on empirical data, not some socialist plot.

 
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El Mariachi

Super Anarchist
41,182
0
Jfc, just how much do these tests costs? In like L.A. Dollars? $500? $300? $61.98? The price of three StarFux double lactosi?.............

 
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