USPSTF has acted irresponsibly with the new mammography guidelines.

According to the United States Preventive Services Task Force (USPSTF) study introducing Mammography screening test to 40-49 year olds have clearly shown to reduce the mortality due to breast cancer. But there is an issue of high incidence of false positives among this age group (97.8 per 100 women per screening round as opposed for the 40-49 age group as opposed to 86.6 per 100 women per screening round). These false positives have not lead to a subsequent increase in over diagnosis. The incidence of over diagnosis is greater among the older age group. The argument of false positives as a reason for revising the guidelines is pointless. Since mammography is clearly a screening test and previous studies have over and again shown that, the benefits clearly outweigh the risks.

The anxiety and distress to the patient were variable after a false positive result. There was no significant increase in general anxiety levels of the patient after a false positive result, though there was a reported increase in the breast cancer specific anxiety levels.

The study states there is a higher Number needed to Invite (NNI) for the 39-49 age group standing at 1904, in order to prevent single breast cancer mortality as opposed to NNI of 1339 for the 50-59 age group. But if you compare the relative risk of breast cancer mortality for the 39-49 age group with the 50-59 age group, there is minimal difference of 0.85 vs 0.86. If this is the criteria used for revision of the guidelines, then it is a reflection of efforts to stand in line with the health care reforms of the US President rather than taking care of the benefits of the patients.

Even though the screening detected invasive breast carcinoma is the least for 40-49 age group. For 1000 women per screening round, the detection of invasive carcinoma is 1.8, the USPSTF is very clear on the benefits of screening mammography in patients of 40-49 age groups, and clearly states that even though the patients in the 40-49 age group experience a greater number of false positives; this does not reduce the life saving benefits of the screening test. The meta analysis of the data used for the new recommendations reveals that the screening trials indicates breast cancer mortality benefit for all age groups from 39 to 69 years.

The USPSTF study is very specific about the additional diagnostic tools being used after a positive screening mammography result. The 40-49 age group has the highest rates of additional imaging modalities (84.3 per 1000 women per screening round) though this age group has the least biopsy rates (9.3 per 1000 women per screening round). The argument of the patient having forced to undergo painful and complicated procedures, is refuted by the USPSTF study themselves,.

In conclusion the USPSTF study on the basis of which the revised guidelines for mammography has been devised is paradoxical, and the revision is a clear indication stating that the USPSTF are more concerned about additional health costs incurred rather than putting the welfare of the patient first. The USPSTF has acted highly irresponsible towards the entire medical fraternity. Instead of working towards increasing the number of patients of 39-69 age group undergoing mammography screening, they have created more confusion among the practitioners as well as new problems for the patients. Many of the 40-49 age group women who will undergo mammography screening in the US will now stand at a risky corner with health insurance not covering the cost required for the procedure, eventually increasing the financial burden on a health care seeking US family.

Disclosure: I am not a physician based in the US. I have no other conflict of interest.

USPSTF Site

The meaning of Speech

The amazing world of linguistics always has to a certain degree amazed me and left me wondering how we have inherited this beautiful form of human interaction. To realize the importance of linguistics, I always try this mind exercise. Imagine yourself to be a cave man trying to survive the everyday hard ships of pre-historic life. This does not include fighting the dinosaurs because they were extinct long before the most primitive forms of human ancestors appeared on the face of the earth. But it sure included the hunting and gathering job. One fine day you find another lovely pre-historic human ancestor woman and you try to communicate the excitement in a very primitive way. She is very impressed by your courting and tries to convey a positive reinforcing message back to you. It grows into a small relationship that further develops into a small hunter-gatherer family. As the relation progress, you develop a multitude of signs, sounds and symbols that help you and your hunter-gatherer mate much more efficient in food gathering. As time progress, you have kids; you try to teach the same tricks that you have learnt as a fellow hunter-gatherer. Till now, there is very little difference between the communications found in animals and those of humans.

But matters become more complicated as the human population grows and the area available for the hunting operation shrinks. There are more persons hunting for the almost fixed number of animals in a particular area. Suddenly you realize the importance of cooperation. As more and more people join your small hunter-gatherer commune, you understand another important aspect of killing animals. The predictability of certain subset of animal behavior makes it easier to fetch food. The problem here is you will have to teach other members of your group about the new knowledge that you have gathered. For that you make a new set of symbols, develop a new set of meaning for them.

As the civilization progressively shift from a hunter gatherer to a cultivating or farming society, the scale of cooperation between individuals have multiplied to several folds. You need someone to plant the seeds, another one to take care of the crops at night from the wild animals, a set of people to harvest the crops, another subset to store a small amount of them for planting again and process them for future consumption and storage. Along with the activities of the humans continuously getting more and more complicated, the need for conveying all these into a coherent and widely understandable form also increases.

Speech for the most part evolved as part of the intrinsic human nature to communicate with sounds. The primitive sounds evolved into a more progressive set of phonetics, that can be used in various permutations and combinations, to express new ideas, that were never thought of, when the basic framework for these sounds were laid out.

But the most intriguing aspect is how the humans learnt to represent sounds with symbols. Although today for many of us, the sounds and the written representations of them are so instantaneous, that was not the case when the human society was in its crawling phase. This ability to relate sounds to symbols must be as a result of a day to day occurrence that we seldom give utmost importance. Certain ideas or objects are far easier to be represented in a pictorial form than in a preordained set of syllables or sounds. The same dilemma of convincing an idea phonetically but rather easily through pictorial representation must have led to the development of a direct correlation between a sound and a written or drawn symbol.

Extending this few symbols and sounds to a fully fledged language is by itself is an impressive technological breakthrough, if you think about it. But, a little bit more of logical insight into it reveals these are all a very direct extension of progressive complexity. The more symbols and sounds you have, the grater the tendency of people to use it in a different way than it was originally intended to be used. The pre-historic humans also found that, this mish mash, jumble lead to lack of understanding of the original idea that it was meant to be conveyed. This random use of symbols and word also affected their efficiency as a group.

As a self learning system, the human society in its effort to minimize the loss of efficiency tries itself to introduce a certain set of rules. This prevents certain sounds to be used with only certain others and so and so. The rule making also exposed a vulnerability of sounds and symbols. If you have a very large repository of sounds and symbols you will have to specify the particular usage rules and associations. In an effort to reign in the problem of complexity, the number of symbols and signs and sounds are reduced to a bare minimum. The reduction in the number of symbols and sounds meant, there is an increasing need of combining a greater number of these individual elements to express an idea. So here comes the role of grammar. From a simple set of combinatorial rules to a full structured language, this is pretty much a very scientific and logical journey.

For me language is an amazing tool, which has helped humans to standardize and simplify the interactions with one another. It is a product of social nature of human beings. It is also a reflection of the increasing complexity of the human life over centuries. It is a window to the thought process of humans as well as how human brain is capable of organizing information and convening information.