Mammograms – What’s the Real Bottom Line for American Women?

by sunsets_for_you/via Flickr

Diana Mason, AJN’s emeritus editor-in-chief, posted here on the new U.S. Preventive Services Task Force mammography recommendations earlier this week, noting some troubling questions AJN had raised years ago about how much evidence actually supports the wholesale acceptance of yearly screening for women age 40 and older.

But we know that the bottom line for many American women remains this: “Are you really telling me that it’s better not to know as early as possible that I might have cancer? You must be kidding!” After all, we’ve all heard of someone whose life may have been saved by the early detection provided by a mammogram or a breast self-exam.

What about the other side of the experiential coin? Forget the evidence for a minute. Let’s not talk about the fact that, as Maryann Napoli pointed out in AJN in 2004, the “technology leads to the unnecessary treatment of some cancers that might have remained latent, and it also detects invasive breast cancers so slow-growing that women will have long lives regardless of when tumors are found.” That’s what the science may be telling us. That’s for the number crunchers.

What we want to know is more basic: have you or your patients ever experienced real suffering and anxiety from a false positive result, or negative consequences from treatments that you may now believe to have been unnecessary? Is there really anything to this concern—and will it ever be enough to convince women without significant risk factors for breast cancer that it might actually be better to wait for that mammogram?

(For some illuminating historical perspective on the topic, see the Op-Ed piece in today’s NY Times, Addicted to Mammograms.)

Top Recent Reader Comments

We like your comments. In fact, we need them. We’re grateful when you express an opinion, raise a question, respond to each other. Below we’ve collected some recent comments that we particularly appreciated. We have a constantly growing number of readers or visitors. We’re happy about this–but we hope that more of you will go beyond reading and take a moment to let us know your responses. (About your privacy: When you comment, you have to give a valid e-mail address to the system. However, this e-mail address will not be published unless you deliberately insert it into the body of the comment. When you sign your comment, you can use your full name or initials or whatever else you’d like to identify yourself to other readers.  It’s entirely up to you!)

About Nurses Write, Right?:

“If 1 percent of the three million nurses in the USA would write about what they do, we could take over health care.”
–Dr. Teena McGuinness

About Saving SimBaby-Teaching Nurses to Speak Up, a post about using simulation technology for training nurses:

“I used to dread simulation situations (like ACLS years ago when it was much more stressful). Now I think they are the best way to learn and to teach some situations. Reproducing a certain degree of anxiety helps young nurses, and more experienced nurses, learn how to keep anxiety and stress from becoming fear. Being forced to repetitively face those anxieties diminishes the likelihood that a nurse will be overwhelmed by them in a real situation. No one likes to have an audience watch them perform, but learning to perform when you have an audience makes you better at whatever you’re attempting.”
-Suzanne Magee

About Trauma in Pregnancy: An Expert’s Calm Look at What Nurses Need to Know:

“I cared for a woman who was 39 weeks pregnant and was involved in a MVA where there was a death in the other car. Because of the magnitude of trauma on the other car, there was a significant mechanism of injury present to warrent keeping her for fetal heart monitoring and to monitor her as well. Turns out she had a partial abruption and needed an emergency c-section a few hours later.”
–Jo Hendrix

About From Flu Vaccine to Abortion Right: The Same Argument?:

“Somewhere in this I really miss the reason for someone NOT taking the flu vaccination, and this becoming such a big issue. Our society has become OVERLY sensitive to every potential infringement to our rights.”
–Jackie

“I stood in line and took the H1N1 vaccine.

“I didn’t do it out of guilt, or because of media induced panic. When it came down to it, I did it because of a child I love, and for a close family member who is pregnant. That’s all. I don’t want to catch the virus at work, and give it to either of these people. So far, my arm hasn’t fallen off or anything.

“I respect every health care worker’s right to make their own decision about the vaccine. Of course, all kinds of parallels can be drawn from this issue, including the rights of smokers to smoke, the right to drink soda without taxation, the right to drive without a seat belt, be overweight, or ride a bicycle without a helmet.

“One characteristic of effective conflict resolution between two parties is to stay issue focused. Otherwise, indeed, “slippery-slope” thinking occurs. A health care worker may not want the H1N1 vaccination, but be pro-life. One doesn’t necessarily support the other.

“I agree, the arguments are similar, but one issue at a time, please.”

–JParadisiRN (an artist and nurse who blogs)

About An End to Interruptions: Nurses Preventing Medication Errors:

“I saw this article about UC San Francisco. It is a great idea and more is being done around this as it is a problem. I have also heard of a “no interruption area” that is drawn around the med cart or Pyxis. When a nurse is inside this zone, no one can interrupt them. This has also been successful. Any other ideas? If your facility hasn’t implemented something like this, please consider it. Medication errors cost our system many many dollars a year.”
–Peggy

About Why Doesn’t the U.S. Have an Office of the National Nurse?:

“In today’s environment of healthcare reform, A National Nurse could and would represent nursing views and galvanize Nurses as the back bone of healthcare. Nurses provide the care let our views be known. Where do I sign up to support this endeavor?”
–Tafi Vista, RN, CM

Lastly, a bunch about The Top 5 Things You Wish They’d Taught in Nursing School:

“Wish we were taught to juggle 7-8 patients with IV’s beeping, demanding families, post ops and admissions while the unit secretary called out sick and there was no nursing assistant scheduled for that day, the computer system is down and your co-worker is really not feeling well and she needs to go home if you could watch over her patients while she tries to find a replacement! Just some real life scenarios that you don’t learn in nursing school!!”
–Andrea Johnsen

“As a new nurse in an adult ICU, I wish someone in school had taught me that when I started in July, the residents also started in July, so when I needed a doctor to write an order for a fentanyl or versed drip, they were pretty much as clueless as I was…..”I wish they had a class in nursing school on “How to interact with families that are less than cooperative and polite…””
–MaryJo Nonnemacher

“There was not nearly enough hard science or quality clinical experience. Too much emphasis on “reflecting,” and other emotional topics. That stuff is important too, but when you teach it at the expense of quality experience that will help to protect your license once you graduate, that is not okay. I felt horrendously under-prepared by my nursing school experience and I feel like the burden was placed on me to learn all the things that would actually help me in reality.”
–Luke

“I wished I had known about nursing opportunities in the US Public Health Service. When I found out about the variety of roles and travel opportunities, I had already put down roots and established an acute care career. Schools need to do better in helping students be aware of career possibilities.”
–Shawn

“Wishes there were available clinical sites in places that challenge a student nurse instead of places that are just “available”.With the number of nurses retiring it is harder to get clinical placements with nurses that have a large amount if experience as well as knowledge. Which can limit the clinical placements.”
–Joanne

“I graduated from a hospital school and feel that the extra bedside experiences were very helpful. However, time and experience gave me the critical thinking skills. This is why it is so important to have a skill mix that includes new and experienced nurses working every shift. Equally important is that nurses are rewarded for staying at the bedside and recognized for the labor of love it truly is.”
–Misha

Mammography Screening: Change Isn’t Easy

Diana J. Mason, PhD, RN, AJN editor-in-chief emeritus

By jared, via Flickr (creative commons)

Exactly what is the evidence supporting annual mammography screening and breast self-examination for women over the age of 40?

The U. S. Preventive Services Task Force (USPSTF) conducted a systematic review of this issue and concluded that the evidence for mammography screening of women before the age of 50 years is equivocal and the evidence for breast self-examination is inconclusive. The report notes that the Task Force reached a different conclusion about the quality of the studies on mammography than did a Cochrane Collaboration review done in 2001, with the Cochrane review having much less confidence in the quality of the available research

In April 2001 and January 2004, AJN published two controversial commentaries on the topic by Maryann Napoli, a member of the AJN editorial board and deputy director of the Center for Medical Consumers. Napoli pointed out that the available evidence from large international studies didn’t support the belief that early detection of breast cancer actually resulted in lower mortality rates and that the high number of false positive tests resulted in unnecessary anxiety and treatment. At the time, there was even some evidence that premenopausal women who are diagnosed with breast cancer through mammography may actually die earlier than women who are not screened. More recently Napoli has been updating her thoughts on mammography screening in response to new research (but not yet the USPSTF guidelines) at her center’s Web site.

Breast cancer is a leading cause of death among women, but we can’t assume that early screening will save lives. As we discovered with prostate cancer, some cancers simply won’t be eliminated by any treatments we have available, and we need a more critical examination of the potential adverse effects of all those biopsies. 

Maybe the new emphasis on the importance of comparative effectiveness research for measuring quality and controlling costs might help us to design studies that will provide stronger evidence for the proper place of mammography and breast self-examination for reducing the number of deaths from breast cancer.

 

What Do Medical Researchers and Legislators Have in Common? Conflict of Interest, for One

By Shawn Kennedy, MA, RN, AJN interim editor-in-chief

In a not-so-old blog post I did last month, I reported on a conference I attended in Vancouver.  There, editors from JAMA presented a study revealing that ghostwriting was a major problem for the leading medical journals. Articles were being drafted by writers other than the researchers. In some cases, the writers didn’t have access to all the data, which meant that analyses, conclusions, and—in some cases—recommendations for treatment were based on incomplete or misinterpreted findings.  As described in a New York Times article on the issue, medical product and pharmaceutical companies have much to gain if the safety and efficacy of their products are reported in a positive light.

Conflict of interest is a major concern whenever someone who stands to personally benefit can influence a decision. The National Institutes of Health, which is the leading medical and health research agency in this country, has imposed strict rules for employees limiting consulting and speaking fees involving outside companies and institutions that may have a stake in research outcomes. Most government agencies, research or not, impose rules to avoid conflicts of interest.

Last week, NBC News reported that protestors staged a sit-in at the Hartford, Connecticut, offices of Senator Joe Lieberman, demanding that he stop taking campaign contributions from insurance companies. 

FDA Commissioner’s Letter to Health Care Professionals About H1N1 Vaccine Safety

Below we reproduce a letter from Margaret Hamburg, Commissioner of the U.S. Food and Drug Administration (FDA), to all U.S. health care professionals. It explains why the FDA (and most experts) believe the current H1N1 vaccine is as safe as any of the seasonal flu vaccines that are produced using the same process. Many nurses remain reluctant to get the vaccine, as are many patients. Some we’ve heard from have changed their minds as they’ve seen the sudden and devastating effects of this virus on patients in their hospitals. We hope this letter will provide some context for thinking about the current H1N1 vaccine, and for addressing the concerns of patients.

Dear Healthcare Professional,

I am writing first to thank you for your extraordinary efforts during the 2009 H1N1 influenza outbreak. 

As this new infectious disease sweeps through communities across the country, you must juggle your usual patient care responsibilities with a special role in influenza response.  Delays in vaccine delivery and the persistence of myths about vaccination have not made your job any easier.  Thank you for rising to this public health challenge.

I am also writing to provide information that can be helpful as you talk to patients about the 2009 H1N1 influenza vaccines — the best tools we have to prevent severe illness and death caused by the virus. 

As the Commissioner of the U.S. Food and Drug Administration (FDA), I am pleased to have this opportunity to communicate with you directly at this key moment in time.

The Department of Health and Human Services is working with influenza vaccine manufacturers and state and local public health officials to make these vaccines widely available.  So far, more than 41 million doses of the 2009 H1N1 vaccine have been allocated to the states for distribution across the country, and more is becoming available every day. 

Some of your patients may be asking how the FDA, the manufacturers, and the scientific community can have confidence in vaccines that were available just six months after the 2009 H1N1 virus emerged. Understanding more about the manufacturing and approval process for these vaccines should help you to answer their questions.

Every year, FDA and vaccine manufacturers follow a series of steps to make a new influenza vaccine targeted to the three main circulating strains of influenza. These steps have produced effective and very safe vaccines time and again, adding up to hundreds of millions of doses administered in the United States alone.

We followed this same path for the 2009 H1N1 vaccines.

Making the 2009 H1N1 Vaccine

First, scientists at laboratories in the United States and elsewhere modified the 2009 H1N1 virus into a version suitable to be used as the “seed” for the development of vaccines.  The process that was followed is similar in every respect to that which is employed every year for the preparation of seasonal influenza vaccines, as slightly different strains appear regularly each year. 

Overcoming Barriers to Kidney Transplantation

By Genevieve Coorey, BSN, MA(Ed.). Coorey is the quality assurance and program director at the National Kidney Foundation and was the lead author of “Barriers to Preemptive Kidney Transplantation,” published in the November issue of AJN.

 

Honoring a dad's gift of life

Talk with any nursing colleague who cares for people with a chronic, complex disease and you will hear about the resilience and patience with which they accept—even triumph over—the effects of their illness.  

Cheryl learned nine years ago that her kidneys were failing. “At one point, I was so weak from anemia and malnutrition I could barely lift a dinner plate. Walking through a grocery store was a struggle. I used a wheelchair briefly because my legs were so filled with fluid. My husband . . . had to carry me at times, because I was too weak to walk.” 

A long-time school friend gave Cheryl one of his kidneys. She took up biking when her recovery allowed and the next summer she rode a 69-mile segment of a huge annual bike ride across Iowa; two years later she rode all 500 miles. Now Cheryl is a seven-time gold medal winner at three separate National Kidney Foundation U.S. Transplant Games events and a two-time bronze medal winner at the World Transplant Games. Extraordinary.

Every year, thousands die while waiting for an organ transplant. Yet the compassion and selflessness of others—complete strangers in fact—may offer hope for some. This is illustrated by Linda’s story:

Saving SimBaby – Teaching Nurses to Speak Up

The baby’s condition is going downhill fast. A medical team surrounds the infant, tersely exchanging instructions. The gripping scenario has the participants’ hearts beating fast, but the baby on the table is SimBaby, a manikin with sophisticated robotics that’s used in health care simulation training.

As in a real situation, “there is adrenalin in a simulation,” explains Elaine Beardsley, MN, RN, clinical nurse specialist in the pediatric simulation program at Seattle Children’s Hospital. “Even though it is a simulated environment, people get nervous. People talk more.” However, Beardsley says, the structured communication training within the simulation “cuts the chatter.”

The November AJN Reports focuses on ways that SimBaby is helping teams of nurses and physicians at Seattle’s Children’s Hospital learn to avoid the kinds of communication breakdowns that, studies have shown, can lead to errors in stressful situations. The training includes creating a safe environment in which nurses and residents are encouraged to speak up to physicians “when they perceive mistakes being made.”

“Simulation, in my mind, is about getting us to communicate better,” says Jennifer Reid, MD, assistant professor of pediatric emergency medicine at the University of Washington School of Medicine and Seattle Children’s Hospital and codirector of the hospital’s ED simulation program. “Our training is such that physicians and nurses are usually educated, trained, and practice more or less in parallel. Simulation is an opportunity-a rare one-for us to learn and train together, working consciously on our communication skills. When else do I ask a nurse directly if she has any idea what I as the physician am thinking? When else do physicians and nurses actually sit face-to-face and talk about what it felt like to be a part of that team and the elements of communication that helped or frustrated them?”

Simulation training is increasingly big now in most nursing schools, as well as in some hospitals. Does it increase a team’s ability to work together and to make sure they are always on the same page? Can it help nurses become more confident about alerting a team to potential errors? And what, we wonder, will the future of simulation training look like just ten years from now?

‘Mercy,’ Revisited: A Nurse Goes from Harsh Critic to Fan

By Peggy McDaniel, BSN, RN

The new NBC television series Mercy is starting to grow on me. Like some other recent shows (Nurse Jackie and Hawthorne), this drama features nurses as the lead characters. As I explained here a while back, my response to the first episode was very negative. Disparaging comments made about nurses by other staff and by patients’ family members struck me as unnecessary and irritating. Lines like “what do you know, you’re only a nurse?” were hard for a real nurse to take. My first impression was that the characters could have been women in almost any career. The words and actions of Veronica, one of the lead characters, seemed harsh and inappropriate. The overall image of nursing was negative.

So now for my confession: I have continued to watch Mercy. And I’ve become less of a critic and more of a fan. We still get more dramatic effects than convincing reality. For example, in a recent episode, Veronica runs in and bangs a patient’s chest with her fist, an action which ultimately restarts the patient’s heart. I still miss the comparatively realistic practices depicted in ER; Mercy doesn’t attempt to get such details right. 

But recent story lines have shown our nurse heroines to be strong patient advocates. This is a true (believable, and inspiring) nursing role. Even if the story line takes liberties with what a real nurse would do—such as when a character visits a patient’s son at his home to encourage him to visit his dying mother—the point about patient advocacy is made and appreciated. Advocating for our patients and promoting their health and welfare is a nursing priority.

Have you continued to watch Mercy? Have your views of Veronica, Sonia, and Chloe altered as you’ve gotten to know them? What other nursing roles and tasks would you like to see portrayed? I am hoping for story lines that show off other important nursing roles, such as educator, role model, coordinator, among many others. Let’s hear your ideas. Maybe the network will listen!

Are Domestic Violence and Pregnancy Preexisting Conditions?

By Peggy McDaniel, BSN, RN

Kaiser Health News recently ran a story about an attorney who was denied private insurance coverage based on a “preexisting condition”—that is, treatment she’d received following a domestic abuse incident. A majority of states have passed laws prohibiting insurers from denying coverage based on treatment for domestic violence, but  eight states as well as the District of Columbia have no such legislation. It is a challenge to track the occurrence of such denials. Insurers often use alternative ways to find out about a history of domestic abuse. They have been known to search for protective orders at local courthouses, which is public information, and search through medical records for documentation of treatment related to such incidents. 

A bitter irony is that nurses are expected to be aware of and directly question patients about suspected abuse, yet in doing so we could be setting up patients for future loss or denial of coverage. 

Pregnancy, likewise defined as a preexisting condition, can also be used to deny coverage. Health reform bills under consideration would disallow the practice of basing insurance rates on gender, a practice which has in effect discriminated against women, particularly those of child-bearing age. 

The practice of denying private health insurance coverage based on these and other preexisting conditions must stop. As a nurse and a consumer, I believe that everyone should be able to buy health care at a reasonable price. A rate such as $1,000 per month for a family is not affordable. In the end we all pay if people do not have some kind of coverage, since the uninsured do eventually receive care—from ERs, which are mandated to provide this care. 

By moggs oceanlane, via Flickr

The very idea that a person can be denied health insurance coverage for a history of domestic violence should encourage us to look closely at reform efforts under discussion and actively join in the conversation. As nurses we are asked to support our patients and promote physical and mental health.  If the very support we give, such as a referral to a domestic violence support group, causes a patient to lose her insurance, we all fail.

An End to Interruptions: Nurses Preventing Medication Errors

By Christine Moffa, MS, RN, AJN clinical editor

By NathanF/via Flickr (Creative Commons)

I have a hard time focusing when I am repeatedly interrupted. How many times have you walked down the hall to get something, met with an unexpected request or encounter, and then found you couldn’t remember where you were going or why?

A few years ago I was working as float nurse in an outpatient facility. One of the specialties I floated to was the pediatric clinic. There were seven or eight nurses (a mix of RNs and LPNs) working at the same time, with half assigned to administering medication, mostly vaccines, and the others performing telephone triage and monitoring patients in the observation room.  I can now admit that I used to pray to get assigned to the triage section—not because giving injections was a problem, but because the setup of their system terrified me.