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December 8, 2009

The Joys of a False Positive

What the apostle Paul has to do with the new mammogram guidelines.

Lynn Cohick

The U.S. Preventive Services Task Force released recommendations on breast cancer screenings November 16, stating that too many women were given unnecessary tests based on an initial “false positive” mammogram. The task force discouraged women ages 40 to 49 from regular screenings, saying they were not necessary until age 50. As cancer groups and women’s health organizations have decried the new guidelines, the task force clarified its position last week, saying that women can have mammograms whenever they want, but that they are more effective for women ages 50–74.

breast_exam01D-pinkw.jpg

A recent “false positive” myself, I cannot tell you how happy I am to be in such a group. My first mammogram was suspicious, and the second did not clarify findings, so a third was done. A radiologist reviewed the results with me right away, showing me the trouble area (near the armpit, where 50 percent of breast cancer is found). My physician said that while the new spots could simply be more calcification clusters, their location and strange appearance raised concerns. So a biopsy was done, and — praise God — no cancer was found.

While the task force’s new protocols treat false positives as a negative thing — resulting in unnecessary anxiety and more money spent on unnecessary tests — I see false positives as the result of due diligence in preventive health care. But since my field of expertise is biblical studies, not health care, I won't get into the details of health care strategy. Instead, when I read the report a few weeks ago, I began thinking about the phrase “false positive,” which sounded like an oxymoron. And my mind turned to the “false apostles” that Paul writes about in 2 Cor. 11:13. These preachers taught a different gospel, disrupted the Corinthian church, and defamed the imprisoned apostle’s work. The “super apostles” are false because they masquerade as true but are not.

Likewise, a medical false positive gives the impression of being the real thing but in the end is not. The difference is that we want a false positive from our doctor, while we do not want false apostles in our churches. So the analogy didn’t quite work.

Then I thought of the biblical passage in which Paul mentions those who preach Christ out of envy and ambition. The Philippians were seemingly upset about this group, who were preaching Christ out of rivalry against Paul. In other passages (Gal. 5:16–26; Phil 2:12–15; Eph. 4:17–5:20), Paul directly lays out the ethical and moral codes for all believers as they live out their Christian life through the Holy Spirit. But here (Phil. 1:15–18), Paul’s response is instructive: He waves aside the Philippians’ worries and dismisses the envy of the rival preachers. What matters, says Paul, is that Christ is preached. The fact that the other preachers’ motives are false does not negate their positive impact for the gospel: “But what does it matter?” he writes. “The important thing is that in every way . . . Christ is preached. And because of this I rejoice.”

Paul is fine with a “false positive,” because in the end, it's the results that matter. So, too, in the case of mammograms; would that all women could be fortunate enough to have a false positive. The imperfections of science and the idiosyncrasies of each woman’s body means that false positives can never be avoided entirely. Instead, perhaps we should embrace the false positives with humility, and remember that it is the end result, our health, that matters most.

Lynn Cohick is professor of New Testament at Wheaton College, and author most recently of Women in the World of the Earliest Christians (Baker Academic).

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Posted by Katelyn Beaty on December 8, 2009 11:38 AM

Comments

This is the weirdest analogy I've ever read.

Posted By: muse | December 8, 2009 12:45 PM

Let's try another analogy. If you want a website that is up 99% of the time you can probably get one for $5 to $10 a year. If you want one that is up 99.9% then it will be more. The gold standard of 99.999% is even more. You can attempt to get close to 100% but you will never be able to guarantee 100% uptime. So you are always approaching 100%. Each amount of money you spend will get you more. The difference between 99 and 99.1 is much, much less in cost than the difference between 99.9 and 99.99. Probably a different of 10 fold. You will never catch all cancer early, not matter if you start screening at 18. But you could spend a lot of money on early screening if you wanted to.

So this, like most medical recommendations may mean some people will not get their cancer caught as early. But on the whole money will be saved and able to be used for other medical services. It is not a zero sum game, but there are reprocussions of too much medical treatment.

Posted By: Adam S | December 8, 2009 12:55 PM

Just a comment about diagnostic testing in general. An ideal diagnostic test (mammography or any other test)would diagnose every single case of the disease with no mistakes. ( i.e. neither false positives nor false negatives).There are no ideal tests and so in some instances the disease is not identified and in others it is mistakenly identified. A certain number of false positive results are to be expected. However, most of the discussions about false positive results that I have read fail to mention that all diagnostic proceedures have some degree of physical risk. In some proceedures the risk is small, in others larger. So as a rule of thumb going forward, please, lets not forget that all proceedures carry risks and those risks must be weighted agains the potential benefits of the proceedure. That balance of risk vs benefit is part of what epidemiolgists, researchers and clinicians do as part of their job. The move to more evidence based medicine is, on the whole,a good move, but it does mean more of these sorts of discussions. As Adam S pointed out above, there is a point (different for every proceedure) where the risks of the proceedure outweigh the benefits of the proceedure for a population. It's complicated and that's why different groups are in disagreement about mammography recommendation.

Posted By: Nancy Janisch, DVM, M Div. | December 8, 2009 5:39 PM

NPR had a panel discussion in the couple of days after this recommendation came out in which a panelist stated that in Europe mammograms are much better at detecting cancer early than they are here. (In other words, they have fewer false negatives.) She stated that the key reason (in her opinion) is that medicine there is more centralized so that there are more centers there that are better at it than there are here and that, because of the centralization, the radiologists (?) who read the results in Europe are required to do approximately 10 times more readings (I think each year) in order to be certified. Something on the order of about 500/year here and 5000/year there.

If this report is true, then I think the whole debate over the frequency of testing entirely misses the boat. What led to a change in the recommendation is that, here, we have too many false positives AND too many false negatives. Changing the frequency of the tests doesn't do anything to change either of those things, and, as a result, more women die here than in Europe.

Now, I don't believe the European docs are any smarter, and I'd match our best against their best, but if the system allows more of them to specialize in a way that our system does not, it means, apparently, that there are more docs who are more highly skilled there than here (at reading mammograms) and as a result, fewer women die. Isn't that what we really want, rather than just more testing?

I agree with Adam S., that we're never going to get to 100% accuracy, and likewise, there will always be some disparity in access to the best healthcare, but our system is seriously unjust, and apparently, sometimes deadly, in its current state, especially for our most vulnerable who don't have the resources to fight the system to get what they need.

So, yes, a false positive, in the whole scheme of life, may not be the worst thing in the world, but, all-in-all, I'd like the healthcare system to give the doctors what they need to get it right for more people more often.

Posted By: Christian Lawyer | December 9, 2009 1:53 AM

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