Uruguay’s mandatory breast cancer screening for working women aged 40-59 is challenged
BMJ2013;346doi:
http://dx.doi.org/10.1136/bmj.f1907(Published 21 March 2013)
Cite this as:BMJ2013;346:f1907
A woman in Uruguay is challenging the obligation法律上義務 for working women aged between 40 and 59 years to be screened for breast cancer every two years.
A decree頒布命令 issued in 2006 by the then president, Tabaré Vázquez, an oncologist, made biennial screening for breast cancer a part of a series of regular, state funded health checks that female employees must complete to get the “health card” that all workers need.(烏拉圭總統是腫瘤科醫師,自2006年頒佈法令---40-59歲有工作婦女應每二年做一次 乳房篩檢)
A 52 year old state sector computer engineer is the first person known to have refused screening. She recently began legal proceedings to seek an exemption免除 刪減額 from the country’s health ministry(有ㄧ位52歲婦女拒絕篩檢並請求衛生部長免除刪減額)
“I read about the international debate about the risks of mammograms,” the woman, who wanted to be known by her initials, AR, told the BMJ. “I couldn’t believe that in my country there has been no public discussion about this. There is a lot of fear of cancer here. I think most women think it can only be good to have more checks.”(因為乳房攝影有導致乳癌發生機率…)
But international research has raised concern over the potential dangers of mammography, because it can lead to treatment for minor tumours that would never have threatened the woman’s health. A raised risk of cancer from exposure to x rays is another concern.
“I was shocked when I heard about the policy [in Uruguay],” said Juan Gérvas, a Spanish GP and expert on public health with an interest in the risks of breast cancer screening. “It’s the only country in the world with this sort of mandatory screening. And there is absolutely no scientific basis for applying this to women between 40 and 50.”…………
The Oregon ACO Experiment — Bold Design, Challenging Execution
Eric C. Stecker, M.D., M.P.H.
N Engl J Med 2013; 368:982-985March 14, 2013DOI: 10.1056/NEJMp1214141The Affordable Care Act (ACA) and the Center for Medicare and Medicaid Innovation emphasize accountable care organizations (ACOs) as mechanisms for achieving cost savings while ensuring high-quality care. ACOs are expected to contain costs through improvements in health care delivery and realignment of financial incentives, but their effectiveness remains unproved, and there are reasons for concern that they may fail.
Failure of the Oregon experiment would not only jeopardize health care for vulnerable Oregonians but also call into question the viability of central tenets of the ACA.
In 2011, Oregon Governor John Kitzhaber, a physician, worked with the state legislature to create coordinated care organizations (CCOs………)
On the basis of the CCO structure, the state received a modification to its federal Medicaid waiver on July 5, 2012, for the Oregon Health Plan, allowing it to change its program design and receive additional financial support.3 The Oregon Health Plan includes Medicaid and the Children's Health Insurance Program (CHIP) and is overseen by the Oregon Health Authority.
However, as committed as many Oregon stakeholders are to this experiment,2 there is a distinct possibility that it will fail. The state's proposal for the Oregon Health Plan to achieve savings and quality improvement without diminution of eligibility or benefits depends on a combination of improved administrative efficiencies and effective health care delivery reforms……….
Many of these approaches have not been shown to reduce costs.1 Although studies have consistently shown that patient-centered medical homes (often incorporating disease-management programs) can achieve cost savings while improving quality of care, the evidence comes from large, highly integrated care networks with years of experience and a history of iterative improvement
……………….
On the performance front, policymakers and payers should ask whether provider-productivity metrics effectively account for population-management efforts (versus individual episodes of care), whether providers are offered incentives related to prespecified quality and value metrics, and whether patients are given incentives to seek high-value care.
台灣政府是只要騙選票而以,圖利特例團體(財團,公家自己是應該的?!勞保與軍 公教保之差別不就是如此嗎?!政府財政拖垮,關執政黨屁事!歐巴馬可是要負擔債務上限與財政懸崖等等考驗---今年美國刪減聯邦人員18萬人,聯邦財務緊縮等等困擾,仍未解決……..
Cancer Screening Campaigns — Getting Past Uninformative Persuasion說服 信仰
Steven Woloshin, M.D., Lisa M. Schwartz, M.D., William C. Black, M.D., and Barnett S. Kramer, M.D., M.P.H.
N Engl J Med 2012; 367:1677-1679November 1, 2012DOI: 10.1056/NEJMp1209407
One obvious approach was to use powerful tools of persuasion — including fear, guilt, and a sense of personal responsibility — to convince people to get screened.
“If you're a woman over 35, be sure to schedule a mammogram. Unless you're still not convinced of its importance. In which case, you may need more than your breasts examined. Find the time. Have a mammogram. Give yourself the chance of a lifetime” (see image Mammography Screening Advertisement from the American Cancer Society, 1970s.). This screening campaign is an example of pure persuasion. No nuance here: breast cancer is so common and deadly, and mammograms so effective, that you'd have to be crazy to forgo screening.
……. New York Times Magazine that read, “The early warning signs of colon cancer: You feel great. You have a healthy appetite. You're only 50” (see slide show at NEJM.org). Many 50-year-olds who find this message scary may be surprised (and relieved) to learn that most 50-year-olds who feel great and have a healthy appetite do not have — and will not soon develop — colon cancer. The National Cancer Institute estimates that a 50-year-old's risk of developing colon cancer over the next 10 years is 6 in 1000, and his or her risk of dying from colon cancer is 2 in 1000…….
Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence
Archie Bleyer, M.D., and H. Gilbert Welch, M.D., M.P.H.
N Engl J Med 2012; 367:1998-2005November 22, 2012DOI
Discussion
Screening can result in both the benefit of a reduction in mortality and the harm of overdiagnosis. Our analysis suggests that whatever the mortality benefit, breast-cancer screening involved a substantial harm of excess detection of additional early-stage cancers that was not matched by a reduction in late-stage cancers. This imbalance indicates a considerable amount of overdiagnosis involving more than 1 million women in the past three decades — and, according to our best-guess estimate, more than 70,000 women in 2008 (accounting for 31% of all breast cancers diagnosed in women 40 years of age or older
Familial risk of early and late onset cancer: nationwide prospective cohort study
BMJ2012;345doi:
http://dx.doi.org/10.1136/bmj.e8076(Published 20 December 2012)
Cite this as:BMJ2012;345:e8076
Conclusion Though the highest familial risks of cancer are seen in offspring whose parents received a diagnosis of a concordant cancer at earlier ages, increased risks exist even in cancers of advanced ages. Familial cancers might not be early onset in people whose family members were affected at older ages and so familial cancers might have distinct early and late onset components.
Mammography Screening — Polling Results
James A. Colbert, M.D., and Jonathan N. Adler, M.D.
N Engl J Med 2013; 368:e12February 28, 2013DOI: 10.1056/NEJMclde1301407
…………..
We received 1240 votes. Overall, 39% of the readers who voted supported initiating screening at the age of 40 years, 44% supported initiating screening at age 50, and 17% did not support routine mammography screening. Geographically, Journal readers from Central America and South America were much more likely than readers from other regions of the world to recommend mammography screening starting at the age of 40………請自行參考
請問施肇榮醫師(理事):如果台灣婦女按國健局宣傳,定時癌症篩檢,日後發現乳癌或大腸炎,是否可申請國家賠償?!
