A good illustration of much of what’s wrong in American healthcare and politics was precipitated in recent days by the U.S. Preventive Services Task Force. It issued new recommendations saying that most women should not get mammograms in their 40s and should get one every two years starting at age 50. This differed from previous conventional advice that women 40 and older should be routinely screened every year.
Testing the system
Don't turn task force's mammogram guidelines into political football
The new recommendations are exactly that—suggestions intended to help physicians and patients make informed decisions.
But the task force report prompted a backlash from some providers and cancer activists. Not surprisingly, the radiologists weighed in against the recommendations, raising fears of more deaths from breast cancer. Scared government officials promised they wouldn’t change anything.
Then we had the squawking of the health reform opponents. Nanoseconds after the report’s release, the political interests bemoaned the advent of “rationing” by the government. Public figures who until now have shown scant interest in public health transformed into latter-day paladins for patients.
Let’s start with the actual merits of the recommendations. The panel—half of whose members are women—concluded that the benefits of routine annual screening did not outweigh the risks. This is a hard concept for many patients to grasp. But there is abundant scientific evidence showing that cancer screening often uncovers tumors that may grow so slowly as not to present a danger or go into remission by themselves; that the discovery of such cancers may subject the patient to debilitating medical treatment, including excessive exposure to radiation; that the information about the presence of a possible threat may cause unnecessary psychological distress; and that the cascade of treatment may prove costly to the patient and/or her insurer. A good primer on the subject is Should I Be Tested for Cancer? by H. Gilbert Welch of Dartmouth Medical School.
The testing question has sparked much discussion in recent years over prostate cancer. The standard test—the prostate-specific antigen test—generates lots of false positives and negatives. Doctors have been encouraged to talk with patients about the benefits and risks because treatment for the disease can result in incontinence and impotence, not to mention other physical and emotional traumas.
Where do consumers and cancer activists get the idea that more is always better when it comes to cancer screening? It arises from a medical system that profits from the overuse of services. It rarely tells people about the harm that too much intervention can create. (First, do no harm?)
As for the reform opponents, they portrayed the report as the work of wild-eyed radicals bent on rationing care. No matter that the HHS task force was established in 1984 when noted Bolshevik Ronald Reagan was president. No matter that it based its conclusions on years of scientific research. No matter that it said some women, such as those with a family history of breast cancer, should probably be tested more often. No matter that one panel member said the cost to the government wasn’t a consideration.
Shortly after the mammogram report, the American College of Obstetricians and Gynecologists—which declined to embrace the mammogram recommendations—issued its own set of relaxed standards for Pap smears, suggesting they be delayed until age 21. It also said women younger than 30 should undergo a cervical screening once every two years instead of annually.
The mammogram and Pap smear developments offer a tiny ray of hope that some day science, reason and patient-centered care will triumph over economic gain and political posturing.
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