Rational Arguments

We had an excellent call on Stand Up! with Pete Dominick today where an oncologist wanted to counter some of what I said about the necessity of mammograms for women in their 40s.  He brought up a couple of points worth repeating:

1)  There was no oncologist on the panel making this recommendation

I don’t dispute this.  I think that the recommendations would have been stronger with an oncologist’s voice involved.  However, I don’t believe that this invalidates the findings.  The USPSTF is a group of researchers and experts in evidence based medicine evaluating research (much of which was performed by oncologists).

2) The amount of harm from radiation is minimal

Again, no dispute.  Although the actual amount was underestimated on the radio, it’s still not a ton.  What I didn’t get to say on air, however, is that there is harm from false positives in mammograms.  When the likelihood of disease is low (and it is for a woman in her 40s), a positive test is more likely to be benign than malignant.  Many women have to undergo further testing, and sometimes surgery, because of false positive tests.  That’s the true harm.

3) There is some (minimal) benefit to mammograms for women in their late 40s.

Again, I’m not arguing.  I just agree with the panel that the harms likely outweigh the benefits in this age group.

Notice I haven’t even brought up costs (which are significant).

Now remember that none of this outlaws mammograms or prevents someone who wants one from getting one.  It’s just a recommendation on whether there should be universal screening.  It’s not socialism or fascism or anything else.  Please don’t make this political.  The system is already pretty bad without adding that to it.

Remember that post about survival rates versus mortality rates?  The one where I talked about mammography?  If the amount of email I get about a post has any relation to the number of people who read it, that one was popular.  People care passionately about breast cancer.  I was trying to explain how we do more testing in the US, and how that isn’t necessarily a perfect good.  Many of you disagree.

Well, the US Preventive Services Task Force agrees with me:

In its first reevaluation of breast cancer screening since 2002, the independent government-appointed panel recommended the changes, citing evidence that the potential harm to women having annual exams beginning at age 40 outweighs the benefit.

“We’re not saying women shouldn’t get screened. Screening does saves lives,” said Diana B. Petitti, vice chairman of the U.S. Preventive Services Task Force, which released the recommendations Monday in a paper being published in Tuesday’s Annals of Internal Medicine. “But we are recommending against routine screening. There are important and serious negatives or harms that need to be considered carefully.”

Several patient advocacy groups and many breast cancer experts welcomed the new guidelines, saying they represent a growing recognition that more testing, exams and treatment are not always beneficial and, in fact, can harm patients. Mammograms produce false-positive results in about 10 percent of cases, causing anxiety and often prompting women to undergo unnecessary follow-up tests, sometimes-disfiguring biopsies and unneeded treatment, including surgery, radiation and chemotherapy.

Understand, the USPSTF is a multidisciplinary group of experts who take this stuff seriously.  It’s the kind of outfit I wouldn’t mind joining someday.  They all looked at all the research, and identified an area that not only may be doing no good, but also doing harm.  Although they don’t consider money, I’d also add we may be wasting a lot.  And yet:

[T]he American Cancer Society, the American College of Radiology and other experts condemned the change, saying the benefits of routine mammography have been clearly demonstrated and play a key role in reducing the number of mastectomies and the death toll from one of the most common cancers.

“Tens of thousands of lives are being saved by mammography screening, and these idiots want to do away with it,” said Daniel B. Kopans, a radiology professor at Harvard Medical School. “It’s crazy — unethical, really.”

This kind of rhetoric, calling the USPSTF “crazy” and “unethical” does nothing to move the debate.  It’s also not based on research.

Understand – most of the “waste” in health care comes from just this sort of outpatient care.  It’s not easy to identify, and even harder to cut.  It won’t be universally popular, and it won’t win you political acclaim.  It needs to be discussed and debated.  And sometimes, new evidence will make us realize we were wrong.

If you’re not willing to make any cuts, though, we’re doomed.  If you declare any recommendation to reduce expenditures as rationing or unethical, then we will go bankrupt.  We might as well close up shop now.

As a side note, the task force also recommended:

The new guidelines also recommend against teaching women to do regular self-exams

But I’m not seeing a lot of people crying out over a potential decrease in self-exams.  Of course, there’s not much money in those.