When I heard about the US Preventive Services Task Force mammography recommendations issued on November 16, I had two thoughts. The first was that these recommendations are old, not new, but people keep ignoring them for political reasons. The second was that the Republicans would exploit these recommendations to claim that the Obama administration was attempting to ration healthcare. What I hadn’t counted on was that the politically motivated claim of rationing would resonate with so many women despite its complete lack of factual support.
As I wrote recently, these recommendations are over 12 years old. They were the conclusion of a consensus panel convened in 1997 (when Bill Clinton was president) and reissued by a second panel in 2002 (when George W. Bush was president). While there is certainly legitimate disagreement over interpretation of the safety data, there is precisely zero evidence that these recommendations were motivated by politics or economics.
Ignoring the recommendations, though, was politically motivated. Congress got in on the act and essentially mandated continued routine screening mammography for women 40-49. They were responding to the various organizations loosely characterized as the breast cancer lobby, whose members assumed and then insisted that if some screening was good, more screening must be better. In other first world countries, the recommendations were adopted long ago as the standard of care.
It was not a stretch to envision the Republicans trying to exploit these recommendations for political purposes. After all, they are not constrained by the truth. The same people who fabricated the idea of “death panels” were not going to be able to resist the idea of “breast panels” convened to deprive women of what breast cancer surgeon Dr. Susan Love aptly and humorously disparages as “a right to be radiated.” Supposedly the “breast panels” had gotten together to decide who shall get breast cancer and who shall be spared and decided to favor the breasts of women over 50.
The beauty of a lie, particularly a big lie, is that if you say it often enough, people will begin to believe it. Even though death panels never existed; even though they were a complete fabrication of Sarah Palin and Republican operatives, they struck a chord in the American public. Republicans implied, or even stated, that Barack Obama wants to kills you to save money for the US government. Never mind that the healthcare policies of Republicans can and do kill people by depriving them of health insurance and therefore access to care. Never mind that Barack Obama is strenuously trying to do exactly the opposite: provide care for everyone, and make sure that care is based on scientific evidence. What’s the value of the truth when a lie is so much more politically advantageous.
So American women were primed to ascribed nefarious motivations to the new recommendations: the timing of the recommendations is supposedly suspect, the fact that the president is a Democrat is supposedly not coincidental, the mere idea of saving money by applying scientific evidence is merely a cover up for rationing.
But the timing is not suspect; the recommendations have been proposed repeatedly over the past decade. The identity of the president is coincidental; the same recommendations were proposed under George W. Bush. Saving money by applying scientific evidence is not rationing; no one is being deprived of medically beneficial care. Anyone who wants to have a mammogram can get one; you simply have to pay for it if it’s not medically indicated.
The irony is that everyone claims to favor “evidence based medicine.” Well, this is what evidence based medicine looks like. The scientific evidence does not justify routine yearly mammograms for women aged 40-49. But instead of opting for evidence based medicine, the American public seems to favor fear based, politically motivated medicine.TIP:
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Comments
"The best way to insure you live a long life is to wear a seat belt."
"Now with Sebellius back-pedaling, I predict that 40 will remain the standard. "
It probably will. People say that want evidence based medicine, but only when the evidence confirms that they already believe.
There are 25 million women in the U.S. between the ages of 40 and 49.
At my hospital a screening mammogram costs $80 (but let’s say with parking and gas it is $100)
25 million X $100= $2.5 billion / year
If you divide that by the number of people in the country (300 million) we get $8.30 per person per year
If mammograms save 1 life in 1900 (as reported by the government task force) that is 13,000 woman
Would you give a few bucks a year to save some woman’s lives ?
It is a matter of money.
let's get universal healthcare- but let's pay for it by fighting fraud , raising taxes, less defense spending etc...
NOT by some government plan that is going to cost the lives of many women !!
"is the recommendations' failure to support the teaching and promotion of breast self-exams."
That recommendation is based on the evidence that breast self exams don't lower the death rate from breast cancer. Doctors have known this for many years.
Thanks for the kind words.
I also wonder if our obsession with "wellness" is what is bankrupting American healthcare by promoting screening tests that don't work.
"It is a matter of money."
You've only looked at the cost of making the right diagnosis with mammography. You have not considered the cost of making the wrong one (which happens far more often), and that is considerable. To find the true cost, you need to calculate that and add it in.
You don't bother to factor in the fact that you are exposing 25Million women to radiation in an area that is prone to cancer. Nor the cost of all the false diagnoses which outnumber the true positives by 50-1.
As you point out about the mammography guidelines, this issue has been proposed, discussed, and written about previously, and the information is available to anyone with Google at their disposal.
It doesn't hurt to point it out yet again. Thanks for this post, and stating what so badly needs to be said.
When we have clowns like Inhofe denying global warming, it's not surprising other clowns are using this report for political purposes. As someone said, "Hypocrisy is the fuel that Washington runs on."
" You have not considered the cost of making the wrong one (which happens far more often), and that is considerable. To find the true cost, you need to calculate that and add it in."
You may be right- let's say I miscalculated by a factor of twenty- that's $160 per year - or about 50 cents per day.
As a society we have to decide- do we save 50 cents a day at the cost of thousands of womans lives.
I will admit- I don't know the answer.
Also- I think you need to point out to your readers evidence based medicine is not as clear cut as it might sound- because nobody knows what dollar value to put on a life. It is a judgement call- Honestly, having an MD degree does not make us any more qualified to make that call- Who knows what a womans life is worth ?
I certainly don't know- but I'll pay my 50 cents today
"you may be right- let's say I miscalculated by a factor of twenty"
It could easily be far more than that. For every woman aged 40-49, hundreds have biopsies that turn out to be unnecessary. That's a lot of money spent on unnecessary surgery.
How much does it cost for a biopsy, for anesthesia, for an OR? How much does it cost for 6 rounds of chemo or a complete course of radiation therapy? How much does it cost to treat the complications of the treatment?
"How much does it cost for a biopsy, for anesthesia, for an OR? How much does it cost for 6 rounds of chemo or a complete course of radiation therapy? How much does it cost to treat the complications of the treatment?"
You are right again ! I don't know--- but I guess you don't either.
So how do we have such strong opinions on something that is going to cost the lives of thousands of woman ??
It is possible that it is an amount we could pay without sacrificing too much from our comfortable American lives-
We ARE a rich country.
Having said all that, I am 44 and plan to continue having mammograms because I have a number of factors that place me at higher risk of breast cancer. I think the recommendations always have to be weighed in light of your specific circumstances.
"but I guess you don't either."
I can tell quite a bit about it.
In women aged 40-49, to diagnose one cancer requires:
556 mammograms
47 additional diagnostic imaging procedures
5 biopsies
In contrast ...
In women aged 50-59, to diagnose 1 cancer requires:
294 mammograms
22 additional diagnostic imaging procedures
3 biopsies
And that's for biopsy proven cancer, which may or may not be aggressive. It is estimated that approximately 1 in 5 breast cancers diagnosed by mammography in women aged 40-49 would spontaneously disappear if left alone. Therefore, 20% of the women in that age group are being treated unnecessarily.
"Having said all that, I am 44 and plan to continue having mammograms because I have a number of factors that place me at higher risk of breast cancer."
According to the USPSTF, you should have routine mammograms in your 40s.
"It is estimated that approximately 1 in 5 breast cancers diagnosed by mammography in women aged 40-49 would spontaneously disappear if left alone. Therefore, 20% of the women in that age group are being treated unnecessarily."
So 80% are being treated correctly !!!- We are going to let those 80% of women suffer from cancer because 20% will suffer from treatment ???
Not everyone would die from Diabetes- but we treat them- not everyone would die from Hypertension -but we treat them-- If I have skin cancer, I'm getting it cut off- but it may not kill me.
Medicine is not perfect- 80% is a very good number in this imperfect world
C'mon Amy- this is too easy- you are usually right- but you screwed up on this one- admit it- you don't want to let thousands of woman die to save some money- save money elsewhere or just raise taxes !!
lawmakers from both parties suggested that the task force had been swayed by insurance companies that stand to save money if fewer screenings are performed.
"We can't allow the insurance industry to continue to drive health-care decisions," said Rep. Debbie Wasserman Schultz (D-Fla.)
And yet the death rate for them has barely budged. That's the problem. Those who are diagnosed with aggressive tumors still die and those who are diagnosed with non-aggressive tumors have only marginally better outcomes from getting treated in their forties.
There is nothing magic biologically about the age 40. Women can get breast cancer in their 30's also. No doubt the number of screening mammograms need to save one life in women aged 30-39 is even higher than 1903. But if you think that it is reasonable to spend any amount of money to save one life, why aren't you clamoring for routine yearly mammograms for women aged 30-39? Why shouldn't we be aggressively trying to save them?
Glenn Beck to Al Franken, Rush Limbaugh to Barney Frank, it’s enough to give someone emotion sickness. Why is it that some people seem to regard politics as a sport; that anything that they can say that demeans a view that opposes theirs and demonizes the contralateral side is a positive for their side. A tribal holdover, perhaps. Why is it that some people can only make their points by calling the others names, by painting diverse groups with a monochromic brush, and by characterizing complex arguments in absolutist terms? Is it the desire to be provocative, or an inability to see any validity in arguments outside their insular experience?
It has ever been thus in American politics I suppose. The stench persists.
When you say ‘the republicans’ exactly to whom do you refer?
Please tell me how congress ‘essentially’ mandated screening for anything?
The republicans are not “constrained by the truth”, particularly if you disagree. The implication is of course that your team, by contrast, is blessed with indubitable veracity.
“Even though death panels never existed”. I don’t care at all for Sarah Palin, she’s obviously challenged, but I can’t find her stating that they did, only in her simplistic manner stating concern that committees will issue guidelines which will make very personal decisions influenced by impersonal considerations. Of course we will ration health care, just from a bureaucratic means rather than the financial one we now use. Both are bad, you just prefer the bureaucratic method. I don’t know which is worse, and I suppose we won’t know till we try it. To deny that in England, for instance, decisions about end of life issues are made by cold regulations frozen by financial reasons is to circumvent the very truth you accuse ‘the republicans’ of doing.
Evidence based medicine and politically and fiscally influenced governmental policy are the same thing?
I’m sure that you have much more knowledge on this particular subject than do I; at least you should. It’s not the validity of the recommendations but the bitter manner in which shrill partisans scream at the other side that I find repugnant. I know good democrats, and good republicans. I disagree with both of them at times, and find blinders uncomfortable.
One of the reasons I left the practice of medicine was that I didn’t like the manner in which we practice it in this country; I’m not against reform. One of the reasons my father left politics was bombastic discourse like yours.
But I guess we need someone like Sarah on the other side to balance things out, so that the people in the middle can get some idea of how to proceed.
"But if you think that it is reasonable to spend any amount of money to save one life, why aren't you clamoring for routine yearly mammograms for women aged 30-39? Why shouldn't we be aggressively trying to save them?"
C'mon Amy- that is the "slippery slope" argument- anytime someone uses the "slippery slope" 2 things are true--
1)- it is a diversion from the real argument
2)-there is always the other side- "If you are not afraid of letting women die- why let women in their fifties have mammograms?"
But, I think I have finally just become a nuisance-
I really just wanted to point out that "evidence based medicine" is not like a math equation- there is not always one clear answer
thank you so much for responding to all my posts- I love your articles !!!
Keep up the fight for Universal Healthcare !!!!!!!!!!!!!!!!
"that is the "slippery slope" argument"
I'm not using it as a slippery slope argument. I'm using it to demonstrate that when it comes to policy decisions, the line has to be drawn somewhere. It is easy to say that it doesn't matter how much money we spend to save one life, but it does matter. There are additional considerations.
For example, we have a speed limit on highways of 65 mph. We could save a lot of lives if the speed limit were 20 mph. We could save even more lives if we mandated that cars were armored like Sherman tanks. But we don't do either of those things. Why? Because we judge the cost per life saved to be too high.
Opponents of the new guidelines like to portray this decision as unusual, but decisions like it happen all the time.
"we have a speed limit on highways of 65 mph. We could save a lot of lives if the speed limit were 20 mph. We could save even more lives if we mandated that cars were armored like Sherman tanks. But we don't do either of those things. Why? Because we judge the cost per life saved to be too high."
I think you finally sold me !- Heck, I'd be a liar if I said I didn't like having more money !- I’m over my guilt- I agree with you-let’s spend less money and keep our taxes low !!
Thanks Amy
A clarifying question: Statistics make my eyes cross! So for those women for whom an annual mammogram WOULD (however statistically "insignificant" the number might be *harumph*) find cancer earlier (to the tune of 1 year?) are we saying that it doesn't matter because it doesn't add up to a statistically significant percentage difference in the outcome of their cancer? So does it result in a difference in the outcome for ANY of these women? Maybe it's my entirely unscientific, folksy thinking, but if it helps one woman, it's worth it. Am I naive to think it's better to risk false positives than to miss one real event? I'll pay more for that.
PS--my friend caught her breast cancer last year by way of self-exam, so when they say self-exams have no discernible value/impact (and then people extrapolate from that information that people should stop doing them) I can't help but think of her.
I'm serious.