AmyTuteurMD's Open Salon Blog

Insured breasts matter more

Mon, 23 Nov 2009 09:11:14 -0500

Every year, for lack of timely screening and treatment, hundreds of women will die of breast cancer. No, I’m not talking about the change in mammography screening guidelines for women aged 40-49. I’m talking about women of any age who will not have access to mammography or treatment if a healthcare reform bill is not passed. Without health insurance, these women will die preventable deaths.

Republicans have exploited the release of the new mammography guidelines to argue that the Obama administration does not care if more women die of breast cancer. Ironically, their opposition to a public option for health insurance virtually condemns up to 600 women per year to die a preventable death from breast cancer. Republicans apparently believe that insured breasts matter more.

That seems a rather bizarre distinction to make. I could understand, though not agree, if they claimed that Republican breasts matter more. They have an interest in making sure that women who will vote for them will live to return to the polls each year. But the distinction between women who are insured and those who are uninsured crosses political lines.

I could understand, though not agree, if Republicans insisted that profits matter more and supported the new guidelines to benefit their friends in Big Insurance who depend upon them to vote against healthcare reform. The US Preventive Services Task Force recommended ending routine yearly mammograms for women aged 40-49 because the data show that the risks of false positives, unnecessary biopsies and unnecessary breast cancer treatment outweigh the benefits. That can only be helpful to insurance companies who can increase profits by reducing marginally effective and ineffective procedures.

But, instead, the Republicans claim to base their opposition to the new screening guidelines on their reverence for life. They insist that President Obama, in a crass effort to save money, is rationing mammography. To hear them tell it, it is worth virtually any amount of money to save even one additional woman from becoming a breast cancer fatality. Yet the reality is that they are only concerned about the breasts already covered by health insurance.

Republicans are apparently unmoved by the fact that up to 600 women die each year because their lack of health insurance prevents timely access to mammograms, diagnostic procedures and breast cancer treatment. Insuring the breasts of the uninsured would have a far larger effect than merely saving those 600 lives (each one of which is supposedly valuable enough to justify the spending of any amount of money). That’s because the benefit would not be limited to preventing deaths from breast cancer. Current estimates suggest that as many as 45,000 people die preventable deaths every year because of lack of health insurance.

Republicans claim to oppose healthcare reform because it is too expensive. But according to them it’s worth almost any amount of money to prevent a single death. They also oppose healthcare reform because they claim it will lead to rationing. But there is no more brutal form of rationing than to ration health insurance itself, giving it arbitrarily to those who happen to work for an employer who chooses to provide access to insurance and denying it to everyone else.

Do insured breasts really matter more? Or are the Republicans hypocritically exploiting women’s fear and misunderstanding over the new guidelines in order to score political points? If Republicans truly care about making sure that not a single woman dies a preventable death from breast cancer, they’d be clamoring for a quick vote on healthcare reform, and they’d vote for a public option as the best way to end preventable deaths from breast cancer.

Otherwise, we’d be forced to conclude that Republicans don’t really care at all about saving lives and are just a bunch of hypocrites using fear mongering to divert attention from their self serving support of the insurance industry. And they wouldn’t want us to reach that conclusion, would they?

Rules changed to save money! Not mammograms, speed limits.

Fri, 20 Nov 2009 10:11:08 -0500

There has been much righteous indignation expressed in response to the new US Preventive Services Task Force changes that no longer recommend routine mammograms for women aged 40-49. The indignation takes two basic forms. The first is the assertion that it is worth any amount of money to save even one life. The second is that the recommendations are cynically motivated by a desire to save money by “rationing” healthcare.

Yet people fail to consider that we make policy decisions all the time because we don’t believe that it is worth any amount of money to save even one life, and because we want to save time and money. Consider the case of highway speed limits.

It is well known that lower speed limits decrease fatalities. Since over 37,000 people die each year on our nation’s highways, this is not merely an academic point. If we reduced the highway speed limit to 25 mph we could undoubtedly save tens of thousands of lives. If, in addition, we mandated that all cars were armored like Sherman tank, we might be able to save every one of those more than 37,000 people each year. Yet we don’t do that. Why? Because it would cost time and money and we don’t think that it’s worth it.

We won’t even take less drastic measures to reduce highway fatalities. Knowing full well that increasing the highway speed limit from 55 mph to 65 mph would cost lives even as it saved time. That’s exactly what happened. According to researchers Ashenfelter and Greenstone:

In 1987 the federal government permitted states to raise the speed limit on their rural interstate roads, but not on their urban interstate roads, from 55 mph to 65 mph for the first time in over a decade. Since the states that adopted the higher speed limit must have valued the travel hours they saved more than the fatalities incurred … We find that the 65 mph limit increased speeds by approximately 3.5% (i.e., 2 mph), and increased fatality rates by roughly 35%. In the 21 states that raised the speed limit and for whom we have complete data, the estimates suggest that about 125,000 hours were saved per lost life. Valuing the time saved at the average hourly wage implies that adopting states were willing to accept risks that resulted in a savings of $1.54 million (1997$) per fatality …

Of course not every hour saved is money earned, so the real cost per fatality is probably far lower. Regardless, as a matter of policy, the American people don’t think it is worth the amount of time and money it takes to save one additional person from a fatal car crash.

The relationship between fatalities and the highway speed limit is just one example of the myriad policy decisions that are made every year that must balance lives saved against cost. Although opponents of the new mammography guidelines are trying to characterize such decisions as tawdry at best and immoral at worst, there is no other choice. We are always forced to draw arbitrary guidelines. Why, for example, should the highway speed limit be 65 mph? Why not 75 mph? Or for that matter, why not 69.3 mph since there is nothing particularly special about whole numbers ending in 5? Each decision represents an arbitrary balancing of costs against human lives.

Similarly, though people claim to be outraged at dropping the recommendation for yearly mammograms in women aged 40-49, why aren’t they clamoring that the recommendations should be extended to yearly mammograms for women aged 30-39? If they truly believed, as they claim that they do, that it is worth any amount of money to save one life, they should be insisting on screening for women aged 30-39 since breast cancer can occur in that group, too.

Moreover, there’s nothing special about whole numbers that end in 0. Why not recommend yearly screening women aged 28-39? For that matter, there’s nothing special about yearly intervals. Why aren’t they recommending screening for all women every 6 months instead of every 12 months? Surely we could save a few more lives that way, too.

The fact is that we are forced to make relatively arbitrary policy decisions when it comes to safety issues of any kind. We are always forced to balance benefits and costs. We don’t really believe that it is worth any amount of money to save even one life. We don’t even believe that it is worth getting to our destination a little later to save 37,000 lives lost on the highway each year.

That’s why the outrage over rationing is entirely misplaced. If by rationing people mean considering cost when making safety decisions, we ration every day in many ways. We live in the real world, and in the real world there is not unlimited money. A dollar spent on mammograms is a dollar not spent on another form of healthcare that may have a much better benefit to cost ratio. It is not rationing to suggest that some money spent on mammograms might be better spent elsewhere. It is merely common sense.

Breast panels

Thu, 19 Nov 2009 08:11:05 -0500

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.

Medicine, mammography, and the imperfect view

Wed, 18 Nov 2009 08:11:16 -0500

Americans, particularly American women, are shocked, bewildered and angered over the change in mammography guidelines. Many emphasize that it is changes like these that foster distrust in the medical system and lead people to seek alternative practitioners. That’s unfortunate because the change in guidelines highlights one of the most important strengths of modern medicine: medicine is constantly changing in response to new scientific evidence; “alternative” health doesn’t change because its not based on scientific evidence; its based on belief.

In other words, what lay people perceive to be the biggest weakness of modern medicine is actually its biggest strength.

Medicine is like a frost covered windshield. We cannot yet see the full view because we lack a complete understanding of how the body works, and we lack a complete understanding of many diseases, particularly cancer. Unlike the real world, where we can totally wipe away the frost obscuring our view through the windshield, in medicine we have to content ourselves with ever increasing clearing of various spots. And unlike the real world, where we can wait to totally wipe away the frost before we start to drive, in medicine we must keep moving forward despite our incomplete view.

We get into trouble when we try to shortcut the process by making assumptions instead of waiting for definitive evidence. Medical screening is just one area in which we’ve been forced to backtrack on our assumptions when new evidence becomes available. We have assumed that because some screening is good, more screening is better. That assumption was never supported by scientific evidence.

There is a large body of scientific evidence showing that biennial mammographic screening of low risk women aged 50-75 leads to lower death rates from breast cancer. There is no evidence that the same approach a similar impact on death rates in women aged 40-49. Yet we implemented routine screening because we assumed that more screening is always better. The thinking was “better safe than sorry.”

With more experience and with more scientific evidence we’ve cleared away more of the mist obscuring our view. Routine yearly mammographic screening in low risk women has minimal if any impact on death rates. That’s because it picks up small tumors that aren’t likely to develop into aggressive cancer and does not increase the diagnosis rate of the aggressive tumors that are likely to kill women.

Paradoxically, the failure of routine screening mammography has convinced American women of its success. All of us know women, or are women, whose small breast cancer was diagnosed by a routine mammogram, who had lumpectomy, and perhaps radiation or chemo, and are now cured. The scientific evidence tells us that almost all of those cancers would have remained stable or possibly even disappeared if they had not been found and treated.

In some ways, that’s even more distressing information than the change in mammography guidelines. It means that thousands of women have undergone unnecessary biopsies, unnecessary surgeries and unnecessary chemo and radiation, not to mention unnecessary anxiety and fear. We didn’t cure these women. We treated them even though they didn’t need it and then took credit for what would have happened anyway.

A disaster like this would never happen in “alternative” health because it doesn’t change with new scientific evidence since it is not based on scientific evidence. That’s one of the reasons why “alternative” health remedies are never tested before they are implemented. What would be the point? And it’s one of the reasons why advocates of “alternative” health ignore evidence that their treatments don’t work.

“Alternative” health does not advance new theories, acquire new information and modify theories based on new information. The same “remedies” that were used hundreds of years ago are offered now as if nothing has changed in the interim. Classic books in “alternative” health tend to have only one edition. There’s no need to have more editions when nothing changes.

In “alternative” health, things are simple, remedies are static, and certainty is prized. That is very comforting to human beings who value certainty in an uncertain world. Medicine is messier. The human body is complicated, and disease is complicated. We are constantly acquiring new information about both. Treatments and medical recommendations change in response to this new information. No one can be sure that the therapy recommended today won’t be superseded by a better therapy found tomorrow.

Only one thing is certain. The recommendations issued this week are sure to be amended at some point in the future, most probably because we find a better screening tool for breast cancer than mammography. We need, and we are looking for, a screening tool that will be able to tell the difference between aggressive breast cancers and those that will go away on their own.

It is unfortunate that we are periodically forced to reassess medical recommendations. However, it would be tragic if people viewed this reassessment as a failure and stopped listening to recommendations. Returning to the windshield analogy: it is a shame that we sometimes need to change course when our view expands, but it would be tragic if people decided on that basis to drive without ever looking through the windshield at all.

New mammography guidelines aren't new

Tue, 17 Nov 2009 08:11:48 -0500

The National Institutes of Health (NIH) Consensus Development Conference on Breast Cancer Screening for Women Aged 40-49 … concluded that data on the benefits and risks of screening mammography for women aged 40 through 49 are sufficiently mixed that informed decision making, rather than a blanket recommendation for all women, is an appropriate course of action.

No, those recommendations were not issued yesterday. They were issued on January 23, 1997.

The recommendations issued yesterday November 16, 2009 by the US Preventive Task Force were these:

The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient's values regarding specific benefits and harms.

In other words, the new guidelines are almost exactly the same as the old. So why have women age 40-49 been undergoing routine screening mammography in the intervening 12 years. The answer is a cautionary tale about allowing Congress to make medical decisions.

Epidemiology Professor Virginia Ernster, in a commentary in the American Journal of Public Health in July 1997, described the NIH 1997 Conference and its aftermath.

[A] panel of 12 individuals had been chosen by the NIH … on the basis of their having relevant clinical, methodologic, or consumer perspectives but not having published on the subject of mammography screening. This panel had extensively reviewed the relevant literature and … considered the evidence presented at the conference.

The evidence was presented by:

32 speakers-investigators from the eight major international trials and other radiologists, clinicians, epidemiologists, statisticians, and consumer representatives- presented data on the potential benefits and risks of screening for women aged 40-49 women aged 40 through 49.

As described above the Conference concluded that the evidence of benefit was not strong enough to warrant recommendation of routine screening mammography for women aged 40-49. Any potential benefits were outweighed by the unnecessary biopsies, treatments and even the unnecessary radiation.

What happened next?

While some speakers lauded the panel for its conclusions, many (radiologists in particular) expressed outrage and criticized not only the panel's conclusions but the objectivity of the panel members and the planning process that preceded the conference…

And then the politicians got involved.

Within days … the Senate voted 98 to 0 to endorse a nonbinding resolution that the National Cancer Advisory Board (NCAB, the presidentially appointed committee that advises the NCI director) consider recommending mammography screening for women aged 40 through 49 or "direct the public to consider guidelines issued by other organizations."…

A letter sent to NCAB members and signed by 39 women members of Congress stated, "We believe the only real option is to give guidance to the women in this country." It went on to say, "Without definitive guidelines, the lives of too many women are at risk …

On March 27, 1997, a press conference was held to announce the NCAB's recommendation … that NCI advise women aged 40 through 49 at average risk of breast cancer to have screening mammograms every year or two. A "Joint Statement on Breast Cancer Screening for Women in Their 40s" was issued by NCI and ACS. Although the possible limitations of screening were mentioned, the clear message to the American public was that women in their 40s should be screened…

Europe, in contrast, took the scientific evidence to heart and screening mammography is restricted in low risk women to biennial mammograms from age 50-69.

That brings us to yesterday’s recommendations published in the Annals of Internal Medicine:

The USPSTF … commissioned 2 studies: 1) a targeted systematic evidence review of 6 selected questions relating to benefits and harms of screening, and 2) a decision analysis that used population modeling techniques to compare the expected health outcomes and resource requirements of starting and ending mammography screening at different ages and using annual versus biennial screening intervals…

For biennial screening mammography in women aged 40 to 49 years, there is moderate certainty that the net benefit is small. Although the USPSTF recognizes that the benefit of screening seems equivalent for women aged 40 to 49 years and 50 to 59 years, the incidence of breast cancer and the consequences differ. The USPSTF emphasizes the adverse consequences for most women—who will not develop breast cancer—and therefore use the number needed to screen to save 1 life as its metric. By this metric, the USPSTF concludes that there is moderate evidence that the net benefit is small for women aged 40 to 49 years.

The new (actually old) recommendations have predictably ignited a firestorm of controversy. However, the USPSTF is receiving support even from breast cancer activists. According to The National Breast Cancer Coalition, which describes itself as a powerful voice, speaking for women and men across the country, demanding victory in the war against breast cancer:

The over-emphasis on the importance of screening, despite a lack of strong evidence, has been elevated to such a degree that some even equate screening with prevention of breast cancer. The National Breast Cancer Coalition hopes that today’s release of the US Preventive Services Task Force (USPSTF) revised recommendations will put the brakes on this run-away train and will put screening and its limitations into proper perspective.