This week, the revised U.S Preventive Services Task Force (USPSTF) mammography guidelines monopolized newsprint and airtime. Was this truly Page 1 news? For a few days, mammojournalism pushed aside stories on the war in Afghanistan, double digit unemployment, Iran’s hidden nukes, the president’s foreign nation tour and the war on terror.
(Note to readers: The phrase ‘war on terror’ is now verboten in the the Obama administration. No spokesmen will utter it, except on deep backround. I unabashedly use it since it seems that our enemies are still at war with us.)
Of course, it’s not the science of mammography that is white hot – it’s the politics of breast cancer that is volatile and combustible. Medical guidelines in every specialty are revised regularly, yet no conflagration erupts in the public square, as occurred last week. When my own specialty revises colonoscopy guidelines every few years, the public and the medical community respond with a collective yawn. Not so for breast cancer,which has lobbyists and political muscle that fights to make sure that their cause remains a national priority. Even mainstream medical organizations and public advocacy groups are in their corner. Maggie Mahar writes at HealthBeat that the initial reaction from many health professionals, breast cancer survivors and advocates has been outrage and anger, with many insisting that women’s health will be compromised if these recommendations are implemented...Leading this onslaught are some key members of the cancer establishment: The American Cancer Society, The American College of Radiology and the National Cancer Institute.
First, the USPSTF was accused of being a tool of medical cost control fanatics. I agree there was bias – from the accusers, not from the USPSTF. The mammogram brigades had an agenda and weren’t going to be derailed by solid medical data. The USPSTF has earned a reputation for objectivity and caution. They do not make recommendations that are beyond the data, despite political pressure to do so. Unlike most medical societies and advocacy groups, they are skeptical and conservative, two qualities that are often lacking in the medical arena. They should be applauded for calling it like they see it. Instead, they are chastised by those who are distressed by their recommendations. However, just because we dispute the outcome, doesn't mean that the system is flawed. For example, if we don’t like a jury’s verdict, does it mean that the trial was unfair?
Preventive medicine is overrated, a heretical statement from a physician who performs screening colonoscopies. While I support mammography and colon cancer screening, their medical benefits are much more modest than the public realizes. With respect to mammography, the data demonstrating meaningful benefit to women, particularly those under 50, have always shown relatively small gains for them. This test is often portrated as a lifesaver, but this is an exaggeration. Yet, there is a juggernaut of support for annual exams behind it.
What about the downsides of yearly mammograms for average risk women in their 40s? In addition to the test’s limited efficacy in this group, here are some real concerns from overuse.
- Anxiety for patients and families
- False postive results which lead to invasive medical care
- Detecting cancers that may never progress.
Of course, cost is also a factor, even though the USPSTF is prohibited from considering it in their deliberations. Where is the data that yearly mammograms in younger women are cost effective? This is analogous to the PSA test in men for prostate cancer. How many men are harmed by the PSA in order to save a single life? You cannot argue that saving a life is worth any cost, as this is not how our society operates. We all know that if we lowered the highway speed limit to 40 mph, or raised the driving age to 25, that we would save lives. Yet, we do not demand these revisions. We accept low risks of catastrophic events in our daily lives.
The USPSTF revisions are being co-opted by the political right as a prelude to medical rationing. I reject this broadside, just as I do the protests from the medical left, whose enthusiasm for mammography exceeds the evidence. If rationing means that every American cannot have every available medical benefit on demand, than I am a rationer. Of course, we all know that loaded terms like rationing are routinely sanitized to make them more palatable, even if their meaning doesn’t change. Here are a few sanitization examples.
New & Improved Sanitized Descriptions
Global War on Terror morphs to Overseas Contingency Operation
Medical Rationing is scrubbed to Evidenced Based Medicine
Whistleblower is buffed into Truth-teller
Interestingly, Kathleen Sebelius, Secretary of the Department of Health and Human Services, is sprinting at top speed away from the new USPSTF guidelines. I hope she doesn’t collapse from exhaustion. I am troubled by her retreat, as are fellow medical bloggers Medrants and The Covert Rationing Blog. The Obama administration is devoting over $1 billion dollars to fund comparative effectiveness research (CER), which is supposed to use solid medical data to determine which treatments actually work. Its objective is to eliminate ineffective care, which would result in billions of dollars of cost savings. Now, the USPSTF, appointed by the federal government, has issued solid CER guidelines that our government is rejecting with alacrity and zeal. Anyone want to wager on whether CER has a prayer to succeed? The Health Care Blog notes that our government's revised CER policy is 'not on our watch'.
The USPSTF presently endorses screening colonoscopy between the ages of 50 and 75. In the forseeable future, this guideline will be revised, when new technology replaces this procedure. When this occurs, should I welcome a development that will serve humanity, or grab a pitchfork and a microphone and cry foul. One of the most intractable challenges in health care reform is to separate one’s own interest from the public interest. If there is to be any chance of success, we need to be governed by science and medical evidence. The mammography mania we have just witnessed demonstrates that we are not equal to the task. The public and many physicians are convinced that more medical care means better health, a fallacy that may take at least a decade to unravel. This is the Gordian Knot of health care reform.
Ironically, the American College of Obstetricians and Gynecologists just announced that they think we are doing too many Pap smears. Hmm, first too many mammograms and now Pap smears also? Sounds like a vast GYN conspiracy is in the making.