October 11, 2015

The Mammograms Controversy

Recently, the U.S. Preventive Services Task Force was the subject of a great deal of criticism for issuing revised guidelines that recommended that, except for women who have specific elevated risk factors, such as a family history of breast cancer, women not receive regular mammograms until age 50. These revised guidelines were roundly attacked. As Blogger Helen Searles wrote in a December 1 posting:

“Within hours of announcing its findings, the Task Force faced a barrage of attacks from women, doctors, journalists and politicians across the U.S. The onslaught was swift, harsh, and emotionally charged.”

She goes on to point out that the Task Force was accused of making its decision based on a desire to save healthcare dollars through “rationing,” a term injected into the discussion by lawmakers, such as Congresswoman Marsha Blackburn, who said: “This is how rationing begins. This is the little toe in the edge of the water.”

On the surface, this appears to be a recommendation purely based on the economics of doing additional mammograms and getting a relatively low yield in term of saved lives. Although, as a society, we can and should allocate scarce health care dollars based on where they can do the most good, it is clear that we are not ready to have a rational debate on health care based on traditional cost-benefit analyses.

However, what got lost in this discussion, which Ms. Searles characterized as advice “understood by many as a step backwards for women” is that there are sound medical reasons for this recommendation.

The Task Force’s recommendation could have been based on two medically-based rationale, aside from the psychological stress of having received a false positive reading from a mammogram:

  • The breast biopsy which routinely follows a screening that detects the possibility of cancer entails medical risks of increased infections and bleeding, as noted on the Mayo Clinic web site. As a person who received a false positive on a prostate cancer screening a few years ago, I can testify to the risks of excessive bleeding. For anyone taking medication for cardio-vascular disease, this risk is addressed by requiring the patient to suspend taking blood thinners for at least 10 days before the biopsy and for several weeks after it. For a patient who already has cardio-vascular disease, that decision to suspend the taking of medication has some potential for increasing the risk of blood clots.
  • The radiation to which a woman is exposed in receiving a mammogram has a potential cumulative impact in increasing her risks of cancer. That risk is minimized by having the mammograms start at age 50, but increases to some degree by starting the mammograms at age 40. As an article in the December 15 issue of The Wall Street Journal written by Shirley Wang cites two studies published in the Archives of Internal Medicine which demonstrate that exposure to increased radiation from CT Scans significantly raises the risk of cancer for many people. In the article, Dr. Amy Berrington, the investigator from the National Cancer Institute who led the studies, notes that while the radiation exposure from mammograms is far lower than for CT Scans, women need to take into account the increased risk of getting cancer from the cumulative exposure to radiation from multiple tests.

To the degree that women have a benign tumor, but elect to get surgery to remove the tumor through a mastectomy, there is also the normal risks from any surgery and complications from it, including the risk of acquiring an infection at the hospital at which the surgery is performed.

This is not a simple decision, and it particularly illustrates one of the fundamental paradigm shifts Americans will need to make in thinking about health care. There is a current perception by most Americans that more care is always better care, and that an attempt to scale back health care is a “takeaway.” The argument that we cannot afford unlimited health care is a non-starter for those who believe that they deserve every bit of care that is available.

However, if we can start to get them to understand that, in many instances, more aggressive care can produce worse medical outcomes, we have a fighting chance to bring health care costs under control. Our lawmakers, including HHS Secretary Sibelius, who distanced herself from these revised guidelines by saying that women should keep doing what they have always been doing, did a disservice to the long-term debate on how we get the best health care at the lowest cost for everyone.

The goal should be to get the optimal care, not the most aggressive care, for everyone. Better yet, the goal should be to improve health, not rely on the health care system to correct preventable health problems.