Mammogram Debate Highlights Major Reform Barrier
The current debate over the proper age at which to begin screening women for breast cancer seems to be one of the few things that unite the left and the right. While conservative politicians and talk show hosts rant about how the new recommendations of the U.S. Preventive Services Task Force (USPSTF) show that healthcare reform will lead to rationing, a left-wing commentator, George Lakoff, writes that "47,000 women could die as a result of the new mammogram guidelines."
Lakoff asserts that if doctors followed the USPSTF's recommendation that average-risk women aged 40-49 not receive mammograms, one in 1,904 women in that age group would die unnecessarily of breast cancer. (Actually, the USPSTF said 1904 women would have to receive mammograms to prevent one death.) With more than 20 million women in that age range, Lakeoff calculates, the recommendation would result in about 10,000 of them not receiving timely treatment that could have saved their lives-a figure that he cuts to 5,000 because some of these women are older than 40. But he doesn't stop there: He also claims that if the 80 million women under 40 did not receive mammograms, 42,000 of them would die of breast cancer as a result.
Of course, nobody in the public health arena or at the American Cancer Society is proposing that all women under the age of 40 receive mammograms, because the risk of getting breast cancer at that age is so low. So on that basis alone, Lakeoff's thesis is absurd. But even if the odds of average-risk women dying of the disease at, say, age 30 were one in 100,000, Lakoff and other like-minded observers would argue that not providing mammograms to them was rationing. At $750 apiece, however, annual mammograms for the entire female population of the U.S. (including, presumably, children) would cost $115 billion per year, with very little reduction of mortality among younger people. Much of that money could be better spent on health care for those who actually need it.
The USPSTF, a highly-respected body of medical experts, made its case based on scientific evidence showing that screening women at lower ages leads to more false positives and invasive tests than screening them from age 50 onwards. It did not mention cost effectiveness, yet I have no doubt that this consideration was on the minds of the guideline setters, just as it is when they develop other screening guidelines. As a commentary in the New England Journal of Medicine explains, "Screening mammography for women in their 40s is clearly effective. The problem is that the benefit is tiny and expensive."
The fact is that we don't have an open-ended budget to provide screening tests as often as we'd like for every person, regardless of their age or degree of risk. That may sound heartless in light of the women who have died of breast cancer in their 40s. Yet, as we consider comparative effectiveness research and the other steps we must take to improve and preserve health care for the nation as a whole, we must be willing to make these kinds of tradeoffs. Each individual is important, but so is every other individual.
Alarmed by the strong public reaction to the USPSTF guideline, the government has already backed away from it. As for what this flap might mean for the future of reform, Dr. Kevin Pho, an astute observer of the health care scene, writes: "If recommendations from an entity like the USPSTF - as non-partisan and robust as it gets - get so much resistance from doctors, patients, and even the government itself, findings from a comparative effectiveness body stand absolutely no chance of changing medical practice."