Posted by Nolan Miller on Nov 19, 2009
Filed Under (Health Care)
This week the United States Preventive Services Task Force, an independent panel appointed by the Department of Health and Human Services to create guidelines for preventive care, revised the recommended screening regimen for breast cancer. The New York Times reported on it here. The USPSTF report appears in the Annals of Internal Medicine here. The new guidelines, and the reactions to it, provide an interesting window on the battle ahead for those who would try to improve the efficiency of our health care system.
The main revisions of the guidelines is to recommend that, for most women without particular risk factors like a family history of breast cancer, regular mammography should begin at age 50 rather than age 40, and that for those aged 50 – 74, they should get screened every two years instead of every year. These recommendations are based on new evidence regarding the benefits and costs of early screening.
The benefits of early detection are clear. If a cancer is detected early the patient’s prognosis improves significantly. However, according to the USPSTF report, this benefit is greater for women aged 50 to 74 than for women in their 40s.
In addition to the benefit of screening, the USPSTF also identifies costs of screening in a section entitled “Harms of Detection and Early Intervention:”
The harms resulting from screening for breast cancer include psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results. Furthermore, one must also consider the harms associated with treatment of cancer that would not become clinically apparent during a woman’s lifetime (overdiagnosis), as well as the harms of unnecessary earlier treatment of breast cancer that would have become clinically apparent but would not have shortened a woman’s life. Radiation exposure (from radiologic tests), although a minor concern, is also a consideration.
The report identifies false positives as being particularly likely among women in their 40s.
Why the change in the cut-off? The USPSTF study found that screening reduced the relative risk of death from breast cancer by about 15% for both women in their 40s and women in their 50s. However, because breast cancer is more common among women in their 50s, they would need to screen 1904 women in their 40s to prevent 1 breast cancer death, while they would only need to screen 1339 women in their 50s to prevent a breast cancer death. Although the benefits of screening are similar, the risk of breast cancer is higher for those in their 50s than those in their 40s, and this, coupled with the harm from screening discussed above, led them to revise their recommendation.
The New York Times reports that the physician group that advises the National Cancer Institute on new cancer research, has decided that the new evidence merits inclusion in the body of information it distributes to interested parties. In particular, the previous screening recommendations, issued in 2002, came out at a time when there was “limited research on overdiagnosis and no statistical modeling asking how often women should get mammograms.” And, the problem of overdiagnosis is the primary reason the USPSTF cited for changing the recommendation.
Whatever, you think of the recommendation, that’s what it is. Agencies like the American Cancer Society are studying the recommendation and the underlying evidence and may or may not revise their recommendations. However, the reactions have provided an interesting insight into what happens when someone recommends reducing the use of a medical procedure.
Kathleen Parker in the Washington Post suggests that the timing might be political. “Could the research be aimed at cutting costs at the expense of women’s health?”
A group of female House Republicans are arguing that this is what happens when you put the government in charge of health. From the NY Times’ Caucus blog, according to Rep. Cathy McMorris Rogers of Washington, it’s “an example of how government-run decisions could be made,” and “The timing is very curious to me.” Marsha Blackburn of Tennessee said “This is the little toe in the water and this is how you start getting a bureaucrat between you and your health care.”
Doctors have also been reluctant to embrace the guidelines. Some argue that their patients are going to want the test, anyway. In addition, if we screen fewer patients, there are going to be more women in their 40s who get cancers that are not discovered until later than they would have been if they had been given yearly mammograms. This will lead to additional deaths. If we screen every two years instead of every year, there will be women in their 50s whose cancers grow for a year longer before they are detected, which will also lead to additional deaths. Doctors are understandably reluctant to take responsibility for these additional cancer deaths. Public health is about averages, while a doctor’s practice is about a relative small group of actual people. If the guidelines have served them well so far, why should they deviate?
And this brings us to the personal dimension. Many people can point to an actual person who survived cancer because of early detection, or to someone who might have survived cancer if their cancer had been detected earlier. This provides a very personal reminder that reduced screening means more deaths. Even if it is a small number of deaths, and even if the small number of deaths is dwarfed by the cost, and even if the money used on screening women in their 40s for cancer could save more lives if used to screen some other group for a different disease. People are fundamentally not wired to set aside these “real” lives in favor of statistical lives and someone else’s dollars.
I started writing this on Monday, when the new recommendations were first announced. The final word came down today when I picked up the New York Times and say the headline “Screening Policy Won’t Change, U.S. Officials Say.”
The Obama administration distanced itself Wednesday from new standards on breast cancer screening that were recommended this week by a federally appointed task force, saying government insurance programs would continue to cover routine mammograms for women starting at age 40.
Perhaps the new recommendations are right, and perhaps they’re wrong. I don’t know. If it were my friend or relative, I’d probably say it is too early to discard the old recommendations, especially if . But, what is clear is that if we are going to reduce the cost of medical care, we are going to have to start making choices of this sort. Much of the Obama administration’s promised reduction in health care spending is supposed to come from using Blue Ribbon Panels of experts like this to evaluate scientific evidence and recommend ways in which we can provide better care at lower cost. If we do this (and I think we need to, since the alternative will be reducing care based on something other than scientific evidence) we’re going to have to trade off statistical lives against dollars spent in various different ways in attempt to get the most bang for our medical buck, and recommend doing less of some things and more of others. Doing so is going to give ammunition to politicians looking to score points, threaten providers, stoke advocates, and twist the emotions of everyday people. Along the way we are going to have to interpret complex scientific and statistical evidence that does not definitively establish what the right thing to do is.
This case study may night provide a lot of insight how we will solve this problem in the future, but I think it says a lot about how we got where we are today.