The New Mammogram Recommendations

I have one word for those who are freaking out over the United States Preventive Services Task Force’s new mammogram recommendations suggesting that most women in their forties should not undergo  regular screening mammograms.

Chill.

Good lord! You would have thought the task force recommended witholding treatment from any women in her 40s who had breast cancer, or banned her from getting a mammogram, or threatened to jail any insurance company that had the nerve to pay for said mammograms.

Could we all please take a breath and look at the facts for a moment?

  • Fact. The USPSTF is just one of three major bodies (including the National Cancer Institute [NCI]  and the American Cancer Society [ACS]) that releases screening mammogram guidelines. The ACS has already said it has no plans to change its recommendation that women in their 40s have regular screening mammograms; the NCI is reviewing the data.
  • Fact. The issue of mammograms for women in their 40s has been controversial for decades; the USPSTF has updated its recommendation based on new evidence.
  • Fact. The USPSTF did NOT consider any economic data in making the new recommendation–only scientific data.
  • Fact. What is appropriate for a large population is not necessarily appropriate for an individual woman, which is why the task force still recommended that women talk with their doctors about their individual need for a mammogram.

The USPTSF guidelines are based on medical evidence and analysis considering the potential benefits  against the potential risks. This is how drugs are approved, it’s how doctors make individual patient treatment decisions, it’s how many of us live our lives every day. It would really be a shame if this approach is thrown out the window because certain groups can yell louder than other groups.

The political backlash is, to be honest, scaring me. Congress is calling for hearings, the White House is “distancing itself” from the guidelines, the “rationing” word has been used more than cancer in this discussion. In one radio report, an analyst noted that the guideline change was “the best weapon the Republicans could have” to fight healthcare reform.

Um, excuse me?

I write a lot about health policy issues, particularly about the need to follow evidence-based guidelines when they exist and other issues related to both quality and cost. I’ve been learning about and writing about our bloated health care system and efforts to reign it in for nearly 25 years now (and, by way of full disclosure, once ran a provider relations department for a managed care company).

And I can tell you this: Now is not the time to start ignoring scientific evidence (and this is no way commenting on the evidence the task force considered; I haven’t reviewed it and am not qualified to do so) in favor of gut feeling and politics when it comes to making population-based medical/health recommendations. If we do this, then our healthcare system–heck, our entire economy–is doomed.

Instead, we need more consideration of the evidence and, yes, we also need to consider cost along with efficacy. If two treatments are equally effective and one costs half as much, why should we go with the more costly one?

I’ve got news: This is not rationing. This is rational. Rationing is what we do now when women in their 50s and 60s who should be getting annual screening mammograms don’t because they are uninsured or can’t afford them. Rationing is why there is so much evidence showing that women without health insurance or with Medicaid coverage are more likely than other women to be diagnosed with late-stage breast cancer.

Remember 15 years ago when women with breast cancer insisted that they be allowed access to stem cell transplants even though there was no evidence that they were more effective than conventional treatment yet cost hundreds of thousands of dollars more?

I was a newspaper reporter then and I remember writing stories about women picketing outside insurance companies to gain coverage for the procedure and states considering legislation to mandate the coverage. Then came government-sponsored, well-designed clinical studies demonstrating no benefit of autologous bone marrow transplants over medium- to high-dose chemotherapy and, overnight it seemed, the issue disappeared.

This situation reminds me of that. For years we’ve known that teaching women how to do breast self-exams doesn’t make a difference in breast cancer outcomes (and outcomes are what matters–not simply finding a cancer but whether the woman would have died from that cancer). We know that the dense breasts many women in their 40s have make mammograms less than ideal.Why are we suddenly acting as if someone just told us the sky really isn’t blue?

Instead, we should be listening to Nancy Brinker, who started the Susan G. Komen for the Cure Foundation. Instead of belittling and decrying the task force’s recommendations, she asked the question we should all be asking: So why don’t we come up with a better screening tool than the mammogram? One that is more reliable for women in their 40s?

If only everyone would view the issue in such a rational light.

Until then, I have one request: Could we please just calm down and leave the medicine to the professionals instead of the politicians?

7 Responses to “The New Mammogram Recommendations”

  1. Rian

    Until then, I have one request: Could we please just calm down and leave the medicine to the professionals instead of the politicians?

    I agree with the sentiment behind the statement but on an individual level, supply drives demand for health care services. Unlike the rest of the broader economy, current levels of health care demand don't arise organically by people choosing to spend their dollars on health care… you need a physician to order tests and whatnot, and when you couple that with perverse incentives (more tests = more money in a physician's pocket), you end up with *more* health care, not necessarily *better* health care. (Which ties back into your overall argument here.)

    If it were possible to divorce compensation from *quantity* and attach it to *quality*… well that would be something.

    Anyway, just a thought…

  2. Anonymous

    Alisa. . you probably know this, but talk to your doctor about your own individual risk and then make a decision based on that. . . And so glad I was able to help!

  3. Alisabow

    Deb–so glad you wrote about this because I've been thinking that I needed your take on the issue. And now I can come here and READ IT. I seem to keep aging right as they change the guidelines. I'm going on 40 and have never had a mammogram. It does scare me a little–the idea of waiting another 10 years to have one done… assuming that's what ends up happening. And totally with you–politicians should not be making our medical decisions.

  4. Loraine

    Great post, in particular this bit of sanity:
    “This is not rationing. This is rational. Rationing is what we do now when women in their 50s and 60s who should be getting annual screening mammograms don't because they are uninsured or can't afford them.”

  5. About me:

    Thanks Tracy. And you are precisely the type of woman who SHOULD have repeated mammograms (possibly MRI) in her 40s, as I'm sure you already know.

  6. Tracy Shack

    As a woman in her 40's (who has had multiple biopsies over the years), with a mother who has lost far too many friends to breast cancer, I agree that the pressure should be on finding better screening tools. Great blog Deb

Leave a Reply

You must be logged in to post a comment.