Disease screening is often a delicate balance. Catching a disease in its early stages almost always makes it more treatable, and can prevent permanent damage or even death. But it’s also cost-prohibitive to screen every person for every disease – even if you could convince everyone to show up for their regular doctor’s appointments – and so difficult decisions about benefit vs. cost and risk must be made.
Who actually makes those decisions is one of the key features of the U.S. health care debate. It’s nice to think that they are made by clinicians looking at the latest in medical research, but choices about what screens are affordable enough to be useful often boil down to which are considered acceptable for coverage by health insurance. In theory, insurance companies will follow the recommendations of scientific societies and expert task forces entrusted to analyze available data and make a decision. But what if those experts disagree?
That’s the battle being fought this week as new recommendations about mammograms for breast cancer screening are released by the U.S. Preventive Services Task Force. Published Tuesday in the Annals of Internal Medicine, the recommendations go against the grain of recent practice advising all women to start receiving mammograms at the age of 40, with yearly screening after the age of 50. Now, the task force says women who are not high-risk due to genetic factors or family history don’t need routine mammograms until age 50. Even then, screening every other year is sufficient until the age of 75, the task force concluded.
These new recommendations were not received quietly, as you may have discerned from the media covearge. University of Chicago professor of radiology Robert Schmidt told the Chicago Tribune that the recommendations were “arrogant and irresponsible.” My wife reports that one of the ladies of The View called the decision “gender genocide.” Some medical societies have come out in favor of the new practice, while others said they will stick to the old guidelines. Ultimately, the decision on whether to be screened (if not the decision on how much screens will cost) lies with patients themselves. So here’s a quick primer on the support and opposition to the new recommendations.
The Argument for Fewer Mammograms
– Breast cancer is rare in young women: The task force noted that a 40-year-old woman only has a 0.19 percent chance of dying from a breast tumor. That’s slightly less than 2 out of every 1,000 women. Mortality rates for breast cancer don’t rise significantly until after age 50.
– False positives can cause harm: In the hands of experienced mammographers, false positives are rare, but more frequent screens will necessarily create more opportunities for a misreading, especially in young women, where the rate is higher. False positives can create anxiety in the patient, and lead to expensive tests or procedures that may not have been necessary.
– Younger women are harder to diagnose: Also noted by the task force is that it’s hard to predict what small tumors caught at very early stages will do – it’s possible that costs and treatments will be accrued to fight a tumor that will never become deadly in the woman’s lifetime.
The Argument for Routine Mammograms
– True benefits remain: Despite their recommendations, the task force still found that mammograms in 40-something women are beneficial. Women who received regular screening were 15 percent less likely to die of breast cancer. And the mortality from breast cancer overall has dropped 30 percent since 1990, as previous panels recommended routine screening for younger women.
– Less frequent screening may not reduce costs: The task force argues that doing fewer screens for women in the 40s and half the screens in women above age 50. But some are skeptical of that calculation, arguing that less frequent screening will create both more false positives and later detection of tumors, removing at least some of that cost decrease.
– Changing the recommendations may confuse patients: Some doctors also argued that creating a conflicting message will only create more questions in the minds of women already flooded with information about breast cancer risks and prevention. “It’s really going to roll back the small gains we’ve made over the past 30 years,” Schmidt said. “Negative recommendations for this significant public health issue, in the absence of any meaningful viable alternative for reducing breast cancer mortality, have consequences.”