The Mammogram Debate: The Beginning of Rationing or Business as Usual?

Last week the U.S. Preventative Services Task Force (USPSTF), based on existing medical data, made recommendations concerning the efficacy of mammograms in the diagnosis of breast cancer in women.    The USPSTF classified this as a “C” class recommendation (more about this later).   In summary they recommended the following:

a. Most women in their 40’s do not need screening mammograms, and mammograms should be reduced to just one every other year after a woman reaches fifty years of age.

b. The need and efficacy of manual breast examinations was also questioned.

c. These recommendations can change based on a person’s family history.

I don’t think that anyone expected the storm of public opinion that this would create.   After the recommendations were made public everyone from politicians to physicians to cancer societies weighed in.   Now it’s my turn.

Should Science or Emotion Dictate Policy?
In defense of the USPSTF their recommendations are scientifically sound.  It has correctly concluded that screening mammograms for women between the ages of 40 and 49 are not as effective as they are in diagnosing breast cancer in women between the ages of 50 and older.  Before the age of 50 years, mammograms are diagnostically correct 1 out of every 1900 mammograms.  After the age of fifty, mammography finds breast cancer 1 in every 1300 mammograms.  Using statistics, these changes show that there is a marked and important difference depending on when in a women’s life a mammogram is done.   When looking at “cost effectiveness” the recommendations are correct…but are they the right thing to do?

Recommendations Do Affect Policy
Within a few hours of the release of the recommendations, so many politicians were back- peddling that it almost created a tsunami on the shores of the Chesapeake Bay.   Make no mistake about the importance of the USPSTF recommendations.  They will affect policy.   The new healthcare reform bill states quite clearly that only preventive recommendations made by the USPSTF ranked an “A” or a “B” would be covered by the new healthcare program.   Since these recommendations were classified a “C”, these recommendations will eventually become policy for ALL insurances, not just for government based health programs.   That is the pattern that rules the day.   Once Medicare changes its screening recommendations or physician payment schedules, within two years all private insurances do the same thing.  All of them. When a politician states that keeping the healthcare program privatized would eliminate these recommendations becoming policy, history has in no way shown this to be true.

In my opinion, the USPSTF conclusions are not significant enough to stop recommending mammograms between the ages of 40 and 49.  Thousands of lives are saved by early detection.   So pink ladies, please don’t picket me.   I’m on your side AND the USPSTF’s side.  But must we look closely at the hypocrisy of this issue.   In April of this year the USPSTF made similar recommendations concerning the efficacy of the PSA test to prevent deaths of men from prostate cancer.  There are currently limitations on how often a man can get a PSA (prostate cancer screening test) and debate as to whether this test is even valid.    As a point of information there are approximately 40,000 deaths from breast cancer every year compared to 27,000 deaths from prostate cancer.

Why This is Our Fault
America needs to wake up and realize that if we are going to fix our health care program many difficult and unpopular decisions need to be made…including how often mammograms and PSAs should be done.  How come there is no uproar about the number of African-American or Latino deaths due to obesity and their ability to receive access to blood pressure control?  How come there is not an uproar that the healthcare program does not including a way for Americans to lose weight and control their blood pressure and cholesterol so that we can save a great percentage of the 600,000 people who die every year from heart disease?

This is a complicated debate.  I believe that women should get yearly mammograms and men yearly PSAs and rectal examinations.   I believe it is cost efficient and saves lives.   However, there is a price for this; a price than can be offset if Americans stop smoking, control their weight, cholesterol and blood pressure.   Make no mistake about it; the USTPST is making decisions that might eventually cost people their lives.  We don’t like to talk about it, but unfortunately that is a daily occurrence in medical care.  As a doctor I make those decisions…but as a patient YOU make those decisions too.   The person that is overweight and is smoking while ordering their burger at the “drive-through” is not only making a decision about their health, but by eventually taxing the resources of the health care system they will one day affect someone else’s ability to get health care…maybe you.  Let’s debate that!

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