XX Factor: the blog

The Mammogram Panic

I've been trying to understand the flap this week over the recommendations from the U.S. Preventive Task Force—a group ill-prepared to handle the controversy—to delay routine mammograms to age 50 for most women. And now, in a truly terrible coincidence of timing, we have a second round of commotion over the advice of the American College of Obstetricians and Gynecologists to push pap smears to screen for cervical cancer back to age 21.

The politics are irresponsible but obvious: Tie the recommendations to the boogeyman of rationing, if you oppose the White House on health care. Never mind that neither set of recommendations binds insurers or anyone else. ACOG's pap smear advice will be "set in stone," Sen. Tom Coburn said, and adopted without regard to differences among patients. Sarah Palin naturally piled on, suggesting that the new advice is really all about "bureaucratic pressure to control costs."

Why do many women seem susceptible to the fear-mongering? Why is it hard to see that the costs of overscreening can outweigh the benefits of early detection?

Kevin Sack does a good job of beginning to answer these questions in the NYT this morning. The evidence about the danger of overscreening asks us to upend how we've long thought about risk. After years of dutiful breast self-exams and teenage pap smears, there's a new playbook. That's a lot to get used to, I suppose.

Also, I think, these evidence-based recommendations ask us to give up a couple of myths we hold dear. The first is that saving one life is worth any amount of trouble or money. "One life out of 1,904 to be saved,” Sen. Kay Bailey Hutchison said of the stats about getting mammograms in your 40s. Right, and the point should be, that's not much bang for the buck. But what if it's your life, your bang? We seem frozen on that question, unable to have the deeper discussion that should follow from it.

The second myth we've grown attached to is that more tests and screenings equal more control. If you get regular mammograms and pap smears, then you're protecting yourself. It's a kind of talisman: You won't get cancer, or at least you won't die of it. Cut it out early and fast! Now we have to absorb the idea that some slow-growing cancers are better left alone. We have to let go of the illusion that testing guarantees wellness and confront the far less reassuring reality that false positives lead to unnecessary interventions that can hurt us—biopsies and radiation treatment and removal of relatively harmless growths. Remember the adage that the cure can be worse than the disease? It's unsettling. But also true.

Tags: breast cancer, cervical cancer, mammogram, pap smear, us. preventive task force

Emily Bazelon is a founding editor of Double X, and a writer and editor at Slate.

Comments

differences between doctors and politicians

By: ideas | Tue, 03/16/2010 - 06:24

The economic cost determines the management actions in relation to health. And we all know that preventive medicine is cheaper than there, but only referred to by doctors as the first alternative. Those who handle the money come the day, but not the future.
ideas para regalos

Mammograms

By: Gail Muench | Sun, 11/22/2009 - 00:11

What this article fails to tell us is that nearly all breast cancers found in pre-menopausal women are more aggressive and fast-growing tumors. While they may not be as many cancers found in women in their 40s and younger, these cancers are much more dangerous and more likely to be killers if not found and treated in a timely manner.

Not too much but too little prevention drives health care costs

By: Kati | Sat, 11/21/2009 - 16:10

I wonder if the stats aren't deceptive. If 1,900 mamograms save one life, how will that life be lost? I suspect that treatments for that life might cost more than 1,900 momograms, including treatment for false positives. Just think about the cost of 3 or more courses of chemotherapy, at least 3 or more surgeries (the last one usually for brain cancer), and perhaps a total of 3 months in hospital, plus visiting nurses and hospice care (at home or in a hospice facility)....

And then of course there's the issue of that one person becoming disabled (drawing full social security before retirement age), stopping paying taxes, needing a full time care giver (another person in the family giving up his/her job, stopping paying taxes, and getting paid a modicum stipend out of state fund to care for that person?), perhaps the cost of putting her kids in foster care, etc. The loss of that one life might be costing quite a bit more than one million bucks...

Dying and disability costs a lot more than prevention (the committee also advised against self exams.... all of the women I know who have come down with breast cancer found it themselves at an early treatable stage).

There should be more testing for other conditions as well rather than less: just think how much cheaper it is to snip off a pre-cancerous polyp during a colonoscopy that might run from $2,000 to 3,000 than to treating a colon cancer that has spread throughout the body, with again, disabililty, loss of income, loss of ability to take care of dependents, etc.

On the other hand invasive and painful treatments pursued when all hope of recovery has been lost are indeed unwarranted. If we have to monetize the cost of a life, that's where we should focus because it's both to the benefit of the patient and of the budget.

@Devon-Low risk vs High risk patients

By: im1 | Sat, 11/21/2009 - 10:31

Devon,
If current guidelines were implemented while you were in your 40s your doctor might have still recommended mammograms yearly. Family medical history and your medical history would be a factor in this decision. My understanding is that they are changing the recommendations from starting at 40 to 50 only for people considered to be low risk (no family history of breast or ovarian cancer, plus other medical factors).

Delayed mammograms

By: Devon | Sat, 11/21/2009 - 01:15

Well, thanks for caring. If I hadn't already started having mammograms at the age of 40, I'd be dead now, or well on my way to being dead. I was 45 when I was diagnosed. The mammogram caught it early. It was not "slow growing and better left alone" It was one of the faster growing kinds and never presented as a lump. I guess as long as it's not you that has the cancer, it's ok to sacrifice that "one in 1904"!

"One life out of 1,904 to be saved,”

By: janeslogins | Fri, 11/20/2009 - 16:05

"One life out of 1,904 to be saved,” I am not even sure the the statement is valid.

There might be a statistical probability that 1:1904 was saved.

one reason

By: im1 | Fri, 11/20/2009 - 15:51

I didn't get the freak out either but it seems from some friends that they are afraid these recommendations will translate into less access to the doctor for education and discussion. They fear that without a recommended test fewer women will get to see the doctor and overall reproductive health will be compromised by losing out on this education side of the interaction during/after an appointment made for a test. I understand this fear even if I don't think it will come to pass.