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Mammograms and leeches

With the Senate health bill dropping on Wednesday night, I haven't had time to dig into the new mammogram standards as deeply as I'd like. Suffice to say, you could hardly imagine a better example of why cost control is so hard: This was a recommendation from an institution with no actual power that was based entirely on accepted medical evidence. Cost was not a component in the analysis. This is simply the data on whether mammograms make sense for most women between 40 and 50, not whether they're "worth" doing as opposed to other expenditures.

And the political outcry has been deafening. None of it, however, has questioned the underlying science. It's all been based on a bias that mammograms are good for everyone, and the standards should remain unchanged. A reader's e-mail captured the absurdity of the situation well:

I don't know if you saw this news item yesterday, but the U.S. Treatment Services Task Force announced that leeches aren't a particularly good treatment for most ailments. While noting that leeches might still be useful for certain specific circulation disorders, the USTSTF recommended against their use in other situations, like halitosis and appendicitis.

You can imagine the outrage. Although the Task Force has no power to make anyone do anything, Rep. Dave Camp (R) was heard on NPR's Morning Edition saying, "This is an even better example than death panels to illustrate the insidious encroachment of government into the health decisions made between a doctor and a patient." Camp also neglected to address the facts that overuse of leeches is (1) expensive, and science-based recommendations about appropriate use would save the government money without harming patients, and (2) can lead to negative side effects, such as upsetting the body's natural humoral balance.

Widespread concern of regular citizens that leeches would no longer be offered by their doctors, was shared by industry leaders. "I am deeply concerned about the actions of the USTSTF in severely limiting access to leeches. These recommendations, in combination with recent Medicare cuts to leech reimbursement, jeopardizes access to both long proven and cutting-edge bloodletting technologies," stated James H. Thrall, M.D., FACR, Chair of the American College of Bloodletting Board of Chancellors. Dr. Thrall neglected to note that the USTSTF did not limit access to anything, and merely made a recommendation.

Fortunately, the Secretary of Health and Human Services rushed to the microphone to pledge for the record that there would be no changes to Medicare or Medicaid coverage while she was on the job. "My message to patients is simple. Leeches have always been an important life-saving tool in the fight against pretty much any sickness they still are today. Keep doing what you have been doing for years -- talk to your doctor about your individual history, ask questions, and make the decision that is right for you."

Few commentators highlighted the rigorous science-based process of the USTSTF, the evidence against leech use in most cases, and the harms caused by the excessive use of leeches to treat illnesses ranging from fever to flatulence.

And yet, I've some sympathy for the outraged parties here. Disproving the assumed protection offered by mammograms feels like a step backward. The presence of mammograms was psychologically important. Yesterday, we had this big weapon in the war against breast cancer. Today, we're being told that it's not that big of a weapon, and shouldn't be used as often. In point of fact, this data is a medical advance. But it feels like a retreat. And people don't like to retreat against a hated foe, even if the retreat is strategic.

By Ezra Klein  |  November 20, 2009; 8:20 AM ET
 
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Comments

so is this how comparative effectiveness research would work? They'd get recommendations and then the HHS Secretary will back away from it. Nice to see it play out BEFORE the legislation is passed exact proof that it will be completely ineffective in cost control.

Posted by: visionbrkr | November 20, 2009 8:26 AM | Report abuse

Welcome to my world of family medicine and primary care.

Many times daily I repeat a variation on this theme. A patient with symptom/illness/medication X has heard about a test/procedure/medication. S/he may have heard about it from a friend, on the news, on the web, or even from an (uninformed but well-meaning) consultant. I explain that there is no evidence that this will provide a benefit and/or that there is evidence for potential harm, outline the options, and offer to answer questions. The final result too often is to go for the intervention 'because it can't do any harm, right?'

We (humanity) are not well equipped and rarely trained or experienced at dealing with distant (time/space) or abstract risk. Our risk circuitry is designed and tuned for immediate physical threat, where 'doing something right now' is likely to have a better survival value than deliberating or collecting more information. As a species, we are relatively tone deaf to the sounds of long term risk and harm and exquisitely tuned in to even the softest hint of short term benefit.

A colleague refers to this as arrested development - we are all 16 year old males.

Posted by: pheski | November 20, 2009 8:49 AM | Report abuse

You missed the opportunity to add that this is evidence that we should give the government far more control over health care.

Posted by: ostap666 | November 20, 2009 8:57 AM | Report abuse

So Ezra- what do you think the odds are that the public option would have sane guidelines on when to pay for a mammogram for women?

Posted by: spotatl | November 20, 2009 9:09 AM | Report abuse

I don't know if you're fair to critics of the task force recommendations, Ezra. For example, the American Cancer Society disagrees with the recommendations based on a different reading of the studies and the best tradeoffs between risks.

I have no idea whether they're right, but this doesn't sound like hysteria.

http://www.cancer.org/aspx/blog/Comments.aspx?id=331

Posted by: Sophomore | November 20, 2009 9:18 AM | Report abuse

It's a "big weapon" rife with false positives, and that leads to all sorts of unnecessary, expensive, and often really harmful treatment. The medical equivalent of those wonky satellites that would think a flock of geese was an ICBM.

Chemotherapy is an awful thing to experience, and going through it for nothing is a BAD thing. But the real problem here is that people make money off of these tests, off of the treatment, off of the drugs, etc... cutting that market means they make less. And unlike the random woman who goes through unnecessary treatment based on a false positive, these medical interest groups can hire lobbyists and PR people.

Posted by: NS12345 | November 20, 2009 9:23 AM | Report abuse

Don't always agree with Ezra, but I certainly do here. The hysterical response to this news was remarkable to behold. Medical science changes its mind sometimes, and that's good.

Posted by: MikeR4 | November 20, 2009 9:29 AM | Report abuse

It's worth underscoring one more point.

The task force recommendations are its conclusions about the best way to trade off risks. In many cases, decisions about trade offs like these are difficult - there isn't a free lunch - and they can't be based entirely on science. For example the recommendation that mammographies for women over 50 be cut back was based on an analysis showing that every-other-year screenings could provide 80 percent of the benefits of annual screening while cutting the risks almost in half.

Is that the right tradeoff? Have they really been so precise in measuring harm and benefits? Might it be better to maintain the status quo until we can provide advice that is better targeted to particular women and kinds of cancer?

You don't have to be hysterical to ask these questions.

Posted by: Sophomore | November 20, 2009 9:37 AM | Report abuse

"In point of fact, this data is a medical advance. But it feels like a retreat."

The facts do not care how you feel.

I agree with Sophomore that, based on the same facts, one may disagree with conclusion, but how it makes you "feel" is not an argument for the validity of the strategy.

A good blog post on the mathematical balance here: http://scienceblogs.com/goodmath/2009/11/the_balance_of_screening_tests.php

Posted by: dpurp | November 20, 2009 10:07 AM | Report abuse

Only three percent more women will die under the new guidelines.

Why did Klein leave that part out?

Posted by: msoja | November 20, 2009 10:12 AM | Report abuse

Leave the "Only" out of my prev comment.

Three percent more women will die under the new guidelines. I blogged it at my own site three days ago. Is it not the precise tip of the death panel iceberg?

Steven Pearlstein, in yesterday's Washington Post (you may have heard of it) says that one has to weigh "the benefits of routine screening -- deaths avoided and years of life extended" against the negatives. What are the negatives according to Pearlstein? "[M]edical problems caused by complications that arise from biopsies, along with the mental anguish that goes along with the large number of false positives that crop up on mammographies of women in their 40s".

Klein won't even stick his neck out that far.

Deaths avoided versus complications and stress. Hmm, I'd rather be dead than stressed, wouldn't you?

Posted by: msoja | November 20, 2009 10:36 AM | Report abuse

--"The presence of mammograms was psychologically important."--

Absolute rubbish, Klein. Mammograms are PHYSICALLY important. You ought to be ashamed of yourself, every single day.

Posted by: msoja | November 20, 2009 10:39 AM | Report abuse

I think that early detection is often confused with increased survival. The fact that a cancer is detected on the average 3 years earlier using mammograms does not increase the survival rate from cancer. European countries do not screen as aggressively as we do, and they have similar outcomes in terms of survival rates. In reality, these recommendations would bring us in line with the rest of the educated, civilized world. The National Cancer Institute has mentioned this fact for the last 10 years at least, but mainstream medical practice based on induced hysteria in women afraid that they too might have BREAST cancer is hard to turn around. Why women are so petrified of breast cancer and complacent about the far more common lung cancer, or the leading cause of death in women (heart attacks, anyone?) just goes to show that common sense flies out the window when your sexual bits are being considered.

Posted by: carolcarre | November 20, 2009 10:57 AM | Report abuse

Ezra, my objections are to the data, which is in fact in dispute. The task force itself found a 3% improvement in overall survival, net of any treatment disadvantages (15% improvement in breast cancer survival) when screening women 40-49.

The recommendation against were based on "harms" consisting primarily of anxiety and the pain of repeat mammograms and biopsies, the majority of which are needle biopsies.

I did read the actual study.

70% of women with breast cancer don't have identifiable risk factors. I would be dead under these guidelines - mine was caught in a routine mammogram at 41, already spread beyond the ducts.

I'm one data point BUT in reading the actual study, I felt that the decrease in mortality was under weighted, the importance of anxiety and minor inconveniences was over weighted, and non-mortality improvements (less side effects from less extensive treatment, such as being able to avoid chemo) were not weighted at all.

Bad models produce bad results, and I thought this model did not weight things in an appropriate manner.

My argument is with the data. My interest in it is driven by my knowledge I would have been in that 3% had these guidelines been followed in my case - and I know other women will die if these are followed - on average 3% more women 40-49 per year.

I regard being dead as a much bigger "harm" than being worried about having to get a second mammogram or a needle biopsy.

Posted by: VirginiaGal2 | November 20, 2009 11:12 AM | Report abuse


As these comments show, this is an argument FOR Comparative Effectiveness, not against. Mammograms aren't as cut and dry as something like beta blockers after an MI or shooting for an undetectable viral load in HIV; the risk vs. reward is more difficult to parse out.

In medicine there are all sorts of things like this where we really don't know what to recommend. If you've got 10 endocrinologists in a room; you'll get 10 different sets of recommendations on what set of lab values corresponds to controlled diabetes. Lots of things out there lack consensus, and the response shouldn't be, "let's punish medicine because medicine hasn't provided us with the answer yet," but to help them out with more data and better data.

Posted by: ThomasEN | November 20, 2009 11:29 AM | Report abuse

Should anyone have trouble making up his mind about Klein's integrity, or lack thereof, juxtapose his statement above...

"I haven't had time to dig into the new mammogram standards as deeply as I'd like."

... with the five paragraphs of sarcastic parody he followed it with, directed at those finding fault with the standards.

Klein is as dishonest as he is disingenuous.

Posted by: msoja | November 20, 2009 11:39 AM | Report abuse

The real takeaway from this particular brouhaha should be a warning about the likelihood that any of the cost cutting expectations of the current bill would be realized.

When faced with implementing programs demonstrated by CMS to be effective Congress has folded time and time again. Now we have the Secretary of HHS backpedaling without any real knowledge of either the science or the stakes.

What makes supporters like Ezra think that things will be any different when the next study shows that whatever medical device suppliers are selling isn't as effective as people have been led to believe?

Posted by: Athena_news | November 20, 2009 12:19 PM | Report abuse

I hate it when people use leeches as an example of obsolete quackery.

http://en.wikipedia.org/wiki/Hirudotherapy#Medicinal_use

"Medicinal leeches are now making a comeback in microsurgery. They provide an effective means to reduce blood coagulation, relieve venous pressure from pooling blood (venous insufficiency), and in reconstructive surgery to stimulate circulation in reattachment operations"
-JI

Posted by: jeirvine | November 20, 2009 12:54 PM | Report abuse

I'm stunned that this was your one post on this issue.

"And yet, I've some sympathy for the outraged parties here. Disproving the assumed protection offered by mammograms feels like a step backward."

Huh? Disproving the assumed protection for ALL medical procedures and tests will feel like a step backward. In the case of cost-effectiveness, constraining utilization to high value-based medicine actually IS a step backward clinically, but we make the judgment that the cost overrides the lost step backward.

I've got sympathy too-- but unlike you, I don't also think that we've taken meaningful steps forward on cost control, precisely BECAUSE the public reaction-- and government reaction-- focuses on the sympathy rather than the science. This is precisely the point, Ezra. For YOU to be sympathetic, when you're of the belief that IMAC and comparative effectiveness are the two key steps to cost control-- its stunning. If you're truly sympathetic, then you'd conclude that simply put some faceless experts on a committee to determine changes to the health care system isn't going to cut it. We need politicians to be honest and do some heavy lifting-- something Obama has shown little predilection to do. He instead decided to use his political capital on the public option.

Posted by: wisewon | November 20, 2009 1:25 PM | Report abuse

"I haven't had time to dig into the new mammogram standards as deeply as I'd like. "

PS-- Your role is NOT to "dig into mammogram standards." We've got experts with actual training and qualifications to do that. Your role was to do what Pearlstein said instead. This was a complete abrogation of the process Obama hopes to use as our primary cost control mechanism.

These are the types of post that make me frustrated with your partisan analyses-- Pearlstein makes the exact right point of someone familiar with the issues at hand-- you're reluctant to point out the obvious disappointment that Obama et al. are acting EXACTLY like those skeptical of the cost control measures proposed would expect from government.

Posted by: wisewon | November 20, 2009 1:29 PM | Report abuse

The problems with the task force's recommendations is that they are trying to objectively assess something that's ultimately subjective. The harm of false positives are real (increased anxiety, unnecessary procedures), but everybody is going to assign a different value to those harms. There's no right way to judge the trade-off.

Based on what I've read & the conversations I've had the past few days, most women *are* willing to accept the harm of increased anxiety & unnecessary procedures from a false positive for the small but real possibility that the mammogram will detect breast cancer & save their life. So, in that sense, the task force got it wrong.

Posted by: PeterH1 | November 20, 2009 1:33 PM | Report abuse

The harm from the early mammograms is more than just psychological, it also includes the effects of the cumulative ionizing radiation from the mammogram procedures themselves which increases the risk of breast cancer.

But of course, as we all know, no one wants any more medical care than is absolutely necessary and overutilization is clearly driven by physicians' profit considerations. So clearly no one is actually upset by these new recommendations other than mammographers themselves who see the payments on their second homes drying up....

FWIW, I had my first mammogram at age 49 because there is no evidence that mammograms prior to age 50 prolong life (although they may indeed detect cancer).

Posted by: J_Bean | November 20, 2009 1:43 PM | Report abuse

I have come to the conclusion that energy should be focused not on how to reduce unnecessary or inefficient testing, but rather how to make testing cheaper and safer. The market for these tests is always going to be here, and it's always going to be hard to tell people that they shouldn't get regularly tested for something. So the best you can do is make the testing as cheap and as non-invasive as possible so that the cost-benefit analysis becomes less burdensome.

Posted by: constans | November 20, 2009 2:07 PM | Report abuse

J Bean, you have several errors in your post.

Per the task force, mammograms in women 40-49 reduce total mortality by 3% and breast cancer mortality by 15%. That is net all ill effects of testing.

The controversy is because the task force judged that 3% improvement in survival to be offset by anxiety and the inconvenience and stress of retesting.

BTW, the radiation in a mammogram is minimal and has negligible effect on your risk of breast cancer.

I am one of the many women very upset by these recommendations. I had no risk factors and got my mammogram at 41 b/c it was routine. I had breast cancer that had already spread beyond the ducts. I would be dead if I had waited til 50.

In fact, the evidence - which the task force included in the study, if you had read it - is that mammograms prior to 50 decrease mortality by approximately 3% in women 40-49.

And THAT is why so many women who have no financial stake in this are so extremely angry.

Posted by: VirginiaGal2 | November 20, 2009 2:39 PM | Report abuse

VirginiaGal2: You mean well, but you are misreading the paper and it's various criticisms. Since 1990, mortality in the 40-49 year age group -- of women diagnosed with breast cancer -- has dropped 3%/yr. That's still a very small number and there is not evidence either way that aggressive screening is the cause of the improvement. Better chemo, more testing of genetic markers, fewer environmental causes (aka "smoking" and "drinking alcohol") may be contributing even more to the improvement. There are cases of breast cancer in women in their 20s and 30s and even in teens, so why not screen them yearly? Or every 10 months or every 17 months? The only way to determine the optimal screening approach would be to randomize a large number of women to various screening regimens and follow them for a couple of decades.

In the past people have been equally sure about the importance of post-menopausal hormone replacement, antibiotics for the treatment of childhood ear infections, vaccines for rotavirus, and PSA testing, to name a few.

Posted by: J_Bean | November 20, 2009 4:14 PM | Report abuse

J Bean, actually, I am not misreading the paper. Perhaps you should go back and read it again - it is online at http://www.annals.org/content/151/10/716.full with links back to the task force web site.

The 3% comes from "Screening between the ages of 50 and 69 years produced a projected 17% (range, 15% to 23%) reduction in mortality (compared with no screening), whereas extending the age range produced only minor improvements (additional 3% reduction from starting at age 40 years and 7% from extending to age 79 years) (8)." See http://www.ahrq.gov/clinic/uspstf09/breastcancer/brcanrs.htm#clinical

This number is not referring to the annual decrease in breast cancer mortality - it was the TASK FORCE's estimate of the decrease in mortality specific to women 40-49 receiving routine screening mammograms annually.

The study weighed the estimated 3% decrease in mortality, and a 15% decrease in breast cancer mortality, specifically due to mammograms, against the anxiety and expense of false positives that require additional testing to resolve.

The number of women screened to save one life is about 1904 in women 40-49. For women 50-59, it's 1339. That is not a large difference.

Direct quotes from the Systematic Evidence Review Update:

"Combining results, the pooled relative risk for breast cancer mortality for women randomly assigned to mammography screening was 0.85 (95% CrI, 0.75-0.96), which indicates a 15% reduction in breast cancer mortality in favor of screening (Figure 2)."

"Trials of mammography screening for women age 39-49 years indicate a 15% reduction in breast cancer mortality for women randomly assigned to screening versus those assigned to controls. This translates to a number needed to invite for screening to prevent one breast cancer death of 1,904 (95% CrI, 929-6,378) over multiple screening rounds that varied by trial. These results are similar to those for women age 50-59 years, but indicate less effect than for women age 60-69 years."

"Mammography screening at any age is a tradeoff of a continuum of benefits and harms. The ages at which this tradeoff becomes acceptable to individuals and to society are not clearly resolved by available evidence."

These are quotes from the task force document "Screening for Breast Cancer:
Systematic Evidence Review Update for the U. S. Preventive Services Task Force"

I do know what I've read.

Posted by: VirginiaGal2 | November 20, 2009 6:14 PM | Report abuse

I'm sure you've read the various position papers published in Annals this week. However, I do believe you are misinterpreting what you have read. Here's a nice summary:
http://www.nytimes.com/2009/11/20/opinion/20aronowitz.html?em=&adxnnl=1&adxnnlx=1258768108-P8ZyM/h7G8qitdTCyQFT4g

Posted by: J_Bean | November 20, 2009 8:54 PM | Report abuse

J Bean, what I posted is not a position paper about the report - THESE ARE QUOTES FROM THE ACTUAL REPORT, which you would realize had you bothered to read the report itself.

The links are links TO THE ACTUAL REPORT, not to commentary about it.

I am not misinterpreting the task force report - I AM QUOTING FROM IT.

The actual report itself gives the 3% decrease in mortality rate, and the 15% improvement in breast cancer survival.

The actual report itself gives the 1 life saved per 1339 in women ages 50-59, and 1 per 1904 in women 40-49.

It is difficult to see how one could possibly "misinterpret" the exact numbers given in the actual report.

The Aronowitz op ed you cite is an opinion piece, not the report and not a summary of the report.

One of the many news stories that notes the 15% BC survival improvement is at

http://www.npr.org/templates/story/story.php?storyId=120562878
"Breast cancer deaths declined 19 percent over time among women who didn't get regular mammograms. But women who did get screening mammograms had a 48 percent reduction in breast cancer mortality. That's very different from the U.S. task force's estimate. It says the evidence indicates that mammograms reduce breast cancer deaths by 15 percent among women ages 40 to 49."

Unfortunately, too many people here and elsewhere have not bothered to go out and read the report itself - and are making blatantly incorrect statements about its contents.

I stand by my original statement - I do not feel that the line was drawn correctly here. I feel too little weight was given to the 3% reduction in overall mortality with screening 40-49 year olds. I feel too much weight was given to "anxiety" and repeat screenings, which are relatively minor. I saw absolutely no consideration of the decreased side effects of early detection and less invasive treatment.

And I am one of the 3% who would be dead under these guidelines, as my breast cancer was detected in a routine mammogram at age 41.

Posted by: VirginiaGal2 | November 20, 2009 10:05 PM | Report abuse

One persons unnecessary test is another persons life saving test - And the difference between the two is never black and white.

The fact that annual screening leads to a decrease in mortality should be the only factor. As a female, if I had to choose between unnecessary anxiety, costs, and even interventions like biopsies to save the lives of a few women - bring on the unnecessary stuff.

When they decide, definitively and collectively, that frequent screening leads to more deaths, then I will consider changing.

Posted by: Jodigirl | November 21, 2009 11:34 AM | Report abuse

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