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Mammograms for all, all the time?

Dana Milbank's column on the new mammography standards seems strangely sanguine about letting Congress shut down independent scientific processes just because it doesn't like the result. But for all his criticism of the panel, he doesn't really question the science. Instead, he quotes Nancy Brinker, who heads Race for the Cure, saying, "Let me say it as clearly as I can, as a breast cancer survivor whose breast cancer was found with a mammogram at the age of 37. … Mammography saves lives."

But then why not triple mammograms?

One thing you're seeing here is a strong bias not just in favor of treatment, but in favor of the status quo on treatment. The evidence says we should have fewer mammograms than we do. However, those additional mammograms save some additional lives, and that's a powerful argument in the public sphere. People are more afraid of being the extremely rare individual to die because they didn't get an early screening than of being the fairly common individual who has to get a slew of invasive tests and endure weeks of terror because they got a false positive, or worse, gets serious and dangerous surgery based on a faulty test.

But no one is arguing that we should double, or triple, the frequency of mammograms. Why? Because it's not feasible, I guess. But if we're already admitting that there's some frequency that's not desirable, why settle on the status quo? My hunch is that it's comforting to believe that we've figured this one out already, and for groups that don't want to see a reduction in mammography, at least the status quo lays out ground they can defend. But I'd be very skeptical of arguments that seem to justify a virtually unlimited amount of mammograms, as opposed to arguments that have something to say about the correct level.

By Ezra Klein  |  November 24, 2009; 4:07 PM ET
Categories:  Health , Health Coverage  
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I'll just ask this once more. What are the odds that a public option would be able to have reasonable guidelines on whether to pay for a mammogram?

Posted by: spotatl | November 24, 2009 4:40 PM | Report abuse

One think that gets lost in the criticism I think is that the standards for these types of tests help establish the baseline, the lowest acceptable standard of care coverage. The science apparently says that mammograms should be given regularly starting at age 50. If you are younger than that and feel the intense need for more tests, then pay for better insurance or pay out of pocket for tests. I think that HCR is too often defended on television by congressman with the claim that insurance will always cover every test and procedure. The achievement of HCR will be that all americans receive the most necessary health care, not all health care conceivable.

Posted by: eglabe19 | November 24, 2009 4:49 PM | Report abuse

You can still sue your doctor if he/she didn't perform the mammogram. Maybe the risk to the doctor losing a lawsuit is low given the guidelines, but doctors would probably order the test to avoid the headache. Well, this healthcare expansion bill does nothing on malpractice suits because trial lawyers have already bribed the Democrats. The lack of tort reform in the bill is one of many reasons why this healthcare expansion bill is no reform bill at all.

Cost-effectiveness analysis (also known as social planners deciding what is best for patients) is always too slow to anticipate technological advances. By the time a CEA or CBA study is completed, a new standard of care has already been developed.

As for mammography adoption, I'm surprised why liberals aren't supportive of more mammography use. My understanding is that mammography utilization is still quite underpenetrated (uninsured or underinsured as some factors); therefore, I would think that these government sponsored guidelines might even deter appropriate adoption of mammographies.

Mammography is a poor example of illustrating why Ezra Klein thinks status quo thinking is often problematic.

Posted by: RandomWalk1 | November 24, 2009 4:54 PM | Report abuse

A major point of the panel, as I understand it, was that there isn't some magic prescription that will save the maximum number of lives, and when and whether to do mammograms should be based on individual risk factors not some one-size-fits-all formula.

Excessive radiation can contribute to cancers, so monthly screening is obviously counterproductive. What is a more reasonable frequency? Whether a woman should get annual screenings before or even after age 50 depends on risk factors. Also important are the treatment decisions if an anomaly is found after screening. Because there are obviously many women who had inadequate access to care or were discouraged from invasive treatment and then died, some women go to the other extreme and have double mastectomies if a lump is detected, even if it might be slow-growing.

As someone who was diagnosed with breast cancer, which I found myself, at age 53, possibly caused by radioscopy I had in Europe when I had severe pneumonia at age 18, I found the panel's recommendations to be very sensible.

What to do is a very tough decision, but we can't anticipate or protect ourselves against every risk. Life ends in death for all of us. It is just a question of when and how and how painfully, and the best prescription is to enjoy life while you can.

Posted by: Mimikatz | November 24, 2009 4:56 PM | Report abuse

What eglabe19 said. The outcry over the mammogram recommendations has centered on the notion that it might "prevent" woment from getting mammograms before age 50. However, the fact that someone else will not pay for something you want does not "prevent" you from getting it. The issue is at what point is it reasonable for a mammogram to become a shared cost (which is what insurance is) and at what point should you have to foot the bill yourself. The whining, of course, will be that this means people who can afford to pay for their own tests get better care, but if there is no scientific evidence that the care they are purchansing provides additional benefit, the those who do not get it are by definition not being deprived of anything. (I fully recognize that logical arguments are not worth squat on almost any health care subject, which is why I dispair of a good end to the current exercise.)

Posted by: exgovgirl | November 24, 2009 4:59 PM | Report abuse

At some point America is going to have to get over the entitlement culture. Republicans, especially, seem to have a problem reconciling the fact that they don't want to give anything up -- no healthcare rationing, no cuts to benefits, no cuts to defense spending, but they don't want to pay for it.

How is it that the party of free trade and capitalism has such a hard time with extending the use of cost-benefit analysis to social decisions.

I'm 31. Both my paternal and maternal grandmother's had breast cancer. But you know what? If scientific data says that it does not make statistical sense to recommend mammograms for women in their 40s, fine. We should not be recommending it. Insurance companies should not be paying for it. And if the millions of dollars going towards mammograms for women in their 40's can be used to broaden coverage someplace more useful, lets do that. Or lets cut a sliver off medicaid spending. Or do more well-baby checkups. Yes, somewhere some woman in her 40's is going to die because she was the statistical aberration and didn't get checked because of the new recommendations. That sucks. And that's life. And if that's me, so be it. The point is, if we can't have grown-up conversations about the acceptable trade-offs between levels of coverage and our ability to pay for it...


Posted by: realityexists | November 24, 2009 6:00 PM | Report abuse

More to the point: At least some of the women who point to their own experience of early diagnosis have been overtreated. No one really likes to talk about it, least of all breast cancer specialists. We're not really sure which cancers can be safely left alone.

The fact is, not all cancer grows throughout the rest of your body; sometimes it stays encapsulated, and not much of a threat. But we as a culture have such a horror of cancer that we immediately say, "Cut it/poison it/irradiate it out of me!" Shouldn't we figure out a more rational approach?

Oh, and we do know that the more biopsies you have, the more likely you are to eventually develop breast cancer. But we don't know why, and no one's talking about that, either. The new guidelines aren't just about emotions.

Posted by: uberblonde1 | November 24, 2009 6:06 PM | Report abuse

People seem to forget it once was standard to get chest x-rays to "prevent" lung cancer, and that you got your feet x-rayed at shoe stores, to prevent bunions i guess

Those standards got changed, so should the hysteria-induced yearly mammogram, which is based on the notion that women are at a high risk of breast cancer (they are at a much higher risk of lung cancer, which they aren't being x-rayed for)

Posted by: carolcarre | November 24, 2009 7:26 PM | Report abuse

I would think it would be ill-advised to deny a first degree relative of a breast cancer victim, like Nancy Brinker, access to a mammogram. The USPSTF only made an exception for the known BRCA genetic mutations, although there is good evidence that other unknown genetic factors contribute as well. The guideline was remarkably shoddy work--par for the course for George Bush appointees I'm afraid.

Posted by: bmull | November 24, 2009 7:31 PM | Report abuse

Ezra, while I appreciate that your heart is in the right place on this topic --gathered from your previous post on it--you're missing the fundamental problem. The study makes clear that mammograms are better tools to diagnose breast cancer in women over 50. The study also points out that mammography is weaker and much more prone to error in women under 50. The take him point is that science has a task to make mammography stronger and better so that it can help women who do in fact get breast cancer before the age of 50. Better mammography in these women would advance medicine but also increase costs. Basically, the answer is not that mammograms should only be used for women over 50. Women under 50 do get breast cancer but the technical science needed to diagnose these women is lagging, ie evidence based medicine argues that the current state of mammography indicates that there are benefits for women over 50 but the technology isn't strong enough to make the same case for women under 50.

Posted by: goadri | November 24, 2009 9:21 PM | Report abuse

spotatl, what are the odds that a private option would be able to have reasonable guidelines on whether to pay for a mammogram?

Posted by: dpurp | November 24, 2009 10:35 PM | Report abuse

"However, those additional mammograms save some additional lives"
And cost some additional lives. The problem is that everyone assumes that additional testing does not have unintended negative consequences.

Posted by: staticvars | November 24, 2009 11:40 PM | Report abuse

A mammogram isn't just invasive, it hurts. Terribly. I literally (yes, literally) had nightmares after my one and only. I won't be having another until well after I'm 50, and the technology is different.

And I laugh at Americans who think they need them every year after turning 40. In Britain the standard is 50, and you don't see any women clamoring to get them earlier.

And if you REALLY want to stop breast cancer, why not just have your breasts removed? Now that's over treatment, but it sure would work.

Posted by: KathyF | November 25, 2009 1:43 AM | Report abuse

I agree with "stativars" the risk of treatment seems to be discounted in these discussions. Even correctly performed treatments have risks and in a massive systems like this mistakes will happen. As well over-testing inevitably leads to over-treatment which does increase risk.

Posted by: DisplacedCanuck | November 25, 2009 4:52 AM | Report abuse

Socialism is all about fighting over the disposition of other people's lives.

Get used to it.

And when the slugs get around to fighting over the disposition of *your* life, I hope you like it.

Posted by: msoja | November 25, 2009 8:59 AM | Report abuse

The controversy about the new mammogram recommendations illustrates how the boundaries of the medical-industrial complex shift depending on the topic under consideration. Now it's "good guys" like the Cancer Society and the pink-ribbon folks who want to ignore evidence-based guidelines because their organizational and fundraising strategies are grounded in the status quo. (Don't even mention the radiologists!) Excessive use of health care services is going to be very hard to discipline according to good science whenever this scenario pops up, as long as someone's ox is being gored. And this one wasn't even driven by cost concerns.

Posted by: bill0465 | November 25, 2009 11:49 AM | Report abuse

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