Breast Cancer Screening: New Fuel for an Old War of Words and Data

Breast Cancer Screening: New Fuel for an Old War of Words and Data

By Charles Bankhead, Staff Writer, MedPage Today
Published: November 19, 2009


A controversy that has alternately simmered and boiled for more than 40 years reached a flash point this week when the U.S. Preventive Services Task Force published recommendations for breast cancer screening with mammography.

The recommendation to delay routine screening in average-risk women until age 50 brought out ardent supporters on both sides of the issue, as reflected in coverage by MedPage Today and in consumer and professional media from coast to coast.

Although media coverage might have created the impression of a new controversy, the strong, conflicting opinions go back at least as far as 1969, when initial results of the first large-scale breast cancer screening program were announced. Data from the Health Insurance Plan (HIP) of Greater New York showed a 30% reduction in breast cancer mortality in women ages 40 to 64 who underwent clinical breast examination and screening mammography (JAMA 1971; 215: 1777-85).

With longer follow-up, the HIP data suggested the mortality benefit of screening was limited to women ages 50 and older. By 1977, the authors of that study had concluded that women ages 40 to 49 did not benefit from screening (Cancer 1977; 39(suppl): 2772-82).

Shortly afterward, a Swedish study demonstrated a beneficial effect of breast cancer screening in women ages 40 to 74 (Radiology 1981; 138: 219-22). In contrast to the HIP data, follow-up for as long as 20 years showed a mortality benefit in women ages 40 to 49, as well as older age groups (Lancet 2003; 361: 1405-10).

Several other studies reinforced the value of breast cancer screening, and mammography gained widespread acceptance among physicians and scientists alike. However, disagreements persisted about the purported benefits of screening in younger women and about the appropriate screening interval (Int J Epidemiol 2004; 33: 43-55).

http://www.medpagetoday.com/HematologyOncology/BreastCancer/17127

The Republicans are using this controversy as an example of what is going to happen with "rationing care". They are either ignorant of the facts or lying outright.

It's actually a major point, and that's the problem.

The right can't present it reasonably, and the left can't really face it.

After you dispose of some inefficiency, after you dispose of "padded" payrolls, you're left with some nasty facts. The overwhelming majority of medical expenses go for chronic illnesses. Much of the rest go for tests, and some moderately rare but very expensive treatments are doled out. Get rid of all the easy things to dispose of and the best you do is lower the curve--you don't "bend it", you shift it so that you get a year or two's reprieve.

You can control costs to some extent, but if you can't control *all* the costs ultimately that will just reduce salaries. We seem to "get" the problem when GM and Ford say they need to control costs and, when push comes to shove, that means payroll and benefits. To some extent the deficits run up by Medicare are coupled with cost-shifting. When I was treated for an ear infection, I paid more than my current insurance would have, and my insurance pays more than Medicare would have. Yet the clinic wasn't making a ton of money, and the doctors didn't all drive Jaguars. Some uninsured overpaid and subsidized Medicare while other uninsured defaulted on payments; it was the insurance companies that really provided the funds that kept the clinic open.

Ultimately the only way to control costs is to look at "rationing"--a horrible word for the process. It's not "rationing", it's looking not just at benefits but at costs. I keep saying that if we really valued life "at any price" we'd have essentially 0 traffic fatalities a year. But we don't value life at any price--we actually don't value life all that greatly, but as soon as somebody else picks up the tab the value, in our estimation, soars. Esp. if it's our lives or the lives of those close to us.

So early in 2009 a panel was set up to consider not just benefits, but costs. Why? Because costs matter--not just financial costs, as this controversy points out. Yeah, you can save lives--but you create grief from the false positives. I haven't heard a peep out of it, for good reason. Nobody wants to hear it. In the case of mammograms, the recommendation was nuanced and didn't exclude mammograms for high-risk groups; that's often lost when the stats are tossed around.

This controversy shows something else important. In the late 1990s Medicare was put on a "trigger": If costs increased by more than a certain amount the law stipulates steps to immediately and automatically reduce costs. Yet every year the trigger's been tripped Congress has decided it's politically too inexpedient to let the law do what it was intended to do--and also inexpedient to revise the law. So they pass an additional appropriation to bail out Medicare. So here we have a cost/benefits analysis instead of just a benefits analysis, and the recommendation says to reduce the number of mammograms--it'll cost some lives, reduce emotional costs for a lot of women, and reduce financial costs. The immediate response is an outcry because nobody wants to support something that politically sensitive, or something that sounds that politically sensitive. Were this done by a government body in charge of stipulating what would be covered by a single-payer system or by those participating in a central insurance exchange, Obama or Congress would promptly pressure the system to revoke this cost saving. After all, they've already done it for the last 10 years or so with Medicare.

In other words, the only costs that will be saved are those that are politically tolerable to whoever's in power in the WH and Congress. The "savings" from the Medicare bill a decade ago largely didn't materialize because of politics, sometimes politics masquerading as other things; so I take the predictions about the current spate of proposals to be so much fiction because they'll also be subject to political and rhetorical pressure. At the same time costs will increase--just as Medicare costs increased--because it'll be deemed politically expedient to tweak the law to extend coverage to new procedures or groups.

They were weighing the harm from unnecessary biopsies and X-rays against the benefit from finding more cancers earlier.

I remember reading about the disagreements on whether wide scale pre-menopausal screenings were warranted years ago but I've never seen a summary of various studies pulled together. I thought most women knew about this, but I guess that I was wrong.

So it's ridiculous to think it has anything to do with current health care reform. I don't trust the panel because there were no oncologists on the 16 person panel but there were THREE health insurance company representatives on it.