Rationing Mammograms

March 24, 1994|By TRB

WASHINGTON — Washington.--In December the National Cancer Institute revised its guidelines on mammogram screening for breast cancer. Previously, it had recommended regular mammograms for all women over age 40. Now it makes no recommendation for those between 40 and 50. Its position is that the evidence is not clear. Women, it says, should study the data and decide for themselves.

This is a deeply unsatisfying recommendation, for two reasons. First, if the experts at the National Cancer Institute can't decide whether mammograms are worth while for women in their 40s, how on earth is a non-expert supposed to decide for herself?

Second, this is not a question that society can leave completely up to individual women. In various circumstances, a decision must be made at the level of social policy. Health-care reform is the most obvious example. If we are going to guarantee something called ''health care'' to everyone -- one way or another -- does that or does it not include mam- mograms for women in their 40s? Even under current arrangements, insurance companies must decide whether this is a benefit they will pay for, and the government must decide whether to cover it in Medicaid. So what's the answer?

It seems obvious, to start, that there is no magical dividing line at age 50. The experts are unanimous that regular mammograms starting at 50 cut the breast cancer death rate by a third. But if mammograms are tremendously valuable at age 50, they can't be worthless at age 49. Clearly it's a continuum: The exam gets more useful as you get older. Anywhere you draw the line is going to be arbitrary.

Mammograms of women in their 40s catch cancer in about one out of 400 cases, and it has to be better to catch it earlier rather than later. What are the drawbacks? The test itself is harmless. There is the psychological trauma of ''false positives,'' initial diagnoses of cancer that turn out to be wrong. And apparently scar tissue from the biopsy of lesions that prove benign can sometimes block the view of genuine cancerous lesions in later years. If that was the entire downside, it would be hard to see the problem with making mammograms standard for women in their 40s.

Of course there's the cost. The National Cancer Institute insists that economic considerations did not figure in its guideline change. But they inevitably figure in real life. If all 18 million American women in their 40s got an annual mammogram, at $150 a pop, that would cost $2.7 billion a year.

The institute maintains that there is no good evidence that any lives would be saved as a result. But future studies may change that conclusion. As a very rough back-of-the envelope calculation, take the figure of one in 400 that identify a cancer, and figure that (say) half of those might otherwise have gone undiagnosed until it was too late. It works out to more than $100,000 per life saved.

Worth it? You can argue that one either way. But the larger point doesn't go away in any event. What about women in their 30s? Their 20s? Their teens? The cost per-life-saved goes up, yet the exams are unlikely to prove completely worthless. But you've got to draw the line somewhere, and at the point where you draw that line you are putting a price tag on human life -- even your own life.

Americans are notoriously bad at questions like this. We find it hard to make rational judgments about very small risks of very bad outcomes. Usually, political conservatives are the more hard-headed bunch. They enjoy ridiculing liberal hysteria on matters ranging from environmental hazards to auto safety to nuclear de- terrence. On this question of mammograms, however, they have seen an opportunity to score points off of President Clinton by pandering to exactly the sort of anxieties they usually mock.

The standard benefit package under the Clinton health care reform plan offers mammograms only beginning at age 50. ''As if by imperial edict,'' charges Bernadine Healy, the Clinton plan ''has ruled out screening mammography for women in their 40s.'' She accuses Mr. Clinton of using the institute's revised guidelines ''to justify a cost-based decision to limit women's health-care choices.'' Dr. Healy, formerly director of the National Institutes of Health, is now a Republican Senate candidate from Ohio.

In truth, the Clinton plan ''rules out'' nothing. It defines a minimum benefits package, which any plan purporting to assure health care for everyone must do. Women in their 40s would be perfectly free to have mammograms, and insurance companies would be perfectly free to offer mammogram coverage. And the president's plan would make mammograms available for the first time to millions of women in their 50s, for whom the value is unquestionable.

But the telling phrase is ''cost-based.'' Is it now the ''conservative'' position that any ''cost-based'' health-care decision is immoral? That any consideration of the ratio of cost to benefit amounts to health-care rationing? If so, ''hold onto your wallet,'' as those guys used to like to say.

TRB is a column of The New Republic, written by Michael Kinsley.

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