Medicine trumps politics

Our view: Mammogram guidelines shouldn't be fodder for health-reform foes

November 23, 2009

The recommendation by the U.S. Preventive Services Task Force that mammograms not be given routinely to women under 50 and that the teaching of self-exams be de-emphasized has sparked a spirited debate among doctors, researchers, advocates and ordinary women. That's a good thing. The questions of when such screenings are most effective and what benefits and risks they provide are too seldom considered in a medical culture that tends to assume more tests are always better. There are thousands of examples of women whose potentially deadly cancers were caught early because of mammograms, and many others in which women suffered unnecessary consequences ranging from anxiety to needless treatment because the tests raised false alarms. It's a debate worth having.

But using that question of medicine and public health policy as a talking point to oppose reforms of the health care system that would result in vastly greater access to medical care for millions of people is nothing but scaremongering. Opponents of President Barack Obama's health care reform effort are ominously pointing to this recommendation as proof that health reform will result in the rationing of care and that people will die as government bureaucrats scramble to cut costs.

This line of reasoning ignores the fact that rationing already exists in the American medical system. Millions of low- and middle-income women are prevented from having mammograms because they lack health insurance. Others find treatment for breast cancer rationed by insurance company bureaucrats who scramble to increase profits by denying coverage, sometimes on the flimsiest of pretexts. And the extent to which private insurance companies now offer coverage for screening tests is often determined by state mandates that they do so.

Those mandates, incidentally, are also something many conservatives oppose; when they talk about allowing the sale of health insurance across state lines, they mean they would like people to be able to purchase lowest-common-denominator policies from states that take a minimalist view on what kinds of tests, procedures and treatments ought to be covered.

The fear tactics on mammograms also ignore another feature of a health care system in which the government plays a larger role. The government isn't run by bureaucrats but by politicians. It's no coincidence that Health and Human Services Secretary Kathleen Sebelius disavowed the task force's recommendation after a public outcry, or that the White House moved quickly to announce that Medicare's policy on mammograms wasn't changing. If anything, placing greater responsibility for health care in the hands of government is going to lead to more coverage than necessary, not less.

What's getting lost is any serious discussion of the recommendations. The task force studied new data from England and Sweden and found that the risks associated with breast cancer screening are much higher for women in their 40s, but the chance of detecting cancer is much lower, making for a lopsided risk/reward ratio. Seven years ago, the same panel recommended mammograms for women under 50 and that screenings be given annually, as opposed to once every two years. In both cases, members said the question was a tough call.

Similar debates have been raging for decades about screening tests for breast and other kinds of cancer (notably, prostate cancer and, just last week, cervical cancer): how accurately they diagnose people who actually have cancer, how often they provide false positive findings and whether early detection makes a difference in the prognosis. Dr. Alfred Sommer, the Johns Hopkins ophthalmologist and epidemiologist, notes that the push for early detection and treatment has led to "an epidemic of diagnoses of small, unimportant cancers" without reducing the number of serious cancers we find later, leading to costly, painful and sometimes risky treatments that prove unnecessary. That suggests we need to put resources into developing new, more-accurate screening techniques that offer greater benefits at less risk of harm. That would be the proper response to the mammogram guidelines, not politically motivated attacks.

Readers respond
Yes, there is already a rationing of health care in the country with the uninsured and denied coverages. But what about those who have great health plans? Now insurance companies will have the ammo to decrease coverage by cutting preventative tests like Pap smears, prostate screening and mammograms.

Debbie

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