Mammograms, Evidence, And Emotional Debate

I think it’s safe to say that the U.S. Preventive Services Task Force has opened an interesting can of worms recently at a rather inopportune moment. They have published what is, to my understanding, an evidence-based report on screening for breast cancer, including the use of mammograms. Emotional topic, without a doubt.

There have been some rather extreme responses as can often be expected when the discussion is driven by emotion. This discussion is taking place at a time when the current health care reform climate is volatile at best. People have already started proclaiming that “this is rationing of care – and exactly what health care reform is going to do”, “this will prevent women from getting the care they need”, and “hell yes, as a doctor I am still going to perform them regardless of what the study says”.

Let’s make sure that we understand the conclusions of the report.  All suggestions are given a grade that reflects the level or degree of recommendation. Recommendations are just that – recommendations, not demands or rules.

The part that seems to have everyone outraged is this:

“The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.”

But read on a bit and we find that there is a Grade C recommendation – which means “recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small”. Their suggestion for practice?

“Offer or provide this service only if other considerations support the offering or providing the service in an individual patient.”

The intriguing part of this debate is this: if you’re looking for “rationing of care”, then this isn’t the place to look for it. Take, for example, a diagnosis which has had a similar scenario play out in the health care world. It’s name? Low back pain. There have been many lessons learned from the back pain research that could help to provide some voice of reason in the debate over breast cancer screening.

Back pain has been researched to a great extent simply because of it’s cost and prevalence. It is estimated that 80% of the US population will have back pain in any given year. In 2005, the cost of back pain care in the US was $85.9 billion – up from $52.1 billion in 1997. Estimates range as high as $170 billion per year. Sadly though, there are more people suffering from back pain now than ever before. We’re spending more money, and getting worse results. And when you look at the scientific evidence related to low back pain, we find that approximately 92% of people with low back pain get better within 8 weeks, regardless of the treatment (or with no treatment at all). But there are countless assessment procedures and treatments, most of which have little to no scientific support, applied at-will to those with back pain, over and over again on any given day in any city in the United States.

Comparatively speaking, the total cost of illness for breast cancer has been estimated at $3.8 billion, of which $1.8 billion represents medical care. So if you were looking at “government cost containment and rationing of care”, then breast cancer simply isn’t the place to do so. As soon as someone dares to discuss “evidence” regarding assessment, the emotions boil over.

Now I will be the first to acknowledge that “breast cancer” and “back pain” are going to provoke two totally different emotional responses. It’s easy for people to get emotional about cancer. Chances are good we all know someone that has either has cancer, or had cancer and died. I can look to my own family tree for this.

But cooler heads need to prevail in this discussion – and in all discussions that pit emotion against evidence.

Representative Lynn Woolsey, a Democrat of California, notes that “We’re not going to ration anything. We’re going to give people choices based on science.”

This is not a partisan issue or debate. Of course, there has also been a backlash to the backlash.

Professor Theodore Marmor, a health care policy specialist at Yale University, noted that "People are holding up the standard of medical care that any medical treatment that does any good for anybody cannot be denied. That is a ridiculous standard."

Here’s a novel thought contained within the report. It comes from Diana Petitti, MD, MPH – the vice chair of the U.S. Preventive Services Task Force: "So, what does this mean if you are a woman in your 40s? You should talk to your doctor and make an informed decision about whether a mammography is right for you based on your family history, general health, and personal values."

The proper solution involves clinical reasoning. It involves a dialogue between physician and patient. It involves the physician listening to the patient. The scientific research doesn’t take away your ability to be a doctor – it fosters your ability to utilize the scientific method WHILE you are being a doctor. Don’t just go forward with doing testing because “it’s your choice and right as a doctor”.

And part of the resolution of this issue is patient education. It involves the patient becoming a better consumer of their health care, and their health information.  It’s not just an issue of awareness that the problem exists or awareness of self-assessment. It’s also an awareness of the risk factors, what is appropriate for you based on your “family history, general health, and personal values”, and awareness of the effect of lifestyle on reducing those risks (if possible).

Granted, the U.S. Preventive Services Task Force could have chosen to discuss a less-emotional topic (like back pain) to get people to support the concept of evidence-based research. Suffice it to say that I am sure that the answers to this and many other examples in health care lie somewhere between “yes, screen everyone” and “no, don’t bother”. The answer certainly isn’t more fear, and the answer isn’t more emotion. Yes, we have a name for that happy ground – it’s called “clinical reasoning” and “consumer awareness”. And it works hand-in-hand with evidence – not counter to it.

Photo credit: cpurl