Monday, November 23, 2009

The mammogram tempest

I don't really wonder that a lot of people are confused by the media treatment of this week's announcement about mammograms, and clearly the unnamed Courier editor is among them. There are a couple of factors involved in this that shouldn't be, and they muddy the water considerably.

The first is that this is a science story, an area where we can count on our journalists to fail us pretty generally. Start talking about random trials, control groups and methodologies and their eyes instantly glaze over. They just want the bottom line, and they have a hard time remembering that the conclusion of a scientific study does not constitute a fact, but rather the best estimate the scientists can get of the truth given the specific conditions involved. Big difference.

In this case what we have is a new report from the US Preventive Services Task Force, an independent panel of experts on preventive care set up by the Reagan administration to "review the evidence of effectiveness and develop recommendations for clinical preventive services." The PSTF

"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."
(Incidentally, this backs up a similar conclusion from a study not long ago in Canada.) It's a simple, straightforward message. On looking at the current evidence, the panel found that the benefits of routine mammograms for low-risk women do not outweigh the associated risks.

The second factor making a huge mess of this is that a small proportion of people in this country are convinced that health-care reform is about rationing, killing off Republicans early and making lots of Democrats, and so they jumped in with both feet on the idea that this is a a nefarious scheme to deprive women of their necessary cancer tests. (Like they ever gave a rat's behind before about preventive services for women.) They came out screaming bloody murder (again) over nothing, and this is where we are.

In a way I wish it were a little more like the screamers fear. The profit motive in US health care leads to huge amounts of overprescription, overtesting, unnecessary procedures and other highly profitable waste. I think it would be reasonable to infer that profitmaking insurance companies will look for a way to use this to deny reasonable coverage. This has nothing to do with the public plan, which of course does not yet exist.

But it just isn't that important. It's another data point in the continuing refinement of our understanding that science pursues, no more, no less, and if more experts agree, a consensus may emerge to stop pushing women to have these tests because they're not necessary.

The editor basically gets it right in describing how to respond, but his tut-tutting the experts for unclear communication is ridiculous. The media have messed up the message, not them.


Anonymous said...

spoken like a true man. if you had to worry, you'd understand the editorial.

Steven Ayres said...

And when you're afraid, reason is meaningless.

Mia said...

I heard from someone on a panel on NPR that by following those guidelines in America, one in about 1900 women would likely miss an opportunity for early detection. I don't know what to think about that. On one hand, it's a person, on the other, it's a lot of money that could be used for? I want to say prevention or research, but the savings wouldn't end up there, unless we were talking about something like a Single Payer plan. Anyway, the other thing that keeps bothering me is that I also heard that mammograms cost around $100. It seems almost ridiculous that we even have a middle man (insurance) involved. I think you wrote something about that before Steven, about not having routine Dr. visits be insured, but just having major medical? I prefer Single Payer myself. I feel pretty staunch about healthcare and profit not being bedfellows.

Steven Ayres said...

I'm sure that at the other extreme, relentless testing of everyone would turn up a lot more possible cancers. The other side of the equation, generally ignored, is that testing also involves radiation known to cause cancer and other negative health effects, in addition to the injuries wrought by the procedure itself, unnecessary biopsies, infections, etc.

While it seems to me that the procedure is barbaric and provides very poor results overall, I'm not meaning to take a position on whether a 40-year-old woman should start biannual mammograms. I think everyone should do their own research and do what seems right for them. Here I'm only concerned about the distortion of the issue in the media, and I think that's been strong and to a large extent politically motivated.

I'm not sure what you're remembering, but for the record I'm a single-payer advocate myself, having lived in one such system for many years. I'm willing to accept a lot less than that in the current effort, if only to establish a foundation to build on.

Mia said...

Ok, I put the 1/1900 into another scenario and into better perspective for myself. What if, at the door to the Dr.'s office, rarely, only about 1/1900 times, a vent cover fell and killed whoever was walking through. But it was a very very expensive vent cover that all doctors used, and would have to be replaced every year in order not to fall. Now this is a quick painless death, and of course we would say fix it and avoid those deaths; these are very unacceptable numbers. Ok, now about the radiation. I don't want to talk about it because I have a CAT scan coming up that is COMPLETELY unnecessary, but my Dr. has no interest in hearing anything other than the conclusion she made in 5 minutes while I was in her office. It's a long story, but I'm stuck with her, and if I want to get the surgery I want (deviated septum jfyi) to get, then I have to have another (this will make 4 in 5 years, plus an MRI) CAT scan - not to mention all of the drugs I had to try AGAIN, that didn't work the first 10 times. I don't want the radiation, and I absolutely agree with you about the harmful effects not being weighed in. Also, I don't subject myself to much media, so I haven't seen the distortions, but I know about the whole "It's Obamacare starting....." thing. Very predictable, and maddening. I also would be willing to accept less care for Single Payer, the rest a person could pay for if they wanted right - without a middle party! Where did you live with SP if you don't mind my asking? You were happy with the care and availability of it?

Steven Ayres said...

I lived and worked in Japan for seven years starting in the late '80s. I'm generally suspicious of conventional medicine, so I had little occasion to use the system, but it was mandatory and cost me a relatively small payroll deduction. When my appendix started acting up, I got prompt, efficient, skilled care from people who listened to my needs and fulfilled them, as well as a very positive outcome. The "co-pay" cost was negligible.

Of course I have many friends and relations with experiences in the Japanese health-care system, and while they vary from person to person -- no system is perfect -- I don't know anyone who would prefer a US-style system.