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A Times Editorial

Science, not emotion

Afederal panel's advice to rewrite mammogram standards is a provocative example of the tough decisions ahead as the country struggles to reform health care. The U.S. Preventive Services Task Force this week advised women with no known risk factors for breast cancer to forgo routine mammograms until age 50, and then to seek one only every two years. The rationale: Both the emotional and fiscal costs of the current standard — annual mammograms for all women after 40 — outweigh the preventive gains. The immediate backlash is a preview of fights to come over the delivery of health care in this country.

Initial reports suggest the panel's advice won't change overnight the mammogram schedule for most women, their doctors or their insurance policies. The American Cancer Society and American College of Radiology said they won't be changing their guidelines. And Health and Human Services Secretary Kathleen Sebelius was not helpful Wednesday when she sounded dismissive of the new advice and said no federal policy would be changed. But the discussion prompted by new scientific evidence is well worth having and is indicative of the kinds of changes Americans must be open to if the country is ever to get a handle on its outsized medical spending by better aligning medical procedures with outcomes.

The task force, an advisory panel of 16 medical experts from around the country, was established 25 years ago under the Reagan administration as a group that could sift through scientific data to establish sound medical standards for prevention and primary care. Just seven years ago, the group recommended the mammogram standard they altered this week. The panel changed its mind after new studies showed too many women receive false positives from mammograms and others had surgery for slow-growing cancers that never would have endangered their lives. The upside of all that regular screening for women in their 40s: one life saved per 1,904 women screened.

Having human life boiled down to such a cold cost-benefit calculus can be emotionally uncomfortable. No one wants to consider the possibility that a loved one could miss early detection of breast cancer if she doesn't have regular mammograms in her 40s — regardless of the odds. But the medical community, insurance companies and individual patients have long considered such calculations to allocate resources for preventive care such as prenatal care, annual physicals or dental cleanings.

In reaching its decision, the task force reviewed new data from mammography studies in England and Sweden and commissioned six groups to analyze the data. For many, the findings highlight for the first time the significant collateral damage created by a medical technology that has a high false-positive rate and isn't yet sophisticated enough to answer the questions doctors and patients need to know: Is a tumor slow- or fast-growing, malignant or benign? To determine that, patients can undergo expensive additional tests and possible surgery only to discover there was no threat at all. Meanwhile, medical costs grow exponentially. A 2006 study by a Copenhagen-based research center, the Nordic Cochrane Center collaborative, suggested that 10 women in 2,000 are unnecessarily treated as a result of mammogram screenings.

The United States spends roughly 16 percent of its gross domestic product on health care — far more than many other developed countries. Britain long ago adopted a less stringent standard: Begin mammograms at 50 and have them every three years. The task force didn't go that far, and its recommendations deserve thorough vetting by the broader medical community. And women in their 40s should always have the option to finance mammograms either out of pocket or through optional insurance coverage.

But a basic tenet of our health care system must include a willingness to base medical standards on science, not emotion. That is the only chance the country has for making health care more available and affordable for all.

Science, not emotion 11/18/09 [Last modified: Wednesday, November 18, 2009 6:14pm]
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