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Breast Cancer Policy Makers Still Don’t Get It

May 31, 2011
Written by: , Filed in: Breast Imaging, Medical Ethics
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Health care policy makers mean well, but they don’t know much about people.

That’s one of the lessons (albeit an inadvertent one) to be drawn from a revealing DOTMed News analysis of the controversial November 2009 United States Preventive Services Task Force (USPSTF) recommendation against routine mammogram screening for women in their 40s.

A year and a half after the USPSTF announcement, we’re still arguing about it:

  • The American Society of Breast Surgeons is ignoring the recommendation. Deanna Attai, MD, the society’s communications chair, said, “We’re basically endorsing annual screenings for women over 40.” Balancing the danger of false positives, she said, is the fact that cancer in younger women is more likely to be an aggressive form.
  • The American College of Radiology (ACR) still recommends regular mammograms every year or two for women in their 40s. “Breast cancer mortality has dropped substantially since the introduction of regular screening,” said Carol H. Lee, MD, chair of the ACR breast imaging commission. “We have a public health measure that is proven in practice to work; why roll it back at all?”
  • Michael LaFevre, MD, the USPSTF co-vice chair, said he translates the task force’s updated recommendations this way: screening should be discussed (with a patient’s doctor) for women in their 40s, encouraged for women in their 50s, and strongly encouraged for women ages 60 through 74.

The arguments against regular screening mammograms for women in their 40s focus on:

  • Too much cost—and not just financial cost. Anxiety-producing false positives generate expensive, painful, and unnecessary tests and treatments. “If a woman screens regularly,” said Dr. LaFevre, “there’s about a 50 percent false-positive rate for women in their 40s.”
  • Not enough benefit. Among 1,000 40-year-old women, said Dr. LaFevre, about 30 will die from breast cancer if they don’t have screening. “If we screen from 50 to 74, we can reduce that number by seven, which is a pretty good drop in mortality,” he said. “If we back that down to 40, we may be able to save one more. It’s not zero, but it’s small.”

But look at the issue from the perspective of a 40-year-old woman: “You’re saying I should probably skip mammograms for the next 10 years if I’m healthy and don’t have risk factors. You’re saying there’s a good chance I’ll be falsely told I have cancer, which would scare me and lead to unnecessary tests and treatments (which my insurance may pay for). You’re saying that out of 1,000 40-year-old women, only one is likely to have her life saved if she has regular mammograms in her 40s. You say that number is ‘not zero, but it’s small.’

“But what if I’m that one? Don’t you see why I don’t care about expense or fear if the alternative is leaving my husband a widower and my babies without a mother?”

The USPSTF and other policy makers deal with intellect and numbers. They had better figure out how to deal with emotions and people.

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