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Mammogram panels?

Posted at 9:08 AM on November 17, 2009 by Bob Collins (11 Comments)
Filed under: Health

The timing couldn't possibly have been worse for the government to release new guidelines on when women should have mammograms to detect breast cancer early enough to save their lives -- right in the middle of the nation's health care debate over the role of government in health care decisions.

The guidelines, if you haven't heard, recommend women not have mammograms until age 50, instead of age 40, as most groups who research the issue suggest.

"There is no doubt that mammography screening in women in their 40s saves lives. To recommend that women abandon that is absolutely horrifying to me," Dr. David Dershaw, director of breast imaging at Memorial Sloan-Kettering Cancer Center said.

So why did they? Dr. Otis Brawley of the American Cancer Society suggests cost is behind this:

The USPSTF says that screening 1,339 women in their 50s to save one life makes screening worthwhile in that age group. Yet USPSTF also says screening 1,904 women ages 40 to 49 in order to save one life is not worthwhile. The American Cancer Society feels that in both cases, the lifesaving benefits of screening outweigh any potential harms. Surveys of women show that they are aware of these limitations, and also place high value on detecting breast cancer early.

"With its new recommendations, the USPSTF is essentially telling women that mammography at age 40 to 49 saves lives; just not enough of them.

And what Brawley didn't say, Dr. Sanjay Gupta did. Gupta, who was Barack Obama's initial choice for surgeon general before he decided to stay at CNN, speculated today that once the government recommends guidelines for medical care, private insurance companies will be quick to stop covering anything else.

Not death panels, mamography panels. It's worth pointing out, perhaps, that the government's guidelines now match Canada.

But Susan Pisano, spokeswoman for American Health Insurance Plans, appears to dismiss the concerns:

"Most of our member companies look at [the task force's guidelines] as the standard. But if you are in your 40s and have a discussion about risk and benefits and your doctor gives you a referral slip, then that generally is going to be covered."

Still, the story does highlight the extent to which cost factors into health care decisions, even after the possibility a life being saved is recognized.

Comments (11)

"But if you are in your 40s and have a discussion about risk and benefits and your doctor gives you a referral slip, then that generally is going to be covered."???? Many women who found out they had cancer from a mamogram say they were not in a high risk group. No family history of breast cancer, etc. I say ALL women who have breasts are at risk and should be screened. How can anyone say it's not worth the cost to save lives.

Posted by Mary Petersen | November 17, 2009 9:23 AM

As a former chair of the East Metro Board of Directors of the American Cancer Society, I'm disappointed by USPSTF findings.

As a public releations professional, let me offer this warning to any private health insurance plan thinking of changing your coverage of mammograms because of this new recommendation.

How would you like 100 angry, pink-clad breast cancer surviors in your lobby, with signs and a cancer specialist with talking points? Along with every television station camera in town -- including a few national media?

Take my advice, you don't want to go there.

Posted by Bob Moffitt | November 17, 2009 9:36 AM

I wish the news articles mentioned what the comparison was? Money? ... gotta tell you, that's what people will assume. And, as Mr. Moffitt offers, that will destroy any ability of the public to accept this.

Was the comparison about "worth it" based upon the fact that getting a mammogram exposes the woman to radiation, which is also bad for you? Having a mammogram has health consequences of its own.

That argument is no different than taking drugs, where there's a potential health risk on an individual level. But, is the probability of that health problem high enough to warrant taking it based upon what will happen if you don't take it?

With a mammogram, there's the risk of what happens if you *do* get the exam, and the risk of *not* getting it. This can be measured in incidence of disease, without a dollar value.

And, inevitably, this is the difference between Public Health and Medicine.

Either the initial report or the initial media reporting should have included the 'yardstick' being used to measure "worthwhile".

Posted by Elizabeth T. | November 17, 2009 10:11 AM

This paragraph in the Time piece partially answers Elizabeth's question:

"The new recommendations are based on analyses of two sets of data. In the first analysis the task force examined the results of existing trials on mammography, much of which had not changed since the panel last considered the issue in 2002; this time, however, the data was re-evaluated taking into account the current, and better, understanding of the potential harms associated with mammography — information that shifts the balance of risks versus benefits of screening."

Which is to say that women should probably discuss the pros and cons of getting annual mammograms in their 40s with their doctors. It is noted that for some groups of women, reducing mammograms to a biannual schedule (every other year) retains 85% of the benefits, while reducing risks by 50%. That is good information for women to have that helps them make an informed decision. Hysterical reporting about 'mammogram panels' is not.

Posted by bsimon | November 17, 2009 10:48 AM

I had not heard - "The guidelines, if you haven't heard, recommend women not have mammograms until age 50, instead of age 40, as most groups who research the issue suggest"

But is this ANNUAL mammograms? or mammograms at all?

My wife is in a at risk group and has had ANNUAL mammograms since she turned 25. Her mother had breast cancer at 29, her grandmother died of breast cancer at 53.

Posted by BJ | November 17, 2009 10:55 AM

via - http://open.salon.com/blog/amytuteurmd/2009/11/17/new_mammography_guidelines_arent_new

These recomendations have been around since 1997. We're just catching up to what has been a standard in Europe for 11 years or so.

It's all about risk assesement... if you do not have the risk factors, is it really worth it?

I do agree with one part of the Salon article... maybe too much emphasis has been placed on one test (that can yield both false positives and negatives). Maybe we need to look at the underlying cause of the cancer and spend more money there.

Just a thought.

Posted by pcomeau | November 17, 2009 11:52 AM

//if you do not have the risk factors, is it really worth it?

My guess is there are two separate answers to that. One from women who are alive because a mammogram spotted breast cancer at a young age, and one from those who aren't.

That's the question with any risk assessment? What's one life worth?

And what's the fallout effect from answering THAT question?

Posted by Bob Collins | November 17, 2009 12:33 PM

A line is drawn somewhere with any procedure. Why isn't the question being asked about 30-somethings? 20-somethings? Teens? What about the fact that every woman is at some risk, though it may be minimal?

Please, don't get all indignant about the value of a life until you're prepared to take the logic to its conclusion. Guidelines must be established pragmatically, not emotionally.

Posted by isherwood | November 17, 2009 12:56 PM

Asking a question of placing a value on a life is not the same as being indignant.

The reason we're not talking about teens, 20s and 30s is simple. The American Cancer Society and medical researchers set the bar at 40.

It's not a debate between me and the government. It's a debate between independent cancer groups and cancer groups established by the government AND -- more importantly -- the fallout from whichever side "wins."

The time to talk about it, frankly, IS right now; not later.

Posted by Bob Collins | November 17, 2009 1:13 PM

Asking a question of placing a value on a life is not the same as being indignant.

Exactly... and in fact values are already placed on lives by the insurance companies (not implying any evil here, this is the simple fact of actuarial tables. Numbers driven risk assesments to determine amount and degree of coverage).

We like to ignore this in the U.S. but sadly, at some point, we have to make a decision of worth of a human life. Is it worth it to continue life support, Is it worth it that a 70 yr old get screened for cancer. Is it worth it to screen a 12 year old.
What is the cost of treatement if caught early, late, etc.

Part of the reason we are in this mess is we refuse to discuss the tough questions... Rationing of health care is already happening, and will always happen. What isn't happening is discussing what needs to be rationed and why, including the ethics of it all.

Welcome to life...

Posted by pcomeau | November 17, 2009 1:49 PM

//What isn't happening is discussing what needs to be rationed and why, including the ethics of it all.

It's not? (g)

Posted by Bob Collins | November 17, 2009 2:19 PM