Friday, November 20, 2009

How many women does breast cancer cost?

This week, the U.S. Preventative Services Task Force (USPSTF) released new recommendations for mammogram screenings. The most dramatic of the recommendations states women in their 40s should no longer receive the screenings and women 50-74 should receive screenings every two years.

The reasoning behind the new recommendations is contrary to the long-standing position taken by the American Cancer Society, which recommends women begin receiving mammograms at age 40 (annually for women over 50). The USPSTF explained its new recommendations by saying many women experience “false positives, anxiety, and unnecessary biopsies as a result of the test.”

The USPSTF justification is not only troubling - it is condescending. The agency is taking the position that because women in their 40s may experience unnecessary anxiety, they should not be screened at all? This says nothing about the anxieties of being diagnosed with breast cancer, a diagnosis almost 200,000 women are expected to receive before the end of 2009. It also has no comment to the fact that early detection of breast cancer is critical in lowering women’s risk of death from the disease. Beyond all of that, it implies women are too fragile to deal with the anxieties themselves, and therefore need “protection” from the process completely.

The data proffered by the agency is essentially a cold, economic analysis:

“The task force acknowledges that mammography saves lives among women in their 40s. But it estimates that more than 1,900 women have to be screened for a decade to save a single life. Among women in their 50s, when breast cancer is more common, only about 1,300 women have to be screened; among women in their 60s, only 377.”

I am not naive to the fact that cost-benefit analysis plays a role in major agency decisions, particularly in allocation of resources, but this is disturbing. Dr. Otis Brawley, Chief Medical Office for the American Cancer Society, shares my concern. "With its new recommendations, the [task force] is essentially telling women that mammography at age 40 to 49 saves lives; just not enough of them.”

This news was followed quickly by a release this morning recommending young women push back the age at which they begin receiving cervical exams. Dr. Cheryl B. Iglesia, the chairwoman of a panel that developed the guidelines, assured the New York Times the releases are not political. However, that certainly does not mean the application will not be. While a universal health care package can mean valuable screenings for the uninsured, continued release of materials like this could mean a reduction in coverage for preventative care.

My mother was diagnosed with breast cancer in her 40s. There was previously no history of the disease in our family. Her doctor found it during a routine screen, so early that my mom couldn’t even feel it when her doctor pointed it out. However, if given another year, doctors predicted her survival rate would have been less than 25% what it was at the time it was discovered. This scenario may not be the most common, but it is a reality. Even though the decision to begin mammogram screenings remains a doctor-patient conversation and it appears women could still elect to begin screening at 40, what are some other implications of these regulations? Is the cost-benefit analysis playing an appropriate role in these decisions? Perhaps the most difficult question, should factors apart from finances be considered in determining how many women a regulation “costs”?


Eve said...

A few years ago I began having a number of reproductive issues that require more frequent check ups. I now just need a check up once a year, but each year when I request an appointment I deal with the same issue: the receptionist asks me about the time I last received an exam and then tells me that I can wait another two years. The receptionist never asks me about my medical history.

It is unwise to recommend that women change the regularity of their exams because only so many women that are screened have cancer. I am 24 years old and otherwise in perfect health, just because statistics say I may not need annual exams does not mean that these exams did not save my life.

Insurance companies penalize young women because of their potential to reproduce, and then agencies discourage annual exams. These policies may alleviate some women from anxiety, but they will kill others.

Erin S. said...

This is very troubling. It also makes me want to do a larger investigation into attitudes in the scientific community towards medical conditions suffered only or mostly by women. Was thinking this yesterday, too, as I medicated a migraine. Three times as many women as men suffer from migraine; is it a coincidence that medicine knows so little about the causes of this debilitating condition? But then again, maybe I'm being a little too cynical.