The squabbling generated by recently revised mammography screening guidelines showed that in the great American health care reform debate, physicians like myself are not always above the fray. In fact, we can sometimes be the fray.
Consider the American College of Radiology's official counterpoint, which began with the sensational headline: "USPSTF Mammography Recommendations Will Result in Countless Unnecessary Breast Cancer Deaths Each Year."
Countless? No, in fact one of the clinical reviews that informed the United States Preventive Services Task Force (USPSTF) new recommendations put up a very specific number of how many women would die of breast cancer under the new guidelines. In order to prevent one woman aged 40-49 from dying of breast cancer, 1,900 women would have to be screened for a ten-year period. Weighing the benefit of saving one life against the harms generated by the screening process -- primarily the additional testing that women with falsely positive screening mammograms would have to go through -- the USPSTF decided that it was no longer worth recommending routine screening of women in this age group.
Putting it another way, the USPSTF decided that in a ten year span, it would be better to let one women die of breast cancer than to have 1899 women undergo testing that in the end would be of no benefit, or even some detriment, to them. Universal screening is, after all, a kind of a lottery in which everyone agrees to put something at risk, with the hope of being the One who wins it big. Some people go for lotteries, while others abstain.
Of note, the task force continued its counting, concluding that screening 1,300 women aged 50-59 for 10 years would prevent one death, and that only 400 women aged 60-69 would have to be screened to save one life. In these age groups, the USPSTF enthusiastically supported mammographic screening.
The recommendation not to routinely screen women aged 40-49 for breast cancer came as a reversal of guidelines previously issued by the USPSTF in 2002. Understandably, this felt like a betrayal to those who've dedicated their energies to fighting breast cancer, particularly to women who've had their lives saved by a mammogram.
Why did the USPSTF do an about-face? The report states that the new recommendations were based on data from several new randomized controlled studies on breast cancer screening, and from a new, more sophisticated review of previous data. New data, new review, new recommendations.
The American College of Radiology (ACR) found the new recommendations to be more flawed than novel, and they came out swinging. If you're not in the sciences, you'd be surprised at how subjective objective data can be. It seems that the facts often vary, and when they don't, their interpretation does. Though physicians would like to present a unified, spotless lab coat appearance to the public, a certain kind of scientific wrangling goes on all the time. But the ACR's statement appeared more inflammatory than educational, more K Street lobbying than scientific debate. If entrenched vitriol is a genre of literature you enjoy, you should read the entire statement for yourself .
Attacking the science as 'seance'
It's well recognized within my profession that USPSTF screening recommendations tend to be more conservative than those issued by other prevention groups. But that wasn't the nuanced argument the American College of Radiology statement was trying to make when it claimed the USPSTF recommendations ignored "valid scientific data" and "direct scientific evidence from large clinical trials," were "inconsistent with current science," and were, in a word, "unfounded." On the contrary, the recommendations were heavily "founded" and based on a comprehensive review of the most current research. One may disagree with the conclusions that the USPSTF drew from the data, but to repeatedly accuse the task force of being more seance than science is, well, "unfounded."
Assigning intent: the government made me do it
The ACR went on to depict the USPSTF as being a government pawn bent on reducing costs by rationing care, noting that the task force was "created by a federal government-funded committee," and that "The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) gave HHS the authority to consider USPSTF recommendations in Medicare coverage determinations for additional preventive services."
But is federal funding for health research a bad thing? Because the alternative has increasingly become a plethora of biased, industry-sponsored studies, and I've had my fill of those. I'm not out to demonize the health care industry, but their loyalties are to shareholders first and patients second. Dolphins don't swim for pleasure: it's who they are. And businesses exist to make money, the more the better. Industry-sponsored studies are understandably designed to put their pill or device in the best possible light, and we've seen repeated instances where the industry either slow-tracked or left unpublished studies that appeared to have unfavorable results. Under the heading, "Don't ask the barber if you need a haircut," if we chose a health care system where private-industry is both the dog and the leash, we're destined to go wherever the dog wants. And the dog prefers high profits over low profits.
The Voice of Reason
The antithesis of the American College of Radiology's provincial, turf-protecting press release is an LA Times op-ed piece by breast cancer specialist Dr. Susan Love. "Weighing the Benefits of a Mammography" is a smartly-crafted, honest, forward-thinking view of the complexities of breast cancer and breast cancer screening.
"Although we all would like to think that public health pronouncements are the unmitigated truth about any issue, rarely is that the case," wrote Dr. Love. "We can only give our best guess, based on the available data and our understanding of the disease. Luckily, research continues, hypotheses are reformulated and new recommendations are made."
Love wrote that the shift in guidelines was not the result of a government or insurance company conspiracy, but came about because a lot has changed since the last recommendations were made in 2002. She pointed out that we now have a different understanding of the biology of breast cancer, realizing that "breast cancer" is really "breast cancers"--different kinds of breast cancer growing at different speeds and with different levels of aggressiveness. She pointed out that mammograms are less accurate in the denser breast tissue of younger women, who also are more sensitive to the carcinogenic effects of low-dose radiation. Love quoted a 2005 British study suggesting that it is possible for women to develop breast cancer because of the cumulative radiation from yearly mammograms.
"The public anger at these recommendations is understandable," wrote Love. "But it should be directed at an honest effort to evaluate the benefit of mammography, and at the fact that we still don't know the cause of breast cancer or how to prevent it. Early detection is not our best prevention -- it's not even prevention. It just finds cancers that are already there."
The Rx for what is ailing our health care system
If we're ever going to get control of the Beast -- a health care system that is draining everyone's bank account and making some people sick--we'll have to hold honest, publicly-digestible discussions about what each particular medical intervention can do for us in terms of lives lengthened or lives improved; and what it will cost us, both personally and financially. That's because science can only inform us; it can't tell us what to do. Part in parcel to these discussions will be an admission that if our health care resources are not limitless, when we choose to do one thing, we choose against another. If you want to call that rationing, fine.
Who will lead those discussions? Political leaders have proven incapable of giving the public any bad news (we tend not to re-elect those who do), and the insurance and health care industries have their profits to think about. That leaves physicians and health care scientists to lead us through these increasingly complex choices. The American College of Radiology's response to the USPSTF recommendations is a reminder that physicians can be entrenched and profit-driven. And Dr. Love's response is proof that in our best moments, we physicians deserve the trust that patients and the public have honored us with.
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