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# Give Thanks To Kathleen Sebelius For Saving 47,000 Women From Death By Cost-Benefit Analysis

Posted: 11/24/09 03:43 PM ET

Cost-benefit analysis can kill. The failure to distinguish statistics from arithmetic can kill. In the current debate over mammograms, the number of women projected to be at risk of death due to cost-benefit analysis is about 47,000.

That is the approximate number projected to die by the United States Preventative Task Force if their recommendations on scaling back mammograms had been accepted. It is their number, if you do the arithmetic, which they apparently did not.

Their statistics say that the life of "only" one woman in 1900 will be saved if mammograms start at age 40 instead of age 50. In other words, a 40-year-old woman's "risk" of dying from breast cancer in the next ten years is only 1 in 1900. That seems like no risk at all. 1 divided by 1900 equals .000526. About half a woman per thousand. Miniscule, right?

Now, how many women in America would be affected?

The most recent (July, 2008) census figures say there are about 304,000,000 Americans, of which 50.7 percent are female. That's about 154,000,000 females. Roughly 80,000,000 of them are under forty and about another 20,000,000 between 40 and 50. Of the 80,000,000 under 40, each one, under the proposed guidelines, would not get a mammogram until age 50. If "only" 1 in 1900 die as a result, that would be .000526 times 80,000,000, which equals about 42,000.

In short, moving the mammogram age from 40 to 50 would result in the deaths of 42,000 women now 40 or under, according to the statistics of the United States Preventative Task Force. Of the 20,000,000 between 40 and 50, it could mean the deaths of as many as 10,500 women, though the figure may be somewhat lower because half are more than halfway through the critical period. There might be as few as half, say, 5,000 deaths. Adding 42,000 and 5,000, we get a ballpark figure of 47,000 of currently alive American females who would die needlessly under the proposed task force restriction on mammograms. Of course, as more are born, the absolute numbers would go up.

What is at issue is called "framing." The Preventive Task Force chose the probability of risk frame: only 1 in 1900. But the arithmetic frame reveals the more important truth.

Framing, in this case as in so many others, is a matter of life and death. Take the framing in the NY Times (November 18, 2009) in the front-page news analysis by Kevin Sack and in the op-ed by Robert Aronowitz. Sack frames the mammogram debate as the "science of medicine" versus "medical consumerism." Aronowitz calls it "wishful thinking" that early mammograms could help and speaks of "the very small numbers of lives potentially saved."

You can see why cost-benefit analysis can kill. Its use isn't science. Real scientists do arithmetic as well as statistics. Medical science is about real people, not percentages or statistics, especially when large numbers of real people are involved and small differences in risk can produce large numbers of deaths.

The Preventive Task Force also uses the "harm" frame. The task force observes that more mammograms mean more false positives and claims that false positives do "harm." But no science is presented showing that the "harm" done is greater than the deaths of 47,000 women.

What is the "harm?" Anxiety and unnecessary biopsies from false positives are listed as the "harms." My wife had such a false positive. The anxiety came for economic reasons: she had to wait for a biopsy because no one who could perform one was present when the mammogram was done, due to economic restrictions. The biopsy when it came was simple: a needle inserted to withdraw fluid, like taking a blood sample. No harm. If the biopsy had been done immediately, there would have been no need for anxiety. But the task force does not recommend immediate biopsies as a way to eliminate such "harm."

Aronowitz also claims that the figures show that mammograms haven't helped prevent breast cancer. He observes that the rate of 28 breast cancer deaths per 100,000 people has not changed substantially since the 50's, despite more mammography and better treatments. But that could mean, and probably does mean, that there has been an increase in breast cancer offset by earlier detection and better treatment, saving tens of thousands of lives, but not affecting the overall rate. But he did not consider the possibility that the occurrence of breast cancer might have increased, while the rate of deaths did not change because of earlier detection due to mammograms.

I suspect that the real "harm" intended is economic harm - the costs of the "unnecessary" mammograms and biopsies. But the task force gives no figures weighing the economic costs versus the human "cost" of the deaths of 47,000 women. Now, in cost-benefit analysis, a commonly cited figure for the value of an American life is \$6.5 million. 47,000 times 6.5 million is \$305, 500,000,000. That is, 305 billion five hundred million dollars. Of course, that would be spread over the next forty years, but it's not clear that such a cost-benefit analysis would make this less than the cost of mammograms and biopsies, all moral issues and human costs aside. Unfortunately, the Preventive Task Force doesn't do the calculation, so my figures may be off. The exact figures are not the point. The point is to go beyond rates to numbers.

In the present debate over health care, economics has become the main issue, but the Preventive Task Force hides it by framing. "Cost-benefit analysis" has been reframed as "risk-benefit analysis," as if the Preventive Task Force were not concerned with "cost" to insurance companies and tax-payers, but rather with "risk" to women. But "risk-benefit analysis" is just cost-benefit analysis, which in turn is what corporations use to maximize profit in the short term. Both cost-benefit analysis and the Preventive Task Force were introduced as government institutions by the Reagan administration. They were right-wing moves - part of the strategy to privatize government.

As the Obama administration shifted the health care debate from morality to economics, cost-benefit analysis entered in the form of "evidence-based medicine," where the "evidence" comes from statistics. This is seen as a major way to reduce the cost of health care. This is where "risk-benefit analysis" is cost-benefit analysis publicly and proudly discussed.

Is such an application of cost-benefit analysis always immoral? Hardly. It can be very useful. But it has to be looked at carefully, as the mammogram example shows. In the mammogram example, low probability events can have major effects!

When is a case of "evidence-based medicine" that uses cost-benefit analysis an instance of low probability events that can have major effects, effects serious enough to far outweigh the cost-benefit analysis? This is a serious and difficult question.

It is also a question of concern in the Obama White House. There are three high-powered experts there committed to such questions. One is Ezekial Emanuel, Rahm Emanuel's brother, who is perhaps the best-known advocate of evidence-based medicine. He is an advisor to Peter Orszag, Budget Director, who sees medicine as an economic problem. The third is Cass Sunstein, Obama's Administrator of the White House Office of Information and Regulatory Affairs, also known as the cost-benefit czar. Sunstein is known for specializing in low probability events that have major effects. Political observers should watch how such issues are handled by the administration as they arise.

The official administration reaction is so far against the Preventive Task Force recommendation. Health and Human Services Secretary Sebelius has rejected it and said to make no change.

Hooray for Kathleen Sebelius! Tens of thousands of women owe her their lives.

The political fallout has been instructive. Business columnist for the Washington Post Steve Pearlstein (November 20, 2009) attacked Sebelius as not wanting to save money, but rather promoting waste. This is pretty much what the NY Times position (both front-page analysis and op-ed) seems to be. Most voices on the right have ignored Sebelius' official response and instead attributed the Reagan-era Preventive Task Force's recommendations to official Obama Health care policy, calling it "rationing" health care, while ignoring the fact that most rationing of health care is actually done by insurance companies. As expected, the most radical conservatives have seen this not only as an Obama move, but have likened it to mythical "death panels."

I stand with Sebelius, and I take it to be the official Obama administration view. When arithmetic is added to statistics, this is a clear case of a low probability event with major life-and-death consequences for tens of thousands of people. The overly simplistic framings -- either accepting or rejecting the cost-benefit analysis without looking further -- are dangerous. Just accepting the task force's recommendation is dangerous to the women of this country, now and in the future. Calling it "rationing" and using it to argue against the health care bills in Congress is dangerous to us all.

As we sit down to Thanksgiving dinner, let us thank Kathleen Sebelius.

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04:31 PM on 11/28/2009
Mr. Lakoff: Suggest you read http://www.theatlantic.com/doc/200911u/mammograms.
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blindjester
English and ESL teacher
12:04 AM on 11/29/2009
I read it. It supports his point.

The article you mention indicates that the screening may save 2 lives out of 1900, rather than only 1. (That's with a rate of 7.47 deaths per 1900, rather than 9.5 per 1900, which is the difference between .39% dying with the screenings, and .50% dying without.)

You might argue that 2 extra survivals out of 1900 (let's call it about 1 in a thousand) may not be worth much. But I prefer Mr. Lakoff's framing.
06:26 PM on 11/25/2009
From what I have read on this subject so far, I cannot agree that the decision to stop recommending mammograms for women that are 40 - 50 is strictly based on the money it would save. The statistical one woman with cancer costs more than the mammograms cost for all of the 1899 statistical women that would be cancer free.

Sorry, it just isn't rationing or some plot against women. Please remove the tea bags from the tin foil hats.

The arguments I have heard against mammograms in the 40 to 50 age range are specifically based on the science involved. There are several studies that show that mammograms are not always accurate. Not only is there the false positve problem, but there is a much more troubling 21% false negative problem. If the mammogram procedure does not effectively detect cancer, then what is the point of doing the test?

Why aren't we pursuing more effective methods of detecting breast cancer?
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RMankovitz
Researcher, inventor, entrepreneur, author
02:16 PM on 11/25/2009
One answer to this issue is better technology that can detect lesions in dense breast tissue, while causing no harm - no radiation and no compression. The latest advances in thermography would seem to fit the bill. It appears to be particularly efficacious for uncovering cases of fast-growing cancers in dense breast tissue, ideal for those women under 50. See:

The important role of infrared imaging in breast cancer:

http://ieeexplore.ieee.org/xpls/abs_all.jsp?arnumber=844380

Thermal Infrared Imaging in Early Breast Cancer Detection:

Technological advances now make thermography a serious contender in the field of breast imaging. Here is a link to a study performed in conjunction with the scientists that developed and improved this technology:

Use of digital infrared imaging in enhanced breast cancer detection and monitoring of the clinical response to treatment:

http://ieeexplore.ieee.org/xpl/freeabs_all.jsp?arnumber=1279447

I suggest that breast cancer support groups give some consideration to funding clinical trials in the field of breast thermography. Waiting for the medical community to take action may not be in the best interests of patients. After all, the medical community is the third leading cause of death in the U.S. See:

http://silver.neep.wisc.edu/~lakes/iatrogenic.pdf

My interest in thermography is purely as a research scientist, and I have no personal affiliation with the profession.

Roy Mankovitz, Director
http://www.MontecitoWellness.com
01:49 PM on 11/25/2009
To me, all of these comments precisely highlight the need for MORE cost-benefit analysis by impartial observers - not less as George Lakoff suggests. While I respect Lakoff's general focus on framing, on many issues, There are so many factors that the average citizen or blogger or talkshow host or professor of linguistics does not see or understand. Many have been pointed out already:

* How many cases of cancer would be detected? How many lives would be saved?
* How many cases of cancer would be caused? How many lives lost?
* Screening 200,000 women aged 40-49 would cost \$2 billion each year. Would those expenses and resources be better spend elsewhere? Perhaps research on breast cancer treatment? Perhaps immunizations for children? Perhaps body armor for troops in Afghanistan?
* False positives occur in about 5% of mammograms - so it would appear that most mammograms are indeed wrong, leading to not only anxiety, but also unnecessary biopsies (around \$2000 x 10,000's of women).
* Others I am overlooking ....

Let the experts figure it out. If you care enough, look at recommendation in detail and enter the debate with those experts. But the knee-jerk reactions ("the 'other' party proposed this so I will automatically oppose it") is getting so old so fast. It would be SO refreshing if people started from common ground and worked toward a solution, rather than starting from the differences and shouting past each other!
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csmith14
01:11 PM on 11/25/2009
Unfortunately, Mr. Lakoff who is usually a very good writer, starts from a false premise. He writes, "Their statistics say that the life of "only" one woman in 1900 will be saved if mammograms start at age 40 instead of age 50." He then takes the population of women age 40-50 and extrapolates. The study, however states that for every 1900 mammoagrams done on women age 40-50, 1 will detect a cancer and save a life. There is a subtle difference in these claims, that will lead to a different statistical analysis concerning the efficacy of screening for women in the 40-50 category. The study then calculates risks associated with screening, yes they do exist. that there is value to this approach may be seen by asking a simple question. What about screening 30-40 year olds? How many screenings are needed to catch one cancer and save a life? Is it worth it in terms of both cost and risk? How about 20-30 year olds? One quickly sees that this type of analysis must be done to achieve better health outcomes. I am not an expert in this field and do not know if the study is correct. However, Lakoff frames the issue in an incorrect manner.

T
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12:51 PM on 11/25/2009
Saving a life is always very noble and beyong reproach. By the same token, we should probably do mammogram screening in men since men also get breast cancer, although a very miniscule percentage. The essential point is some cancers could have spread even before they are detectable. These are the most malignant variety and finding them by mammography, no matter how early, does not cut down the mortality rate in these unfortunate patients. Whether early detection actually saves that many lives is debatable because the degree of malignancy determines the mortality in most cases. If one uses statistics this way, one should probably recommend screening of women starting at age 20. Disregarding the harmful consequences of a large number of false positive mammography findings, not to mention the vast amount of wasted resources just because life could theroretically be saved by early screening of all types of cancers and the earlier the better, will eventually bankrupt the entire health care system, sooner rather than later.
12:37 PM on 11/25/2009
One interesting thing that has come out is the claim that mammograms between 40 and 50 would cause as many deaths as would be save.

I am curious how that statistic can be validated. How 10 to 30 years after the exposure can it proven that a breast cancer was caused by a single exposure to low level radiation, and specifically to the mammogram?
What demographic of women aged 40 to 50 who had a mammogram but never had any radiation exposure after aged 50 was used as a comparison to a control group of women 40 to 50 who had no mammogram and also had not exposure to radiation after the age of 50?
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11:42 AM on 11/25/2009
And yet, going by the new guidelines, cancers discovered in 50 year old women might have already advance too far to treat successfully. And what if one of those two women in a 100 is your mom, daughter, sister, wife, friend or yourself? I would much rather err on the side of safety with a false positivie, than missing a true cancer. And I still don't understand why they are dismissing self breast exam.
If this is a forshadowing of rationing of health care, it is scary. I think these decisions should be made by a woman and her doctor, not a prevention task committee, which, if someone dies because they followed these guideline, could also be called a death committee.
12:07 PM on 11/25/2009
That's exactly what Sarah Palin said and got blasted by the liberals. She has been vindicated!
12:40 PM on 11/25/2009
Becaue the death panels Sarah claims are Obama's fault are actually the profit charts of the insurance companies.

Republicans get most of the insurance lobby money and Sarah lies to protect the party lies.
What she claims actually puts women at greater risk since by supporting the insurance lobby's talking points and blaiming Obama, she endangers women.
Leftie, educator, labor activist, Unitarian Univer
10:12 AM on 11/25/2009
Kathleen is the best of the best. She is a fine example of the kind of woman that Democrats appoint to important cabinet jobs. Remember GW's Secretary of Labor? She was the Asian looking (appearance token) wife of one of the Big Bush Boys. And there were others. Dem Women Rule! (and thank God they do).
ThatsTheTheWayItIs
religion, ideology, partisanship are delusional
09:34 AM on 11/25/2009
I worked in medical imaging, attended Radiologists Society North America convention annually, talked to many attendees.

Several radiologists have told me this: if the woman is under 50 years old, they generally cannot see "calcifications" (tumors), because the breast tissue is too dense and supple in young woman.

The result: 98 false positives for every 2 detection. If you're under 50, get a positive scan and a biopsy, 98% of the time it will be negative. Like any operation, biopsies have some danger, even fatality.

The simple truth: mammograms don't work well iin young woman. The technology is not good enough. The recommendations were changed to save women needless biopsies.
10:31 AM on 11/25/2009
Time to get to work on a better detection method.
10:38 AM on 11/25/2009
Yes, indeed.
MaryMay
May your tears come from laughing
08:48 AM on 11/25/2009
Women in their 40s and 50s still have years left to live if treated in time for breast cancer. The \$50 billion of federal funds spent every year to keep 80 and 90-year-olds alive for two more months as they languish in pain, with incurable illnesses, in intensive care or critical care units, should be the focus of money-saving efforts. Early detection is the most economically feasible approach to containing health care costs in relation to breast cancer. Those who benefit from early detection go on to live productive lives, to continue to work and pay taxes, raise their children, take care of aging parents, etc.

Let us not ration preventative testing like mammograms, let us ration testing done on those who pathetically cling to life at all costs, insist that every measure be taken to extend their lives by days, not years, and draw up guidelines for when federal funds and private insurance should STOP in paying for such care. If the family or the dying patient wish to continue receiving every conceivable medical end-of-life treatment, they can pay for it out of their own pockets. How many do you think would then say, "Sure, go ahead and spend whatever it takes of MY money to keep me alive!"?? Not many. As long as someone else is paying the bill, selfishness will reign.
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GoCards1978
Common sense is an oxymoron.
09:35 AM on 11/25/2009
Amen!
11:18 AM on 11/25/2009
So, am I hearing that "rationing" is a solution to our health care mess? Every democratic politician denies that rationing would occur if this health care bill is passed, yet I am reading alot of support from people on here in favor of just that. Do you suppose that they may be misleading us in believing that health care rationing won't happen, just to get our support? It sounds to me like another bait and switch scheme.
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08:45 AM on 11/25/2009
Math is flawed. Changing the age at which mammograms are recommended from 40 to 50 CANNOT change the risk of an undetected breast cancer in someone under 40. It can only increase the risk to women that are between 40 and 50. Therefore, the 42000 women that the author states will die if the new guidelines were implemented are going to die anyway under the old guidelines (more on that below).

The pertinent population is 40 to 50 year old women. Author statets thats 20 milliion women, and at an incidence rate of 1 in 1900, that indeed comes to 10500 women.

Having said that, the survival rate for breast cancer is pretty high. "Rate of incidence" is the rate at which women would be found to have brerast cancer. The author would have you beleive that we are still in the dark ages and that every woman who contracts breat cancer will die from it. Early detection is a near 100% survival rate, and even breast cancer that is fairly far along has a better than 50% survival rate. Exactly how the change in ages would affect survival rates is unknown, but presumably would lower the overall survival rate.

So 10,500 is a gross oversimplification, and grossly exagerrated a mortality rate. The 47000 number is a pure fabrication. Not arguing for or against the changes, but if your going to use math and numbers, at least be honest instead of trying to scare people.
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09:05 AM on 11/25/2009
After some additional research, the 10500 number stands as is. It is certainly an INCREASED mortality rate, and not anything to do with incidence. However, the 47000 number is still bogus math.
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Uggg
08:24 AM on 11/25/2009
United States Preventative Task Force is the main agency that is referred to in the senate bill they are for cost cutting on health care. They are not made up of a Board of Medical personnel but Accountants, and the recommendations that they make are about the buck not lives. And that is taking choice away from the individual , the Most aggressive Breast Cancer that hits women is in the late 30s and 40s and research has shown that early self exams and mammograms do save lives folks that is your death panel so to say and their statistics are flawed . The ACS and Medical Professionalâ€™s have been pushing early screening for years and that should not change
11:21 AM on 11/25/2009
But this is what the democrats want. They want an accountant in D.C. to determine if you get a mammogram. Where is the outrage in this?
12:35 PM on 11/25/2009
Its not a flawless plan, but I will take the motives of the non-profit government guy over the motives of a private insurance exec who stands to make additional money every time he successfully denies me benefits. Its a no-brainer to me.
01:47 PM on 11/25/2009
Actually, the USPSTF is made up of physician, nurses, PhD's, etc. Their recommendations are based on medical studies (see the supporting literature, linked on the USPSTF website). Research has shown that early mammograms produce many more false positives than true positives. In fact, the radiation exposure may cause as many cancers as it finds. Unfortunately, while self breast exams seem like a good idea, the results of numerous studies have shown no concrete benefits, eg reduction in morbidity and mortality; we have known this for many years (the previous 2002 USPSTF recommendations did not endorse breast self exams); though now the evidence is actually tipped towards BSE's doing more harm than good, hence the recommendation against teaching them .
http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm
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Kathleen Reardon
08:00 AM on 11/25/2009
George: Before the release of the new task for guidelines, there must have been considerable confidence that no one would come along and question the research in this way -- decipher its meaning for so many women and unearth the frames used to justify a study group that took too many leaps on the basis of too little reliable "evidence".

The links between "evidence-based research" and politicians seeking to cut costs is made clearly evident in your blog. It is the most persuasive and valuable message I've read on this topic.

If you were to add to the 47,000 women those who would cease to or never do breast self-examinations because of the task force guidelines, this number would likely rise.

This culture is shifting toward blaming people for their serious illnesses. And why? Because our frames are being affected, even infected, with cost-saving considerations. We are sliding toward considering ill people selfish if they want good health care. It's a dangerous slope for which the sliding costs will be high in lives and as a civilized culture.

We shouldn't be angry at women who want to save their lives. We should be angry at so many people who created the economic conditions that are causing us to look at each other and wonder who deserves to live.

Thank you for this. It is an excellent blog and valuable to thousands of women and their families.

Kathleen
08:18 AM on 11/25/2009
Kathleen Sebelius had no choice but to criticize the report.....which has become a major issue in the healthcare refform bill. the only people we should thank are our doctors who best advise us, and our families who stand by us through sickness and in health. The healthcare advisory committees should be abolished....especially when supported by dr. no's twin brother, , the other "emmanuel".
06:38 AM on 11/25/2009
Screening will ONLY save 1 out of 2000 women?

That can't be the math. That means at any given Penn State home football game, 25 at that game will die from not being screened for breast cancer?

I would say we should spend the money if we ONLY saved 1 in 200,000, but 1 in 2000???