Public furor, professional hand-wringing and political posturing over a revised recommendation on mammography screening for breast cancer issued this month by the U.S. Preventive Services Task Force points to a pair of little-discussed but critical impediments to real progress in improving the efficiency and the effectiveness of our healthcare system:
- Our primary media sources of information are increasingly incapable of dealing effectively and informatively with complex or subtle issues.
- We as a society may not be mature enough – culturally, politically, emotionally or intellectually – to make reasonable decisions about the proper balance between individual and collective benefits.
Overcoming these impediments – or working around them – may be essential to achieving the goals of healthcare reform.
There is nothing original in noting the impoverishment of media content: Reliance on sound bites at the expense of depth; the search for sensationalism at the expense of substance; the rush to judgment; the total lack of qualitative evaluation in airing views, allowing serious subject matter experts to be “balanced” by unqualified and non-vetted opponents.
All of these tendencies are writ large in the reporting on the USPSTF’s new mammography screening recommendations. Many media reports focused on how the revised recommendations were “confusing” women; I’d argue to the contrary that the report – if read – is quite clear, that it does not represent a major change, and that any confusion is the result of superficial and ultimately inaccurate media reporting.
The principal points of controversy in the revised recommendations have been widely reported as:
- Where the prior (2002) recommendations supported annual mammography screening for women beginning at age 40, the new recommendation opposes screening of women ages 40 – 49;
- For women ages 50 – 74, the frequency of recommended mammography screening has been reduced from annual to biennial.
Now let’s look at the actual language of the 2002 recommendations and compare it to the language of the newly revised Recommendations:
“The U.S. Preventive Services Task Force (USPSTF) recommends screening mammography, with or without clinical breast examination (CBE), every 1-2 years for women aged 40 and older.”
The Task force went on to say: “The precise age at which the benefits from screening mammography justify the potential harms is a subjective judgment and should take into account patient preferences. Clinicians should inform women about the potential benefits (reduced chance of dying from breast cancer), potential harms (for example, false-positive results, unnecessary biopsies), and limitations of the test that apply to women their age. Clinicians should tell women that the balance of benefits and potential harms of mammography improves with increasing age for women between the ages of 40 and 70.”
“The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.”
“The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.”
In more colloquial terms, the “conflicting recommendations” for the younger age cohorts come down to this:
- 2002 – Women above age 40 should be screened every 1-2 years, but we don’t really know at what age benefit of screening outweighs potential risks, and you should talk with your doctor, get all the information about benefits and potential risks, and make a decision that fits your individual circumstances.
- 2009 – Women ages 40-49 shouldn’t be screened as a matter of routine; they should talk with their doctor, get all the information about benefits and potential risks, and make a decision based that fits their individual circumstances.
For the 50-74 age cohort, the revised recommendation makes explicit something that was well understood and documented in the 2002 recommendation – there are no good data comparing 12-month screening to 24-month intervals, no evidence that annual screening is meaningfully better than biennial; the available research on the benefits of screening tends to rely on a “screened” cohort with screening frequency in the range of 12-33 months.
A clear-headed review, based on a full reading of the recommendations and their rationale, reveals that the new revision is a carefully modulated and subtle change in emphasis – away from automatic annual scheduling for all women regardless of personal characteristics and toward well-informed joint patient-physician decision making based upon consideration of individual characteristics. At age 50, the risks of breast cancer have increased to the point where more nearly automatic screening every two years is advised; women at elevated risk will probably choose to continue annual testing. One cannot help but note that the emphasis on personal characteristics sounds the themes of the “personalized medicine” revolution – and it is perhaps no coincidence that one real change from 2002 to 2009 is the clearer understanding of the genetic basis of many breast cancer cases, and the increasing acceptance of genetic testing to predict breast cancer risks. Widespread testing for genetic predisposition before age 40 would allow increasingly objective assessment of the utility of mammography screening for individuals in the 40-49 age group.
I’ve commented elsewhere on the immaturity implicit in our national obsession with heroic intervention at the end of life, and how that interferes with efforts to make rational decisions about healthcare resource utilization. A similar dynamic is displayed in the public reactions to the perception that screening is being discouraged. Every television outlet in America appears to have aired an interview with one or another woman saved because a mammography before age 50 discovered a cancer of the breast. Invariably, these women are affronted by the idea that every woman should not be screened; the message, explicit or implicit, is, “If these people had their way, I’d have died.”
These personalized stories are emotional and compelling; no one can coldly dismiss them. Of course, the Task Force did not dismiss them either – the report clearly documents estimates of the number of lives that would likely be saved if every woman were screened beginning at age 40. Mature and rational policy processes require that we remain mindful of these individual stories, but go beyond them to look at the broader collective picture – the discomfort of the many, the emotional impact of the false positives, the unwarranted security of the false negatives, the costs of the unnecessary biopsies, the opportunity costs of the resources devoted to the low “yield” of true positives. Wisdom lies in finding the proper balance between going the extra mile for safety or a good outcome for the few and policies that invest limited resources in a socially optimal way. Our future healthcare security requires that we apply such wisdom more broadly and soon.
Edward Berger is a senior healthcare executive with more than 25 years of experience in medical device reimbursement analysis, planning and advocacy. He’s the founder of Larchmont Strategic Advisors and the vice president of the Medical Development Group. Check him out at Larchmont Strategic Advisors.