What’s a woman to do? The latest health care reform is coming in the form of a report from an independent body of clinical specialists who have determined that mammography screening starting at 40 years old has lead to false positives, increased costs and other “risks” that are best handled by changing the time and number of mammograms mandated for women. According to the American College of Radiology, since regular mammography went into widespread use in 1990, the mortality rate from breast cancer has declined by 30 percent. If the recommendations are adopted, the college said in a prepared statement, “two decades of decline in breast cancer mortality could be reversed and countless American women may die needlessly from breast cancer.”
The Health and Human Services secretary Kathleen Sebelius is not driving down this point, but is instead promoting that the decision whether or not to have a mammogram is between a woman and her doctor. No one has discussed that this report is coincident with the issues surrounding healthcare costs reductions and rationing. How will health insurance companies use this study? Will they develop schemes to validate a reduction in the reimbursement for mammograms?
The over-use of new and advanced medical devices has been subject to criticism with respect to the rising costs of healthcare. We all can agree that there is no use in spending money on technologies that are neither necessary nor required. However, changing the triggering age for mammograms from 40 to 50 is not related to the over-usage of fancy mammography machines. Mammography manufacturers such as Hologic do not expect this guidance to have a major impact on their business. For their sake, I hope that they are right. So what cost saving benefits can the healthcare system derive by cutting corners in this breast cancer detection process?
Mammography, up until now, was seen as effective in early detection and in saving lives, which has produced cost savings for employers and improved the quality of life for those diagnosed with breast cancer. My good friend, Dr. Susan Love, believes that even earlier detection is the key. She posits that finding a lump through mammography is not the best approach. We are more likely to reduce the incidence of breast cancer by using technology that can analyze cells in the ducts. Her concept has been commercialized but has not reached widespread utilization.
If the demand decreases (the costs would not be covered for yearly mammograms starting at 40 years old, but only at 50 and every other year, unless you are at high risk) costs will surely increase for the test itself, the medical technology and the interpretation of the results. Will the definition of “high risk” change? If we evaluate women later, it may only put off spending money to confirm or deny false positives or true positives. Whether these new recommendations are embraced by the clinical community and, more importantly, the woman who is 1:7 at risk without a family history remains to be seen.
If a woman chooses to have a mammogram without the support of the doctor or insurance company, she will be on her own to pay for it. We will then be back to where we were before screening for breast cancer and annual mammography was a mandated benefit. Having a mammogram is not an invasive procedure, although it is an uncomfortable one.
We have made great strides with certain types of screening programs, especially this one, where we have been able to improve the quality of life for many low-income and minority women who did not otherwise have access to mammography. We will face serious challenges if many or even most women cannot afford it. The cost of treating later-stage cancer is much higher we already know. Perhaps this debate is worthwhile, but until we gather more evidence, let’s not risk women’s lives and leave them with faced with the choice of paying for a mammogram or providing for their families. The evidence we have to date confirms that getting insurance companies to pay for an annual mammogram for women over 40 years old over the last thirty years of mammography has been more cost-effective and has improved health outcomes. We should not limit our debate to the use of mammograms but include a review of other screenings that are fraught with false positives and are increasing the use of biopsies and physician visits, such as the PSA test for prostate cancer. Why should we discriminate?