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While Health Reform Falters, Mammogram Debate Still Rages

Vitter244.jpg
Vitter244.jpg

Sen. David Vitter (R-La.) (WDCpix)

When a preventive-health panel stirred a storm last November by scaling back its guidelines for breast cancer screening among 40-somethings, Congress was quick to intervene. Indeed, it took just 17 days before senators unanimously agreed to bar the government from using those recommendations to inform federal coverage policies — public or private.

The message was clear: More screenings, not fewer, are better for women’s health.

[Congress1] Yet as the dust settles and Washington’s attention shifts elsewhere, some prominent physicians are questioning the wisdom of the congressional decision to swoop in so quickly to dismiss the expert recommendations. Writing this month in the Journal of the American Medical Association, or JAMA, these doctors are blasting Congress for politicizing an issue they say is better left to medical science.

It’s not a new argument. Preventive care specialists and some journalists were making it in November. Still, that a respected medical journal has returned to the issue now is a good indication that, even if the Democrats’ plans for health reform have hit a wall after last week’s special Senate election in Massachusetts, the thorny debate over preventive health care is far from dead.

“Screening is not simply about benefit, it also causes important harms,” Steven Woloshin and Lisa M. Schwartz, both physicians at Dartmouth Medical School, wrote in the Jan. 13 issue of JAMA. “To make good decisions about screening, patients should understand the trade-offs.”

In the case of routine mammograms, the authors contend, the benefits for women in their 40s are minimal. Without screenings, 3.5 of 1,000 40-somethings will die from breast cancer over the next decade, they note. With screenings, 3 of 1,000 will succumb to the disease — meaning that it requires 2,000 tests to save one life.

“For most women with cancer, screening generally does not change the ultimate outcome,” Woloshin and Schwartz argue.

On the flip side, they say, the harms can be considerable. In some cases, the test comes back mistakenly positive, subjecting the patient to the devastating, if temporary, thought that she’s got a life-threatening disease. In other instances, the test uncovers slow-growing cancers that, even if never found, pose no threat to the patient through her lifetime. The treatment of those latent cancers exposes women to the harms associated with surgery, chemotherapy, or radiation — as well as the constant fear of recurrence.

Steven H. Woolf, a physician at the Virginia Commonwealth University School of Medicine, said those harms shouldn’t be taken lightly.

“Advocates of mammography and cancer survivors often belittle these harms, but a moral duty exists when subjecting millions of asymptomatic women to a procedure that benefits relatively few,” Woolf wrote in the same issue of JAMA. “Whether hundreds of women should endure the consequences of inaccurate mammograms to save one woman’s life is a legitimate ethical question.”

The controversy spins around new recommendations, crafted by the U.S. Preventive Services Task Force, suggesting that 40-something women should no longer get routine annual mammograms, but instead should talk first to their doctors about the potential harms associated with those tests. The task force also recommended that routine screenings for older women occur every two years, rather than annually.

[A clarifier is in order here: Routine mammograms refer, under current protocols, to the annual tests given to asymptomatic women aged 40 and up. *Diagnostic *screenings, on the other hand, occur after a lump or other abnormality is detected. The task force controversy surrounded only the former. Some insurers cover only the latter.]

Many lawmakers defended the guidelines. But others pounced, voicing concerns that private insurers in search of greater profits — or governments in search of leaner budgets — might point to the guidelines as reason to scale back coverage of routine tests. It didn’t help that the recommendations were unveiled in the middle of the most ferocious health reform battle in generations, and that the Democrats’ reform bills would rely on certain task-force guidelines to steer minimum coverage standards for private insurers.

“This is when you start getting a bureaucrat between you and your physician,” Rep. Marsha Blackburn (R-Tenn.), warned at the time. “This is how rationing begins.”

The irony, of course, was that Blackburn was the bureaucrat accusing an independent panel of preventive-care experts of being bureaucrats — a dynamic which raised immediate questions about the capacity of Congress to weed out unnecessary procedures if lawmakers stand ready to riot each time medical science calls into question the entrenched habits of patients and providers.

“The politicalization of medical care is wrong,” Woloshin and Schwartz warn broadly. “Promoting screening irrespective of the evidence may garner votes but will not create healthier voters. It may do the opposite.”

No matter. Less than three weeks after the guidelines were published, the Senate stepped in with an amendment to the Democrats’ health reform bill prohibiting the government from using them to craft policy. Sponsored by Sen. David Vitter (R-La.), it passed unanimously without a tallied vote.

A second amendment, sponsored by Sen. Barbara Mikulski (D-Md.), bars insurance companies from denying coverage for a host of preventive-care services to be named later by the White House. Aside from mammograms, the provision is designed to cover screenings — at no cost to women — for other prominent diseases, such as diabetes, cervical cancer and heart disease. The Mikulski amendment passed 61 to 39.

“We don’t mandate that you have a mammogram at age 40,” Mikulski said on the Senate floor before the vote. “What we say is, discuss this with your doctor. But if your doctor says you need one, you are going to get one.”

Though mischaracterized in the press and misunderstood on Capitol Hill, that’s precisely what the panel had recommended.

“[T]he controversy was fueled by a chain of false premises,” wrote Woolf, a former member of the task force.

Still, there remains a great deal of disagreement within the medical community about the wisdom of the new guidelines. Wendie A. Berg, a Maryland-based radiologist specializing in breast cancer, said the panel’s conclusions are both “puzzling” and “problematic.”

“There are downsides associated with screening, but most women would not consider these harms,” Berg, also a consultant to Naviscan Inc., a manufacturer of imaging equipment, wrote in JAMA. “The overwhelming majority of women are willing to accept these downsides as part of the process of saving lives otherwise lost to breast cancer.”

The issue might go away for a while. In the wake of Republican Scott Brown’s Senate win in Massachusetts last week, the Democrats no longer have the 60 votes to usher a merged health reform bill through the upper chamber. The astonishing development has left party leaders at a loss for what to do next. Some are suggesting that they move on to other issues and return to health reform later in the year. Whenever they do, Woloshin and Schwartz have some advice.

“It is important for the public to remember that the goal of medicine is to help patients live healthier longer lives,” they wrote. “Sometimes more testing helps to reach the goal, but other times less testing does.

“Suggestions to do less may be as much in an individual’s interest as suggestions to do more.”

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