    The United States Preventive Services Task Force has issued recommendations against using mammograms for routine screening for breast cancer among women 40-49, and recommends screening only every two years after age 50. What timing!
    Is this panel trying to singlehandedly kill health care reform?  In an article published today in the Los Angeles Times entitled "Mammography Outcry Points to Trouble for Healthcare Reform," Noam M. Levey writes:
A core tenet of the healthcare overhaul President Obama is pushing through Congress is that medical care can be improved — and costs contained — if the country relies more on experts to determine which procedures and treatments work best.But Monday's mammography report by the U.S. Preventive Services Task Force delivered a swift and stark reminder that few ideas are more explosive in healthcare.
    The American Cancer Society, which strongly supports health care reform so that people who are uninsured and underinsured can receive proper preventive care and treatment, has expressed opposition to the USPSTF recommendation. The ACS recommends annual mammograms in women over 40. Deborah Shlian of The Miami Health Care Examiner reported yesterday that Otis W. Brawley, Chief Medical Officer of the ACS, stated:
"As someone who has long been a critic of those overstating the benefits of screening, I use these words advisedly: this is one screening test I recommend unequivocally, and would recommend to any woman 40 and over, be she a patient, a stranger, or a family member."
    Here is a link to the USPSTF website, which describes the task force in these terms:
The U.S. Preventive Services Task Force (USPSTF), first convened by the U.S. Public Health Service in 1984, and since 1998 sponsored by the Agency for Healthcare Research and Quality (AHRQ), is the leading independent panel of private-sector experts in prevention and primary care. The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the "gold standard" for clinical preventive services.
    The USPSTF has posted this Recommendation Statement on Screening for Breast Cancer in which it sets forth these rather surprising conclusions and recommendations:
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.
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
The USPSTF recommends against teaching breast self-examination (BSE).
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.
    The Task Force admits that annual mammographies saves lives, but it contends that the harms outweigh the benefits. Here is how the Task Forces describes the risks and benefits that are involved:
There is convincing evidence that screening with film mammography reduces breast cancer mortality, with a greater absolute reduction for women aged 50 to 74 years than for women aged 40 to 49 years. The strongest evidence for the greatest benefit is among women aged 60 to 69 years.***
The harms resulting from screening for breast cancer include psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results. Furthermore, one must also consider the harms associated with treatment of cancer that would not become clinically apparent during a woman's lifetime (overdiagnosis), as well as the harms of unnecessary earlier treatment of breast cancer that would have become clinically apparent but would not have shortened a woman's life. Radiation exposure (from radiologic tests), although a minor concern, is also a consideration.
     The Task Force concludes that routine mammograms confer only a "small" benefit on women in their 40's:
For biennial screening mammography in women aged 40 to 49 years, there is moderate certainty that the net benefit is small. Although the USPSTF recognizes that the benefit of screening seems equivalent for women aged 40 to 49 years and 50 to 59 years, the incidence of breast cancer and the consequences differ. The USPSTF emphasizes the adverse consequences for most womenâwho will not develop breast cancerâand therefore use the number needed to screen to save 1 life as its metric. By this metric, the USPSTF concludes that there is moderate evidence that the net benefit is small for women aged 40 to 49 years.
         I find this reasoning somewhat opaque.  Further down the document the Task Force offers this "Explanation" for changing its previous recommendation which had supported routine mammography in women aged 40-49:
 … the current USPSTF is now further informed by a new systematic review, which incorporates a new randomized, controlled trial that estimates the "number needed to invite for screening to extend one woman's life" as 1904 for women aged 40 to 49 years and 1339 for women aged 50 to 59 years. Although the relative risk reduction is nearly identical (15% and 14%) for these 2 age groups, the risk for breast cancer increases steeply with age starting at age 40 years. Thus, the absolute risk reduction from screening (as shown by the number needed to invite to screen) is greater for women aged 50 to 59 years than for those aged 40 to 49 years.***
In conclusion, the USPSTF reasoned that the additional benefit gained by starting screening at age 40 years rather than at age 50 years is small, and that moderate harms from screening remain at any age.
    Again, I simply don't understand the reasoning. If I correctly understand the Task Force's explanation, it takes 1904 mammograms to extend one woman's life, and on the whole this routine procedure reduces the risk from breast cancer among women in their 40's by 15%. This seems to me to be a fairly substantial benefit.
    Personal note: my wife, who is an OB-GYN, disagrees with the panel's recommendations regarding the benefits of routine mammograms and self-breast examination.Â
    For your convenience I repeat this link to the Summary Recommendations of the Task Force.
Visit Professor Huhn's website on health care financing reform for links to information about proposed legislation, studies and reports, public agencies, and private organizations concerned with this issue.
{ 16 comments }
I'd think there would be psychological benefit for women who are tested, in the form of peace of mind. It's a little disturbing to see the idea that negative results are evidence that the test was needless, an idea that seems to fly in the face of the scientific process.
But see http://www.whitehouse.gov/blog/2009/11/17/reality-check-beware-what-2 for the White House Blog response to the USPSTF.
"Isn’t this the first step toward denying coverage for mammograms?
No. The Task force is an independent panel of experts in prevention and primary care that evaluates available evidence and makes recommendations about effective clinical preventive services based on scientific information. Under the health insurance reform legislation, the USPTF would have no power to deny insurance coverage in any way. Their recommendations would be used in health reform to identify effective clinical preventive services."
It looks like the White House is trying to do 'damage control.'
"Under the health insurance reform legislation, the USPTF would have no power to deny insurance coverage in any way.Their recommendations would be used in health reform to identify effective clinical preventive services."
More creepy doubletalk.
And so the rationing begins.
And so the rationing can end IF the medical professionals, adult women, and the men who love them stand firm and say this is BS and will not be tolerated. If this is allowed to slip through with minimal opposition, Quidpro could be right. Give the insurance industry any slack and it will do the right thing……for it's stockholders.
If one woman dies because of the lack of early detection due to this guideline, does that mean the USPSTF qualifies as a "death panel"?
Larry, agreed – the "psychological harm" argument seems groundless. Let's go directly to the bottom line and say what USPSTF wasn't forthright enough to acknowledge. This is all about saving money.
And what if the USPSTF is right, or at least is taking a rational position. One of the criticisms that the CBO levels at the public option is that the CBO does not think that government will be as good at cost containment (rationing) as insurance companies are. This challenges the assumptions of both liberals and conservatives – basically it speaks to all of us. Liberals rail at the "greedy" "soulless" private health insurance companies who deny care or deny coverage for treatment that it regards as either not necessary or at least not medically indicated. But who will perform that function once the government is the insurer? Someone has to. Conservatives talk about "rationing" (I'm lookin' at you, Q) but that's not the real problem with more government involvement – the real problem is that public officials, whether appointed to elected, are not as likely to say "No!" to a patient as a private company is. And let's face it, insurance companies are rationing care now, a lot more than the government would under any of the bills, because the government is going to eliminate exclusions for preexisting conditions and abolish lifetime limits on coverage.
And let's talk honestly about "death panels." That's a figment, Q, a lie – there is nothing in any of the bills like that. But there is a concept that has been with us for a long time, the concept of medical "futility." A huge proportion of the money we spend on health care is expended in the last six months of life, and decisions are made every day about what can and will be done for people. And n entity, public or private – insurance companies, doctors, hospitals, nursing homes, Medicare, Medicaid, the Veterans Administration – can spend hundreds of thousands to "save" the life of a 95-year-old person who is in renal failure, end-stage cancer, and Alzheimer's which is so advanced that he or she can no longer communicate, let alone recognize loved ones.
Soooooo – the USPSTF concludes in this case that saving one person's life (I don't know how many life-years that represents) is not worth 1904 mammograms. A mammogram costs between $100 to $150. Accordingly, the cost of the 1904 mammograms is about $200,000. Add to this the cost of unnecessary treatment resulting from false positives or cancer that is detected but which would not be life-threatening, and the lost work days resulting from the mammograms.
I don't think that this is a liberal or conservative issue. Politics is irrelevant to this question – it cuts across ideological lines. The real question is, how much are we as a society willing to spend on health care?
I don't know where I would come out on the mammogram issue. This has been debated for about 20 years. The AMA and the ACS believe in yearly tests, while the USPSTF and other groups have said that every 2 years is enough. Some states have enacted laws requiring insurance companies to cover annual mammograms after age 40, but most have not.
I do know this. Someone has to make these judgments, either private insurance companies or the law. And these are not easy judgments to make.
When you say, “Someone has to make these judgments, either private insurance companies or the law,” you demonstrate a complete lack of vision. Your posts on this blog have demonstrated your contempt for individual liberty and personal accountability, but I assure you that individuals are actually capable of making judgments about their own health care. I recognize that the current system does generally limit people’s ability to customize their health care plan. Many employers offer only one plan and give employees the binary choice of being covered or not covered, leaving the details of the plan largely to the insurer. But, I think much of this can be attributed to the employer-centered model that has resulted from the government granting tax incentives for employers to provide health care. If you look at almost any other product, insurance or otherwise, that is purchased on the open market, consumers have a wide variety of choices that they can make to customize thee product. For example, auto insurance consumers can decide whether they want high or low liability limits, high or low deductibles, collision coverage, comprehensive coverage, uninsured motorist coverage, underinsured motorist coverage, medical payments, rental car reimbursement, etc. If you had a true free market system for health care, each individual woman could decide whether she wanted an annual mammogram, biennial mammogram, or no mammogram at all. The premiums offered by insurers would reflect both the additional cost of the exam and the potential cost savings from early detection. The woman, not the insurance company or the law, could weigh her own peace of mind, unnecessary anxiety, and the cost of more frequent exams to determine what is right for her.
This is a great conversation to have and I agree that the timing is terrific.
One of the ways that were were supposed to save a fortune, was by preventative care. Of course, this isn't exactly preventative care. But is shows the concept that you can have too much care. That it can in itself drive up medical costs.
The other thing to notice is the backlash against the new care standard. If there is enough of a backlash, will public opinion be able to change the new care standard. If this is the case then the sky is the limit to how much this will cost us.
What about the court system? Can I challenge the care standard in the courts? You know some judge will demand that x-condition (baldness, alcoholic liver disease, ED or anything) be covered.
RE:"….but I assure you that individuals are actually capable of making judgments about their own health care."
Capable?…..perhaps so, but are they willing to make those judgments ??
P.O.L.
I think you are overestimating the amount of choice that people can exercise in this area. Most people can't "choose" to treat breast cancer with a biologic drug regimen that costs $48,000 annually. As a practical matter, if it isn't covered by insurance then we do without. The 17% of the country that is uninsured, and the additional 20-25% who are underinsured (and both numbers are growing) sure aren't making any choices. Wake up! Ideology is not the answer to the problems we face in this area. That prism is distorting your vision and is keeping you from grappling with the real issue here.
Liberals like to call medical providers or insurers "greedy" for charging so much for medical care, but they are wrong. Costs are going up not because doctors or insurance companies are "greedy" but because modern medicine can do so much to prevent and treat illness and injury … and treatments that are on the horizon will be even better and more expensive.
Libertarians like to believe that everything will be great if only we let the free market operate in this area, but they are wrong as well. They want to abolish health insurance and make people pay for medical care out of their own pockets, or abolish tax preferences for health insurance or health spending accounts. Well, I suppose that would put a lid on the cost of health care, but it would also end up denying most people access to health care, and the country as a whole would have a lot of untreated medical conditions, thus reducing our productivity and our overall happiness.
Conservatives tend to want everything to stay the same … "Why do you liberals want to change everything? Just leave the system alone!" Many people are doing all right under the current system, but this ignores the fact that there are a lot of people who are not doing all right – and even if we ignore the plight of people who are uninsured and underinsured, our current system it is not sustainable. Total health care costs have doubled over the last decade and if we do nothing they will double again over the next decade.
My wife and I earn a good living and we could go merrily along under the current system, but we have to answer the question, "What is best for the country as a whole? Not just for you and me, but for our neighbors and friends, children and grandchildren, for all Americans?"
We have to solve the problems of both high cost and inadequate coverage while at the same time maintaining high quality. The Democratic plans solve two of the problems, but it leaves the other unresolved, and that isn't good enough. The Democratic bills provide adequate coverage to 94% of Americans without significantly increasing the overall cost of health care, but they do nothing to "bend the cost curve" down. If we don't solve that problem too, then we will be spending a larger and larger percentage of our national income on health care – 17% now, 21% by 2019, 25% by 2025, and continuing to escalate until 2082 when health care costs exceed national income. We have to lower total overall costs at the same time that we increase coverage and maintain quality. We have to figure out how to solve thousands of issues like whether it is more cost effective to have mammograms done annually, bienially, or only on a doctor's recommendation. Do you see a way to do that?
As for your comment about my having "contempt" for the principles of personal choice and personal responsibility – I am unaware of any such feeling. Perhaps I do, from your perspective. But are you aware of the fact that people often attribute bad motives to persons with whom they disagree as a way of avoiding addressing the merits of their arguments? I ask you to consider the possibility that our differences are not due to any specific character flaws on my part (which I have in abundance), but rather to disagreements we have about the consequences that will flow from different public policy choices.
Actually, Professor, to simply state "death panels" are a lie is pretty disingenuous. It is hyperbole meant to warn folks about the possibility that under public options, etc., these kinds of recommendations could become inescapable policy. The hyperbole is distasteful, to be sure, but simply calling it a lie further clouds the issue and promotes distrust in the whole movement toward reform.
I have to agree with P.O.L. and Larry.
When you just spout the company line – "That's a lie," that is what is going to lead people to question your motives.
It is indisputable that some form of bureaucracy will determine what is covered and what is not. If this shortens or ends a few lives, what should these groups be called by those affected?
One of the reasons that people are so distrustful of insurance companies is the similar demagoguery that has been directed at them over the years.
Professor,
Could you please cite a reference in which any person claiming to be a libertarian has recommended the abolition of health insurance. I can think of few things more inconsistent with libertarian thought than denying people the freedom to contract for health insurance.
You continue to say that “we” face a problem, but you have never provided any rationale as to why you think this is a shared problem. In fact you suggest the exact opposite when you say you could go “merrily along under the current system.” Certainly some people face have medical problems that they cannot pay for, but how do you justify depriving others of their liberty and property to pay for someone else’s problem, when those who ultimately pay do not receive a reciprocal benefit nor were they in any way responsible for the creation of the problem.
I am all for eliminating barriers in the current system that drive up costs and impair people’s access to medical coverage. The employer-provider system, which I think you have to admit is the product of government intervention in this area, presents obstacles to people obtaining and maintaining insurance. There is no reason why someone who loses his job should also lose his medical insurance, provided he can still pay the premiums. And, there is also no reason there should be a large disparity between the cost of purchasing insurance through and employer versus buying it outside. I think these obstacles to obtaining or maintaining insurance would be eliminated if we eliminated the tax incentives for employers to provide health insurance. If you want to maintain favorable tax treatment for health care expenditures, then why not just have an individual above-the-line deduction for all health care expenses paid by the individual. I generally don’t favor using the tax code to either encourage or discourage particular behavior, but I think a personal deduction would not have the adverse side effects of the employer deduction.
I also have yet to hear any explanation provided as to why insurance should cover routine examinations, which is also attributable to the fact that employers provide health insurance rather than people obtaining a plan individually. Let’s use the mammogram as an example. If an insurance plan is going to cover an annual mammogram for women 40-49 and the cost of the mammogram is $100, then every woman between 40 and 49 will pay $100 plus the insurer’s administrative costs more than she would if such coverage was not provided. If the woman paid directly, she could just pay the doctor $100 directly and cut out much of the administrative expense. She would also have more control over whether she wants to undergo routine exams rather than being forced to pay for a service she may not want nor ever use.
There are other things we could do too to improve access without depriving people of choices regarding their own care. For example, we could also make health-care related debt non-dischargeable in bankruptcy to encourage the extension of credit to people who could not otherwise obtain care. This would also reduce doctors’ bad debt expenses and reduce costs for every one else.
Professor,
My succinct post of 11-18 did not accuse anyone of instituting "death panels". I may use that accusation in the future, but I prefer to see how the legislative process plays out. I did mention rationing. You agree it will occur under any reform plan, but offer, by way of excuse, that it occurs at present.
One point to which you repeatedly come back is cost. You ask, near the end of your November 19 post: "The real question is, how much are we as a society willing to spend on health care?" But, at least in the case of private pay/private insurance "we as a society" don't pay this cost. Individuals do, based on individual, personal decisions.
That is my point. If we returned to a point closer to a true insurance model, "we as a society" would not have to address the cost issue. It would be a matter of individual choice. Are we not pro-choice on this issue?
Finally,I would like to commend you and your wife for your concern for those who do not have adequate health insurance, as you expressed in you post of this morning, but I will not. The concern that you clothe in the noble language of sacrifice, you would address with public funds. There should be no commendation in the use of others' funds to assuage your conscience.
OK, back to the original issue:
"We have to figure out how to solve thousands of issues like whether it is more cost effective to have mammograms done annually, bienially, or only on a doctor's recommendation. Do you see a way to do that?"
My knee-jerk reaction was to condemn the results of the USPSTF as strictly a pro-insurance industry plan. However, based on more thought and comparing this issue to the recent changes in policy and treatment for prostrate issues….they may have a legitimate point. I presently see four reasonable courses of action on this particular issue:
1) Leave mammogram policy 'as is' and try to save money in areas that are not a universal hot-button topic. This is probably not the best plan.
2) Do a lot more number crunching and comparative analysis of past practices vs results before issuing any mandates for changes in care or pricing.
3) Craft a 'basic' annual preventative insurance package for the top 25(?) health concerns and offer reasonably priced add-on options for those seeking higher frequencies of examination.
4) Combine 2 and 3 to arrive at tiers of care/coverage based on integrating overall population statistics with personal family history. Anyone desiring preventative care beyond the 'usual and customary' for his or her predetermined class(?) would be obliged to pay for it out of pocket.
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